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    A useful evaluation technique is there- fore to remember that in feet of all ages buy cheap premarin 0.625mg, the talus should point to the first metatarsal and the calcaneum to the 4th or 5th metatarsal (see Chapter 8) discount 0.625 mg premarin with visa. The calcaneum Calcaneal fractures are rare in pre-adolescent children and purchase 0.625 mg premarin overnight delivery, should they occur, tend to be extra-articular and involve the tuberosity2. In older children, calcaneal Skeletal trauma 159 fracture patterns mimic those of the adult; however, the associated incidence of spinal fractures is reduced. Occult ‘toddler’ stress fractures may present in the pre-school child but plain film examination is often negative and the use of alter- native imaging modalities (scintigraphy or MRI) should be considered. The talus Injuries to the talus must be identified owing to their propensity to develop avas- cular necrosis. In children, most injuries tend to involve the talar neck and a variety of fracture patterns (complete and incomplete) may be seen. The metatarsals Injury to the metatarsals in children under 5 years of age tends to be confined to the 1st metatarsal whereas metatarsal injury in children over the age of 10 years 19 is focused upon the 5th metatarsal. An exception to this may be a physeal frac- ture at the base of the first metatarsal, usually a Salter-Harris type II injury, that may be seen in young adolescents and results from a fall from height. The apo- physis of the peroneus brevis can be seen as a vertically orientated ‘flake’ of bone adjacent to the base of the 5th metatarsal on foot radiographs of older children (Fig. The phalanges Fractures to the phalanges may be transverse, oblique or epiphyseal in nature and, with the exception of the distal phalanx of the great toe, have no obvious prognostic complications (Fig. The nail bed of the great toe is attached to the physeal plate of the distal phalanx and, as a result, forced flexion injuries (i. This type of injury provides a route for the spread of infection from the nail bed to the underlying bone (osteomyelitis) and antibiotic treatment should be prescribed as a preventative measure. The axial skeleton The cervical spine Traumatic injury to the paediatric cervical spine is rare as the neck is more flex- ible in children than in adults therefore allowing injury forces to spread along the length of the spine and reduce the likelihood of focal bony trauma6. If trauma does occur then it is likely to be concentrated in the upper cervical region (C1–C3) in children under 10 years of age. In older children, cervical spine trauma pat- terns mimic those seen in the adult patient. The injury mechanism for cervical 160 Paediatric Radiography Fig. Specific paediatric cervical spine injuries and their associated radi- ographic clues to diagnosis are described in Table 7. The radiographic projections of choice for imaging the cervical spine follow- ing injury are the antero-posterior projection of C3–C7 and C1–C3, and the lateral projection from which most diagnoses will be made (Fig. It is essential that the radiographs produced are of a high technical standard to facilitate accurate interpretation and prevent misdiagnosis. Clinical evaluation of the radiographs should include assessment of bony alignment (anterior and posterior vertebral body lines and spino-laminar line), evaluation of vertebral disc and body heights for anatomical consistency, assessment of the relationship between C1 and C2 Skeletal trauma 161 Fig. Injury description Radiographic diagnostic clues Fracture through ring of C1 Loss of bony alignment Bilateral overhanging of lateral masses of C1 on C2 seen on antero-posterior projection Computed tomography (CT) may be useful Torticollis Spine tilted and rotated on antero-posterior projection (head tilting towards painful side) Rotation of C1 on C2 on antero-posterior projection Rotational subluxation at the Rotational asymmetry of C1 lateral masses about odontoid peg atlanto-axial joint on antero-posterior projection Condition usually self-limiting but if it fails to resolve, CT may be useful for assessment purposes Odontoid peg fracture Results from acute hyperflexion (e. Note this positioning can create appearances of dislocation at the C2/C3/C4 level. The thoracolumbar spine Skeletal injuries to the thoracolumbar spine result from high-powered forces and, in children under the age of 10 years, the mechanisms of trauma are typically a fall from a height, motor vehicle accidents or non-accidental injury. In older chil- dren and adolescents sporting injuries and accidents involving motor vehicles (e. However, normal spinal development may result in apparent anterior wedging, particularly in the thoracic spine, and therefore the relative loss of ver- tebral height should be assessed in comparison to other neighbouring vertebrae. Severe axial compression can result in a ‘burst’ fracture of a lumbar vertebra with associated cord damage if backward movement (retropulsion) of the fracture Skeletal trauma 163 fragments into the spinal canal occurs. Fractures of the lumbar transverse processes result generally from direct trauma and may be associated with internal abdominal injuries (e. Identification of the psoas muscle shadow on the antero-posterior lumbar spine projection is important in these cases as obliteration of the psoas muscle shadow is suggestive of internal injury. Plain film radiographic examination of the thoracolumbar spine should include an antero-posterior and a lateral projection.

