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By S. Zarkos. United Theological Seminar.

Glenohumeral Capsule The capsule arises from the labrum and inserts on the neck of the humerus It covers the entire head of the humerus but is not quite adjacent to the glenoid fossa generic 60mg alli mastercard, leaving a small space that separates the two (capsule from the fossa) The capsule thickens anteriorly to form the glenohumeral ligaments Glenohumeral Ligaments (Figure 4–9) These ligaments arise from folds of the anterior portion of the capsule and reinforce the joint They provide stability and prevent translation of the head of the humerus from the glenoid fossa They are composed of three segments cheap alli 60 mg online, all located on the anterior aspect of the humeral head 1 order alli 60 mg mastercard. Superior glenohumeral ligament – Prevents translation in the inferior direction – This along with the middle glenohumeral ligament provides stability of the shoulder from 0–90˚ of abduction 136 MUSCULOSKELETAL MEDICINE 2 order alli 60 mg online. Middle glenohumeral ligament – Prevents translation in the anterior direction 3. Inferior glenohumeral ligament – The primary anterior ligament stabilizer above 90˚ FIGURE 4–9. The glenohumeral ligaments (anterior view) depict a distinct Z pattern formed by the superior glenohumeral ligament, the middle glenohumeral ligament, and the inferior glenohumeral ligament. Long head of the biceps tendon, deltoid, and teres major Static Stabilizers Include the articular anatomy, capsule, ligaments, as well as the glenoid labrum MUSCULOSKELETAL MEDICINE 137 MEDIAL ROTATORS Pectoralis major Anterior deltoid Subscapularis Latissimus dorsi Teres major LATERAL ROTATORS Teres minor Posterior deltoid Infraspinatus FIGURE 4–10. This diagram depicts the relation of the rotators to the upper end of the humerus. Right glenoid cavity of the scapula as viewed from the anteriolateral aspect. Note four short rotator cuff muscles (teres minor, infraspinatus, supraspinatus, and subscapularis). Note the contribution of the coraco-acromial ligaments to the inferior acromio-clavicular joint capsule. Acromioclavicular (AC) ligament Connects the distal end of the clavicle to the acromion, providing horizontal stability 2. Coraco-clavicular (CC) ligament This ligament is made up of 2 bands: Conoid and trapezoid Connects the coracoid process to the clavicle, providing vertical stability 3. Coraco-acromial ligament Connects the coracoid process to the acromion Mechanism of Injury A direct impact to the shoulder Falling on an outstretched arm MUSCULOSKELETAL MEDICINE 139 Classification of AC Joint Separations (See Figure 4–13) TABLE 4–1 Ligament Acromioclavicular Coracoclavicular Clavicular Displacement Type I Partial sprain Intact None Type II Complete tear Partial sprain None Type III Complete tear Complete tear Superior Type IV Complete tear Complete tear Posterior and superior into the trapezius, giving a buttonhole appearance Type V Complete tear Complete tear Superior and posterior More severe than type III with coracoclavicular space increased over 100%. Type VI Complete tear Complete tear Inferior Clinical Patients generally complain of tenderness over the AC joint with palpation and range of motion AC joint displacement with gross deformity occurs in the later stages and is usually seen in a type III or greater Provocative tests Cross-chest adduction Passive adduction of the arm across the midline causing joint tenderness Imaging Weighted AP radiographs of the shoulders (10 lbs) – Type III injuries may show a 25% to 100% widening of the clavicular-coracoid area – Type V injuries may show a widening > 100% Treatment Depends on the degree of separation Acute Types I and II – Rest, ice, nonsteroidal anti-inflammatory (NSAIDs) – Sling for comfort – Avoid heavy lifting and contact sports – Shoulder-girdle complex strengthening – Return to play: When the patient is asymptomatic with full ROM Type I: 2 weeks Type II: 6 weeks Types III or greater: Controversial – Conservative or surgical, depending on the patient’s need (occupation or sport) for particular shoulder stability – Surgical: For those indicated (heavy laborers, athletes) – Generally, no functional advantage is seen between the two treatment regimens Types IV to VI – Surgery is recommended: Open reduction internal fixation (ORIF) or distal clavicular resection with reconstruction of the CC ligament 140 MUSCULOSKELETAL MEDICINE Chronic AC joint pain Corticosteroid injection May require a clavicular resection and CC reconstruction Complications Associated fractures and dislocations Distal clavicle osteolysis – Degeneration of the distal clavicle with associated osteopenia and cystic changes FIGURE 4–13. Classification of AC Joint Separations (Anterior Views) (see Table 4–1 for description). MUSCULOSKELETAL MEDICINE 141 AC joint arthritis – May get relief from a lidocaine injection and conservative rehabilitative care should be sufficient GLENOHUMERAL JOINT INJURIES (GHJ) General Glenohumeral joint type: Ball and socket Scapulothoracic motion or glenohumeral rhythm – Balance exists between the glenohumeral and scapulothoracic joint during arm abduc- tion – There is a 2:1 