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If it shows a good response antifungal and hydrocortisone cream purchase nizoral with mastercard, the same chemotherapy regimen is continued for a further nine months antifungal ear drops dogs buy nizoral now. The prognosis for Preoperative radiotherapy may also be indicated for tu Ewing sarcoma was even worse fungus gnats in cannabis buy genuine nizoral online. Treatment was limited to what preoperative radiotherapy and hyperthermia has proved we would now consider to be excessively low-dose che effective fungus gnats soap generic nizoral 200 mg amex. The mortality rate is bleeding tendency during the resection and the postop highest during the first two years. Only a small propor erative infection risk and that bony bridges show poorer tion of patients die during the following few years, and as osseointegration. Overall, the data cover a sample of more than Intergroup Cooperative Ewing Sarcoma Study) protocol 1,000 patients. The tumors are the most significant in respect of their influence on the treated according to standardized guidelines and evalu prognosis: the most important questions are whether ated in a coordinated manner. This is the only way of metastases were already present at the time of diagnosis, assessing and continually improving the effectiveness of whether the tumor has been removed with a margin of treatment for these relatively rare tumors. These Euro healthy tissue and whether the tumor responded well or not pean studies are now being coordinated with American to the chemotherapy. Thus, tumors located in favorable sites such as the resistance to the respective drugs is present or not. The upper arm or lower leg, and particularly if they respond causes of the development of resistance are the subject of well to the primary treatment, are now associated with intensive research. Even tumors on the coprotein, a membrane protein of the tumor cells, appears thigh, the commonest site of the osteosarcoma, have a to be related to the development of resistance. The situation is not so favorable for Ewing sarcoma be Soft tissue tumors cause of the early formation of metastases. Nevertheless, a the most important high-grade malignant soft tissue tu six-year survival rate of around 50% can still be achieved mor during childhood and adolescence is rhabdomyosar for tumors affecting the extremities ( Fig. This is treated according to the Survival probabilities of over 80% can be expected for 636 4. The spread of the tumor within or their location and provided the primary tumor does not outside the compartment is a key factor when determin metastasize [9]. Nowadays, amputation is unavoidable in just over 10% of cases, and is indicated General aspects of the surgical treatment particularly if major vessels and nerves are surrounded of malignant tumors by the tumor. The goal of resection, whether wide or radical, is always Thanks to imaging procedures we usually have very the complete removal of the malignant tumor. As a rule accurate information about the extent of the tumor prior this can be achieved by a limb-preserving technique to its removal. The resection must be planned very 4 carefully as absolutely no compromise is possible. If necessary, important soft tissue structure must also be removed at the same time. The tumor should not be touched throughout the operation (»it should not see the light of day«. The access routes of earlier operations – for example biopsy channels – must likewise be removed. This is why the plan for the subsequent resection and reconstruction must be known even at the time of the biopsy, since a badly located biopsy scar can make it impossible to subsequently remove the tumor with a margin of healthy tissue without amputation. Depending a on the spread of the tumor in each case, further special ists may need to be called in during the resection in order to perform a vessel or nerve-bridging procedure or skin reconstruction. Close cooperation with vascular surgeons, plastic surgeons, and possibly neurosurgeons, is absolutely essential in a tumor center. Bridging options the following options are available for bridging a bony defect: b autologous bone from another site (e. The two curves in a show the six-year survival rates the use of autologous bone is the least problematic before and after the introduction of the modern chemotherapy pro method in terms of subsequent osseointegration. The probability of survival is currently over patient’s own bone does not cause any rejection reactions, 60%, compared to less than 20% before 1980. The curves were produced on the basis of and the resulting healing process does not usually cause figures compiled from several European and American studies. The disadvantage of this method is that survival rates for Ewing sarcoma are not as