By T. Givess. Grand Canyon University.
This degree of limb length discrepancy has to be addressed for standing with the use of a major shoe lift and in sit- ting with a cutout of the seat buy 30caps himplasia amex. If this discrepancy occurs in young growing children buy 30 caps himplasia amex, the leg length discrepancy is equalized by contralateral femoral epiphyseodesis after careful monitoring with scanograms. However, it is difficult to predict precisely how much remaining growth is present in non- ambulatory children. Another option to gain leg length equality is a varus shortening osteotomy on the long side. Dislocated Hip Leg length discrepancy may be a sign of a dislocated or subluxated hip, which should be ruled out with an appropriate radiograph. When hip dislocation is causing limb length discrepancy, the hip needs to be treated according to the indications for treatment previously discussed. Pelvic Obliquity Leg length discrepancy secondary to pelvic obliquity may be caused by asym- metric contractures in the windblown deformity. However, this discrepancy also occurs as a suprapelvic pelvic obliquity coming from significant scolio- sis. In general, children with CP who develop a suprapelvic pelvic obliquity actually tend to lean into the scoliosis in such a way that the pelvis may be relatively straight when they are sitting. Other adaptive mechanisms to accommodate this pelvic obliquity may also be required until the discrepancy is surgically corrected. Heterotopic Ossification Heterotopic ossification in children with CP has been a problem only at the hip. It tends to occur after hip surgery, especially if the hip surgery is done concurrently with or in close proximity to spine surgery. Ossification of the hip has been reported to occur following hip surgery that is concurrent with spinal fusion110 or dorsal rhizotomy.
A serous membrane lines this fi- Thyroid gland brous sac and folds back at the base to Trachea Base of heart cover the heart’s surface cheap himplasia 30caps otc. Anatomi- cally cheap himplasia 30 caps with amex, the outer layer of this serous membrane is called the parietal layer, and the inner layer is the visceral layer, Right Left also known as the epicardium, as pre- lung lung viously noted. A thin film of fluid be- tween these two layers reduces friction as the heart moves within the peri- Ribs (cut) cardium. Normally the visceral and parietal layers are very close together, but fluid may accumulate in the region between them, the pericardial cavity, under certain disease conditions. Checkpoint 14-1 What are the names of the innermost, middle, and outermost lay- ers of the heart? Diaphragm Pericardium Apex of heart Checkpoint 14-2 What is the name of the Figure 14-1 The heart in position in the thorax (anterior view). THE HEART AND HEART DISEASE 285 Table 14•1 Layers of the Heart Wall LAYER LOCATION DESCRIPTION FUNCTION Endocardium Innermost layer of the Thin, smooth layer of epithelial Lines the interior of the chambers and heart wall cells covers the heart valves Myocardium Middle layer of the heart Thick layer of cardiac muscle Contracts to pump blood into the arteries wall Epicardium Outermost layer of the Thin serous membrane Covers the heart and forms the visceral heart wall layer of the serous pericardium Heart wall Epicardium (visceral pericardium) Myocardium Endocardium 14 Visceral pericardium Pericardial cavity Serous pericardium Parietal pericardium Fibrous pericardium Figure 14-2 Layers of the heart wall and pericardium. The serous pericardium covers the heart and lines the fibrous pericardium. ZOOMING IN Which layer of the heart wall is the thickest? Table 14•2 Layers of the Pericardium LAYER LOCATION DESCRIPTION FUNCTION Fibrous pericardium Outermost layer Fibrous sac Encloses and protects the heart; anchors heart to surrounding structures Serous pericardium Between the fibrous Doubled membranous sac with fluid Fluid reduces friction within the pericardium and the between layers pericardium as the heart functions myocardium Parietal layer Lines the fibrous Serous membrane Forms the outer layer of the serous pericardium pericardium Visceral layer Surface of the heart Serous membrane Forms the inner layer of the serous pericardium; also called the epi- cardium 286 CHAPTER FOURTEEN the human heart is really a double pump (Fig. The right side pumps blood low in oxygen to the lungs through the pulmonary circuit. The left side pumps oxygenated Intercalated disk blood to the remainder of the body through the systemic circuit. Each side of the heart is divided into two chambers. Nucleus Four Chambers The upper chambers on the right and left sides, the atria (A-tre-ah), are mainly blood-receiving chambers (Fig. The lower chambers on the right and left side, the ventricles (VEN-trih-klz) are forceful pumps. The chambers, listed in the order in which blood flows through them, are as follows: Figure 14-3 Cardiac muscle tissue viewed under the mi- 1. The right atrium (A-tre-um) is a thin-walled chamber croscope ( 540).
The cuboid is then reduced to the calcaneus by excision of the calcaneocuboid joint and insertion of a graft purchase himplasia 30caps, which will lengthen the lateral column and reestablish the peroneal arch cheap himplasia 30 caps visa. Next, the navicular should be reduced to the talus and an excision of the medial cuneonavicular joint performed with the goal of at least fusing the talonavicular and cuneonavicular joints. Each of these joints has to be rigidly immobilized with either a plate, typically used on the calcaneocuboid joint, or internal fixation with strong K-wires, usually used on the medial column. Tendon Achilles lengthening and other tertiary deformities as indi- cated are corrected at the same time. Physical examination demonstrated severe but flexible This error caused him to develop high lateral foot weight planovalgus deformities of the feet. There were no toe bearing, as the medial column would not bear weight. Be- deformities, and torsional alignment was external foot cause of poor knee control and tendency for back-kneeing, progression of 30°. He was very crutch use dependent and he used AFOs, which were of some help; however, due to he was a functional community ambulator. Radiographs the crutch use, he would still back-knee with the AFOs. He had a subtalar fusion ing any of the deformities that are present at the time of with a lateral column lengthening (Figure C11. There are many case series reports, especially of subtalar fusion for planovalgus feet in children with CP. Most of these reports focus on nonunion rates, or the need for additional surgery as an outcome assessment. Many publications also report different technical methods for doing the procedure; however, the end result tends to be similar. In general, using different evaluation criteria for subtalar fusions, which are by far the most commonly reviewed proce- dures for planovalgus feet in children with CP, 70% to 90% of the children with subtalar fusions are reported to do well. The outcome of triple arthrodesis has shown a high rate of developing degenerative arthritic changes in the ankle joint on long-term follow-up. Another short-term study demonstrated that children do better if the triple arthrodesis is done before the deformity is so severe that they stop walking. The ex- traarticular osteotomy, in which the osteotomy is made at the level of the calcaneal tuberosity, is similar to the Dwyer osteotomy for varus deformity; however, in the planovalgus foot, the osteotomy is displaced medially.
