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If shortening of the triceps surae muscle is already A summary of the measures for the various conditions is present trileptal 300 mg generic, special stretching exercises for the calf muscles shown in ⊡ Table 3 order trileptal 150 mg amex. In this case buy cheap trileptal 150mg on-line, physical therapy is ap- propriate since the stretching in flexible flatfoot is effec- Conservative treatment tive only if the heel is simultaneously placed in a varus Infancy position, which the child is unable to achieve on its own. If the flexible flatfoot is associated with an abduction Moreover, the mother may be unable to manage this exer- of the forefoot, it is occasionally manifest even at birth. In such cases it is worth straightening the foot with a We consider that the provision of inserts is appropri- cast during the first few months of life. Although casts as below-knee casts can easily slip down and lead the efficacy of insert treatment has not been completely to pressure sores. Moreover, the correction of the foot proven scientifically, we nevertheless manage feet with is better with a long-leg cast. We generally use Softcast fallen medial arches with inserts or shoe modifications. In this form of correction the rearfoot is ferent for treated and untreated feet [16, 17]. A study pushed in a varus direction and the forefoot is supinated conducted in our own hospital with two groups of approx. At the same time the medial longitudinal 20 children with fallen arches with and without insert arch is shaped by the cast. As a rule, we start corrective treatment only after the 2nd month of life and con- tinue the treatment until the foot shape has returned to normal, generally after 2–3 months, by which time the foot has a normal shape in the non-weight-bear- ing state. Whether a flexible flatfoot will continue to persist after the start of walking cannot be predicted with certainty since this depends to a great extent on the quality of the ligaments – and this is difficult to assess in the infant. Walking age If a flexible flatfoot persists after the start of walking, the a b possibility of inserts can be considered. The foot is par- ticularly difficult to assess at this age since the medial foot ⊡ Fig. We make more fun by competing with the child to grasp long objects with a diagnosis of flexible flatfoot at this age only if weight- the toes 414 3. Hopes that the insert or shoe modification will reduce the shoe consumption rate will be disappointed. If the heel is in a very ex- treme valgus position, a so-called inner shoe, i. The desire for cosmetic improvement can also be taken into account to a certain extent, although considerable caution is required here since the correction of the appearance should not be achieved at the expense of pain. If surgery is indicated the operation should not be performed before the age of 8, or preferably 10. Talar reduction In the severest forms, in which the weight-bearing of the foot occurs predominantly, or exclusively, on the medial side, treatment is often required even during early child- hood. Lateral transfixed, the triceps surae is lengthened and the disloca- counter supports are inserted to prevent the foot from sliding laterally tion pouch is closed on the medial side. Navicular suspension treatment showed that the end result was not influenced In this operation, which was first proposed by Lowman by the supports. However, all these studies involved in 1923, the anterior tibial tendon is looped around mild forms of flexible flatfoot or even physiological flat the navicular bone. Other studies, by contrast, have shown that relatively, thereby enhancing the tensioning effect. The the supporting of the medial arch and varization of the relocation of the attachment dorsally also causes the heel with an insert or shoe modification certainly does tendon to exert a more direct effect on the medial arch of produce an effect in more pronounced forms of flexible the foot. The underlying principle is that, by lowering derlying condition of these patients tends to involve pro- the talus and navicular bone, the tendons on the medial nounced ligament laxity and consequently the greater side of the foot (particularly that of the tibialis anterior tensioning effect soon starts to decline. Recurrences are muscle) are constantly overstretched, thus preventing frequent after this operation. Lowman himself was also them from performing their postural function at all. Our aware of this and proposed an additional arthrodesis of prescription for the insert is as follows: Derotation insert the talonavicular joint. However, since this completely with central medial arch support and a supination wedge.

