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By F. Dimitar. California State University, Northridge. 2018.

During conjoint interviews the psychologist should observe interactions between the significant others and responses by sig- nificant others to patients expressions of pain and suffering buy 400mg hoodia mastercard. People who feel that they have a number of successful methods for coping with pain may suffer less than those who behave and feel helpless cheap hoodia 400 mg online, hopeless purchase hoodia 400 mg without a prescription, and demoralized discount hoodia 400mg fast delivery. Thus purchase hoodia 400 mg with mastercard, assessments should focus on identifying factors that exacerbate and ameliorate the pain experience. Is he or she so overwhelmed by pain and other stressors that he or she has little resources left to cope with his symptoms? If so, he or she may meet the criteria for a pain disorder associ- ated with both psychological factors and a general medical condition (if di- agnosed by a physician) in the Diagnostic and Statistical Manual (American Psychiatric Association, 1994). Does the patient have problems with pacing activities, so that he or she does more when the patient feels better, which leads to increased pain and subsequent sedentary behavior? The psychologist should not only focus on deficits and weakness in cop- ing efforts and coping repertoire but also strengths. How has the patient coped with other problems (illnesses, stress) in the past? How successful does the patient feel he or she was in coping with problems prior to pain onset? ASSESSMENT OF CHRONIC PAIN SUFFERERS 223 Educational and Vocational History. Does the patient have a history of achievement, consistent work, and adequate income? Patients without these may be at a further disadvantage in terms of future successes (Dwor- kin, Richlin, Handlin, & Brand, 1986). Does the patient be- lieve that he or she will be able to return to previous occupation? How did the patient get along with coworkers, supervisors, and employees? Did the patient like his or her job and does he or she wish to return to the same or a related job? What plans has the patient made regarding return to work or to resumption of usual activities? If psychologists learns that these factors may impede progress, they can include recommendations for referral to a vocational counselor. Does the patient currently have a supportive network of family or friends? A comprehensive evalua- tion and subsequent report can guide recommendations about these is- sues. Severe difficulties in these areas may warrant a referral to a psycho- therapist or family counselor. Has the patient coped with difficulties in the past by turning to alcohol? Does his or her substance use interfere with his ability to manage symptoms? It is helpful to use an interview such as the Structured Clinical Interview for the DSM–IV (SCID; American Psychiatric Association, 1997) (described later) to determine if the patient meets the criteria for sub- stance abuse or dependence. Patients who are reliant on substances will need additional services for proper treatment. It is important to assess whether patients have a prior history of psychiatric illness. If yes, did treatment begin prior to pain onset, or is treatment related to current pain? How helpful does the patient feel psychological treatments have been (are)? Are there any additional factors from the patient’s history that may impede rehabilitation? Is the patient so overwhelmed by his or her current situation that he or she has become sui- cidal? Patients with psychological dysfunction may benefit from additional support, therapy, or consultation with a psychiatrist for psychotropic medi- cations. Information acquired during the SCID may help determine if the pa- tient meets DSM–IV criteria for several diagnostic categories. The interview 224 TURK, MONARCH, WILLIAMS may also differentiate if depression is a primary factor or is secondary to chronic pain. The SCID–I and SCID–II (1997) can be used to determine whether the pa- tient suffers from any Axis I (primary psychiatric diagnosis) or Axis II (per- sonality disorder) DSM–IV diagnoses (American Psychiatric Association, 1994).

