By M. Eusebio. Walden University.
A French study (Bajos ea cheap viagra soft 50 mg line erectile dysfunction treatment online, 2010) found that obese women are less likely to have had a recent sex partner compared to women of normal weight but that obese people have similar sex practices and enjoy sex as much as other people do; obese women buy viagra soft 50mg amex erectile dysfunction doctor in philadelphia, more than obese men viagra soft 50 mg online erectile dysfunction pills walgreens, are more likely to have an obese sex partner; and unplanned pregnancy and abortion are more likely among obese females because of reduced use of contraception discount 50mg viagra soft mastercard erectile dysfunction exercise video. Goldbeck-Wood (2010) suggests that contraception data, focusing on the ‘pill’ and condoms, be treated cautiously and that long acting reversible contraceptives are suitable for obese women. Management includes reduction in the dose of the offending drug and, if necessary, low a potency antipsychotic drug or anti- testosterone therapy. Only the imagination limits what has been found to be sexually arousing, varying as it has from sneezing to the wind. Paraphilic behaviour is more common in males, although the number of females thought to be affected may be underestimated. Multiple paraphilias in the same person (polymorphous perversity) is a common finding. Paraphiliacs have achieved officially sanctioned positions looking after children, e. Few paraphiliacs look for help before an offence and the history is usually one measured in years before the person is arrested. Perhaps 60% of paedophiles are heterosexual, although figures given for different sexual orientations by different sources may add up more than 100%! Paedophilic behaviour may commence in the late years of life as a consequence of the disinhibiting effects of dementia. Most children seem to become involved with paedophiles because of fear, but a few may be promiscuous and delinquent. Stekel, an Austrian physician and psychologist and one-time disciple of Freud, died from suicide in London. According to classic psychoanalytic theory, fetishism involves persistence of castration anxiety, anxiety being warded off by an uncommon belief that women possess a penis (therefore they won’t want to cut off the man’s penis)! Vogueing – dressing up as a celebrity to achieve arousal; trashcanners steal objects from dustbins of famous people for the same reason While the use of actual fetish objects is more common among males, fetishistic fantasies are possibly equally distributed between the sexes. Treatment is either aimed at extinguishing the fetish (aversion therapy) or helping all parties concerned to adapt to harmless fetishes. Consequences for the victim range from humiliation through beating 2040 2041 to rape or death. This is only a paraphilia if there is a compulsive quality to it and if it is preferred to actual sex with a partner. What is included here is real sadism and masochism rather than simulated masochism. Narratophilia is the seeking of arousal from hearing sexual stories, hybristophilia is arousal sought from criminals, and chrematistophilia is arousal from being forced to pay for sex or from being robbed by the sex partner. Triolism is the name given to the phenomenon whereby a man achieves sexual pleasure from watching his female partner having sex with another man. Fenichel, the psychoanalyst, stated that the transvestite creates a ‘phallic woman’ of himself to allay fears of castration (cf. Few people give up the practice completely despite any drawbacks they may encounter. The fetishistic transvestite is a male who wears female clothes as a fetish and masturbates while doing so; it is often associated with fetishism and masochism. Lastly, the homosexual transvestite, who is of either sex, is attracted, of course, to members of the same sex. It is important not to assume that someone who engages in cross-dressing has something wrong with him. Some men, independent of sexual orientation, find the experience to be a calming one. In fact, not every child with transsexualism retains this diagnosis into adulthood, although many boys who were transsexual as children will be homosexual or bisexual as adults. Many experts believe that gender identity disorder is part of a spectrum ranging from mild atypical gender behaviour through gender dysphoria to gender identity disorder. A collateral history is important to confirm the long-held belief of being trapped in a body of the wrong sex. Primary - always considered himself as being