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If the fracture reduction appears stable serves as a pointer: On the AP view it shows a tent-shaped elevation (a) order protonix 40 mg free shipping, on the lateral view it appears straight and runs at right angles to under the image intensifier purchase 20mg protonix with amex, the follow-up treatment is the the shaft (b) application of a Gilchrist bandage for 2 weeks. The possibility of child abuse must be ruled out particularly in under 3-year olds. Humeral fractures account for almost two-thirds of all acute fractures discovered in cases of child abuse. Most humeral shaft fractures however are seen in adolescents, particularly as a result of direct trauma in sports-related and traffic accidents. Treatment of displaced fractures of the proximal humerus at the age of >12 years: The diagnosis usually readily confirmed by clinical ex- If the situation is unstable after closed reduc- amination (pain, swelling, deformity). Careful identifica- tion in patients older than 12 years of age tion and documentation of the neurovascular status is and an unacceptable degree of displacement essential. Radial nerve and, rarely, ulnar nerve palsies is present (>20°), it is advisable to stabilize occur in approx. In a case of a nerve palsy, we simply monitor the spontaneous course over 6–8 weeks. Recovery can be expected in over 80% of cases as these usually only Closed reduction and stabilization involve neurapraxia. If no improvement is observed clini- In cases of persistent instability or for patients aged over cally or on an EMG, the lesion should be explored and, 12, the fracture should be stabilized after reduction with depending on the findings, treated by neurolysis or a two flexible medullary nails inserted from the distal end graft to bridge any defect. In cases of open fractures with of the humerus on the lateral side (⊡ Fig. We do suspected nerve laceration, the nerve revision procedure not perform percutaneous Kirschner wire fixation since should be performed primarily in connection with the it interferes with early independent shoulder mobilization fracture treatment. Imaging investigations Open reduction AP and lateral x-rays of the humerus, including the hu- In the rare cases of fractures that cannot be reduced satis- meral head and elbow. Conservative Most axial deviations in humeral shaft fractures can be Follow-up controls managed with conservative measures: A consolidation x-ray after 4–5 weeks is indicated only for For simple, stable fractures (compression fractures, untreated deformities and after reductions with or without greenstick fractures), immobilization in an arm sling fixation.
Removal of all devitalized tissues and wound closure with vital homografts order 40mg protonix with amex, which close the wounds and provide growth factors protonix 40 mg with mastercard, lessen this likelihood. Treatment does not differ from that of massive superficial burns, as described in Chapter 7. BURN WOUND MANAGEMENTBASED ON THE SURGICAL APPROACH Two basic general surgical approaches apply in burn surgery. How burn wounds are managed during the initial period, will significantly affect the way the wound is managed topically. Time delay between burn injury and surgery is the key element in the two main surgical approaches. Early/serial burn wound excision Wound Management and Surgical Preparation 91 FIGURE 1 Protocol for treatment of indeterminate depth burn wounds. Once the master plan and management decision have been established, patients are treated conservatively for 10–14 days. These two main approaches differ in the timing of surgery, regardless of the type, diagnosis, and depth of the burn wound. The different philosophy in the surgical approaches resides in the general planning and the day surgery is started. The same burn wound may be treated successfully using either of the two ways, but differences in the postburn hypermetabolic and inflammatory response, blood loss, and possible sacrifice of viable tissue may result. Immediate Burn Wound Excision In this surgical approach all burn wounds are operated on within 24 h after the injury. Deep burns are excised and grafted, whereas superficial burns are treated with temporary skin substitutes. When this technique is utilized, topical manage- ment of the wound awaiting definitive surgical treatment includes the application of clean (nonsterile) plastic wrap or the application of petrolatum-based fine- 92 Barret and Dziewulski mesh dressings. It can also be applied nonsterile, but it can be purchased as long nonsterile rolls that can be easily autoclaved. Burn wounds are sterile early after burning, and colonization has yet to begin by the time patients are sent to the operating room. Within 24 h after the burn injury, all wounds are surgically closed either with grafts or temporary skin substitutes; therefore the application of topical antimicrobials is not necessary. Less expensive materials should be always used, since temporary dressings applied after burn wound as- sessment are to be removed in few hours.
The anteroposterior radiograph of the hip should be taken with the hips in a maximal position of extension with the knee in extension and the toes pointing directly upwards trusted 20mg protonix. Ultrasound can be extremely useful in documenting hip joint 37 Septic arthritis of the hip effusion buy discount protonix 40 mg. Suspicion alone of a septic hip, in the infantile group, should be immediately followed by a needle aspiration of the hip joint. Beyond the neonatal period, the clinical ﬁndings are identical; however, the sedimentation rate is routinely elevated (over 50 in near 90 percent of patients), and the temperature and white blood cell counts and C-reactive protein are usually elevated. Any evidence of a lytic lesion in the metaphyseal neck, or widening of the joint space, in combination with the previously noted ﬁndings, should be followed by needle aspiration of the hip. If purulent material is recovered on needle aspiration of the hip, the optimal treatment is immediate surgical drainage of the infection. Evacuation of all purulent material from the hip joint is necessary, and appropriate drainage should be carried out. Appropriate adjunct intravenous antibiotic therapy should be instituted in accordance with the recovery of an appropriate organism (Pearl 3. In the infantile group of patients it has been estimated that over 50 percent will develop one or more of the consequences of an intraarticular infection in the future. Haemophilus inﬂuenza Kingella kingae >3 years Staphylococcus aureus Adolescents Staphylococcus aureus Neisseria gonorrhea Common orthopedic conditions from birth to walking 38 consider this condition in every patient demonstrating hip irritation. Congenital vertical talus Perhaps the most rigid, and difﬁcult to manage, congenital affectation of the musculoskeletal system in children is congenital vertical talus. A majority of the cases reported in the past, treated by competent practitioners, has resulted in disappointing outcomes. It is imperative that primary care physicians recognize and appreciate foot ﬂexibility. Normally the foot and ankle can easily be mobilized through a full range of motion without evidence of joint stiffness. Stiffness is a characteristic of pathologic deformities of the foot, and is always present in congenital idiopathic clubfoot, and particularly in congenital vertical talus. Congenital vertical talus is recognizable at birth and is most commonly confused with a calcaneal valgus postural foot deformity (Figure 3. The latter condition is a benign postural change that occurs as a consequence of the foot being compressed against the uterine wall.