Radiographic assessment criteria for antero-posterior/ postero-anterior projections of the chest Area of interest to be included on the radiograph The radiograph should include the whole of the chest from cheap hoodia 400 mg otc, and including trusted hoodia 400 mg, the first rib to the costophrenic angles inferiorly and the outer margins of the ribs laterally buy generic hoodia 400 mg online. Rotation The chest of a young child is more cylindrical than that of an adult and there- fore a small amount of rotation will lead to the appearance of significant asym- metry buy discount hoodia 400mg on line. Due to difficulties visualising the medial ends of the clavicles in young children hoodia 400 mg mastercard, rotation is better judged using the anterior ribs, which should be of equal length and symmetrically positioned with respect to the vertebral column. Minimising patient rotation is essential as many pathological conditions may be simulated as a result of rotation (e. Lordosis Lordosis is a common technical fault when performing antero-posterior chest radiography and may be resolved by placing a 15° pad behind the patient’s 56 Paediatric Radiography Fig. Note the unusual cardiac outline and the asymmetric appearance of the anterior ribs. Radiographi- cally, lordosis can be identified when the anterior ribs appear horizontal or are angled cranially to lie above the posterior ribs. The altered position of the clavicles is not an accurate indication of lordosis in children as clavicular posi- tion changes with shoulder movement (Fig. Respiration Failure to achieve satisfactory inspiration is a common problem when radio- graphing children. In young children, the phase of respiration can be assessed by observing the rise and fall of the abdomen. It must be remembered that the shape of the paediatric chest alters with growth and therefore the assessment of adequate inspiration by rib counting also changes (Table 4. Adequate inspira- tion is important in order to visualise the lung fields clearly and to avoid the impression of cardiomegaly and prominent pulmonary vasculature13. Age of child Optimum inspiration 0–3 years 6 anterior ribs, 8 posterior ribs 3–7 years 6 anterior ribs, 9 posterior ribs 8 years + 6 anterior ribs, 10 posterior ribs Exposure A correctly exposed radiograph should demonstrate pulmonary vessels in the central two-thirds of the lung fields without evidence of blurring. The trachea and major bronchi should also be visible as should the intervertebral disc spaces of the lower thoracic spine through the heart. Artefacts Care should be taken to avoid artefacts on children’s clothing (e. Supplementary radiographic projections of the chest and upper respiratory tract Lateral chest The lateral chest should not be undertaken routinely and should only be per- formed if referral criteria satisfy departmental protocols for a lateral projection or following discussion with a radiologist. Lateral chest radiography is often easier to perform on young children if they are seated. The child sits or stands with the side under investigation closest to an appropriately sized cassette. The patient’s chin is raised and the arms are flexed at the elbow and held on either side of the head by a suitably protected guardian to prevent rota- tion. The primary beam is centred to the middle of the area of interest and colli- mated to within the area of the cassette. Radiographic assessment criteria of lateral chest The posterior aspects of the ribs should be superimposed and the vertebrae should be seen without rotation. The radiograph should include the whole of the chest from the apices to the diaphragm. Lateral decubitus (antero-posterior) The lateral decubitus projection is useful when a horizontal beam projection is required and the patient cannot be positioned erect. If a pneumothorax is sus- pected, the projection should be undertaken with the affected side uppermost while if a pleural effusion is suspected, the affected side should be lowermost. The child lies on their side on top of rectangular foam pads of suitable length to allow the whole of the chest to be visualised on the resultant radiograph. The cassette is placed behind the child and the child is positioned such that the median sagittal plane is 90° to the cassette. The child’s knees are flexed to provide The chest and upper respiratory tract 59 stability and the arms are flexed and placed in front of their head. An appropri- ately protected adult may hold the cassette and the patient’s hands if required. Radiographic assessment criteria of lateral decubitus The appropriate area of interest to be included is from the apices, including all of the first rib, to the costophrenic angles and the outer margins of the ribs laterally. Lateral soft tissue neck This projection may be required to investigate a suspected foreign body or soft tissue swelling. The patient is seated so that the median sagittal plane is paral- lel to the cassette.

