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Terms involving comparisons with animals (»Chicken breast«) can prove especially hurtful Keeled chest is never associated with a functional re- Findings of imaging techniques cheap 20mg female cialis amex menopause levels, striction as the heart and lungs are always able to develop radiographic findings sufficiently female cialis 10 mg otc women's health center vancouver bc. The condition is therefore a purely cosmetic The extent of the keeled chest can also be measured objec- problem. Just as with funnel chest, however, keeled chest tively by raster stereography ( Chapter 3. This fact underlines the importance of the role played conservative treatment with a brace, by posture in the development of Scheuermann’s disease. Whether the mechanical deformation of the thorax is also responsible for the development of Scheuermann’s disease The conservative treatment with a brace is much more remains doubtful. Although we know from our experience promising for keeled chest than for funnel chest since, with vertebral fractures that a fracture of the sternum on in the former condition, pressure can be exerted from the same side results in considerable instability and exac- outside to produce a genuine corrective effect. Good erbation of the kyphosis, keeled chest does not involve any results have been reported in the literature and we significant reduction in strength, which means that this have been able to confirm this in our own experience. However, the brace is not always accepted by the patient and the treatment should be implemented primarily in! Try to avoid using expressions such as »pigeon younger children, as it will no longer have much effect chest« or »chicken breast« when talking to patients by the time of adolescence. I try to persuade parents of children with the animal world and applied to humans, these a pronounced keeled chest of the advantages of brace terms have very negative connotations. The clinical pictures are A split sternum and premature sternal synostosis always discussed in detail in chapters 4. Flat thorax is a very specific problem in which the thorax should Occurrence always be considered in connection with the spine. We While the reports in the literature concerning frequency see flat thorax primarily in association with idiopathic show substantial differences, one thing is certain: both adolescent scoliosis, but also in connection with lumbar the prevalence and the severity of scoliosis are largely Scheuermann’s disease (⊡ Fig. If treatment is in- proportional to the severity of the neurological disorder. One study conducted in homes caring for patients with Correction of the thoracic deformity on its own is hardly cerebral palsy observed an incidence of 67% of scolioses ever indicated. The primary aim in correcting the spi- over 60° in those with severe tetraparesis. This can be achieved by a relatively sophisticated procedure Clinical features involving combined anterior and posterior approaches. Patients with severe spastic tetraparesis lack trunk control The problem of congenitally fused ribs is discussed in and therefore find it difficult, or even impossible, to main- chapter 3. While the extremities often show severe spasticity, the trunk may be hypotonic. In an upright References position, the patients tilt to one side or adopt a kyphotic 1. Brinker MR, Palutsis RS, Sarwark JF (1995) The orthopaedic mani- posture, often resulting in long C-shaped deformities. J Bone Joint the patients develop a hip flexion contracture, straighten- Surg (Am) 77: 251–7 ing of the legs during lying or standing causes the pelvis to 2. Haje SA, Bowen JR (1992) Preliminary results of orthoptic treat- ment of pectus deformities in children and adolescents. J Pediatr be tilted forward and the lumbar spine to adopt a lordotic Orthop 12: 795–800 posture, which can likewise assume extreme proportions. Hummer HP, Rupprecht H (1985) Atypische Thoraxdeformitäten: Patients who are able to control their head and trunk to a Beurteilung und operative Konsequenzen. Z Orthop 123: 913–7 certain extent try their best to hold their head as upright as 4. Hummer HP, Rupprecht H (1985) Die Asymmetrie der Trichter- possible, which can result in a compensatory countercurve brust: Beurteilung, Haufigkeit, Konsequenzen. Z Orthop 123: 218–22 in the proximal part of the spine (compensatory bending 5.