good, overall, as those for joint sections can be replaced only in exceptional cases. The removal of the fibula, leaving the introduction of the new treatment protocols. These curves were also based on figures from several European and American studies. Some experiments have shown hyper tive shoulder mobility is, of course, restricted, the passive trophy occurring only with vascularized grafts, not with mobility is relatively good. Another example of the resection of as tumor with However, clinical experience has long demonstrated a margin of healthy tissue despite joint involvement is that hypertrophy also occurs to a comparable extent with presented in Chapter 3. Moreover, fibular regeneration at the old site is of the acetabulum had to be removed at resection, thereby much better after removal without a vascular pedicle and interrupting the continuity of the pelvic ring. The healing atic because of the relatively soft bone and the prevailing at the new site is also generally unproblematic without shear forces. Loosening of the implant rapidly occurs, and a primary vascular connection, at least in adolescents this can result in almost insoluble problems, particularly ( Fig. The hip joint was transferred to the remodeling occurs over time with functional weight sacrum by rotating the acetabulum ( Fig. Particularly in the case of children, the the drawback of leg shortening, this can be corrected at a surgeon must try and manage without the use of an later stage. Whereas bone is severely destroyed by shows how the proximal humerus can be replaced by the autoclaving, extracorporeal irradiation is very promising clavicle. The with the axillary nerve, as a result of a tumor, the implan irradiated bone must be used in combination with an tation of a prosthesis is not a good solution since stable artificial joint since the devitalized cartilage is no longer joint function is not possible without innervation of the usable as joint cartilage. In accordance with Winkelmann’s [40] the other hand (as with the non-vascularized fibula) ap proposed technique, the clavicle was released from the pears to be revitalized. A precondition for this technique sternum and folded down in the acromioclavicular joint. Prostheses As a rule, any bone or joint can be replaced by a pros thesis, which will need to be tailored to the needs of the individual patient depending on the resection. The larger the removed fragment and thus the greater the lever action of the prosthesis, the more dif ficult will be the anchorage and thus the greater the like lihood of early loosening of the implant. Young, active patients in particular place a greater strain on their pros thesis than older patients. In this case, the problem of the unfavorable mechanical situation for tumor prostheses is compounded by the increased loading resulting from the higher activity level of the patient. Right Two years after resection of the tumor and reconstruction with can, in many cases, largely preserve the function of the autologous fibula. The patient is able to walk without a limp and jump, affected part and thus improve the patient’s quality of and regularly plays tennis life [28, 32]. The pseudarthrosis was corrected with an angled blade plate and a vascularized iliac graft. A femur of normal thickness has developed from the fibula, and the leg length discrepancy is just 1. In tumor pa Allogeneic bone (allograft) tients we use a modular prosthesis system. Such grafts must be versatile Modular Universal Tumor and Revision System stored for at least two months at –80°, by which time the (Mutars®. The latter type of pros the combination of allogeneic bone for the shaft and a joint thesis is also available in a silver-coated version, which is prosthesis has proved effective. A woven dacron tube od over the exclusive use of a prosthesis is that the foreign surrounding the prosthetic joint facilitates the ingrowth bone units with the patient’s own bone over the course of of muscles. A special plate was prepared femoral replacement (Mutars system) after resection of the femur with angularly-stable dynamic screws on both ends 640 4. The reconstruction involved a combination of a specially pre b pared hip prosthesis and an allogeneic bone graft that replaced the whole upper section of the femur apart from the hip. The use of the dacron tube, however, has re discrepancy in relation to the other side will become duced the need for this combination of a joint prosthesis apparent.
