Owing to these inconsistent find- helmet with face mask bupropion 150mg for sale, chin strap generic 150 mg bupropion fast delivery, and chin pad order bupropion 150mg without prescription, as ings and the lack of demonstrated proof of efficacy bupropion 150 mg mastercard, well as protective gloves and a mouthguard for all both the American Academy of Pediatrics and the male lacrosse players. Goalies are additionally American Academy of Orthopedic Surgeons have rec- required to wear chest and throat protectors. Many players also wear rib ACL functional braces are available for players with protector vests. Custom-fit braces have not been shown to perform better or offer more protection than off-the-shelf braces (Wojtys and Huston, 2001). RACQUET SPORTS Some clubs require eye protection for badminton, BASEBALL/SOFTBALL squash, and racquetball players. When a lens in a sports frame is struck, it proj- coaches, and on-deck hitters. This recommendation was Mouth guards are recommended, but not mandatory, originally made in 1984 by the Sports Eye Safety Com- to reduce risk of dental trauma. ICE HOCKEY The NCAA mandates the use of helmets with fastened WRESTLING chin straps, face masks, and an internal mouthpiece. Shin guards should pro- vical spine injuries (Reynen and Clancy, Jr, 1994). CHAPTER 17 PLAYING SURFACE AND PROTECTIVE EQUIPMENT 105 Mouth guards are recommended, especially for goal- natural grass and tartan turf. Am J Sports Med 8(1):43–47, keepers, to protect against not only dental injury but 1980. Kulund DN, Athletic injuries to the head, face, and neck, in Kulund DN (ed. Naftulin S, McKeag DB: Protective equipment: Baseball, soft- ball, hockey, wrestling, and lacrosse, in Morris MB (ed. Nicola TL: Tennis, in Mellion MB, Walsh WM, Shelton GL Albright JP, Powell JW, Smith W, et al: Medial collateral liga- (eds. Philadelphia, ment knee sprains in college football: Effectiveness of preven- PA, Hanley & Belfus, 1997, pp 816–827. Powell JW, Schootman M: A multivariate risk analysis of American Academy of Pediatrics Committee on Sports selected playing surfaces in the National Football League: Medicine: Knee brace use by athletes. Am J Barret JR, Tanji JL, Drake C, et al: High- versus low-top shoes for Sports Med 20(6):686–694, 1992. A prospec- Reynen PD, Clancy WG, Jr: Cervical spine injury, hockey hel- tive randomized study. Benson BW, Mohtadi NG, Rose MS, et al: Head and neck Rovere GD, Haupt HA, Yates CS: Prophylactic knee bracing in injuries among ice hockey players wearing full face shields vs college football. Sitler M, Ryan J, Hopkinson W, et al: The efficacy of a prophy- Cantu RC, Mueller FO: Brain injury related fatalities in American lactic knee brace to reduce knee injuries in football. Am J Sports Med Gaulrapp H, Siebert C, Rosemeyer B: Injury and exertion pat- 18(3):310–315, 1990. Sportverletz Sportschaden Sitler M, Ryan J, Wheeler B, et al: The efficacy of a semirigid 13(4):102–106, 1999. A Gieck JH, Saliba EN: The Athletic Trainer and Rehabilitation, in randomized clinical study at West Point. Surve I, Schwellnus MP, Noakes T, et al: A fivefold reduction in Grippo A: NFL Injury study 1969–1972. Final Project Report the incidence of recurrent ankle sprains in soccer players using (SRI-MSD 1961). Keene JS, Narechania RG, Sachtjen KM: Tartan turf on trial: A Wojtys EM, Huston LJ: Custom fit versus off the shelf ACL func- comparison of intercollegiate football injuries occurring on tional braces. Section 2 EVALUATION OF THE INJURED ATHLETE radiography (at the cost of loosing some of fine bone 18 DIAGNOSTIC IMAGING details), the ability of radiography to depict soft tissue Leanne L Seeger, MD, FACR pathology remains inferior to cross sectional imaging Kambiz Motamedi, MD (MRI, CT, and ultrasound). Disadvantages include availability of INTRODUCTION the physician, radiation exposure, and subjectivity of the amount of stress needed. In some cases, it may There are several modalities available for the imaging exacerbate underlying pathology.
