By R. Ismael. Hollins University.

Karbowski A discount estrace 1 mg on-line women's health clinic puyallup wa, Schwitalle M discount estrace 2mg with amex menstrual medication, Eckardt A (1999) Skoliose bei Pati- of brace treatment of scoliosis in Marfan syndrome. Spine 25: enten mit Osteogenesis imperfecta: Eine bundesweite Quer- 2350–4 schnittstudie. Kreiborg S, Barr M Jr, Cohen MM Jr (1992) Cervical spine in the odontoid process in Morquio-Brailsford’s disease. Thomeer R, van Dijk J (2002) Surgical treatment of lumbar ste- dominal musculature mechanism in maintaining spinal sagittal nosis in achondroplasia. Thompson D, Slaney S, Hall C, Shaw D, Jones B, Hayward R p719–22 (1996) Congenital cervical spinal fusion: a study in Apert syn- 19. Pediatr Neurosurg 25: p20–7 Review of the literature and analysis of thirty-eight cases. Tolboom N, Cats EA, Helders PJ, Pruijs JE, Engelbert RH (2004) diatr Orthop 14: 63–73 Osteogenesis imperfecta in childhood: effects of spondylodesis 20. Legrand B, Filipe G, Blamoutier A, Khouri N, Mary P (2003) Péné- on functional ability, ambulation and perceived competence. Vitale M, Guha A, Skaggs D (2002) Orthopaedic manifestations Mot 89:57–61 of neurofibromatosis in children: an update. Lipton GE, Guille JT, Kumar SJ (2002) Surgical treatment of sco- 107–18 liosis in Marfan syndrome: guidelines for a successful outcome. Widmann R, Bitan F, Laplaza F, Burke S, Di Maio M, Schneider R J Pediatr Orthop 22:302–7 (1999) Spinal deformity, pulmonary compromise, and quality of 22. McMaster MJ (1994) Spinal deformity in Ehlers-Danlos syn- life in osteogenesis imperfecta. Wynne-Davies R, Gormley J (1985) The prevalence of skeletal (Br) 76: 773–7 dysplasias. Occurrence A Canadian study investigated 3,200 patients, including 174 who were still in the growing phase (5. While children are less likely to suffer a spinal injury than adults, when a child does sustain such an in- jury, the risk of an associated neurological lesion is much higher than for adults. The incidence of spinal cord injury is around 30– 40/1,000,000 inhabitants [9, 22]. Another study on cervical spine injuries found that these occurred less frequently in children under 11 than in adults, but were associated with a high mortality. The incidence of cervical spine injuries in over-11-year olds matches that in adults and was cited as 74/1,000,000 of the popula- tion/year. Distribution of fracture levels in children and adolescents (after). Fractures at the thoracic level are commonest in this age Etiology group, but rarely occur at this site in adults Traffic accidents and falls from a great height are the predominant causes of injury in children under 10 years [7, 16, 21]. In adolescents, on the other hand, sporting accidents are the commonest cause. In our own investiga- to the fact that the thorax is much more elastic in children tion, the sporting activity that resulted in (severe) and adolescents than in adults. A second frequency peak spinal injuries was skiing in 33% of cases, swimming for the pediatric age group was observed for the thoraco- in 13%, horse riding and gymnastics both in 12% of cases, lumbar junction, where most of the adult fractures also mountaineering in 8%, paragliding in 4% and diving in occur. An increased frequency of accidents has Classification also been reported for trampolining. The risk of spinal A special feature of pediatric spinal trauma is traumatic injuries during skiing is higher in adolescence than either paraplegia without any detectable changes on the x-ray before or after this period. By contrast, the currently (known as SCIWORA syndrome, which stands for spinal popular youth-oriented sport of snowboarding does not cord injury without radiographic abnormality). Such appear to involve an increased risk of spinal injuries (in injuries are not included in the usual classifications since contrast with injuries to the upper extremities) as the they do not produce any radiographically visible lesion. The injuries with radiographically visible frac- Localization tures can be classified as for adult fractures. The principal sites of injury in adults are the lower cervi- cal spine and the thoracolumbar junction (T11–L3). In general, lesions of the lumbar spine are more common To this end we use the AO classification, in which the than cervical injuries. With the exception of vertebral fractures are subdivided according to the mechanism bodies T11 and T12, fractures of the thoracic section are of injury: extremely rare. By contrast, in our own study with A: Compression 51 children and adolescents with 113 fractures we found B: Distraction that the thoracic spine was actually the most frequently C: Torsion affected site of injury (⊡ Fig.