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    The ankle needs to be stabilized actively at 90° generic 0.625mg premarin visa, or her own muscles and use the limbs order premarin 0.625mg online, particularly the arms passively by muscle shortening at the same angle in the and hands order 0.625 mg premarin mastercard. The deformities impeding But such simple conservative orthopaedic measures function are best diagnosed by gait analysis. These should are not always enough for preventing spasticity and in- all be corrected at the same time, which often involves creased muscle tone. Deciding on the actual treatment multilevel surgery, irrespective of the underlying neuro- of increased muscle tone and spasticity, however, poses a logical disease. Muscular insufficiency As regards physical therapy, stretching and rhythmic Muscular insufficiency can result from a flaccid pare- movements (e. Other options include manual borne in mind that a spasticity can also conceal a muscle and atlas therapy. Although these methods result in a weakness, which comes into play when the spasticity is reduction in muscle tone, since they only produce efficiently treated. Innervated muscles can be built up by a short-term effect, the treatments often have to be re- power training in children as well, although this requires peated. Unfortunately, there are only a few corresponding regular controlled training and a motivated and coopera- centers with trained and experienced personnel, particu- tive patient. Braces that firmly grasp and bridge ment, primarily with diazepam (Valium), baclofen (Lio- the affected joints during functional use, i. Certain antiepileptics and standing, are particularly suitable for this purpose. Diazepam (Valium), in low doses, generally loses such as arthrodesis or tenodesis. Modern instrumental its effect after a few weeks at the latest and is therefore three-dimensional gait analysis is especially helpful in the particularly suitable for temporary tone control, e. In our experience, tizinidine (Sirdalud) is not very effective for spastic cerebral palsies. Baclofen Excessive muscle activity (Lioresal), on the other hand, is also suitable for the Excessively strong muscle activity such as spasticity or long-term treatment of spasticity, although it is contra- general muscle hypertonia interferes with the joint mobil- indicated in patients with uncontrolled epilepsy. It is ity of the affected extremities and can also lead to stiffness generally administered by mouth initially (0. Particularly spastic In most cases however, it subsequently has to be dis- muscles have a strong tendency to produce contractures, continued because of the major side effects, particularly in contrast with dystonic or atactic muscles. In such cases, lems disrupt the coordinated sequence of movements, intrathecal administration via an implanted program- prevent the interplay between the antagonists and ago- mable pump represents one possible alternative. While nists and therefore interfere with everyday functions such the generalized side effects can be reduced considerably as sitting, standing, walking and the use of the upper [8, 33], complications such as catheter dysfunction, leaks extremities. Finally, the pump must be changed after to a certain extent by appropriate positioning of the patient 5–7 years. The spasticity usually affects one direction Before the pump is implanted definitively in the of movement at the joints, often extension in the legs and abdominal area, either subcutaneously or subfascially, a flexion in the arms. This can either involve an the patient is seated produces a looser position that also intrathecal bolus injection of baclofen, or else the post- 717 4 4. This method appears onset after 12–72 hours and lasting for between 3 and to be particularly suitable for severely disabled patients, 6 months. The injections may be repeated, and no nega- producing a positive effect on the arms. Unfortunately, tive consequences have been reported to date as a result the implanted pumps are still relatively large, thus re- [4, 13, 32, 38). Furthermore, since few parents and Posterior rhizotomy is another method for reducing patients are willing to accept the implantation of a pump, muscle tone. In contrast with the baclofen pump our own experience with this method remains limited however, this is restricted to the lower limbs. Al- lease of acetylcholine and thus inactivating the relevant though this procedure not only reduces muscle tone but muscle. This method is used for individual muscles or may also affect muscle power, and can also lead to sensory muscle groups.