glenohumeral: scapulothoracic motion accounting for the ability to abduct the arm (60˚ of scapulothoracic motion to 120˚ of glenohumeral motion) – The scapulothoracic motion allows the glenoid to rotate and permit glenohumeral abduction without acromial impingement Classification of GHJ Instability Definitions Instability is a translation of the humeral head on the glenoid fossa without complete sep- aration. It may result in subluxation or dislocation Subluxation is a separation of the humeral head from the glenoid fossa with immediate reduction Dislocation is complete separation of the humeral head from the glenoid fossa without immediate reduction Direction of Instability Anterior glenohumeral instability – Most common direction of instability is anterior inferior – More common in the younger population and has a high recurrence rate – Mechanism: Arm abduction and external rotation – Complication may include axillary nerve injury Posterior glenohumeral instability – Less common than anterior instability – May occur as a result of a seizure – The patient may present with the arm in the adducted internal rotated position – Mechanism: Landing on a forward flexed adducted arm Multidirectional Instability – Rare with instability in multiple planes – The patient may display generalized laxity in other joints Patterns of Instability Traumatic: T. T- Traumatic shoulder instability U- Unidirectional B- Bankart lesion S- Surgical management (Rockwood, Green, et al. A- Atraumatic shoulder instability M- Multidirection instability B- Bilateral lesions R- Rehabilitation management I- Inferior capsular shift, if surgery (Rockwood, Green, et al. Bankart lesion (Figure 4–14) Bankart lesion is a tear of the glenoid labrum off the front of the glenoid; this allows the humeral head to slip anteriorly Most commonly associated with anterior instability This type of lesion may be associated with an avulsion of a small fragment of bone from the glenoid rim 2. Hill-Sachs lesion (Figure 4–15) A compression fracture of the posterolateral aspect of the humeral head caused by abutment against the anterior rim of the glenoid fossa Associated with anterior dislocations A lesion that accounts for greater than 30% of the articular surface may cause insta- bility A notch occurs on the posterior lateral aspect of the humeral head due to the recur- rent impingement Posterior dislocations – Reverse Hill-Sachs lesion – Reverse Bankart lesion FIGURE 4–14. MUSCULOSKELETAL MEDICINE 143 Clinical The dead arm syndrome: These symptoms include early shoulder fatigue, pain, numbness, and paresthesias Shoulder slipping in and out of place, more commonly when the arm is placed in the throwing position (abducted and externally rotated) A syndrome of the shoulder and upper extremity usually seen in athletes (pitchers, vol- leyball servers) who require repetitive overhead arm motion Laxity exam: Some patients are double jointed, which is a lay term for capsular laxity. Ask the patient to touch the thumb against the volar (flexor) surface of the forearm. Patients with lax tissues are more likely than others to be able to voluntarily dislocate the shoulder Provocative Tests Anterior Glenohumeral Instability Apprehension test (Figure 4–16) – A feeling of glenohumeral instability on 90˚ of shoulder abduction and external rotation causing apprehension (fear of dislocation) in the patient Relocation test – Supine apprehension test with a posterior directed force applied to the anterior aspect of the shoulder not allowing anterior dislocation. This force relieves the feeling of apprehension Anterior draw (load and shift) – Passive anterior displacement of the humeral head on the glenoid Posterior Glenohumeral Instability Jerk test – Place the arm in 90° of flexion and maximum internal rotation with the elbow flexed 90°. Adduct the arm across the body in the horizonal plane while pushing the humerus in a posterior direction. The patient will jerk away when the arm nears midline to prevent posterior subluxation or dislocation of the humeral head Posterior draw (load and shift) – Posterior displacement of the humerus FIGURE 4–16. If an indentation develops between the acromion and the humeral head, the test is positive. Imaging General films – Routine anteroposterior view (AP) – Scapular Y view – Axillary lateral view Assess glenohumeral dislocations – Others views West Point lateral axillary: Bankart lesions Stryker notch view: Hill-Sachs lesions Treatment Anterior Glenohumeral Instability (T. In athletes or active individuals, surgery may be considered earlier Posterior Glenohumeral Instability Conservative – Immobilize in a neutral position for roughly three weeks – Strengthening the posterior shoulder-scapula musculature is imperative – Infraspinatus, posterior deltoid, teres minor This phase may last up to six months Surgical – Rehabilitation generally is adequate for the majority of these patients. In the event of a failed rehabilitation program, a posterior capsulorrhaphy is the surgical procedure of choice Multidirectional Glenohumeral Instability (AMBRI) Greater than 80% of the patients obtain excellent results with rehabilitation Surgical treatment may be an option only when conservative measures fail.