Check and document Advantages: Early functional follow-up treatment; simple antifungal diet plan order nizoral cheap online, the axial configurations clinically and radiologically and minimally invasive implantation; good cosmetic result fungus gnats bathroom cheap nizoral 200mg line. Move the adjacent Disadvantages and complication: In the case of obese joints passively through their full range at operation fungus gnat life cycle generic nizoral 200mg. Metal removal can be difficult if the nail Corrective osteotomies for posttraumatic deformities fungus joint pain purchase nizoral 200 mg without prescription. Advantages: Simple and quick assembly, closed reduction, Solid intramedullary nail immediate weight-bearing, dynamization, simple metal For femoral and tibial shaft fractures shortly before or removal. More recent and and the ambitions, particularly in respect of participation less widely used semi-rigid nails attempt to avoid this risk in competitions. Rigid tibial nails should not be used if the growth Metal removal plates are still open as they have to be inserted directly In view of the risk of refracture, a period of 4–6 weeks through the proximal tibial plate. A minimally invasive form consolidation can be confirmed solely on the basis of of internal fixation based on adult traumatology tech painless palpation of the callus. The position can also be niques, has been used as an alternative method in isolated evaluated clinically in such cases. This particularly ap cases: closed reduction and fixation with a fracture-bridg plies to: ing plate advanced beneath the muscle and fixed with clavicular fractures, fixed-angled screws [1]. The general prescribing of physiotherapy after For all other fractures, bone consolidation must be che fracture treatments is not particularly useful in cked by radiography: the fracture is considered to have growing patients. Children’s enjoyment of exercise consolidated if the fracture gap in the area of three of the results in an autonomous, natural rehabilitation four cortices is bridged with callus in two standard projec process, although this may take several months tions at right angles to each other. In practical terms, the verdict of a »consolidated or If progress is slow or even absent, the services of a phys healed fracture« signifies the following for the patient: iotherapist accustomed to working with children should Conservative treatment of the upper extremity: Full be engaged after bone deformities have been ruled out. Increasing spontaneous Active, playful exercises supplemented by coordination axial loading in everyday activities. The latter saves time and costs and patient has already been moving his arm, without also encourages the patients to take responsibility for weight-bearing, during the consolidation phase and themselves. Resumption of sports Conservative treatments of the lower extremity: Full Confirmation of the full resumption of sports activities movement-related stability. Increasing axial loading in depends on the bone consolidation and the restored range everyday activities. Accordingly, External fixator on the lower extremity: Schedule the professional, graduated and individually adapted rehabili metal removal. This should be based on the nature of the injury, the age of the As a rule, and depending on the fracture type, site and age patient, the practiced sport, the desired level of training of the patient, jumping sports, contact sports, ball sports 544 4. This does not apply however to the abnormal position at consolidation can primarily be 4 fractures without any risk of a growth disorder,. If a growth disorder is already present, deformation if spontaneous remodeling is expected. The configuration of the affected (the administration of hormones and other drugs or extremity in terms of length, axes and rotation is described foods do not have any detectable effect. After vertebral hand, an awareness of the limits of spontaneous cor fractures, the function and statics of the spinal column rection of abnormal positions will enable the remodel must be established clinically in three dimensions. Deformities that result tions of the spinal column, abnormal vertical align from inadequate remodeling should therefore be viewed ment, waist triangles. A fundamental philosophical aspect of effective ther apeutic strategies is the integration of the corrective Mobility growth potential as the fourth dimension of pediatric Joint mobility is checked at the earliest 2–4 weeks after cast traumatology. The exploitation of the spontaneous correction and healthy sides by means of the zero-crossing method/ of deformities is linked to the following basic neutral-zero method ( Chapter 2. The subsequent principles: follow-up intervals depend on the site and extent of the deficit and the subjectively experienced functional restric Sufficient residual growth: the remodeling potential tion, which should be queried in detail, and documented, is at its peak before the age of 10 and then declines in relation to everyday and sporting activities. Peripheral neuropathies are common particularly after the more active the adjacent growth plate, the greater elbow