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Associate Professor, University of Nevada, Reno School of Medicine
Biomechanical factors affecting fractures stability and femoral bursting in closed intramedullary nailing of femoral shaft fractures blood pressure 40 over 0 cheap 50 mg toprol xl free shipping, with illustrative case presentations hypertension kidney infection buy toprol xl mastercard. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients prehypertension questions cheap toprol xl. Changes in the management of femoral shaft fractures in polytrauma patients: from early total care to damage control orthopedic surgery blood pressure medication safe for pregnancy generic 25mg toprol xl with amex. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. Early versus delayed fixation of isolated closed femur fractures in an urban trauma center. The treatment of femoral shaft fractures using intramedullary interlocked nails with and without reaming: a preliminary report. Clinical evaluation of a true percutaneous technique for antegrade femoral nailing. The distal part of the femur is considered the most distal 9 to 15 cm of the femur and can involve the articular surface. It is trapezoidal in shape, and hence the posterior aspect is wider than the anterior aspect. The medial femoral condyle has a larger anterior-toposterior dimension than the lateral side and extends farther distally. The mechanical femoral axis, which is from the center of the femoral head to the center of the knee, is 3 degrees off the vertical. The anatomic femoral axis differs from the mechanical femoral axis in that there is 9 degrees of valgus at the knee. This results in an anatomic femoral axis of the lateral distal femur of 81 degrees or an anatomic femoral axis of the medial distal femur of 99 degrees. The mechanical and anatomic axes of the tibia are for practical purposes identical, going from the center of the knee to the center of the ankle. The treatment of distal femur fractures can be complicated by the various muscle attachments, which can impede or hamper proper fracture reduction. The quadriceps and hamstrings result in fracture shortening; thus, excellent muscle paralysis must be obtained for proper reduction. The medial and lateral gastrocnemius results in posterior angulation and displacement of the distal segment. The neurovascular structures about the knee are at risk when an injury of the distal femur occurs. View of the distal femur showing the wider posterior aspect and trapezoidal shape. Lateral view of the distal femur; the shaft is in line with the anterior half of the distal femoral condyles. The axial loading is accompanied by either varus or valgus with or without rotation. The fracture pattern can vary from the most simple extra-articular type to the most complex intra-articular injury. Owing to the gastrocnemius complex, an apex posterior deformity of the condyles occurs as the fragments are flexed because of the muscle attachment. The patient presents with a swollen and tender knee after either a fall or some high-energy trauma (motor vehicle or motorcycle accident). Any attempts at range of motion result in severe pain, and significant crepitus is usually noted with palpation. If there is concern for an open knee joint, the joint can be injected after a sterile preparation to see whether the knee joint communicates with any wound. The physical examination is directed primarily at ascertaining the neurovascular status of the lower limb and determining whether any associated injuries exist, especially the hip (see Exam Table for Pelvis and Lower Extremity Trauma, pages 1 and 2). If there are any small wounds or tenting of the skin anteriorly, the fracture should be considered as being open. The ankle-brachial indices should be obtained if there is a concern for arterial injury. High-energy injuries usually are from motor vehicle accidents and occur in the young patient. These patients often have associated injuries such as a hip fracture or dislocation or vascular or nerve injury. These high-energy injuries generally result in comminuted fractures, mostly of the metaphyseal region. Traction films should be obtained if there is severe comminution of either the metaphysis or articular surface. Dedicated knee films should always be obtained in the assessment of distal femur fractures. In cases of severe comminution, radiographs of the contralateral knee can aid in preoperative planning as well. Patient with a distal femur fracture with intercondylar extension showing the subtle rotational deformities of the individual condyles. The muscle forces are shown on the distal femur, as is the femoral artery and vein entering the canal of Hunter (arrow). The adductor magnus inserts on the adductor tubercle, leading to a varus deformity of the distal segment. A lateral image of the same patient with the popliteal artery and tibial nerve drawn in to show the relative proximity to the fracture ends. Patient with a spiral distalthird femur fracture that appears to be extra-articular. Patient with a closed femur fracture that was initially thought to be extra-articular.