female, even as a child; does see himself as homosexual; 2046 does not report homosexual fantasies; likely to cope well with surgical sex reassignment 2047 Secondary - starts to feel that he is female at a later age, usually in adolescence ; less likely to do well after surgery; described as essentially homosexual or transvestite Transsexualism mimics – adolescence (a time of identity problems), effeminate homosexual males (transient wish for erotic reasons), borderline personality disorder (transient wish related to identity diffusion), and delusions (e. Zhou ea (1995) found that the central subdivision of the bed nucleus of the stria terminalis in the hypothalamus was smaller in male-to-female transsexuals than in normal males and akin in size to normal females. The authors did not believe that this finding could be attributed to hormone therapy. Transsexual people, who naturally do not like the word ‘disorder’, prefer the term transgender. Sex drive has been described as often being low and any sexual orientation is possible. Depression, substance abuse, personality disorder 2050 (borderline/dissocial/narcissistic ), parasuicide, self-mutilation (often to force surgical intervention), and divorce are common. In one study, Dutch psychiatrists considered that gender identity disorder was an epiphenomenon of other psychiatric conditions (especially personality, mood, dissociative, and psychotic disorders) in 270 (75%) of 359 patients. If the patient can live as a woman for a certain number of years he can, in some countries, have a sex change (surgery and hormones). A male-to-female transsexual was refused permission to change the name on the birth certificate in an Irish court in July 2002. In a case that divided medical opinion, a 13-year-old Australian girl was allowed hormone treatment as a possible prelude to later sex-change surgery. Some patients view psychotherapy with suspicion, viewing it as a way of discouraging surgical intervention. Snaith (1987) reported that about 70% of patients are satisfied with the results of gender reassignment. Perhaps the strongest predictor of psychological problems following surgery is level of satisfaction with the results of surgery. Oral androgens might be associated with increased risk of developing hepatocellular carcinoma. Surgical creation of a penis may fall short of expectations and such patients may need to accept non-penetrative sex. A man (most often young, and can be married) exposes his penis, in any state of tumescence, to a female from a safe distance in lonely surroundings, and there is rarely any physical contact. Exhibitionism begins early in reproductive life and becomes most frequent when the perpetrator is under stress. Exposure to minors, a history of non-sexual crimes, a previous conviction for exhibitionism, and exposure of an erect penis suggests recidivism. Rarely one comes across women who repeatedly expose their breasts, and very rarely one sees women who do the same with their genitalia. Coprophagia - eating of faeces, as the preferred method of achieving sexual arousal; may be part of a masochistic ritual; masochist may have to lick the sadist clean; coprophagia and coprophilia, the storing of 2053 faeces are usually associated with intellectual disability, the degenerative psychoses of childhood, and 2049 The De Gascun ea(2006) Dublin series consisted of 52 cases, 45 male to female, and 7 female to male. In some cases it may be pragmatic to make a fetish more acceptable to a partner, e. Group therapy, the effects of which are modest, aims include accepting responsibility, empathising with the victim, and nourishing true motivation for change/controlling behaviour. Drugs used for excessive (uncontrolled, dangerous) sexual drive: These drugs may be best for paraphilia patients with a high sex drive rather than for antisocial paraphiliacs with a low sex drive. Hormones do not guarantee absence of recidivism and they are not a stand-alone therapy. It is important that patients accept responsibility for their actions and that they become involved in psychotherapy.