fractures. Clinical assessment and docu the expected time taken to straighten the deformity, mentation of the sensory and motor nerve functions in in order to avoid unnecessary second opinions and the emergency room and subsequently during outpatient ill-considered corrective osteotomies. Even age-related or pain-related unreliable rection are addressed in the corresponding sections on findings should be documented as such. Occupa rences are probably based on mechanical phenomena tional or physiotherapy is also useful. Thus, in an 8-year Growth disorders old girl, a total length loss of 6 cm can be expected by the this term incorporates complete or partial inhibitions or time of expected physeal closure at the age of 14. Uniform stimulation of the whole growth plate with con sequent excessive growth in length. Partially inhibitory Occurrence: To a slight extent after every fracture, but Occurrence: In contrast with the conventional school of particularly during the remodeling of deformities. At femoral and tibial levels, increases up broken up as a result of continuing growth. Diagnosis: Clinically during the six-monthly check Significant changes in terms of statics can occur in the ups. If a disorder is suspected, radiological investigation lower limbs, depending on pre-existing leg length dis with measuring of the joint angles is indicated. Avoid secondary manipulations on If a residual growth of more than 1–2 years is expected the the callus. The surgeon will need to know the precise extent of the difference and the change in spinal statics, location, size and composition (bony – cartilaginous – fi conservative equalization of any leg length discrepancy, brous) of the bridge beforehand, ideally with the aid of epiphysiodesis or lengthening osteotomy. Prevention: the development of growth plate closures Partially stimulatory cannot be influenced to any great extent and occurs as Unilaterally increased physeal activity in connection with a result of local plate destruction and the traumatic cir delayed healing on one side. In epiphyseal fractures the size of Occurrence: a) Bowing fractures of the proximal tibia, the bridge can be limited by watertight, stable internal b) Radial condyle fractures. If pronounced plate destruction has occurred, Duration: Until bone consolidation, with a maximum local fat interposition should be considered as part of the of several months. Treatment: Possible procedures, either alone or in Consequences: Progressive axial deformity: a) clinical combination, include corrective osteotomies, epiphysio ly apparent valgus deformity, b) slight cubitus varus. The purpose of the latter Prevention: a) Detection and elimination of the initial operation is to restore normal growth activity. Incomplete resections, bridge recurrences Completely inhibitory and overestimated residual growth as a result of prema Occurrence: Rare. After comminuted fractures, secondary ture physeal closure or restricted functioning of plate osteomyelitis. Hubner U, Schlicht W, Outzen S, Barthel M, Halsband H (2000) with/without cubitus varus and ulnar neuropathy. Katz K, Fogelman R, Attias J, Baron E, Soudry M (2001) Anxiety – Intra-articular fractures that have consolidated in reaction in children during removal of their plaster cast with a saw. J Bone Joint Surg (Br) 83: 388–90 4 – External rotation of the distal fragment after femo 8. Am J – Deformity of the forearm shaft with restricted turn Roentgenol 170: 43–7 over movement. The patient determines the indication and fractures with special reference to incidence, etiology and secular the timing depending on the functional and/or cosmetic changes in a Swedish urban population 1950–1979. Child Abuse Neglect 19: 1131–42 sically or because of the extent of the deformity and 12. Marti B (1989) Health benefits and risks of sports: the other side of – Cubitus varus after supracondylar humeral frac the coin. J Bone – Internal rotation deformity of the distal fragment Joint Surg (Am) 83: 323–7 15. J Pediatr Orthop 1: 377–84 children under 6 years there is a risk that the defor 19. Obstet Gynecol 86: 978–81 at an earlier stage, albeit with an increased risk of 21. J stable and unstable lateral condyle fractures of the humerus in Pediatr Orthop B 20: 282–5 children. The human child, however, starts walking with an »unnatural« extended hip position and must compensate for the increased anteversion 4. Sometimes the mother and father do the hips of the human fetus are in a flexed position in the not spontaneously decide to consult the doctor, but only womb. The centering of the femoral head during increased do so after being alerted by a well-meaning grandmother or neighbors, or even a shoe sales assistant. They bring their child to the office and ask anxiously whether their child with the twisted feet is really normal. Occasionally, the child may also be bow-legged or, if slightly older, have pronounced knock knees, which just serves to deepen the worry lines on the parents’ faces even more. For this reasons, a detailed review of the rotational and axial rela tionships in children is appropriate.