Stress radiographs after ankle fracture: the effect of ankle position and deltoid ligament status on medial clear space measurements blood pressure normal heart rate high proven 25 mg toprol xl. Quantitative criteria for prediction of the results after displaced fracture of the ankle blood pressure chart of human body discount toprol xl 100 mg mastercard. Competence of the deltoid ligament in bimalleolar ankle fractures after medial malleolar fixation arteria ethmoidalis anterior buy toprol xl pills in toronto. The injuries are infrequent and the fracture anatomy is partially concealed by adjacent osseous structures pulse pressure difference toprol xl 100 mg on-line. Open reduction and internal fixation is generally mandatory to restore talar anatomy precisely. These results include ankle and subtalar joint stiffness, posttraumatic arthrosis, and osteonecrosis of the talus. Sixty percent of the bone is covered by articular cartilage, significantly limiting extraosseous perfusion to the bone. Disruption of circulation to the talus correlates with open or comminuted talus fractures, leading to an increased risk of avascular necrosis. The blood supply to the talar body enters through the inferior talar neck via the artery of the tarsal canal. Secondary blood supply to the body is derived from the deltoid branch of the posterior tibial artery, entering the talar body along its medial surface. Circulation to the neck, head, and lateral body is supplied via the dorsalis pedis, tarsal sinus, and lateral tarsal sinus arteries. This last artery is an anastomosis between the peroneal and dorsalis pedis arteries. Three main surfaces articulate with the plafond and lateral malleolus, while three surfaces articulate with the calcaneus. The final articulation of the talar head with the tarsal navicular represents an important articulation for midfoot motion. Predictable stiffness with range of motion and posttraumatic arthritic changes is experienced with severe fractures of the talus. With increased energy, the hindfoot supination force generates a fracture of the medial malleolus of the ankle. After completion of the neck fracture, continued hyperdorsiflexion and axial load to the body of the talus may force dislocation of the talar body posteriorly, disrupting significant extraosseous circulation. The mechanism of injury is the same for body fractures as for fractures of the talar neck. Fracture patterns of the body of the talus include coronal, sagittal, horizontal shear, and crush fractures of the weightbearing surface. Lateral and posterior process fractures are sustained by inversion and eversion mechanisms of the ankle, respectively. These fractures are often missed on plain film radiographs of the ankle and diagnosed as ankle sprains. Hawkins classified lateral process fractures into avulsion, isolated, and comminuted types. Posteromedial and posterolateral process fractures lie to each side of the flexor hallucis longus tendon. These are commonly intra-articular fractures of the inferior surface of the posterior talus. Fractures of the head of the talus are commonly nondisplaced because of powerful capsular and talonavicular ligamentous attachments. Displaced fractures of the talar head have a 10% incidence of osteonecrosis and can lead to secondary posttraumatic arthrosis. Fractures of the neck of the talus are defined as fractures anterior to the lateral process of the talus. Fractures of the talar head are intra-articular and the result of axial load to the talonavicular joint with the foot positioned in plantarflexion. They are uncommon but must be looked for in the event of an isolated subtalar dislocation. Talar neck fractures occur in the frontal plane and result from dorsiflexion of the foot against the anterior lip of the distal tibia. The fracture begins transversely along the medial talar neck due to an associated supination force to the hindfoot. The value of the Hawkins classification is that it allows the orthopedic surgeon to predict what to expect with a specific talar neck injury. Talar body fractures are defined as fractures extending into or posterior to the lateral process. After airbag deployment, the torso and lower extremities are directed toward the floor panel of the car. I believe that the incidence of high-energy hindfoot trauma will increase over time. Globally, transport related injuries remain the leading cause of disability from injury. By 2020, traffic injuries will increase from a current 9th position to 3rd disability-adjusted life years lost. The history and the clinical status of the talar injury must be carefully recorded because the injury severity is likely to correlate with the long-term patient outcome. On the initial examination the physician should note pain, motion, crepitus, deformity, soft tissue swelling, open fractures, and associated fractures of adjacent bones to the foot and ankle and should perform a complete neurovascular evaluation of the extremity. Detailed documentation of the talus fracture pattern and local soft tissue injury is paramount. Severe swelling of the ankle is common in the acute fracture of the talus and may progress to fracture blister formation, precluding safe execution of operative incisions.
