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    CHAPTER 10 MUSCLE AND TENDON INJURY AND REPAIR 59 The insertion of tendons onto bone is usually via four decreased flexibility vasodilan 20 mg mastercard, and joint laxity) cheap vasodilan 20 mg, age generic vasodilan 20 mg otc, gender, zones: tendon, fibrocartilage, mineralized fibrocarti- weight, and predisposing diseases (Almekinders, lage, and bone. Synovial fluid within the errors (over training, rapid progression, fatigue, run- sheath assists in tendon gliding. Tendons that are not ning surface, and poor technique), and equipment enclosed in a sheath (Achilles tendon) are covered by problems (footwear, racquets, and seat height) a paratenon. Tendons sus- PATHOPHYSIOLOGY taining compressive loads exhibit increased proteo- Repetitive load on a tendon that results in 4–8% strain glycan levels, larger proteoglycan molecules, and causes microscopic tendon fiber damage. Continued larger less dense collagen fibrils (Hyman and Rodeo, load on the tendon at this level overwhelms the 2000). Damage occurs to the col- Aging also affects the material characteristics of lagen fibrils, the noncollagenous matrix, and tendon with decreased collagen synthesis, increased microvasculature (Hyman and Rodeo, 2000). This results in a stiffer, weaker tendon (Hyman fibrin exudate, and capillary occlusion result in local and Rodeo, 2000). TERMINOLOGY Intrinsic tendon damage (tendinosis) may occur with There is significant confusion regarding the terminology continued tendon overload. Tendinitis, tendonitis, and appear as a number of histologic entities (hypoxic tendinosis are frequently used terms to describe the clin- degeneration, mucoid degeneration, fiber calcifica- ical picture of pain, swelling, and stiffness in a tendon. Paratenonitis: Inflammation of the paratenon or Researchers have demonstrated that chronic paratenoni- tendon sheath. Peritendinitis and tenosynovitis are tis can result in tendon degeneration in an animal model included in this category. Paratenonitis with tendinosis: Tendon degeneration showed no previous evidence of paratenonitis in over with concomitant paratenon inflammation 60% of patients who sustained an Achilles tendon rup- c. Tendinosis: Tendon degeneration without inflam- ture (Kannus and Jozsa, 1991). The initial paratenonitis mation may be causative factor for tendon degeneration or may d. Important factors impaired performance (Maffulli, Kahn, and Puddu, include tissue hypoxia, free radical induced tendon 1998). ETIOLOGY DIAGNOSIS The etiology of chronic tendon injuries is multifacto- The history often reveals repetitive mechanical over- rial and involves a combination of intrinsic and extrin- load. The use of corticosteroid injections around duration, frequency, or intensity of the training regi- weight-bearing tendons such as the Achilles tendon and men. The pain is frequently worse after a period of rest patellar tendon is controversial. Changes in footwear, reports of tendon rupture but there are no controlled equipment, or training surface may be present. The degenerative dations on the use of corticosteroid injections owing to tendon is often tender to palpation or painful with the paucity of scientific evidence regarding their use. Range of motion The surgical treatment of chronic tendon injury is usu- may be restricted (Almekinders, 1998). Ultrasound or magnetic cedures usually involve debridement of the degenerative resonance imaging can be useful in tendons that are tendon tissue. Removal of the involved paratenon or release of the TREATMENT tendon sheath is occasionally necessary. Bony promi- Removing or modifying the mechanical overload (rel- nences may require removal (Haglunds, acromion). Correcting training errors and surgical management but there are a very few controlled equipment problems should also be accomplished. Imm- obilization results in deceased tendon strength and stiffness owing to proteolytic degradation of collagen (Hyman and Rodeo, 2000).

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    Care of burn patients cheap vasodilan 20mg without a prescription, either in the operating room or in the ICU must compensate for these functions until the wounds are healed buy vasodilan 20mg otc. The skin helps to maintain fluid and electrolyte balance by serving as a barrier to evaporation of water discount vasodilan 20mg with visa. Heat loss through evaporation and impairment of vasomotor regulation in burned skin diminish effective temperature regulation. Burned Anesthesia 107 TABLE 3 Functions of Skin – Protective Barrier Immunological Fluid evaporation Thermal (insulation, sweat production, vasomotor thermoregulation) – Sensory – Metabolic (vitamin D synthesis and excretory function) – Social (self-image, social image) surfaces produce an exudate that is rich in protein. Loss of this protein along with diminished hepatic synthesis eventually reduces plasma protein concentration and contributes to accumulation of interstitial fluid (edema). Morbidity and mortality due to burn injuries depend in large part on how much and how deeply the skin is burned. The extent of burn injury is expressed as the percent of total body surface area burned (TBSA). This area is then classi- fied into the area burned superficially and the area burned through the full thick- ness of the skin. Partial-thickness burns will often heal but areas of full-thickness burn must be completely excised, sometimes down to fascia. Tangential excision is associated with more blood loss than occurs with excision down to fascia. Volume resuscitation of burn-injured patients is guided by estimates of percentage TBSA burned. A quick estimate of percentage TBSA burned can be made with the so-called rule of nines (Fig. More accurate estimates must take into account the changes in body proportion that occur with age (Fig. In the early period after injury, the adequacy of resuscitation can be evaluated by comparing the volume of fluid administered with what the patient’s predicted needs are based on common formulas. A critical part of preoperative evaluation of patients for burn excision and grafting is an estimation of expected blood loss. Several key decisions in the anesthetic management plan depend on this information. Among other things, the expected blood loss determines what venous catheters will be needed and whether or not invasive monitors such as direct arterial pressure or central venous pressure will be required. Adequate blood should be typed and crossed and in the operating room prior to the start of surgery because blood loss can be very rapid during these procedures. Surgical blood loss depends on the area to be excised (cm2), time since injury, surgical plan (tangential vs. Anesthesia 109 FIGURE2 An age-adjusted burn diagram can be used to estimate more accurately the total body surface area affected by burns. The area to be excised is estimated by multiplying the total body surface area (m2) by the percentage TBSA burned. Blood loss expected per cm2 can be estimated based on time since injury and presence or absence of wound infection. Table 5 gives an example calculation of estimated blood loss for a hypothetical case. Effects on Circulation Initially the most profound physiological effects of major burn injury are related to hemodynamic function and tissue perfusion. A state of burn shock develops from hypovolemia due to extravasation of intravascular fluid and often myocardial depression as well. Cardiac output is decreased, systemic vascular resistance is increased, and peripheral tissue perfusion is impaired. Hypovolemia results from increased capillary permeability and movement of protein-rich fluid from the vascular space to the interstitial space. Lymph flow is greatly increased but is overwhelmed and tissue edema results. Anesthesia 111 TABLE 5 Calculation of Estimated Blood Loss for Hypothetical Burn Patient Total body surface area 1.

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