Fluid resuscitation should be started according to the fluid resuscitation formula trusted bupropion 150 mg. Fluid administration needs then to be tailored to the response of the patient based on urine output in a stable order bupropion 150mg on-line, lucid cooperative patient buy bupropion 150mg overnight delivery. The ideal is to reach the smallest fluid administration rate that provides an adequate urine output proven 150 mg bupropion. The appropriate resus- citation regimen administers the minimal amount of fluid necessary for mainte- nance of vital organ perfusion. Inadequate resuscitation can cause further insult to pulmonary, renal, and mesenteric vascular beds. It will also increase wound edema and thereby dermal ischemia, producing increased depth and extent of cutaneous damage. Fluid requirements in patients with electrical injuries are often greater than those in patients with thermal injury. The main threat in the initial period is the development of acute tubular necrosis and acute renal insufficiency related to the precipitation of myoglobulin and other cellular products. A common finding in patients with electrical injuries is myoglobinuria, manifested as highly concen- trated and pigmented urine. The goal under these circumstances is to maintain a urine output of 1–2 ml/kg/h until the urine clears. In nonresponding patients, alkalization of the urine and the use of osmotic agents may prevent death. The use of colloid solutions for acute burn resuscitation remains debated. Development of hypoproteinemia in the early resuscitation period increases edema in nonburned tissues. In the absence of inhalation injury, however, lung water content does not increase. Early infusion of colloid solutions may decrease overall fluid requirements in the initial resuscitation period and reduce nonburn edema. However, injudicious use of colloid infusion may cause iatrogenic pulmo- nary edema, increasing pulmonary complications and mortality. The current rec- ommendation is to add 25% albumin solution to maintain serum albumin 2. Albumin solution 5% should be used instead of 25% solution in unstable patients with hypovolemia. Hypotension is a late finding in burn shock; therefore, pulse rate is much more sensitive than blood pressure. Normal senso- rium, core temperature, and adequate peripheral capillary refill are additional clinical indicators of adequate organ perfusion. Fluid shifts are rapid during the acute resuscitation period (24–72 h), and serial determinations of hematocrit, serum electrolytes, osmolality, calcium, glucose, and albumin can help to direct appropriate fluid replacement. Although overresuscitation is usually easy to detect, based on increasing edema and high urine output; underresuscitation may be much more difficult to diagnose and categorize. Persistent metabolic acidosis on measurement 28 Barret FIGURE 10 Approach to the nonresponding patient. Resuscitation fluids must be reviewed and corrected (including fluid boluses) before any other further action is taken. Initial Management and Resuscitation 29 of arterial blood gases may be indicative of continuing hypoperfusion from hypovolemia. As a general rule, patients who have a bad response to the standard Parkland formula and fluid boluses, and present with a continuous high base excess with increased lactate levels, are monitored with a pulmonary artery catheter. Patients with a low cardiac output despite correct resuscitation are candidates for inotropic support. On the other hand, if cardiac output is normal, patients are candidates for colloid administration. If patients do not respond to any of the resuscitation measures, continuous hemofiltration or plasmapheresis should be attempted (see Fig. MONITORING AND PATIENT CONTROL Patients with major burns should receive full monitoring, including: Continuous electrocardiograph monitoring Continuous respiratory rate monitoring Pulse oximetry Central venous pressure Arterial line Foley catheter and urine output Temperature probes Capnometry (ventilated patients) Pulmonary artery catheter (unstable severe burn patients) Esophageal Doppler monitoring (alternative to Swan-Ganz catheters) Doppler monitor for compartment syndromes Central lines and arterial lines do carry some morbidity in burned patients. Judi- cious use of these otherwise helpful monitoring devices is advised.
Brace treatment Brace treatment should be considered for a thoracic kyphosis of more than 50° in a patient who is still ⊡ Fig generic 150mg bupropion with visa. Principle of Becker brace preparation for the treatment of thoracic Scheuermann disease discount 150 mg bupropion otc. Only when the brace kyphoses the lumbar spine to a substantial extent is the patient forced to straighten his thoracic spine otherwise he will fall forwards discount bupropion 150mg without prescription. For the preparation of the cast (whether as a case for a plastic brace or a definitive plaster brace) discount 150mg bupropion fast delivery, the patient must support himself by placing his hands on a chair to ensure adequate kyphosing of the lumbar spine. The brace should not extend up as far as the apex of the kyphosis, but should ⊡ Fig. Inappropriate sports for patients with Scheuermann dis- end roughly at the level of the lower end vertebra of the kyphosis so ease include cycling in a racing cyclist’s position that the patient is able to straighten up 99 3 3. The principle of this Becker brace relies also be achieved with the use of the reclination bracket on its being fitted while the patient’s lumbar spine is (⊡ Fig. At the back the brace extends Results for brace treatment with good compliance: 2/3 only to just below the start of the kyphosis. However, a certain amount of criticism the kyphosing of the lumbar spine, forcing the patient is also now being aimed at brace treatment, calling its actively to straighten his thoracic spine to prevent him- effectiveness into question, primarily because of the self from toppling forward. Authors rightly complain that the (few) existing studies are inadequately controlled. Since the kyphotic posture often represents a protest against the parents, the intrinsic motivation to correct it is sometimes completely lacking. If optimal compliance is desired, a plaster cast must be prepared in a similar manner. A lordosing 3-point brace can be used for thoraco- lumbar and lumbar Scheuermann disease. Since the prog- nosis in this form of the disease is poor in relation to later back pain, we tend to use a cast brace, prepared while the patient is in a position of ventral suspension. This will en- able the lumbar kyphosis to be corrected back to lordosis while the patient is still growing (⊡ Fig. When the brace is ready, its effect must be checked radiologi- cally by lateral views. Brace for thoracic Scheuermann’s disease with an adjust- every 3 months, and x-rays should be recorded every able reclination bracket 6 months (lateral only) until the patient is weaned off the brace. Results of brace treatment in Scheuermann disease: In disease: a before brace treatment,bafter 1 year of brace treatment. The contrast with scoliosis, a genuine correction that persists even after kyphosis has returned to normal completion of treatment can be achieved with the brace 100 3. For lumbar kyphoses on the other hand, an operation tends to be indicated for medical reasons since persistent 3 and significant symptoms are usually present in cases of severe lumbar kyphoses. While our practice in the past has involved the combination of anterior and posterior approaches, we now generally employ a purely posterior approach with wedge osteotomies and thereby create space for the posterior compression. The possible complications of surgical treatment are similar to those for scoliosis surgery ( Chapter 3. In very severe kyphoses, the force of gravity works against all therapeutic efforts, and hyperkyphosis can occur in the non-instrumented area after correction of a kyphosis. For this reason, the instrumentation should, if possible, not only be used in the kyphotic area, but should extend a b to the start of the lordosis. No statistically evaluable data are available on the risk of neurological lesions, although ⊡ Fig. Example of the correction of a lumbar kyphosis in Scheuer- the risk is probably similar to that for scoliosis surgery. On the other hand they Before treatment, b after 6 months in a cast brace involve compression rather than distraction.
