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If instability becomes a problem, a removable splint may be helpful in maintaining the patient’s mobility. Ankylosing spondylitis this may cause a similar arthritis to that in rheu matoid arthritis. Special instruments have been devised to carry out the operative manoeuvres this commonly affects the knee, usually on one through small puncture wounds and under direct side only. There is Degenerative conditions evidence that osteoarthritis may follow excision of (see Chapter 11) a normal meniscus, and it certainly follows a pro portion of meniscectomies for a torn meniscus. Popliteal cysts Current opinion favours trying to preserve as much of the meniscus as possible by trimming these are common at all ages and usually present away damaged fragments and, wherever possible, as painless swellings in the popliteal fossa, often repairing longitudinal peripheral tears. They need only be Cyst of the menisci excised if they are giving rise to symptoms. Larger A cyst usually arises from the lateral meniscus and and more diffuse cysts are often associated with enlarges under the capsule, forming a swelling pathology in the knee joint, particularly rheuma which is tense in certain positions of flexion. These accurately located over the meniscus and does not invariably have a direct connection with the back usually reach a large size. They liable to tear, producing acute or chronic symp are often known as ‘Baker’s cysts’. Removal of the torn meniscus is more likely to produce a lasting cure than simple removal of Treatment the cyst. If a synovectomy is to be carried out this will often cause the cyst to disap Inflammatory conditions pear. Extensive cysts may cause pain and interfere (see Chapter 10) with function and may need to be dissected out, Rheumatoid arthritis usually affects the knee, but this can be a difficult procedure. The differen causing pain, stiffness, synovial thickening and tial diagnosis of popliteal aneurysm should always effusion. In a valgus knee (knock Many patients can be managed adequately by con knee), more weight is carried through the lateral servative methods. With a varus knee (bow leg), the weight is non-steroidal anti-inflammatory agents as neces greatest through the medial compartment. Surgery A large number of patients still have symptoms Pathology severe enough to warrant surgery. The possibilities the knee shows the typical pathological features of are: extensive wearing away of joint cartilage, with 1 Arthroscopic lavage/debridement. This is fraying of the menisci, marginal osteophytes controversial and is probably no better than con and some synovial thickening, but little inflamma servative treatment in severe arthritis. This is used very rarely now as Infections (see Chapter 13) joint replacement has taken its place. It gives good Acute infections pain relief but patients do not like having a stiff knee as this makes sitting awkward.
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Mildly Symptomatic Hyponatremia, Chronic Hyponatremia with Minimal Symptoms, Asymptomatic Hyponatremia Serum sodium usually >125 mEq/L Fluid restriction 800–1,000 mL/day alone or in conjunction with: 0. Severe Hyponatremia Symptomatic patient, serum sodium <125 mEq/L Increase serum sodium by no more than 12 mEq/L in 1st 24 hr at a rate of 1 mEq/L/hr (8–12 mEq/day when serum sodium below 125 mEq/L and slow to 5–6 mEq/day when serum sodium rises to 125 mEq/L). Target level: 125 mEq/L Treat patients with significant neurologic symptoms with 3% saline solution. Serum sodium lab testing every 1–2 hr Acute Life-threatening Hyponatremia Serum sodium usually <120 mEq/L Associated with seizures or coma Clinical goal: Stop seizure and improve neurologic status Therapeutic goal: Same as for severe hyponatremia Administer hypertonic saline solution (3%) Stop hypertonic saline when symptoms. Must evaluate for other causes as well as renal, thyroid, adrenal, cardiac, and hepatic dysfunction. Hyponatremia in neurological patients: Cerebral salt wasting versus inappropriate antidiuretic hormone secretion. Managing hyponatremia in patients with syndrome of inappropriate antidiuretic hormone secretion. See Also (Topic, Algorithm, Electronic Media Element) Hyponatremia the author gratefully acknowledges the contribution of Arunachalam Einstein on previous editions of this chapter. Infectious etiology is suspected, because an upper respiratory infection precedes the symptoms of transient synovitis in ∼50% of cases. Discharge Criteria All patients who have had more serious causes of hip pain excluded and have been diagnosed with toxic synovitis can be discharged from the hospital with good follow-up. Issues for Referral Follow-up with an orthopedic surgeon in 1–2 wk for repeat evaluation. Nearly all children recover from toxic synovitis within 2 wk and without sequelae. Factors distinguishing septic arthritis from transient synovitis of the hip in children. Septic arthritis or transient synovitis of the hip in children: the value of clinical prediction algorithms. Tertiary/latent (>1 yr): Measure for falling titers in 3, 6, 12, and 24 mo after treatment. Usually presents with skin and joint manifestations while renal and neurologic involvement is rare. Updates on B-cell immunotherapies for systemic lupus erythematosus and Sjogren’s syndrome. Torsades de pointes: Magnesium, overdrive pacing, amiodarone Correct underlying abnormal electrolytes.