Localized disorders Fibular deficiency (usually combined with a lon gitudinal problem of the femur and lateral ray aplasia on the foot) Tibial deficiency of the tibia (poss fungus gnats thuricide order nizoral 200mg with mastercard. Associated anomalies the foot is almost always affected to a varying extent by the condition fungus gnats dry soil purchase 200mg nizoral free shipping. One or more lateral rays of the foot are often absent antifungal horse cheap 200mg nizoral fast delivery, and the bony structures of the rearfoot may also be incompletely formed anti fungal herbal generic nizoral 200mg without prescription, or there may be coalition of the bones of rearfoot [21]. In approximately two-thirds of cases, hypoplasia of the femur or a proximal femoral deficiency is also observed. There is usually hypoplasia of the lateral femoral condyle and, in 18% of cases, aplasia of the cruciate liga ments as well [34]. Clinical features, diagnosis the affected lower leg shows visible shortening even at birth. Tibial anterior bowing is generally present and a varus deformity of the tibia is often observed. Sometimes the rearfoot is also dis located laterally and may be at a higher level than the end of the tibia. The rearfoot, and occasionally the metatarsal bones as well, are frequently very rigid as a result of coali should be attempted up until the completion of growth, tion of the talus and calcaneus. For very severe deformities, leaving the leg length unchanged Treatment with or without amputation of the forefoot with prosthetic the treatment of congenital anomalies of the fibula and management or a rotationplasty with a lower leg prosthe lower leg is very complicated and requires considerable sis is usually a better solution in functional respects than experience. However, parents and patients able: often find this the more difficult option to accept in psy shoe elevation, chological respects [32, 33]. If 3 or more rays are present, surgical leg lengthening, preservation of the limb with a lengthening procedure is rotationplasty, recommended. Any treatment of patients with an outwardly visible cases, the parents and child should be carefully guided disability should be accompanied by good psycho towards other options and helped to accept the disability. The therapeutic strategy is based not just on the defor the therapeutic strategy should be discussed with the mity, but also the age of the patient. Preschool age (up to 6 years) the main problem to be resolved is whether preservation Depending on the extent of the shortening in each case, of the complete extremity and leg length equalization a leg length equalization procedure followed by a shoe 310 3. If pos sible, the orthosis should place the foot in a plantigrade Good indications for lower leg lengthening position. While this type of orthosis is less attractive leg length discrepancy at 8 years between 8 and cosmetically than if the foot is placed in the orthosis shaft 15 cm. We always equalize a lower leg length discrepancy of more than 8 cm in several steps, with a maximum of 8 cm (better: 6 cm) in each case. Instability of the ankle mortise is not an absolute con traindication for leg lengthening. Ring fixators (of the Ilizarov type or the Taylor Spatial Frame) can be used to incorporate the foot in the extension and thus prevent dislocation of the ankle (see chapter 3. Procedure if lengthening is not performed the foot can basically be fitted in the lower leg prosthe sis in an equinus position. Cosmetically more satisfying prosthetic management is possible if the forefoot is ampu tated, although the children and parents find this very dif ficult to accept. Amputation also has the disadvantages of possible phantom pain and more difficult guiding of the prosthetic foot (shorter lever arm, loss of the important sensory function of the toes. The decision to have a part of the body cut off is a psychologically painful process, even if the body part in Fig. Lower leg support with separate foot section on a 12-year question hinders the patient in functional or cosmetic old patient with a fibular deficiency and leg shortening of 8 cm. The children foot is in a plantigrade position and their parents must be informed about this option very 311 3 3. If femoral hypoplasia is also present (as is the case Synonyms: Tibial hemimelia, longitudinal deformity of in the majority of patients; chapter 3. This further spoils the cosmetic appearance because the difference in the heights of the knees is clearly visible as Classification soon as the