Anne Lamott1 Introductions should be short and arresting and tell the reader why you undertook the study purchase alli 60 mg otc. In essence 60 mg alli with mastercard, this section should be brief rather than expansive and the structure should funnel down from a broad perspective to a specific aim as shown in Figure 3 cheap alli 60 mg on-line. This should lead directly into the second paragraph that summarises what other people have done in this field buy discount alli 60 mg on-line, what limitations have been encountered with work to date, and what questions still need to be answered. This, in turn, will lead to the last paragraph, which should clearly state what you did and why. This sequence is logical and naturally provides a good format in which to introduce your story. Paragraph 1: What we know Paragraph 2: What we don’t know Paragraph 3: Why we did this study Figure 3. Topic sentences, especially for the first introductory sentence, are a great help. Richard Smith, editor of the BMJ, stresses the importance of trying as hard as you can to hook your readers in the first line. Few readers want to plough through a detailed history of your research area that goes over two or more pages. In the introduction section, you do not need to review all of the literature available, although you do need to find it all and read it in the context of writing the entire paper. In appraising the literature, it is important to discard the scientifically weak studies and only draw evidence from the most rigorous, most relevant, and most valid studies. Ideally, you should have done a thorough literature search before you began the study and have updated it along the way. This will be invaluable in helping you to write a pertinent introduction. You should avoid including a lot of material in the introduction section that would be better addressed in the discussion. You should never be tempted to put “text book” knowledge into your introduction because readers will not want to be told basic information that they already know. For example, the sentence, Asthma is the most common chronic disease of childhood, must be one of the most overused phrases in the last decade. All scientists working in asthma research and most people in the community already know this and don’t want to be told it yet again. Similarly, a phrase that defines the problem such as, Asthma is a condition in which the airways narrow in response to commonly occurring environmental stimuli, is not appropriate, except in a paper about the mechanisms of airway narrowing. It is much better to put your study in the context in which it will be published. For example, an introductory sentence such as, The mould Alternaria occurs ubiquitously in dry regions and is thought to be important in exacerbating symptoms of asthma, defines the background behind this particular research study. In this sentence, the focus of the study and the cause of the 52 Writing your paper exacerbations (Alternaria) rather than the disease itself (asthma) is the topic of the sentence, as it should be. Do not be tempted to begin your introduction by quoting the literature but omitting to say what was found. For example, an introduction that begins with, Previous studies have reviewed injury rates in Australian Army and RAAF recruits undergoing basic training. However, the lack of information about what was actually found does not help readers to put your work in the context of what has gone before. It is always better to quote the findings from previous studies rather than the name of the first author and the details of the aims or methods. For example, you could write, Injury rates in Australian Army and RAAF recruits undergoing basic training were 12% per year in 1997 but were much higher at 47% in Navy recruits who were unable to complete basic training. This sentence explains the prevalence of injuries at a specific point in time and, as such, quotes the science and not the scientist. Before you can begin writing, you need to have an aim or a research question that is both novel and worth answering. The most essential part of the introduction is the last paragraph, which gives details of your aim or hypothesis. This is where the sentence that will dictate the content of the remainder of your paper should be found. This sentence sets up the expectations for the rest of the paper and should be the very first sentence that you write in collaboration with your coauthors.