The pseudoautosomal region of the sex chromosomes is a segment of sequence homology between the X and Y chromosomes in which meiotic cross-over (recombination) can occur purchase viagra soft 50mg amex erectile dysfunction obesity. Depending on its exact location generic 100 mg viagra soft amex erectile dysfunction heart disease diabetes, a gene situated within this region could be inherited either in an autosomal or in a sex-linked manner viagra soft 100 mg on line erectile dysfunction causes and solutions. Normally purchase viagra soft 100mg with amex erectile dysfunction herbs, one X chromosome exists in an inactive, packaged state, formed during the late blastocyst stage: heterochromatic Barr body. Some parts of the ‘inactivated’ X chromosome remain active, the so-called pseudoautosomal regions. They can be caused by the environment during life and then be passed on to progeny. Such processes can change phenotypes and might explain why major psychiatric disorders do not follow the Laws on Mendel and they may explain how environmental factors translate into biology. Chromatin configuration can allow it to be activated (open; euchromatin - can be accessed by transcription factors) or inactivated (condensed; heterochromatin – cannot be accessed by transcription factors). Rett syndrome and even some of the major ‘function disorders’ such as schizophrenia. Modern ideas of inheritance have been called ‘hard inheritance’ (you transmit to offspring only those characteristics with which you were born – based on ideas of Sir Francis Galton [1822-1911] an English eugenicist and polymath and relative of Charles Darwin, and those of Friedrich Leopold August Weismann [1834-1914] a German biologist and evolutionary theorist). Jean- Baptiste Lamarck (1744-1829), a French biologist, believed that the genetic basis of characters could be changed by factors such as the environment or disuse. Epigenetics, a modern concept, suggests that Lamarck may have not have been far wrong. They do not address the question of external validity or the likely clinical heterogeneity within a given diagnosis (e. Psychiatric disorders are probably heterogeneous, with different genetic and non-genetic mechanisms underlying different major genes, polygenetic forms, and environmental causes. The problem is made more complex by reduced penetrance and variable expressivity of the genotype. It may be that certain genes cause non- specific genetic predisposition to psychopathology, and that other genetic and non-genetic components are required to bring about a specific psychiatric disorder. Assortive mating refers to the tendency of people with a mental disorder to mate with a person with a similar disorder. We will come across this issue again in other chapters, especially when discussing schizophrenia. In fact, the ‘typical schizophrenic is more likely than not to have no schizophrenic or schizotypal relatives’. The Amish people, a small and isolated population with a small number of founders, are said to be prone to manic-depression: this group is likely to be genetically homogeneous, and the generality of the genetic findings to other populations remains to be determined (Egeland, ea, 1987). Many reports of linkage of psychiatric disorders to various chromosomes fail to be replicated, a fact that should temper enthusiasm for reported breakthroughs. When genetic predisposition is worked out, prospective studies of at-risk individuals to identify specific non-genetic factors that contribute to the development of illness can be designed. Terms Aetiological heterogeneity: this may result from having both genetic and environmental causes. Alleles: alternative forms, or versions, of the same gene, be they normal or abnormal. Alternative splicing: the manner in which different protein isoforms can be produced. For example, if a gene contained 4 exons and if all 4 exons were transcribed one would be left with a large isoform. Candidate genes: genes encoding for neuroreceptors, enzymes involved in neurotransmission, or other proteins that might play a part in the pathogenesis of a disorder. Previous evidence suggests that such genes 876 Geneticists use the term stochastic which simply means a random event. Barr bodies get there name from the Canadian physician Murray Llewellyn Barr (1908-95). Anticipation: a condition deteriorates clinically or manifests at an earlier age through successive generations, e. Autosomal dominant disorders: examples include achondroplasia, Huntington’s disease (gene at 4p16. Myotonic dystrophy is another example of a triplet (trinucleotide) expansion disorder. Trinucleotide repeat and age of onset are inversely correlated in Huntington’s disease: the more repeats the earlier the onset. Bands: certain stains, such as Giemsa, reveal that chromosomes have a specific banding pattern that allows their identification. Chromosomes can also be identified by, for example, length and position of centromere. Behavioural phenotype: The observed specific relationship between genotype of a syndrome and its behavioural