difference exceeds 5 cm. A lower leg prosthe the best classification was proposed by Kalamchi and sis worn beneath the clothing, on the other hand, is hardly Dawe in 1985 [28] ( Fig. Lengthening is hardly ever possible if (According to Kalamchi & Dawe [28]) simultaneously a proximal femoral deficiency is present. The condition of the hip and knee will also influence the Type Parameter decision. The Lisfranc or Chopart amputation can cause numerous problems in prosthetic management. The stump mobility cannot be used functionally but rather leads to constant rubbing in the prosthesis shaft and to repeated pressure sores. Better amputations are the rear foot amputations according to Boyd or Pirogoff, in which the talus, calcaneus and heel pad are preserved but fused together and with the lower leg, or the lower leg amputa tion according to Syme ( Chapter 3. Adolescence (10–16 years) If major discrepancies in length at still present at this age, a second and possibly third extension operation are per formed. The loss of mobility is function of the tibia with diastasis of the tibiofibular syndesmosis 312 3. Associated anomalies Treatment the foot is normal in only around half of the patients, and the treatment is based on the type of deformity present. Two 3 thirds of children with longitudinal deficiency of the tibia Type I (aplasia of the tibia) show associated anomalies [28, 31], including syndactyly, the primary treatment is always orthotic provision. Quad polydactyly, femoral hypoplasia, cryptorchism, cardiac riceps function and the condition of the distal femur are defects, varicocele, etc. The most elegant and functionally best solution is centralization of the Clinical features, diagnosis fibula [10, 14]. Preconditions are a largely normal distal the shortening and deformity of the lower leg is already femur and a sufficiently strong quadriceps muscle. If the tibia is absent (type I), the femur is severely deformed and a pronounced flexion lower leg is usually curved in a valgus position. Radio contracture of the knee is present, a knee disarticulation graphic investigation reveals a hypoplastic distal femur should be performed before the patient starts to walk, but a thickened fibula. Occasionally, arthrodesis of the femur part of the ankle is unstable and the foot is inverted and and fibula can be useful (particularly if the fibula is also deformed [31]), although it should be borne in mind that the growth plates can be adversely affected by an early arthrodesis. At the distal end, the arthrodesis of the fibula and talus should be accompanied by amputation of the forefoot as part a modified Boyd procedure. The sur geon should be careful to ensure that the epiphyseal plate of the distal fibula is preserved. The talus has a strong tendency to dislocate cranially, causing the Achilles ten don to shorten since it is not stretched. The talus and tibia should then be transfixed with a medullary nail and the distal section of the tibia and fibula should be fused. Etiology Treatment During pregnancy the knee remains in a hyperextended the treatment should start immediately after birth and position in some cases (approx. The lack of cruciate consists of intensive correction and stretching of the ligaments or fibrosis of the quadriceps can, in particular, quadriceps. The hip is placed in 90° flexion aplasia of the cruciate ligaments is a triggering factor or a and the thigh supported down to the knee with a foam secondary phenomenon is not known. Most cases occur block; a weight is secured to the lower leg with bandages sporadically and are not hereditary. When the neutral position has been reached, corrective casts can Associated anomalies then be fitted in increasing flexion. This treatment is very Congenital dislocation of the knee can occur unilaterally successful during the first 3 months [16, 36]. By this stage, the quadri with congenital hip dysplasia, clubfoot and other foot ceps can be surgically lengthened to permit flexion of anomalies. Naturally, the results of this treatment are Clinical features, diagnosis only moderate [16], whereas patients treated conserva the dislocation of the knee is usually obvious at birth. An x-ray will confirm the diagnosis, and a lateral view will usually show increased inclination of the tibial plateau towards the back ( Fig. The differential diagnosis must distinguish between a congenitally recurvated knee and subluxation or dis location. While the knee is also (slightly or moderately) hyperextended in a recurvated knee, the joint surfaces of the femur and tibia are in regular opposition. If the knee is subluxated or dislocated, an ultrasound scan can confirm the presence of the cruciate ligaments at an early stage [38].