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A correc- following sites: tion x-ray with internal rotation can provide information ▬ the thigh discount 600mg trileptal visa, about the precise neck-shaft angle configuration ( Chap- ▬ the pelvis buy cheap trileptal 300 mg on line. While an anteverted hip in association with hip dys- Femoral osteotomies as joint-correcting measures plasia used to be surgically corrected (at least in Europe) Operations on the femur can be performed at the follow- up until the 1970’s safe trileptal 150mg, the value of this correction is now dis- ing sites: puted. In the USA, even then, preference tended to be giv- ▬ intertrochanteric, en to acetabular roof reconstruction. In recent years, the ▬ subtrochanteric, belief that acetabular roof reconstruction is better than in- ▬ on the greater trochanter (trochanteric transfer). Indications for joint-correcting measures Age Finding Operation <2 years – Joint-correcting operations not usually indicated 2–8 years AC angle >25°, flat lateral epiphysis Salter pelvic osteotomy, poss. The latter procedure also has the disadvantage that revalgiza- tion frequently recurs during the course of subsequent growth. At least the intertrochanteric derotation/varus osteotomy has a secondary effect on the acetabulum, im- proving the shape of the acetabulum directly by altering the pressure distribution. The principle of the 3 intertrochanteric osteotomy is shown in ⊡ Fig. An anteverted hip on its own, without the presence a b of hip dysplasia, does not constitute an increased risk for ⊡ Fig. On the other hand, a retroverted hip is and fixation with 90° angled blade plate; a preoperatively, b post- definitely carries a significant risk for early osteoarthritis operatively because of impingement. 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, since the trochanteric apophyseal plate is not affected by the necrosis. This configuration will result in abductor weakness of varying severity. A femo- ral neck lengthening osteotomy can be performed to restore the proper biomechanical configuration. Principle of the femoral neck lengthening osteotomy partially compensated at the same time. 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.

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In a mation order trileptal 150mg on-line, the widening of the bone and possible fallen frag- case of juvenile osteoporosis it is the increased incidence ments ( Chapter 4 cheap trileptal 300 mg otc. Outside the proximal humerus or femur purchase 600 mg trileptal amex, solitary bone cysts are extremely rare. Fractures in the vicinity of Pathophysiology fairly major osteolysis should therefore always be inves- The natural remodeling process in the bone is based on tigated carefully before the fracture is stabilized with a microfractures after loading, which then trigger osteo- contaminating measure. This is a natural process that enables the bone to be strengthened during correspond- ing loading. On the other hand, the sustained absence of loading will lead to a predominance of the resorption process and thus to osteoporosis. Any subsequent local overloading that occurs will lead to an imbalance between resorption and new bone formation and thus to a stress fracture. Periosteal and endosteal proliferation in the sur- rounding area attempt to compensate for the weakening of the bone, which leads to characteristic sclerosis of the bone surrounding the resorption zone. Etiology, history A triggering factor is repetitive trauma, usually caused by the excessive practicing of a particular sport. Load-related symptoms that worsen as the load increases and the ab- sence of pain at night are characteristic of stress fractures. This point is extremely important for the differentiation from an osteoid osteoma, primarily chronic osteomyelitis or even a Ewing sarcoma, any of which can appear very similar in the imaging investigations. Imaging investigations, differential diagnosis a b Several weeks usually elapse between the onset of the first symptoms and the appearance of the stress fracture on a ⊡ Fig. The primary changes in the cortical bone are old boy with extensive Ewing sarcoma an ill-defined cortex and/or intracortical striation. In the cancellous bone, rapid disappearance of the pain and the regression of slightly blurred trabecular margins appear next to scle- the radiographic findings confirm the accuracy of the rotic and radiodense areas. If the symptoms have not subsided after four is provided by a Tc-99m bone scan, which can show weeks, an MRI scan should be arranged. If the findings increased uptake even if the x-ray findings are negative. The increased uptake is usually not as findings are strongly positive, the cast fixation may need pronounced as for an osteoid osteoma, but is similarly to be extended to eight weeks. In a primarily chronic osteomyelitis (which can also show sclerosis as well as fine osteolysis on the plain x- 4. A (fine-slice) CT scan is Sports injuries have become increasingly common in ideally suited for visualizing the fracture line. Ac- extremely sensitive and usually shows marked edema or cording to recent surveys, and averaged across all age an accumulation of fluid (often outside the bone as well), groups, they constitute the commonest cause of injury which readily raises the suspicion of a Ewing sarcoma. Male adolescents in particular appear to be ex- If the history is typical, the MRI scan should therefore posed to a fairly high risk in sport. However, the ap- be performed only after a failed attempt at conservative proximately five-fold increase since 1950 in the relative treatment, otherwise the risk of an unnecessary biopsy is proportion of sports injuries has been brought about by very high. The increasing significance of sports traumatol- If the history is fairly typical and imaging investiga- ogy should not obscure the fact that it is not sport tions reveal the appropriate findings, then treatment that poses the main health risk to children and ad- with cast fixation should be initiated without further olescents, but rather the increasing lack of exercise investigation (MRI) if this is permitted by the site of and the associated obesity and declining physical the fracture. The main health risk to children and adolescents is not sport, but rather the increasing lack of exercise... Sport – a health policy issue Despite the glamour of top-class sport, our hypokinet- ic society with over one-third of »exercise-neglecting« adults is a striking reflection of our difficulty in convey- ⊡ Fig. Stress fracture of the tibial shaft in a 14-year old boy (lateral ing to children the idea of sport for life. Note the fine, ill-defined fracture line and the slight thickening can be successfully associated with positive emotions of the cortical bone anteriorly will it be possible to create the basis for lifelong sport 540 4. The best way of achieving this in young athletes are properly met, the orthopaedist must, the long term is with daily, playful exercise lessons during on the one hand, provide sound medical follow-up care the first years of school or, even better, at preschool age, in relation to their particular sport and, on the other, when the motor learning skills are at their peak. More include parents, and possibly trainers and teachers, in the generally, sport and the promotion of exercise must also treatment and rehabilitation process. Not infrequently become an important political health issue in the context the promising young athlete must be protected from the of primary and secondary prevention, particularly in a excessive ambitions of parents who seek to find their society that focuses on repair-based medicine.