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For gression discount 1 mg estrace visa women's health clinic ne calgary, sagittal profile buy 1 mg estrace amex pregnancy 9 months, rotation, the extent of the this reason, a posterior spondylodesis should never be countercurve, compensation options, alignment, etc. Recommendations for the surgical treatment of congenital scolioses Anomaly Treatment Wedge vertebra, block vertebra, butterfly vertebra Generally no treatment Single lateral hemivertebra of the mid and lower Generally no treatment thoracic or lumbar spine Single dorsal hemivertebra of the mid and lower Hemivertebrectomy from a posterior approach thoracic or lumbar spine Single hemivertebra of the cervical, upper thoracic Hemivertebrectomy from an anterior and posterior approach or lumbosacral spine Double hemivertebra, whole spine Hemivertebrectomy from an anterior and posterior approach Unilateral bar Instrumentation with VEPTR Unilateral bar and contralateral hemivertebra Instrumentation with VEPTR, possibly hemivertebrectomy in addition Intraspinal deformity Neurosurgical resection References 15. Bächli H, Wasner M, Hefti F (2002) Intraspinale Missbildungen– gotic twins. Bradford DS, Heihoff KB, Cohe M (1991) Intraspinal abnormalities spine deformities for intraspinal anomalies with magnetic reso- and congenital spine deformities: A radiographic and MRI study. Brouwer I, van Dusseldorp M, Thomas C, van der Put N, Gaytant M, in congenital scoliosis: a preliminary report. J Pediatr Orthop 11: Eskes T, Hautvast J, Steegers-Theunissen R (2000) Homocysteine 527–32 metabolism and effects of folic acid supplementation in patients affected with spina bifida. Campbell R, Smith M, Mayes T, Mangos J, Willey-Courand D, Kose N, Pinero R, Alder M, Duong H, Surber J (2003) The characteristics 3. Campbell R, Hell-Vocke AK (2003) Growth of the thoracic spine in Congenital, unilateral contraction of the sternocleido- congenital scoliosis after expansion thoracoplasty. J Bone Jt Surg (Am) 85: 409–20 mastoid muscle with inclination of the head towards the 6. Campbell R, Smith M, Mayes TV, Mangos JA, Willey-Courand DB, side of the shortened muscle, rotation towards the oppo- Kose N, Pinero RF, Alder ME, Duong HL, Surber JL (2004) The ef- site side and facial asymmetry. Connor JM, Conner AN, Connor RA, Tolmie JL, Yeung B, Goudie For a long time it was assumed that congenital muscular D (1987) Genetic aspects of early childhood scoliosis. Am J Med torticollis was caused by birth trauma during delivery Genet 27: 419–24 from a breech presentation. Dickson RA, Stamper P, Sharp AM, Harker P (1980) School screen- explain why a pulled muscle should result in a permanent ing for scoliosis: cohort study of clinical course. Jarcho S, Levin PM (1938) Hereditary malformations of the verte- lesion heals up more or less completely without any bral bodies. Lawhon SM, Mac Ewen GD, Bunnell WP (1986) Orthopaedic from a breech presentation nowadays, since a cesarean aspects of the VATER association. J Bone Joint Surg (Am) 68: section is generally performed for this intrauterine posi- 424–9 tion. McMaster M, Ohtsuka K (1982) The natural history of congenital scoliosis. McMaster MJ (1984) Occult intraspinal anomalities and congenital examination of biopsy preparations taken during surgical scoliosis. J Bone Joint Surg (Am) 66: 588–601 treatment revealed any form of hemosiderin deposits 13. Poussa M, Merikanto J, Ryoppy S, Marttinen E, Kaitila I (1991) The such as would be expected after a pulled muscle. Spine 16: 881–7 congenital muscular torticollis is indeed often associated 14. Purkiss S, Driscoll B, Cole W, Alman B (2002) Idiopathic scoliosis in families of children with congenital scoliosis. Clin Orthop with a breech presentation, it has probably nothing to do 401:27–31 with the birth process. Microscopic examination reveals a fibrosis of the children, the sternocleidomastoid muscle is palpable as a muscles that is sometimes seen after necrosis. An ab- tough cord, and it usually easy to detect whether the cla- normal intrauterine posture may be a contributory factor vicular part, the sternal part or both parts are shortened. The A clicking sound is also occasionally elicited by a stretch- occurrence of torticollis in families has been observed. Imaging is not usually necessary 3 Ocular causes are not infrequently involved. X-rays of the cervical spine Congenital muscular torticollis is relatively common, al- are often difficult to interpret in patients with muscular though corresponding epidemiological figures are not torticollis since the bony structures are distorted and the available. In a study in Japan involving 7,000 infants, the vertebral bodies are not shown in the standard projection. The facial asymmetry is not just present as a primary sign, but can also develop secondarily or become Clinical features, diagnosis exacerbated if the torticollis persists for a prolonged Congenital muscular torticollis can be diagnosed on the period. Furthermore, the patient’s brain becomes basis of purely clinical criteria. On palpation of the con- accustomed to the oblique position, which is even- tracted sternocleidomastoid muscle, the doctor can fre- tually sensed as »straight« by the child itself.