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Classificationof growth disturbances due to osteochondro- The situation is quite different cheap hoodia 400 mg free shipping, however generic hoodia 400mg visa, for locally mas on the forearm buy discount hoodia 400mg line. Likewise buy cheap hoodia 400mg line, tumors that cause pain order 400mg hoodia overnight delivery, such as the chondroblastoma, osteoblas- Treatment toma or osteoid osteoma, should be treated. Osteoid os- Since the therapeutic strategies for bone tumors are dis- teomas affecting the upper extremity are often diagnosed cussed in detail in chapter 4. The treatment is based on the usual aspects will be highlighted at this point. Any Benign bone tumors that occur on the scapula, where they are usually located As a rule, surgery is not indicated for benign bone tumors on the ventral aspect, should be removed, as otherwise and tumor-like lesions of the upper extremities if they show the scapula will protrude and shoulder mobility may no aggressive growth locally and do not cause any pain. The same applies to large more conservative approach is appropriate here than for osteochondromas of the proximal humerus, which can the lower extremities. On the forearm osteochondromas the risk of deformation is much less than for the leg. In the upper extremity, neither lesion usually re- on this classification, the corresponding treatment shown quires treatment. In young patients we use Osteochondromas of the distal radius and ulna should the clavicles as a replacement for the proximal humerus. The ulna can be lengthened via an acromioclavicular joint and fixed to the residual fragment intramedullary Prévot nail, which prevents bowing of the of distal humerus[8] (⊡ Fig. Enchondromas on the hand can occasionally prove troublesome if they cause the bone to expand. Removal by curettage is indicated in such cases, and the defect can be filled with a cancellous bone graft. On the other hand, enchondromas that do not cause any problems should be left untreated. Malignant bone tumors The treatment strategies for the relatively common osteo- sarcoma and the rare Ewing sarcoma follow the standard guidelines ( Chapter 4. Certain particular aspects concerning resection are worth mentioning: Osteosar- comas are usually located in the area of the proximal humeral metaphysis. Since the axillary nerve lies very close to the bone in its course from the posterior to the anterior side, a wide resection of the tumor is often not possible without also resecting this nerve. This will then lead to a failure of the deltoid muscle and thus of almost all active shoulder mobility. If very large, malignant, high-grade tumors are present in the shoulder area, the scapula may sometimes need to be removed completely together with the proximal humerus. In doubtful cases the surgeon can opt for the procedure of interscapulo- ⊡ Fig. Left Preoperative view after 3 months of che- The reconstruction is also aggravated by the absence motherapy. Right After proximal humeral replacement by the clavicula of the axillary nerve since it will not be possible to center pro humero technique ⊡ Fig. Principle of proximal humeral replacement in the »clavicula pro humero« technique according to Winkelmann. The clavicle is detached from the sternum and rotated downward in the acromioclavicular joint and fixed to the remaining section of a b the humerus 526 3. The muscles can be refixed to this graft, individuals have to position their hand in extreme flex- which provides a certain degree of purchase. This is not ion when writing to avoid smudging the ink with the the case, however, for metal or plastic prostheses, which palm. A similar procedure can be employed 3 occur during extension, although not all authors have for large giant cell tumors, which are not infrequently observed this phenomenon. Allografts can also be used on the forearm, although If malignant tumors occur on the hand, joint-pre- arthrodesis is usually the better and more lasting solu- serving treatments are not usually possible (⊡ Fig. A right-handed individual is Radiotherapy can help preserve the hand in some cases, able to manage functionally with arthrodesis, whether although finger ray resections are usually more useful of the right or left wrist. Left AP and lateral x-rays of the left wrist in an 18-year old female patient with a central low-grade malignant osteosar- coma.