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    Oxandrolone has also been shown to ameliorate the hepatic acute phase during rehabilitation [94b] buy 0.625mg premarin with mastercard. FIGURE 7 within The ankles are positioned in the neutral position (0 degrees dorsiflexion) with the use of padded footboards (Fig generic premarin 0.625mg overnight delivery. Special attention should be given to the heel of the foot to prevent pressure ulcers premarin 0.625mg with visa. Patients who have sustained a large burn injury require extensive custom positioning regimens, that are closely monitored and altered as dictated by the their medical status. The key to preventing skin breakdown and pressure ulcers is to reposition the patient frequently. This alleviates excessive and prolonged pressure on certain anatomical locations. A written comprehensive positioning and shifting regimen with photographs should be posted in the patient’s room. The entire team along with the patient’s family should be educated on how to implement this positioning program. When the patient is medically stable he or she should be spending a lot of time in the upright position ambulating or sitting in a chair with frequent shifting, in order to minimize the risk of pressure ulcers on already compromised body surface areas. In the operating room (OR) the patient must be carefully positioned to accommo- date the physician’s needs and to prevent complications from incorrect positioning such as iatrogenic pressure sores and nerve palsies. The problems associated with handling a patient with burn wounds are always a concern. Most frequently, patients may be positioned supine, prone, sidelying or, in the cases of special operative proce- dures, they may be suspended by traction. Skeletal traction may be utilized intra- operatively for delicate skin grafting procedures during which shearing may dam- age or destroy the new skin or skin substitute applied. This can be achieved by hoisting the patient’s top four-corner traction frame up in the OR (Fig. The traction’s pulley system is disengaged and all four extremities are tied directly to the top frame. The therapist’s role is to monitor closely the forces exerted on the extremities during suspension and to fabricate a special head sling (Fig. No matter how positioning in the operating room is approached, the team should make sure that the patient’s entire body is positioned correctly and not focus only on the positioning of the operative site. After a skin grafting operation the patient may be placed on bed rest according to the unit’s immobilization protocol. Postoperative positioning is very similar to preoperative positioning, with the emphasis on protecting the newly applied develop in the hand that, if left untreated, may lead to devastating functional limitations. It leaves the hazards at the workplace, but attempts to diminish the effects on the worker (eg, job rotation or job enlargement). The performance of therapeutic exercise and activities to increase endurance. Endurance-type exercise that relies on oxidative metab- olism as the major source of energy production. Alexander technique: Movement education in which the student is taught to sit, stand, and move in ways that reduce physical stress on the body. American Journal of Physical Therapy: The official journal of the American Physical Therapy Association. It provides literature on physical therapy research, edu- cation, and practice.