or cognitive developmental profile and/or any specific association with comorbid psychiatric disorder. Examples include bipolar and schizophrenia-like states in the velocardiofacial syndrome, social anxiety in fragile X patients, and self-injury in Lesch-Nyhan syndrome. Presenilins code for a protein resembling G protein-coupled receptors and similar proteins are found in C. The latter proteins are involved in intracellular trafficking of proteins and may therefore be involved in apoptosis and β-amyloid protein processing. Candidate loci or genes: association studies of disorders and genes (or loci) are more useful if there is reason to believe from prior evidence that the gene or locus is involved in a phenotype, i. Skin pigmentation and tumour formation involving Schwann cells are found in these disorders. The two relatively common types are autosomal dominant conditions, often with fresh mutations. Here one finds peripheral neurofibromas, café-au-lait spots, and pigmented hamartomata of the iris (Lish nodules). Large subcutaneous plexiform neurofibromata may deform parts of the body such as face or limb. Tuberin and hamartin are associated with dysfunction neuronal and glial proliferation/differentiation. Centromere: constricted chromosomal region including site of attachment to spindle; divides chromosome into 2, usually unequal, lengths or ‘arms’. Chromatid: at the end of interphase each chromosome has divided along its length into 2 daughter chromosomes, or chromatids; these remain attached to each other at the centromere. Chromosome: one of a number of small bodies, found in pairs, into which the chromatin of a cell nucleus resolves itself before cell division; visible only during cell division, i. An ‘open reading frame’ is a full set of codons lying between start and stop codons. Coefficient of kinship: measure of expected proportion of genes in common between individuals: ½ for first-degree relatives, ¼ for second-degree relatives. Deep resequencing: a method for sequencing a gene in thousands of subjects, usually employing high- throughput sequencing in order to increase speed and reduce cost. Deletions: loss of whole or part of a chromosome; major deletions (partial monosomy) include Wolf- Hirschhorn (4p-) cri du chat (5p-); terminal deletions involve loss of the telomere; and interstitial deletion occurs within an arm of a chromosome. Dichotomous trait: traits that can only be present or absent, with no ‘shades of grey’. Drumstick: lobular projection from nucleus of polymorphonuclear leucocytes in females. The usefulness of endophenotypes as a simpler path to the genetics of psychiatric disorders has been questioned. Epistasis: 2 or more loci show a multiplicative interaction where the final result is greater than the sum of the effects of individual loci.
Participants had any or a combination istics of interactivity and meaningful play order viagra soft 50 mg amex erectile dysfunction 2015. Material and Methods: The present study was a randomized order viagra soft 50mg with visa erectile dysfunction protocol review article, reliability for all raters were substantial to almost perfect for the single-blinded controlled ongoing trial generic viagra soft 100mg on-line impotence of proofreading poem. Only the knee extension correlation was statistically a secondary outcome measurement purchase viagra soft 100 mg on line impotence drugs. Conclusion: Preliminary fndings suggest obtained at baseline and four weeks after intervention. Hindering factors of oral health care Motor Function test was not different between groups. This study was undertaken to examine the feasi- 1Charles University in Prague, The Third Faculty of Medicine and bility of strengthening training with a sliding rehabilitation machine General Teaching Hospital, Prague, Czech Republic, 2Rehabilita- on stroke patients with sensory aphasia. The charts of patients who admit- Introduction/Background: For a good quality of life and a success- ted to rehabilitation department form Jun 2012 to Nov 2015 were ful social and occupationally reintegration frst of all the dimension reviewed retrospectively. There are twenty four stroke patients with of neuropsychological disturbances and behavioral disorder after sensory aphasia. Center of this study is an Acceptability and side effects of sliding rehabilitation machine was analysis of behavioral disorders after stroke. And clinical parameters (Functional Ambulation Category, questions should be answered: how many patients in subacute dis- Berg Balance Scale, and Korean-Modifed Barthel Index) at