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An electric light bulb cannot be removed by simply pulling it out it must be unscrewed. Rotate the posterior shoulder, allowing it to come up outside of the subpubic arch. At the same time, bring the stuck anterior shoulder into the hollow of the sacrum. Continue rotating the baby a full 360 degrees to rotate (unscrew) both shoulders out of the birth canal. Two variations on the unscrewing maneuver include: · Rotating/shoving the shoulder towards the fetal chest (“shoving scapulas saves shoulders”), which compresses the shoulder-to-shoulder diameter, and · Rotating the anterior shoulder first rather than the posterior shoulder. The anterior shoulder may be 3-95 3-96 easier to reach and simply moving it to an oblique position rather than the straight up and down position may relieve the obstruction. Applying fundal pressure in coordination with the other maneuvers may, at times, be helpful. Applied alone, it may aggravate the problem by further impacting the shoulder against the pubic symphysis. If these measures fail, return to number 4 above and consider cutting or extending the episiotomy, then progress through these maneuvers again. There are several breech variations, including buttocks first, one leg first or both legs first. In any breech birth there are increased risks of umbilical cord prolapse and delivery of the feet through an incompletely dilated cervix, leading to arm or head entrapment. When: Because of the risks of breech delivery, many breech babies are born by cesarean section (see Cesarean section template) in developed countries. In operational settings, cesarean section may not be available or may be more dangerous than performing a vaginal breech delivery. It is up to the care team to decide which option will be the safest mode of delivery for both mother and infant. The mother pushes the baby out with normal bearing down efforts and the baby is simply supported until it is completely free of the birth canal. This works best with smaller babies, mothers who have delivered in the past or frank breech presentation. If a breech baby gets stuck halfway out or if you need to speed the delivery, perform an “assisted breech” delivery. A generous episiotomy will give you more room to work, but may be unnecessary if the vulva is very stretchy and compliant. Have your assistant apply suprapubic pressure to keep the fetal head flexed, expedite delivery and reduce the risk of spinal injury.
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Ultimately, good reporting equates to good communication skills and, in the clinical context, will avoid error and potential harm to the patient. In addition, a clinical history should be taken to include: o Reason for referral, age, menstrual history, symptoms, relevant medication, previous gynaecological surgery / treatment. Details of type of examination and patient consent should be documented in the report. Colour Doppler and/or power Doppler may be relevant in appropriate clinical presentations. Structures to examine/evaluate the pelvic scan should demonstrate: o normal anatomy/variants including age and menstrual status-related appearances of the whole organ in at least two planes o assessment of size, outline, echotexture and echogenicity o pathological findings the following structures should be examined: o Bladder – size, shape, contents o Cervix internal os, external os, cervical canal, continuity with uterus, assessment of size, outline, echotexture o Vagina assessment of outline, echotexture o Rectouterine pouch (pouch of Douglas) -? For example examining the kidneys in the presence of a large fibroid (to exclude hydronephrosis) or to confirm/exclude abdominal ascites where a complex ovarian mass has been seen. It may be useful to have a standardised reporting format for normal gynaecological scans which includes the organs routinely examined and which is acceptable to the imaging department and referring clinicians. The uterus is normal in size but there is a 6mm x 4mm polyp within the endometrium. Anteverted uterus containing several submucosal fibroids on the anterior wall, the largest of which is Xmm in diameter. Ultrasound appearances of both ovaries are normal with a corpus luteum in the left ovary. Adjacent to the right ovary is a complex tubular structure measuring YxYxYmm containing low level echoes. These ultrasound appearances are consistent with pyosalpinx or tubo-ovarian abscess. Portal venous, hepatic venous and arterial systems Diaphragm Contour, movement, presence of adjacent fluid, masses, lobulations Ligaments Appearance of falciform ligament, ligamentum teres and venosum Gallbladder Size, shape, contour and surrounding area. Ultrasound characteristics of the wall and the nature of any contents Common Maximum diameter and contents; optimally it should be visualised to the head of pancreas duct Pancreas Size, shape, contour and ultrasound characteristics of head, body, tail and uncinate process; diameter