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Wakefield RJ purchase estrace 1mg line breast cancer keychains, Kong KO 2mg estrace sale menopause goddess, Conaghan PG, et al (2003) The role of ultrasonography and magnetic resonance imaging in early rheumatoid arthritis. Clin Exp Rheumatol 21(5 Suppl References and Further Reading 31):S42–S49 20. Eich GF, Superti-Furga A, Umbricht FS, et al (1999) The sonography of the metatarsophalangeal joints in rheuma- painful hip: evaluation of criteria for clinical decision- toid arthritis: comparison with magnetic resonance imag- making. Eur J Pediatr 158(11):923–928 ing, conventional radiography, and clinical examination. Kemp HS, Boldero JL (1966) Radiological changes in Arthritis Rheum 50(7):2103–2112 Perthes’ disease. Castriota-Scanderbeg A, Orsi E, De Micheli V, et al (1993) eletal ultrasound—a state of the art review in rheuma- Ultrasonography in the diagnosis and follow-up of hip pain tology. Part 2: Clinical indications for musculoskeletal in children (in Italian). Hoving JL, Buchbinder R, Hall S, et al (2004) A comparison ders by radiography, radionuclide scanning and magnetic of magnetic resonance imaging, sonography, and radiogra- resonance imaging. J Formos Med Assoc 92(8):737–744 phy of the hand in patients with early rheumatoid arthritis. Wilson DJ, Green DJ, MacLarnon JC (1984) Arthrosonog- J Rheumatol 31(4):663–675 raphy of the painful hip. Adam R, Hendry G, Moss J (1986) Arthrosonography of the and power Doppler sonographic changes induced by intra- Inflammatory Disorders 65 articular steroid injection treatment. Marin C, Sanchez-Alegre ML, Gallego C, et al (2004) Mag- Clin Rheumatol 23(4):285–290 netic resonance imaging of osteoarticular infections in 25. Kleinman PK (2002) A regional approach to osteomyelitis 213(5):271–276 of the lower extremities in children. Robben SG (2004) Ultrasonography of musculoskeletal 40(5):1033–1059 infections in children. Aloui N, Nessib N, Jalel C, et al (2004) Acute osteomyelitis print) in children: early MRI diagnosis (in French). Trusen A, Beissert M, Schultz G, et al (2003) Ultrasound Pt 1):403–408 and MRI features of pyomyositis in children. Santiago Restrepo C, Gimenez CR, McCarthy K (2003) 13(5):1050–1055 Imaging of osteomyelitis and musculoskeletal soft tissue 28. Connolly LP, Connolly SA, Drubach LA, et al (2002) Acute infections: current concepts. Rheum Dis Clin North Am hematogenous osteomyelitis of children: assessment of 29(1):89–109 Soft Tissue Tumours in Children 67 5 Soft Tissue Tumours in Children Gina Allen CONTENTS 5. References and Further Reading 82 In general any lesion that is solid (echogenic) or partly solid should be investigated further. When there is a clear history of injury and a partly echogenic lesion is found, then it often may be fully assessed 5. However, this must only be performed with Introduction considerable caution as there are occasions where a malignant lesion haemorrhages, hiding the original The finding of a lump by a child or parent is always neoplasm. Although a good history and a definite diagnosis of haematoma from a single US examination can often go a long way in determin- examination. A haematoma, in the early phases, can ing whether a lesion needs further investigation, be solid and echogenic but it will liquefy over the next imaging can often completely reassure the patient few weeks and then resolve. This inevitable alteration and parents that the lesion is benign, permitting in pattern can be used to diagnostic advantage. Whilst soft tissue lowing such a lesion by additional US examination tumours in children are rarely malignant, it is can be invaluable—watching the “swelling” liquefy important to make an early diagnosis when they over a period of days or weeks until its resolution are! An area of injury that becomes “softer” and “smaller” is in keeping with a haematoma. A lump should never be labelled as a haematoma with- out confirmation of resolution by serial US examina- G. Allen, DCH, MRCP, FRCR The Royal Orthopaedic Hospital NHS Trust, Bristol Road tions, thereby avoiding the rare but significant risk South, Northfield, Birmingham, B31 2AP, UK of overlooking a malignant tumour with secondary 68 G.