admis- ease phase after stroke have defcits in behavior, which kind and sion and discharge were gathered. Results: Korean version of the degree are those defcits, are there any differences in behavioral National Institute of Health Stroke Scale at admission is 19. Functional Ambulation Category was changed form ioral disorders was made with the Neurobehavioral Rating Scale 0. For ognized, mainly – next to wellknown symptomatic of depression more generalized use, randomized controlled study is needed. Early comprehension of individually 1Myongji Choonhey Rehabilitation Hospital, Rehabilitation Medi- customized neuropsychological and behavioral therapy, accompa- cine, Seoul, Republic of Korea, 2Bundang Jesaeng General Hospital, nied by therapeutic care of the social and familiar environment, Rehabilitation Medicine, Bundang, Republic of Korea, 3Boon Dang could be expected as an important factor for improvement of rein- Best Hospital, Rehabilitation Medicine, Bundang, Republic of Korea tegration of these patients. Introduction/Background: The oral health care concerns are mainly related to mastication, dysphagia, nutrition, hygiene and quality of 456 life. Kawahira1 survey in 3 rehabilitation centers was conducted from Oct 8 to Nov 1Kagoshima University, Department of Rehabilitation and Physical 5, 2014, and 117 caregivers completed the questionnaire. All caregivers answered that oral health hibits the reuptake of serotonin and norepinephrine. However, only 83% of them received oral study to determine the non-inferiority of duloxetine in patients with health care training. This training was conducted by caregiver post-stroke depressive disorders against the selective serotonin reup- training programs (47. Material and Methods: A double-blind, parallel- took the form of a clinical demonstration or supervised practice. The effcacy and safety of duloxetine 60 mg/ Lodz, Poland day were also assessed in comparison with those at the standard dose of 40 mg/day. Conclusion: These results demonstrate that duloxetine ments were taken in standardized positions by one rater. The results 40 mg/day and 60 mg/day is superior to paroxetine in terms of ef- are displayed in newtons [N], mean values of muscular strength, ef- fcacy on post-stroke depression and central pain. Megumi1 clusion: Muscle force of (A) upper limb demonstrates 39% decrease 1 short time after stroke. Man shows more signifcant decrease than Kagoshima University, Department of Rehabilitation and Physical women (40% vs 35%). Grant of Kagoshima University Hospital, Department of Rehabilitation, Medical University of Lodz, Poland 502-03/5-127-05/502-54-173. Material and Methods: Two raters Medicine and Rehabilitation, Makassar, Indonesia, 3Hasanuddin (A and B) tested 38 post-stroke patients. For the intra-rater reliabil- Hospital, Physical Medicine and Rehabilitation, Makassar, Indo- ity investigation, rater A tested the participants on three separate test nesia occasions (days 1, 2, and 3) at the same time of day. For the inter- rater reliability investigation, raters A and B independently tested Introduction/Background: Cerebrovascular incident or stroke is the participants on the same test occasion (day 3). The classifcation will stratify the stroke survivor into vegetative, non-vegetative total dependency, minimally independ- ency, moderate independency, independent supervised, vocational 458 limitation, vocational supervised, and normal respectively. He was referred to speech pathologist, A barium swallow was outpatient clinic and inpatient ward of Akademis Jaury Hospital in carried out to assess the swallowing and swallowing therapy was Makassar, Indonesia. WalkAide is single channeled with transcu- Saga University, Rehabilitation Medicine, Saga, Japan taneous electrodes with the wireless control of stimulation through Introduction/Background: The purpose of this study was to deter- a tilt sensor. Twenty individuals who had experienced stroke ≥6 months tients with spastic upper limb hemiparesis. Material and Methods: previously and had a functional ambulation classifcation score of The study subjects were 12 post-stroke outpatients with spastic up- ≥5 took part in the 4-week intervention, and were followed up for per limb hemiparesis (age: 52 to 73 years, males: 10). WalkAide assisted gait training, and physi- injected into the spastic muscles and orthotic treatment was done cal therapy was combined during interventions. It has been reported that most of stroke patients recover mind is a motor neuron disease. Mate- factors which affect swallowing