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Some journals request that you check your spelling using the Oxford English Dictionary trileptal 150mg on line, others specify the Macquarie Dictionary or Webster’s Dictionary buy trileptal 150 mg line. It is best to know about the quirks of your journal of first choice so that you can adopt their format early in the piece cheap trileptal 300mg on-line. To expedite the publication of your work, try to be realistic and choose the right journal first time. However, if your paper is rejected and you decide to submit it to a second journal, then keep in mind that some journals request that you also send the previous reviewers’ comments plus your responses. The editor will want to be assured that you have addressed and/or amended any problems that have already been identified. There are no published statistics about journal shopping 20 Getting started practices, but an editor will obviously not be interested in a paper that has been rejected from other journals on the basis of fundamental problems with study design. Remember that if you do submit to another journal, reading the instructions to authors and modifying the manuscript accordingly will improve your chances of publication. This may also save you time because many journals will automatically return papers that do not meet their standards. A study by researchers at Stanford University suggested that prestige, whether the journal usually publishes papers on a particular topic, and reader profiles are important factors that influence decisions about where to send a manuscript. In the end, your decision on where to send your paper will be based on many factors and, in deciding, you will need to respect the advice of your colleagues and coauthors. Uniform requirements The Uniform Requirements are instructions to authors on how to prepare manuscripts, not to editors on publication style. International Committee of Medical Journal editors (www3) All draft papers should be prepared in a format that is consistent with the “Uniform requirements for manuscripts submitted to biomedical journals”. The group naturally became known as the Vancouver group and the standard format is still referred to as Vancouver format. The first uniform requirements for manuscripts and recommendations for formatting references were published in 1979, and an updated version can now be accessed via the world wide web (www3). The Vancouver group eventually evolved into the International Council of Medical Journal Editors (ICMJE) who publish the uniform requirements on their website. The ICMJE uniform requirements have been revised at intervals 21 Scientific Writing since their inception and are now widely adopted by the majority of medical journals. If you are writing a scientific paper, you need to be conversant with these standardised requirements for formatting both your paper and your reference list. Although some journals still have significantly different format requirements for references, the advent of reference database software (www4) means that lists can be more easily changed to different formats. Over 500 journals now use the ICMJE uniform requirements and either cite the document or make reference to it in their instructions to authors. The uniform requirements are clear and concise instructions to authors on how to prepare a manuscript for submission to a journal and which style to adopt. In the event of the acceptance of your paper for publication, the copy editor may ultimately change your style. However, regardless of publication style, many journals still require papers to be submitted according to the standard uniform requirements. Too few authors do this, but there is little point in writing a 400 word introduction when the journal has a limit for the whole article of 600 words. Richard Smith20 Although many journals require papers to be submitted according to the uniform requirements, each journal also has its own instructions to authors that are published on the journal website or in the printed copy of the journal. Sometimes the instructions are only published once or twice a year, for example, JAMA publishes its instructions to authors in January and July. The instructions to authors for many journals can be accessed via a central Medical College of Ohio website (www5). As soon as you have decided where to submit your paper, you should obtain the instructions to authors, read them carefully, make note of all of the relevant points, and then read them carefully again. In addition to requiring papers to conform to the uniform requirements, each journal often lists its own specific submission requirements.

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