In cases of longstanding instability can fungus gnats kill cannabis best nizoral 200mg, damage to the tendons may have occurred antifungal gel for sinuses purchase nizoral 200mg online, resulting in signs of peroneal tendinitis fungus gnats ladybugs buy nizoral with american express. To perform the Thompson test fungus gnats root rot order 200 mg nizoral with amex, the patient is placed prone on the examination table with both feet dangling from the end. The examiner should also observe the resting position of the foot when the patient is relaxed. In the normal case, resting tension in the gastrocsoieus complex holds the foot in slight plantar flexion when the patient is lying prone (Fig. When the Achilles tendon is intact, the foot passively to visualize and is usually assessed only by feel. In the presence of a partial tear of the movement occurs at the subtalar joint, making it difficult Achilles or injuries to the gastrocsoieus aponeurosis, such as to detect whether abnormal inversion is taking place at tennis leg, the normal plantar flexion response occurs. The test is per seeks to reproduce subluxation or dislocation of the per formed with the patient standing and facing away from oneal tendons anterior to the lateral malleolus. The test may also be done by grasp position of maximum dorsiflexion, to maximal eversion, ing the heel directly and turning it into varus. The arrows indicate the direction of the compressive forces applied to the first and fifth metatarsal heads. The arrow indicates the direc tion of the rise of the first metatarsal in response to external rotation of the lower leg. Further irritation of the nerve may be produced by reciprocally moving the first and fifth metatarsals up and down in opposite directions. Occasionally, the examiner may appreciate a palpable click while compressing the metatarsal heads. If this produces calf pain, then deep vein thrombosis of the calf may be present (Fig. Obviously, injury to the gastroc soleus complex may also be aggravated by this maneu ver. The physical findings in common conditions of the leg, ankle, and foot are summarized in Table 7-1. Todd Wetzel Cervical and Thoracic Spine Bruce Reider he spine performs two important functions in the articulating ribs provide even greater stability and sup human body. The injuries and the disorders that affect the spine can interfere with one or both of these functions and may produce symptoms accordingly. The spine is composed of 24 distinct vertebrae—7 cervical, 12 Surface Anatomy and Alignment thoracic, and 5 lumbar—perched on the solid base pro When inspecting the cervical and the thoracic spine, the vided by the sacrum and the pelvis. The structure of each overriding goal should be to detect any departure from vertebra follows the same basic pattern, with modifica perfect symmetry. Possible causes of asymmetry include tions, as required, to fulfill its own particular function. The col such as that seen in torticollis, or localized masses from umn formed by these bodies provides much of the stabil tumors or glandular enlargement. The portion of each ver To inspect the cervical and the thoracic spine from the tebra posterior to the body is known as the posterior ele posterior aspect, the patient is asked to stand facing ments. These include the pedicles, which link the rest of directly away from the examiner (Fig. Because the the posterior elements to the vertebral body; the laminae; spine is located just deep to the dorsal surface of the body, the posterior facet joints; and the transverse and spinous posterior inspection reveals the most specific information processes. From the top of the head to for the spinal cord and its nerve roots, provide additional the natal cleft over the sacrum and the coccyx, all struc stability, and function as attachment sites for the intrinsic tures should appear perfectly symmetric. At the point structural elements to the neurologic elements of the where the cervical spine joins the occiput at the base of spine means that structural abnormalities, such as herni the skull, a definite bump, called the inion, should be ated disks, fractures, or degenerative changes, can often either clearly visible or palpable, depending on the hair produce neurologic symptoms. Beginning at the inion, the spine should be visible as a linear furrow the cervical spine serves as a pedestal for the head running all the way to the sacrum, studded with small and is adapted to allow the mobility necessary to vary the bumps that represent the spinous processes of the verte position of the head in relationship to the surrounding brae. The increased exposure and mobility of the straight that a plumb line dropped from the inion would cervical spine places it at greater risk for trauma or pass perfectly over it and hang down in the natal cleft. Not only are the individual vertebrae one large spinous process is seen to stand out from those designed to