of main duct Spleen Size, shape, contour and ultrasound characteristics including the hilum. Assessment of volume pre and post-micturition 49 bladder Prostate Size and shape Gastro Wall thickness, contents, diameter of lumen, motility, presence/absence of masses intestinal tract Other Where relevant include: omentum, muscles, abdominal wall, possible hernias, lymph nodes sites structures for potential fluid collection (including upper/ lower abdomen and the thorax) Proceed to examination of the pelvis where necessary (Refer to gynaecology section) During the examination the ultrasound practitioner should demonstrate. The ultrasound practitioner should be able to tailor the examination according to the clinical presentation, and the emphasis of the examination of the abdominal structures may be altered according to the clinical scenario and patient history. Sufficient clinical information should be supplied with the request, together with either a working diagnosis or a specific clinical question to be answered. The purpose of the scan is to survey the entire organ if possible with representative images of normality and any pathology being taken. Left side down decubitus, left posterior oblique and intercostal surveys of the liver and biliary tree are essential if the entire organ is to be evaluated, as these positions allows access to areas of the liver not seen in the supine position. Exclude the presence of free fluid in the upper abdomen before turning the patient. The intestines are part of the abdominal cavity and gassy bowel has typical patterns which should be recognised by experienced operators. The abdominal ultrasound examination is inevitably a clinical examination and any tenderness during a scan should be noted and stated in the report, indicating where possible whether it is organ-specific or diffuse.
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In the subjects’ supraspinatus tendons and in 13% of their infra particular, those showing higher specificities and likelihood spinatus tendons. The results of two of these abnormal labral signal, joint fluid, absent subacromial or studies are strikingly similar, and are described in Tables 7. The clinician should 138 Evidence-based M anagem ent of Acute M usculoskeletal Pain Chapter 7. There complex fractures of the proximal humerus and the scapula are no explicit data on its cost effectiveness in the investigation (Castagno et al. There are no data on the validity of M R-arthrography for images are processed by a computer that arranges the slices for acute shoulder pain. H owever, the isotope show up as darker spots on the images and indicate management must still be guided by some concept of the index ‘pooling’, or regions in which blood is collected. The clinician can formulate a working diagnosis Scintigraphy is used for detecting occult fractures (M atin that summarises the discernible features of the condition accu 1979), tumours (M cNeil 1984), infections (M erkel et al. Suggested serious conditions but there are no other indications for their terms for common mechanical conditions giving rise to acute use in the assessment of acute shoulder pain. Their applications shoulder pain on the basis of clinical assessment findings are are beyond the scope of these guidelines. They 1 199 1 express what is known about the presenting condition after clinical assessment. Clinicians should note that it is not neces There is a need to educate consum ers about the lim itations of im aging and the risks of radiation exposure. Five studies of clinical diagnosis involving different nothing else can be specified: clinicians have concluded that it is of limited reliability. When the pain appears to arise from a particular region As the cause of acute shoulder pain cannot, in most cases, of the shoulder: be identified at the initial consultation (Phillips and Polisson 1997; Solomon et al. The natural history of a condition is the course it is likely the suggested taxonomy aims to reduce the confusion to follow under natural circumstances. For example, ‘subacromial bursitis’, ‘supra By the original definition, ‘acute’ shoulder pain is ‘that due spinatus tendonitis’, ‘rotator cuff tear’ and ‘impingement to a condition which is likely to resolve spontaneously by syndrome’ are terms used more or less interchangeably to natural healing’ (Bonica 1953). To that definition could be describe sim ilar clinical presentations (Buchbinder et al. They create false impressions of disparate diagnostic resolve within a short time (a period of less than three months) entities that are readily distinguishable clinically. It is a general term implying damage and/or loss of func There are obvious ethical restraints to studying people with tion without attributing cause. It is more than a description of painful conditions and deliberately leaving them untreated. Uncertainty of diagnosis creates problems in epidemiolog shoulder where the source of pain is unclear after clinical ical research and in practice.