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In cooperative patients and on special locations (face cheap alli 60 mg on line, hands) grafts can be left exposed discount alli 60mg without prescription. Antimicrobial creams (bacitracin or polysporin) should be applied on the surface of the grafts to prevent contamination of graft seams and graft desicca- tion discount alli 60 mg with amex. If the exposed method is used in hand grafts buy alli 60 mg visa, the ukulele splint should be considered to allow full range of motion and good graft positioning. When all dressings have been applied, the anatomical location should be elevated and protected. Postoperative instructions are given to the nursing staff and on call team, and the patient and relatives are informed of the postoperative wound care plan. Grafts are inspected 5–7 days after surgery unless the clinical picture of the patient dictates otherwise. INTRODUCTION Over 1 million people are burned in the United States every year, most of which injuries are minor and treated on an outpatient basis. Almost all of these treated as outpatients do not require operative treatment. However, approximately 60,000 burns per year are more severe and require hospitalization, and roughly 3000 of these patients die. Between 1971 and 1991, burn deaths in the United States decreased by 40%, with a concomitant 12% decrease in deaths associated with inhalation in- jury. These im- provements were probably due to prevention strategies resulting in fewer burns of lesser severity, as well as significant progress in treatment techniques. Improved patient care in the severely burned, including operative strategy and techniques, has undoubtedly improved survival, particularly in children. Bull and Fisher first reported in 1952 the expected 50% mortality rate for burn sizes in several age groups based upon data from their unit. They reported that approxi- mately one-half of children aged 0–14 with burns of 49% total body surface area (TBSA) would die, 46% TBSA for patients aged 15–44, 27% TBSA for those 221 222 Wolf of age 45–64, and 10% TBSA for those 65 and older. The dramatic effect of the practice of early wound excision on burn mortality cannot be overempha- sized. This single advancement has led, in my opinion, to the routine survival of patients with massive burns in centers with experience in their care. Burn wounds can be roughly categorized into two classes: partial-thickness and full-thickness. Partial-thickness wounds will generally heal by local treatment with skin substitutes or topical antimicrobials, and therefore do not require opera- tive treatment. Full-thickness and very deep partial-thickness wounds, however, will require other treatments to affect timely wound healing. Since all the elements of the epidermis have been obliterated in full-thickness wounds, healing can occur only through wound contraction and/or spreading epithelialization from the wound edges. In a sizable wound, this process will take weeks to months to years to complete. To accelerate this process, skin grafting with the necessary keratinocytes from other parts of the body can be used. Alert patients do not generally tolerate this procedure, so anesthesia is necessary. Therefore, these procedures to accelerate burn wound closure are performed in the operating room. This chapter reviews the general principles of burn surgery, defines which patients should receive operations for burn wound closure, discusses necessary equipment and skills including patient preparation, reviews an excision and grafting proce- dure for a major burn, and discusses the techniques generally chosen based on the patient and injury characteristics. The discussion is general and therefore applicable to all specialists doing burn surgery. However, some of this information is by necessity an opinion and should be treated as such. Some local practices followed at different institutions may differ significantly from what is espoused here; however, they all should adhere to the general principles of burn surgery.

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For example generic alli 60mg online, does the patient believe that they have no control over symp- toms? Or do they notice that their behaviors influence their symptoms to some extent and that there are predictable patterns with respect to their pain? It is also useful to ask patients to rate their pain on a 0–10 scale (e buy alli 60 mg visa. They might be asked to rate their pain “right now 60 mg alli visa,” “over the past weeks buy 60 mg alli amex,” “usual or average pain,” “most severe pain,” and how much their pain affects their regular activities. These ratings can be informative in generating hypothe- ses and might also be used to evaluate progress during treatment. A patient who assigns very low ratings but grimaces and limps while moving about the clinic may be underreporting his or her pain. On the other hand, a pa- tient who assigns a 10 as the lowest pain experienced may be making a plea for help. The patients might also be asked about the location and changing (spreading) of pain, the characteristics of pain (e. These questions can be presented orally or patients can be asked to complete a question- naire addressing these topics. There is no simple way to assess a person’s pain level, but how a patient describes his or her pain might be as useful as knowing the pain level itself. Difficulties sleeping frequently accompany chronic pain and can create a vicious circle of suffering. Lack of sleep can contribute to pain, and experi- encing pain can make it more difficult to sleep soundly. In a comprehensive evaluation, patients should be asked about their sleep—specifically, do they have any difficulty initiating or maintaining sleep? If the patient endorses any of these difficulties, psychologists can probe further and help determine whether there are (often easy) changes that can be made. For example, does the patient discontinue caf- feine consumption eight hours and alcohol four hours before bedtime? ASSESSMENT OF CHRONIC PAIN SUFFERERS 221 What does the patient do when he or she wakes up in the middle of the sleep cycle? Patients should be asked about what treatments they have tried in the past and are using presently. Also, are they or health care providers considering addi- tional treatments in the future, such as surgery for their pain? If there is a pending treatment, what does the patient know about the procedure(s) be- ing considered, what are the patient’s expectations about the likely results, how confident are they in the potential of this treatment? How worried are they about the treatments being considered, what do their significant oth- ers think about the treatment(s) being contemplated? Answers to these questions are useful in evaluating whether patients have already assumed a self-management role or whether they see themselves as reliant on others for all their care. When patients with persistent pain seek compensation for lost wages or are involved in litigation, these processes can add an additional layer of distress. Keeping up with paper- work, phone calls, visits to physicians and hospitals, and meetings with attorneys are often undesirable activities. They may have realistic con- cerns about the potential outcomes of the assessment. Moreover, patients involved in litigation are usually in the awkward position of having to “prove” how disabled they are as a result of an injury. The more they at- tend to their limitations, the less they attend to their improvements. Yet an important part of rehabilitation is taking note of capabilities and maximiz- ing a “wellness” role. Psychologists should ask patients about these areas in order to assess whether compensation or litigation statuses might inad- vertently be contributing to and maintaining the patients’ symptoms.

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