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Femoral neck lengthening osteotomy: A typical con- sequence of femoral head necrosis is shortening of the femoral neck with concurrent overgrowth of the greater trochanter order hoodia 400mg with visa, since the trochanteric apophyseal plate is not affected by the necrosis trusted hoodia 400mg. This configuration will result in abductor weakness of varying severity buy hoodia 400 mg online. A femo- ral neck lengthening osteotomy can be performed to restore the proper biomechanical configuration discount 400 mg hoodia. Principle of the femoral neck lengthening osteotomy partially compensated at the same time cheap 400mg hoodia amex. The shaft is moved to a more lateral and distal posi- A lengthening of around 1–1. The surgeon must be very teric fragment is moved distally; a preoperatively, b postoperatively careful, however, to avoid injury to the vessels that enter a b c d ⊡ Fig. X-ray series for a 12-year old boy after a congenital hip teric elevation. A femoral neck lengthening osteotomy was imple- dislocation and lateral femoral head necrosis with lateral epiphyseal mented to correct the length of the femoral neck and the lever arm of closure, head-in-neck position and shortening of the femoral neck (a). Situation 1 year postoperatively (d) At 14 years of age on completion of growth (b) pronounced trochan- 193 3 3. The acetabulum is pulled ventrally and pressure in the joint is increased as a result of lengthening laterally. A triangular wedge of bone secures the result- of the femoral neck, the procedure is indicated only if the ing position. The pivot point for the transfer is the sym- joint conditions are good (largely normal). This operation flattens an excessively steep ac- etabular roof, improves the roof coverage ventrally and Pelvic procedures narrows the acetabular angle (see above) (⊡ Fig. We hardly ever perform the Salter osteotomy ▬ Chiari osteotomy of the ilium, before the age of 2, preferring to wait and see how the ▬ triple osteotomies, situation develops spontaneously. Many mild cases of hip ▬ periacetabular osteotomies, dysplasia improve over time and do not require treatment ▬ shelf operations. Only if the acetabulum is very small, thus prevent- ing a stable closed reduction, do we follow the Salter All of these operations have their own indications and are osteotomy with an open reduction in the same session. Even in 2-year old patients we frequently await the spon- taneous outcome of events despite an acetabular angle of Salter’s osteotomy of the innominate bone (ilium): In over 30°, since the acetabulum can largely correct itself Salter’s osteotomy, the pelvis is divided above the during this stage of development provided the femoral anterior inferior iliac spine down to the transverse sci- head is well centered. Even more important than the acetabular angle for the evaluation is the shape of the lateral acetabular epiphysis and the concavity of the joint surface. If, by the age of 3 years, an acetabular angle of 30°, a flat epiphysis and inadequate concavity of the joint surface are all still present, then the Salter osteotomy is indicated. Since the operation is only feasible while the symphysis remains sufficiently mobile, it is no longer indicated after the age of 8. A Salter osteotomy can restore the normal hip configuration in small children and even excellent long- term results can be expected. Although one would expect lateralization of the femoral head to occur as a result of the angular movement with the center of rotation in the a b area of the epiphysis, this does not actually happen in reality. Principle of the Salter pelvic osteotomy (osteotomy of The postoperative management after a Salter oste- the innominate bone. The ilium is divided above the anterior inferior otomy involves fixation in a hip spica for 6 weeks. The iliac spine (a), the distal fragment is transposed ventrally/laterally, a triangular bone graft with the base facing laterally is wedged between fixation wires are subsequently removed and the child the fragments and fixed with a Kirschner wire (b) is mobilized. X-ray series for a 3-year old child with hip dysplasia (here fixed with an external fixator instead of an angled blade plate) involving an excessively steep acetabular roof and slightly off-center and a Salter pelvic osteotomy was performed on both sides with an hips on both sides (a). An intertrochanteric derotation varus osteotomy interval of 4 weeks (b). We The contralateral side should therefore be operated on at perform an acetabuloplasty most often for neuromuscular the earliest after 4–6 weeks. In principle, acetabulo- While the Salter osteotomy is a relatively simple and plasty is also a suitable operation for an excessively steep tried-and-tested operation, complications can still occur acetabulum in toddlers. A lesion of the sciatic nerve can oc- The correction options with acetabuloplasty are bet- 3 cur when the Gigli saw is used in the greater sciatic fora- ter than those with the Salter osteotomy, as the pivot men. We ourselves have had the misfortune to observe point with the former procedure is nearer the acetabulum an irreversible partial sciatic nerve lesion (after several (triradiate cartilage compared to the symphysis). Vascular injuries, delayed bone healing and ever, the risks associated with acetabuloplasty are greater. Furthermore, the osteotomy is performed closer to the joint and is technically more demanding Acetabuloplasty : An acetabuloplasty involves a dome- than Salter’s innominate osteotomy.