Less frequently prehypertension webmd discount toprol xl uk, appendicitis may result in the spread of purulent content in the abdomen blood pressure 700 toprol xl 25 mg on line, leading to diffuse guarding blood pressure jadakiss buy toprol xl 100mg visa. Patients with haemoperitoneum from blunt or penetrating trauma or ruptured vascular tumours such as hepatocellular carcinoma or hepatic adenoma hypertension remedies cheap 50mg toprol xl overnight delivery, may also exhibit board-like abdominal wall rigidity. Finally, severe pancreatitis causing mesenteric and intestinal oedema may produce an abdominal examination consistent with diffuse peritonitis. Ascites Progressive, vague, non-acute and poorly localized abdominal pain in association with a sense of increasing abdominal girth raises a suspicion of new-onset ascites. Patients with advanced liver disease have the stigmata of portal hypertension discussed above. New or progressive ascites in these patients may reflect a new insult to an already failing liver, such as a portal vein thrombosis or hepatocellular carcinoma. In a patient with known ascites, new-onset abdominal pain may be the first symptom of spontaneous bacterial peritonitis. Primary intestinal dysmotility disorders are rare but should be considered in patients with chronic nausea, vomiting, abdominal distension and constipation without a clear aetiology. Most patients with large bowel obstruction have an incompetent ileocaecal valve that allows the colon to be somewhat decompressed as pressure is transmitted to the small bowel. Patients with a competent ileocaecal valve effectively have a closed-loop large bowel obstruction leading to severe pain and progressive abdominal distension with localized peritonitis over the colonic segment involved. The most common causes of large bowel obstruction are colon cancer, incarcerated hernia, sigmoid or caecal volvulus, faecal impaction and diverticular strictures. Classically, left-sided colon cancers tend to present with obstruction while right-sided cancers produce bleeding. Obstructing cancers or impacted faeces may paradoxically produce diarrhoea as liquid stool leaks through the mass. In toxic patients with abdominal distension and diarrhoea, toxic megacolon from overwhelming Clostridium difficile infection must be considered. Pseudo-obstruction describes colonic dysmotility that may be triggered by medications, stress and infection. Patients with pseudo-obstruction usually continue to pass stool and flatus intermittently. Abdominal examination usually reveals a soft abdomen with diffuse mild rebound tenderness without significant guarding. The catheter insertion site should be inspected for erythema or purulent drainage, although these signs may be absent. There may be mild distension and mild diffuse tenderness, but rebound and guarding are unusual. Constipation Chronic constipation causes significant diffuse abdominal pain in elderly patients. In thin patients, dense stool can be palpated in the transverse and sigmoid colon. Rarely, faecal impaction produces the clinical picture of bowel obstruction with nausea, vomiting, abdominal distension and abdominal tenderness. Right Heart Failure Chronic right heart failure may cause hepatic congestion resulting in ascites, hepatomegaly and even splenomegaly. Patients may complain of mild, diffuse or epigastric abdominal pain with associated nausea. Tricuspid stenosis is likely to be present if the pulsations occur just before ventricular systole, while tricuspid regurgitation is more likely if the pulsations occur during systole. Urinary Retention Older patients are also prone to developing acute or chronic urinary retention. Benign prostatic hyperplasia is the most common cause in men, while pelvic floor laxity with the development of a cystocele or rectocele is a common aetiology in women. Some may only report urinary frequency and overflow on questioning as they become accustomed to their chronic symptoms. Physical examination will reveal suprapubic fullness, and palpating the dome of the bladder will make the patient feel an urge to urinate. When the bladder is massively distended, there may be significant tenderness, mimicking peritonitis in some cases. Carcinomatosis Peritoneal carcinomatosis from advanced gastrointestinal or gynaecological malignancy should be considered in patients with new-onset ascites (Figure 35. The history may reveal worrisome symptoms such as a change in bowel habit, chronic bloodtinged stools or postmenopausal vaginal bleeding coupled with weight loss, night sweats and fatigue. A firm, palpable mass may be appreciated on abdominal examination if the underlying cancer is sufficiently large. If a rectal cancer is palpated on digital rectal examination, the sphincter tone should be assessed to identify involvement of the sphincter muscles. Ruptured mucoceles of the appendix or ovaries may lead to pseudomyxoma peritonei, in which extensive gelatinous fluid fills the abdomen. The disease is slow to progress, but the presentation is often similar to that of a gynaecological malignancy. Gastroenteritis Fortunately, there are many benign, self-limiting conditions that cause non-acute, generalized abdominal pain. Bacterial or viral gastroenteritis presents with vague, crampy abdominal pain, nausea, vomiting and diarrhoea. Key Points A thorough history and physical examination allow the healthcare provider to formulate a differential diagnosis upon which to base further testing and interventions if necessary. When a patient localizes their abdominal pain to a particular region, the history and physical examination should be tailored to distinguish between the conditions that commonly affect the identified region. Generalized abdominal pain has a vast differential diagnosis, but it is still possible to identify the most likely condition present using detailed history and physical examination skills.
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