abnormalities, but these studies in- rial and Methods: Case description: We report a case of 70 years cluded all stroke types. Therefore, it is still unclear what factor af- old gentleman with sudden onset of dysphagia and posing a di- fect prognosis of dysphagia in supratentorial stroke. The individual was brought to our clinic with focused thalamic hemorrhage patients who received rehabilitation in 03 weeks history of dysphagia and no associated motor or sensory a post-acute rehabilitation hospital and examined relationships be- weakness. There was history of hypertension but not diabetes mel- tween clinical evaluations and severity of dysphagia to clarify fac- litus. Material and Methods: Subjects were 91 patient has no neurological defecit except for dysphagia, his cranial patients (34 females and 57 males, mean age 68. Seon-duck 1National Rehabilitation Center Research Institute, Clinical Re- presenting with Acute Stroke. It search for Rehabilitation, Seoul, Republic of Korea, 2National Re- is known that these changes are likely to represent the confuence habilitation Hospital, Health Promotion Center for the Disabled, of micro-infarcts. It might then be expected that these changes Seoul, Republic of Korea could represent a signifcant risk for vascular dementia. We Introduction/Background: It has been previously shown that stroke wanted to fnd out whether those patients who developed cognitive survivors did very little physical activities after the onset of stroke. Was the stroke simply a sentinel event in nearly two-thirds of the time they were inactive. And could social inactivity is likely to cause the physical and psychological we use the Fazekas (a measure of the extent of deep white mat- problems. Material and Methods: Participants training program that included resistance, aerobic, balance, fexibility were recruited upon admission to our Acute Stroke Unit. We tested 92 patients (48 men, 44 women) with Introduction/Background: The objectives of this study were to as- stroke (median age 72, range 54–82). Results: There was signifcant difference at QoL be- ischemic stroke (>3 months) were enrolled in our study. The func- 1Fujita Health University, Rehabilitation Medicine, Toyoake, Ja- tional statue was assessed according to the Barthel index, the New pan, 2Fujita Health University Hospital, Department of Rehabilita- Functional Ambulation Classifcation and the «Timed up and go tion, Toyoake, Japan test». Results: The participants’ median age was 58 years, Introduction/Background: Previous papers reported that patients 30 men (60%) and 20 women (40%). The dominant side was affected in Methods: We selected 86 cerebral infarction patients who admitted 64% of cases. Depressive profle and poor mental QoL were both associated the average length of stay, the proportion of home discharge, and with functional impairment as assessed by the Barthel Index. The period from the onset of cerebral infarction to re- depression were prevalent in ischemic stroke patients.
Post-reduction films are required and a post-reduction neurovascular exam must be documented order viagra soft 50mg with mastercard erectile dysfunction age 36. The most common cause of these injuries is motor vehicle accidents or sports injuries generic viagra soft 100mg with mastercard erectile dysfunction prevalence age. Patients commonly will have extreme pain to palpa- tion over the joint viagra soft 100mg without prescription impotence marijuana facts, swelling and/or palpable deformity buy viagra soft 100mg overnight delivery erectile dysfunction and diabetes ppt. Patients <25 yr old may have a Salter-Harris Type I injury since the medial epiphysis of the clavicle has not fused (see Table 8. Less com- monly, injury can occur by an upward or downward indirect force on the upper ex- tremity. Soft Tissue Injury • Impingement Syndrome—Impingement syndrome describes the chronic and progres- sive degeneration of the tendons of the rotator cuff and the long head of the biceps and the subacromial bursa secondary to mechanical trauma in the subacaromial space. The greater tuberosity of the humerus compresses the tendons against the lateral as- pect of the acromion causing impingement and progressive deterioration. The classic test for impingement syndrome is performed by stabilizing scapular movement with one hand while passively flexing the upper extremity over head. A better test to distinguish impingement involves resolution of pain with injec- tion of 10 ml of 1% lidocaine into the subacromial space. Presentation, treatment and disposition are discussed