Full elbow mobility is usu- Treatment ally restored only after several months buy cheap bupropion 150mg on-line. Physiotherapy is Conservative indicated only if movement restrictions persist for several Non-displaced fractures undergo bone healing in a months purchase 150mg bupropion with amex. Fishtail deformity: After the distal epiphysis has ossi- fied order 150 mg bupropion amex, one occasionally sees a central bony retraction Surgical in otherwise normal cheap 150mg bupropion visa, but now more prominent, con- ▬ Radial condyle: Primarily or secondarily displaced dyles. On the AP x-ray the distal humerus resembles fractures are anatomically reduced in an open proce- a fishtail. Conservative treatment of a fracture of the radial condyle treated conservatively. We have never observed this change in and a radial condyle that has consolidated too proximally, shape in fractures that are stably fixed with compres- or even migrated proximally after pseudarthrosis, pro- sion screws [30, 31]. It is probably a radiological phe- duce opposite effects on the elbow axis. Considerable dispute exists as to the indication, and par- The excessively large radial condyle often exagger- ticularly the appropriate age, for a revision of the pseud- ates the axial deformity. Spontaneous correction cannot be ex- ture management, lateral approaches with extensive pos- pected. The indication for a corrective osteotomy is terior soft tissue removal from the radial condyle, inade- based on the patient’s symptoms. Although the proximal radial epiphyseal plate only After supracondylar and condylar fractures, those of the accounts for 20% of the growth in length, it pos- radial head are the third commonest elbow fractures dur- sesses an impressive potential for spontaneous cor- ing growth. Mechanical factors may play a and primarily affect the age group between 4 and 14 years crucial role in this remodeling process, for example it. They are the result of an excessive valgus stress in can be activated by early independent mobilization. The primary determining prognostic factor is the Conservative treatment impairment of the blood supply via the periosteal Simple immobilization in a long-arm cast is appropriate radial neck vessels caused by the initial trauma or in the following cases: even iatrogenically through an invasive therapeutic ▬ before the age of 10 with angulations of less than procedure. Otherwise, possible compli- cations include avascular necroses, loss of the radial head Surgical treatment shape and serious functional restrictions, particularly in A closed reduction with subsequent Prévot nail fixation respect of movements with forearm rotation. In this pro- cedure, the fragment is reduced as far as possible by the Diagnosis application of external finger pressure and a concurrent Clinical features pronation/supination movement. Any residual deformity Local swelling, tenderness, painful restriction of a fore- is corrected via an elastic medullary nail advanced into arm turnover movement. The implant is advanced as far as the epiphysis, which is then reduced by rotating the Imaging investigations angled nail end (⊡ Fig. If the fracture is severely, or even completely, displaced, Small fragments close to the epiphysis may indicate epiphy- it may not be possible to reduce the small epiphyseal seal involvement. Nevertheless, an open, views or – if uncertainty still exists – an MRI scan. Epiphyseal fractures (Salter types III complete displacement into the joint, or IV) are rare. These fractures frequently occur in combination with other fractures of the elbow (particularly those of the olecranon, Follow-up management and controls radial condyle, proximal ulna and avulsion fractures of the! A maximum of 2 weeks’ immobilization, followed by epicondyles, as well as elbow dislocations). The radial independent mobilization with complete avoidance head fracture is the crucial prognostic factor. A conservative, non-invasive or (if reduction is re- lowed as soon as possible within the limits of pain. This means: avoid at all costs transarticular wire Clinical controls should be continued for up to 2 years fixations, screws or plate fixations on the still grow- after the trauma in order to check for growth disturbances ing proximal radius. The interpretation of the AP views is aggravated by the overlapping of the distal 3 humerus. It is important to distinguish between a normal apophysis and a fracture: The ossification center in the area of the triceps attachment appears around the age of 9 and may be divided into two centers. The thin, bright line a b c should not be confused with a fracture, particularly dur- ing physeal closure around the age of 14. By contrast, the cartilaginous apophyseal section can result in an under- estimation of the degree of displacement associated with fractures.