permit only limited movement but also the above and below it. A, inion; B, trapezius; C, transversocostal muscle group; D, C7 spinous process; E, Tl spinous process; F. Coronal defor Above this, the spinous processes of the cervical vertebrae mities of the spine include a list and scoliosis. A list is a pure planar shift to one side in the coronal and back tends to make the C7 and Tl spinous processes plane (Fig. The trapezius is the most superficial and the part of the spine is shifted to one side, so that a plumb most easily identifiable of the posterior neck muscles. Scoliosis is a more complex, helical deformity Deep to the trapezius lies the transversocostal group in which a curve in the coronal plane is combined with of muscles and the even deeper transversospinal group. A well-compensated scoliosis, defined the splenitis cervicis, the iliocostalis cervicis, and the longis as one in which thoracic and lumbar curves are roughly simus cervicis and is visible in the proximal neck lateral to equal in magnitude but opposite in direction, may be the superior trapezius. In these cases, visually trac tures visible from the posterior position should also ing the path of the spinous processes may help the exam appear symmetric. The shoulders should be level, and the iner appreciate that they follow a subtle S curve, scapulae located equidistant from the spine. The rib although the vertebra prominens is located directly prominences on either side of the spine should be sym above the natal cleft. When the patient is instructed to relax and to If a subtle scoliosis is suspected, looking for the rib allow the upper extremities to hang limply at the sides, prominence usually associated with thoracic scoliotic the size and the shape of the space between the arms and curves makes the deformity easier to detect. At the base of nence is a reflection of the rotational component of the spine, the posterior landmarks of the pelvis should appear symmetric and level. A pelvis that does not appear to be level may be the result of either a leg length discrep ancy in a patient with an otherwise normal spine or a fixed spinal deformity. Departure from symmetry in any of these parameters may suggest a localized anomaly or a deformity of the spine in the coronal plane. In the the scoliotic curve are rotated around the longitudinal axis most common type of scoliosis, adolescent idiopathic scol of the spine, with the transverse processes on the convex iosis, the thoracic convexity and, thus, the rib prominence side of the curve rotating posteriorly and those on the con are most often located on the right side. The ribs on the convex side, pected, asking the patient to bend forward as far as possi therefore, are more prominent, and those on the concave ble emphasizes the rib prominence (Fig. A sis, asymmetric twisting of the neck, known as torticol particularly sharp-angled kyphosis is called a gibbus. In very severe cases of scoliosis, the gibbus usually reflects a sharp angulation of the spine at serpentine course of the spine may so shorten its effec a single vertebral level. Possible causes include congenital tive length that the rib cage appears to rest on the iliac anomalies, such as wedge-shaped vertebrae, or vertebral crests. Such a flat back appearance may be observed be associated with conditions that may cause spinal after surgery to correct thoracic scoliosis (see Fig. Anterior inspection of the spine is of limited the cutaneous nodules of neurofibromatosis. From a lateral perspective, the cer check carefully for the appearance of symmetry. The neck vical and the thoracic spine should be observed in both should appear straight, with the head sitting squarely on the sitting and the standing positions. When viewed from the side, the spine is not at all straight; it is a series of gentle, complementary curves (Fig. A curve that is concave posteriorly is called a lordosis, and one that is convex posteriorly is called a kyphosis. A cervi cal lordosis, with the head resting comfortably over the middle of the trunk, is present in normal individuals. A reduction in this normal lordosis, with straightening of the curve, is a common, nonspecific reaction to cervical spine pain. More dramatic reduction or even reversal of this lordosis may be seen in ankylosing spondylitis. A milder deformity is the so-called sniffing position, in which the face of the patient appears to be thrust out anteriorly. Flexion at the cervicothoracic junction, with extension of the proximal segments, results in this posi tion of cervical protrusion (Fig. The normal cervical lordosis is usu ally balanced by a smooth transition into a normal tho racic kyphosis. Normal thoracic kyphosis is between 21° and 33° when measured radiographically by the Cobb method.
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