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    As NASA engineers profess: “Faster (briefer) generic premarin 0.625mg amex, better buy premarin 0.625 mg, cheaper: you can have any two of these buy generic premarin 0.625mg line, but not all three. What is curious is the extent to which discontinuities were evident (beyond those included in the system- atic review) in studies’ rationales, treatment methods, and outcomes cho- sen. Almost all study introductions invoke costs and demands on health care and loss of work; few measure either. At least half do not make clear whether they expect pain ratings to change, although these are universally measured and reported. Perhaps because of editorial restrictions, the fac- tors affecting the choice of components, their order, timing, and processes, are rarely described. Whether these apparent confusions in accounts of treatment reflect real contradictions embedded in treatment methods and processes is an open question. It is of some concern that beyond its basic assumptions—that thoughts, emotions and behavior influence one another, that behavior is determined both by the interaction of individual and his or her environment, and that individu- als can change their thoughts, emotion, and behavior (Keefe et al. On education, argu- ably, psychologists and their colleagues unnecessarily restrict themselves to the initial gate control model (Melzack & Wall, 1965), underusing the rich neurophysiological research which has resulted from the initial proposal of that model. There is a dearth of models described in terms that are accessi- ble to the lay public of central nervous system plasticity developing subse- quent to pain, and of the nonconscious psychological processes that influ- ence the processing of pain at spinal and supraspinal levels. Emotion is still poorly integrated with this, perhaps because of the lack of adequate overall 286 HADJISTAVROPOULOS AND WILLIAMS models and the shortage of data on nonconscious processes (Keefe et al. The findings of sophisticated and large-scale studies of cognitive therapy in mainstream psychology (Chambless & Ollendick, 2001) are rarely ad- dressed in the pain field, yet they provide testable models for particular components of treatment and for more examination of processes of change. To an extent, we are constrained by our measurement instruments: For in- stance, cognitive strategies are measured in terms of frequency, which may be important for some but neglects appropriateness of content and timing, which are crucial in a more integrated model of mind and body. Well- focused study of particular mechanisms (see Vlaeyen & Linton, 2000, re- view) offers more secure building blocks for examining multicomponent treatment than do components as currently described. Patients may be overambi- tious or overcautious in identifying them, or restrict themselves to duties to the exclusion of more pleasant and reinforcing activities; the experience of staff can enrich the range of goals and increase the likelihood of estimating an appropriate time span and size of increment. However, a patient’s goals (and that of those close to him or her) may differ substantially from those of treatment staff and of the funders and referrers who impress their expec- tations on staff. Return to (unsatisfying) work, foregoing compensation due after accidental injury, abstinence from all analgesic and psychotropic drug use, and taking regular exercise are areas where more seems to be ex- pected of pain patients than is achieved by the general (pain-free) popula- tion, and staff and patient may differ on what is a reasonable goal. Although prosaic, it could be that failure to maintain treatment gains lies partly in the choice of goals, and the extent to which they express the patients’ desires and hopes. Further issues in maintenance and generalization may concern the extent to which patients feel “expert” at the end of treatment. Tradi- tional therapeutic relationships can counteract the development of pa- tients’ confidence in their own expertise, rather than respect for staff mem- bers’ knowledge and skills. Although booster sessions are often invoked as the solution, none has shown lasting benefit (Turk, 2001). We still know very little about the processes that undermine treatment gains, given that they are probably as diverse and complex as are patients’ circumstances, and the use of mean data at follow-up (following an implicit model of natural de- cay of treatment gains) is unlikely to disclose any. There remain also hints of the pejorative terminology and patronizing representation of pain patients, explicit in early studies and descriptions of chronic pain populations, and now expressed more in the implication that they have no skills, take no responsibility, and aspire only to recline in the bosom of their enslaved families for their remaining decades. It is notable, but rarely commented on, that although in all other areas of health and ill- 10. PSYCHOLOGICAL INTERVENTIONS AND CHRONIC PAIN 287 ness social support is identified (by theoretical and empirical work) as a po- tent factor promoting health, help provided to pain patients by those around them is often characterized as contributing to disability. A study by Feldman, Downey, and Schaffer-Neitz (1999) is a notable exception, and found social support to have both main and buffering effects against dis- tress associated with pain; an unrelated study by Jamison and Virts (1990) showed good family support (as reported by the patient) to be associated with better outcome of rehabilitation. Most of the work under the rubric of social support comes from patient–spouse interaction and largely corre- lational studies. These were originally thought to support the operant for- mulation, by demonstrating the association of spouse solicitousness and patient disability. However, even these studies and further replications show relationships between patient and spouse behavior to be mediated by gender, state of the relationship, and mood: The picture is substantially more complicated than suggested by the dominant study paradigms and measures of the 1980s and 1990s (Newton-John & Williams, 2000). FAMILY AND MARITAL THERAPY Background and Description Family and or marital therapy is also used as an adjunct to the treatment of chronic pain in adults, and more directly in relation to pain and related be- havior in children and adolescents, but much less is written regarding the topic (Kerns & Payne, 1996).

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