We observe whether the thoracic kyphosis evens out as the At what age should school medical examinations patient straightens up from a forward-bending posture take place? From the orthopaedic standpoint purchase hoodia 400 mg line, the aim of the ex- amination is discount 400mg hoodia otc, firstly generic hoodia 400mg mastercard, to identify congenital disorders and cheap 400mg hoodia, > Referral to specialists: Fixed kyphosis in the thoracic spine secondly purchase hoodia 400mg online, to detect growth disorders that develop during area or (also including mild) kyphosis of the lumbar spine puberty. Since an annual school medical examination (usually identifiable by areas of pigmentation over the is not feasible for reasons of cost and organization, spinous processes in the upper lumbar spine area). In toddlers, cases of genu varum are invari- > All congenital deformities should be apparent soon ably pathological, and a genu varum in children under after the start of compulsory education, i. Ideally, the child should already valgum with an intermalleolar gap of up to 10 cm can have been attending school for 1 year so that the PE readily be tolerated. They primarily give cause for concern teacher can report whether any coordination disorder if the child is obese. The degree of anteversion can readily be conditions almost always manifest themselves via the measured clinically ( Chapter 3. The pain prompts the parents > Referral to specialists: Anteversion of more than 40° to take the child to the doctor even if no mass screening measured clinically in an adolescent. Torsion abnormalities are frequently observed in the low- In both quantitative and qualitative terms, scoliosis er leg. The foot axis is normally between 0° and 30° lateral represents the number one problem during the growth to the femoral axis. Scoliosis develops at the start of puberty and is known to start two years earlier in girls than in boys. Foot abnormalities: Observing the callus formation on > The examination at the start of puberty should ideally the feet is extremely useful. Of course, although we should not just consider or- thopaedic criteria when establishing the time for the > Referral to specialists: Callus formation on the medial school medical examination, disorders of the musculo- arch of the foot. Spine 18: The skeleton develops in the embryo from a primar- 1572–80 ily cartilaginous skeletal structure. Carr AJ, Jefferson RJ, Turner-Smith AR (1991) Familial back shape in adolescent scoliosis. At birth, the Acta Orthop Scand 62: 131–5 diaphyses already appear to be largely ossified on x-rays, 3. Dvonch VM, Siegler AH, Cloppas CC, Bunch WH (1990) The epide- whereas the epiphyses still lack any ossification centers, miology of »schooliosis«. J Pediatr Orthop 10: 206–7 which only appear during the first few years of life. Hefti FL, Hartzell ChR, Pizzutillo PD, MacEwen GD (1983) Dot pat- epiphyseal plate is located between the diaphyses and the tern analysis for back shape measurement in scoliosis. Mohle-Boetani JC, Miller B, Halpern M, Trivedi A, Lessler J, Solo- Bone growth takes place via two mechanisms mon SL, Fenstersheib M (1995) School-based screening for tu- berculous infection. Nissinen M, Heliovaara M, Seitsamo J, Poussa M (1993) Trunk periosteal (appositional) thickness growth. Spine 18: 8–13 Growth, particularly the type of growth that leads to an 7. Yawn B, Yawn R, Hodge D, Kurland M, Shaughnessy W, Ilstrup D, increase in diameter, also involves constant bone resorp- Jacobsen S (1999) A population-based study of school scoliosis tion. Velezis M, Sturm P, Cobey J (2002) Scoliosis screening revisited: In interstitial growth bone is formed from the initial findings from the District of Columbia. Cartilage is a semi-solid, elastic 788–91 tissue and extremely old in terms of evolutionary devel- opment. Before bone appeared, fish existed with a purely cartilaginous skeleton. But this type of appositional growth also occurs in the animal kingdom, for example in the shells of mussels and > Definition snails or in corals. Growth processes take place primarily in children Endochondral growth and adolescents. Long bones possess their own growth system in the form of epiphyseal plates. But it is not just the skel- Endochondral growth involves bone formation from etal system that possesses the ability to growth: Every a cartilaginous precursor.

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