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J Bone Joint Surg Am 84-A: 1842–8 cents wait until growth is completed and run the risk of 17 generic female cialis 10 mg on-line breast cancer 05 cm. Tanchev P generic female cialis 20mg without a prescription menstruation calculator menstrual cycle, Dzherov A, Parushev A, Dikov D, Todorov M (2000) no longer being competitive? Spine 25: 1367–72 questions we need to know more about the long-term ef- 18. Williamson A, Chen A, Masuda K, Thonar E, Sah R (2003) Tensile mechanical properties of bovine articular cartilage: variations fects of the aforementioned illnesses. Legitimate doubts exist as to whether a thoracic Orthop Res 21: 872–80 19. Clin Scheuermann disease or spondylolysis actually rep- Sports Med 21: 77–92 resents a major problem in later life. Wren T, Beaupré G, Carter D (1998) A model for loading-depen- apply, however, to a tilt deformity, which leads to dent growth, development, and adaptation of tendons and liga- impingement in the hip and constitutes a distinct ments. J Biomech 31: 107–14 form of pre-arthrosis – and coxarthrosis does actu- ally appear to be more common in former athletes than in the general population. Consequently, ex- cessive loading should be avoided particularly dur- ing early puberty. Beunen GP, Malina RM, Renson R (1992) Physical activity and growth, maturation and performance: A longitudinal study. Dorizas J, Stanitski C (2003) Anterior cruciate ligament injury in the skeletally immature. Herman M, Pizzutillo P, Cavalier R (2003) Spondylolysis and spon- dylolisthesis in the child and adolescent athlete. Hasler C, Dick W (2002) Spondylolyse und Spondylolisthesis im Wachstumsalter. Hatton J, Pooran M, Li C, Luzzio C, Hughes-Fulford M (2003) A short pulse of mechanical force induces gene expression and growth in MC3T3-E1 osteoblasts via an ERK 1/2 pathway. Hefti F, Morscher E (1985) Die Belastbarkeit des wachsenden Be- wegungsapparates. Hefti FL, Kress A, Fasel J, Morscher EW (1991) Healing of the tran- sected anterior cruciate ligament in the rabbit. Mankin K, Zaleske D (1998) Response of physeal cartilage to low- level compression and tension in organ culture. Morscher E (1968) Strength and morphology of growth cartilage under hormonal influence of puberty Reconstr. Karger, Basel New York (Surgery and Traumatology, vol 10) 3 Diseases and injuries by site 3. History To ensure that the patient’s back is at eye-level, the examiner himself should not stand but preferably ▬ Trauma history: Has trauma occurred? Inspection from behind – What was the patient doing (sport, playing, normal We observe the position of the shoulders, the height routine)? We look for pigmentation over the ▬ Pain history: spinous processes, especially over the lumbar spine, Where is the pain located (neck, upper thoracic spine, as this can be an indication of (usually pathological) lower thoracic spine, lumbar spine, lumbosacral kyphosis in this area. If so, does the pain occur We assess the sagittal curves and establish a pos- only while changing position, or does the pain cause tural type: normal (physiological) back, hollow back the patient to wake up at night? Does the pain occur (increased thoracic kyphosis and lumbar lordosis), on bending down or straightening up again? Does the fully rounded back (kyphosis extending down to the pain also radiate to the legs? Does the pain occur on lumbar area), hollow-flat back (hyperlordosis of the coughing or sneezing? If Scheuermann disease is suspected backwards or forwards, then postural variants are ask specifically whether the patient is involved in cycle involved rather than (fixed) pathological changes. Are We observe whether a ventral or dorsal overhang is pres- there problems of micturition or defecation? Small children may need to stand on a box so that the iliac crest is at the examiner’s eye level. Girls who have reached puberty should also a be allowed to wear their brassiere.

Inhalation Injury 73 FIGURE5 Algorithm for airway management in patients at risk for inhalation injury cheap 20mg female cialis overnight delivery menstruation questions answers. Although there are risks associated with unnecessary intubations discount 20mg female cialis with amex womens health kit doterra, in the absence of equipment or training for endoscopy or if close observation is not possible, empirical prophylactic intu- bation is the safest course of action if there is doubt about the status of the patient’s upper airway. Special consideration must also be given to transportation of patients between institutions. This may involve a significant period of time (hours) in a setting of limited resources. When transferring the patient to a tertiary care or burn center airway management, decisions should be made in consultation with the accepting institution. However, we have seen serious morbidity and even mortality due to airway complications in pediatric patients who had relatively trivial burns but were intubated for transport. Clearly defined indications for intubation should be identified prior to transport to justify the significant risks of intubation. Inhalation Injuries to the Larynx and Tracheostomy In addition to the more immediate airway concerns (obstruction and asphyxia) in the acute burn patient, management decisions must be made regarding more long-term consequences of thermal injuries to the larynx. Later sequelae include airway narrowing secondary to subglottic stenosis, compromise of laryngeal pro- tection of lower airways and parenchyma from aspiration, and impaired voice quality. The arytenoids, true vocal cords, and the subglottic region are the areas most prone to long-term scarring. Patients presenting with significant risk factors for inhalation injury should be examined endoscopically for evidence of laryngeal burns. Presence of signifi- cant thermal injury to the larynx makes it more prone to injury by an endotracheal tube. When possible, early extubation reduces the risk of exacerbating a laryngeal injury. When extubation is not possible tracheostomy is another option that may help to limit laryngeal injury. The early popularity of tracheostomies for initial airway management in burn-injured patients gave way to reports of unacceptably high rates of complications. In the most often quoted study regarding the risks of tracheostomy in burn patients, Eckhauser et al. Moreover, a 100% correlation was found between cultures of the burn wound and cultures of the endotracheal aspirate. Presence of a tracheostomy stoma, especially through a burn injury, was assumed to facilitate contamination of the respiratory tract with microorganisms from the burn wound. Tracheosto- mies were considered an increased risk in burn patients and a more conservative approach was recommended, with tracheostomies reserved for specific indications rather than for so-called prophylactic airway control [6,7]. More recently many clinicians have published comparisons of clinical out- comes for burn patients managed with translaryngeal endotracheal tubes and tracheostomy tubes. These studies indicate that the risk of pneumonia for patients with tracheostomies is the same as the risk for patients with translaryngeal endo- tracheal tubes [8,9]. The general consensus now is that with current methods of supportive care, the risk of pneumonia appears similar in patients with tracheostomies and those with translaryngeal endotracheal tubes. Tracheostomy offers several advantages over a translaryngeal endotracheal tube in certain patients. For those requiring prolonged mechanical ventilation, the tracheostomy tube has been reported to reduce dead space, improve compli- ance, lower peak inspiratory pressures, and facilitate airway suctioning. Tracheos- tomy also offers protection from laryngeal and tracheal injury. Prolonged transla- ryngeal intubation is associated with laryngeal injury. Tracheostomy is especially beneficial for patients who have sustained inhalation injury to the larynx. Mechan- ical irritation to the larynx by an endotracheal tube exacerbates inhalation injury to the larynx caused by heat or chemical irritants.

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