Other causes to consider include In 1995 quality 2mg estrace feminist women's health center birth control, the American Medical Society for Sports hyperthyroidism estrace 1 mg without prescription breast cancer types, inflammatory bowel disease, bacte- Medicine (AMSSM) and the American Academy of rial colitis, and antibiotic-induced colitis. Sports Medicine (AASM) stated that mandatory HIV The history should focus on travel, hobbies, animal con- testing should not be a requirement for competitive tacts, antibiotic usage, dietary habits, and ill contacts. Exercise during maximum 16 mg a day), and bismuth subsalicylate such an infection does not alter its length or severity (262 mg, 2 qid prn). Other respiratory viruses, such patients who are toxic, febrile, or are having bloody as influenza virus (Blair et al, 1976; O’Connor et al, diarrhea. Lomotil contains atropine and causes anti- 1979), however, have been shown to impair pul- cholinergic side effects (Fenton, 2000). If symptoms worsen, the workout should orally qid) for 10–14 days (Gilbert, Moellering, and end and the athlete should rest until symptoms Sande, 2002). Exercise should be delayed until below the neck symptoms have resolved (Eichner, 1993). First, training lymphocyte, CD4, and CD8 counts or the CD4:CD8 with below the neck symptoms hampers the workout ratio (Terry, Sprinz and Ribeiro, 1999). Second, without a resistance training increases lean body mass and medical evaluation athletes may not realize the severity 180 SECTION 3 MEDICAL PROBLEMS IN THE ATHLETE of their illness (Eichner, 1993). Phys sion of Norwalk virus during a college football game Sportsmed 23:63, 1995. Gilbert DN, Moellering RC, Sande MA: The Sanford Guide to Antimicrobial Therapy, 32nd ed. CONCLUSION Gleeson M et al: Immune status and respiratory illness for elite swimmers during a 12-week training cycle. Int J Sports Med Moderate exercise seems to be an immune stimulant 21:302, 2000. Gleeson M et al: Salivary IgA levels and infection risk in elite while intense exercise causes immune suppression. There are no reliable immune markers, however, that Goodman J: The immune response, in Stites D Terr A (eds. Norwalk, CT, Appleton & When athletes become ill proper care and advice can Lange, 1991, p 34. Hayden FG et al: Effectiveness and safety of intranasal iprat- Athletes with HIV can safely exercise without fear of ropium bromide in common colds. Ann Int Med 125:89, affecting their own illness or increasing the risk of 1996. Heath GW et al: Exercise and the incidence of upper respiratory Slowing or suspending training according to the “neck infections. Klentrou P et al: Effect of moderate exercise on salivary immunoglobulin A and infection risk in humans. Kostka T et al: The symptomatology of upper respiratory tract infections and exercise in elderly people. Levy BT, Kelly MW: Common cold, in Griffith’s 5 Minute AMSSM, AASM: Human immunodeficiency virus and other Clinical Consult. Baltimore, MD, Lippincott, Williams, and blood-borne pathogens in sports: The American Medical Wilkins, 1999, p 246. Society for Sports Medicine (AMSSM) and the American Lillegard WA, Butcher JD, Rucker KS: Handbook of Sports Academy of Sports Medicine (AASM) joint position state- Medicine: A Symptoms Oriented Approach, 2nd ed. Birkebaek NH et al: Bordetella pertussis and chronic cough in MacKinnon LT, Hooper S: Mucosal (secretory) immune system adults. Am Rev Respir Dis 114:95, F RM: Infectious mononucleosis in the athlete: Diagnosis, dom- 1976. Fam Masters PA, Weitekemp MR: Community-acquired pneumonia, Pract News 32(16):36, 2002. Bruunsgaard H et al: In vivo cell-mediated immunity and vacci- Matthews DE et al: Moderate to vigorous physical activity and nation response following prolonged, intense exercise. Eichner R: Infection, immunity, and exercise: What to tell Mayer M, Wanke C: Acute infectious diarrhea, in Rakel RE (ed. Philadelphia, PA, Sanders Fagnan LL: Acute sinusitis: A cost-effective approach to diagno- 1999, p 13. McDonald W: Upper Respiratory Tract Infections, in Fields and Fahlman MM et al: Mucosal IgA response to repeated Wingate Fricker (eds.

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