below: 204 Emergency Medicine 8 Orthopedic Emergencies 205 8 206 Emergency Medicine 8 Orthopedic Emergencies 207 8 208 Emergency Medicine • Stage I: Edema; anterolateral shoulder pain described as a dull ache which increases with activity; usually seen in young adults. Rest, ice, anti-inflammatories and physical therapy to strengthen rotator cuff muscles is recommended. If patients have failed nonsteroidal therapy, corticosteroid injection may improve pain. Diagnostic tests include reproducible anterolateral shoul- der pain with either the Yergason’s test (elbow flexed at 90 degrees, with forearm supi- nated against resistance) or the Speed’s test (shoulder flexed at 90 degrees, elbow ex- tended, forearm supinated against resistance). The impingement sign is positive, and there is primarily lateral shoulder pain with abduction of the upper extremity between 70 and 100 degrees. It is difficult to delineate bursitis from tendonitis or impingement syndrome, but treatment is similar. If conservative therapy fails, a corticosteroid injection into the bursa may improve the pain. This deposition is thought to be due to repeat microtrauma and degenerative changes. Calcium deposits may first be an incidental finding on radiographs, and the patient may be as- ymptomatic. Patients may present with pain between 70 to 100 degrees of abduction and may have marked swell- ing and tenderness over the joint. The exam- iner may hold the arm at 90 degrees abduction and see if the patient can maintain the position (Drop Test). Plain film radiographs may show narrowing of <6 mm between the superior aspect of the humerus and the undersurface of the acromion (normal 7-14 mm). Acute tears are usually secondary to forced abduction and may be associated with glenohumeral dislocations (commonly inferior glenohumeral dislocations). Patients should receive ice, analgesia, sling immobilization and prompt orthopedic follow-up. Patients should receive analgesia and orthopedic follow-up for phys- iotherapy and possibly surgical correction. Orthopedic Emergencies 209 The Elbow Joint Anatomy and Function • The elbow joint is a hinge joint comprised of the distal humerus and the proximal ulna and radius. The elbow is capable of flexion and extension from 0 to 150o as well as supination and pronation. The radius articulates with the capitellum, the articulating surface of the lateral condyle. The lateral epicondyle is the origin of extensor and supinator muscles, the medial epicondyle gives rise to the flexor muscles. During extension, the olecranon fossa on the posterior aspect of the hu- merus receives the olecranon. The main function of the ulno-trochlear articulation is flexion-extension; the radio-capitellum joint is responsible for supination-pronation. The radial nerve runs posterolateral around the joint, coursing anteriorly as it moves distally down the radius. The ulnar nerve courses posterior to the medial condyle before mov- ing anterior-lateral in the forearm. Management 8 Prehospital Prehospital care entails immobilization to prevent further neurovascualar injury, elevation and ice. In addition to mechanism, inquire about onset, quality and radiation of pain (static or dynamic). Physical Exam Neurovascular exam is crucial especially if elbow dislocation is suspected. If dislo- cation has occurred, immediate reduction with sedation and analgesia is recom- mended. All lacerations in the vicinity of the elbow joint must be considered to involve the joint space until proven otherwise. Always remem- ber to identify other injury by examining the clavicle, shoulder, humerus, forearm, wrist and hand. In the lateral view, make special note of the posterior fat pad; even in occult fractures, the posterior fat pad will be 210 Emergency Medicine visible secondary to the displacement of the fat from the olecranon fossa by the effusion. False positives can occur if there is laxity of the triceps when the arm is not in true flexion. An anterior fat pad can be seen normally on the lateral film but will be more pronounced when an effusion or hemarthrosis is present. If there is concern for an in- fected joint, aspirate should be sent for cell count, glucose, protein and culture. Classification, Treatment, Disposition and Complications Fractures and Dislocations Injury Classification Description Treatment Disposition Complications Distal Suprcondylar: Distal Volkmann’s Humerus Extension humerus ischemic Fracture displaced contracture posteriorly (0. Fibrosis or fx with immobilization Ortho ankylosis from separation consult prolonged joint of the condyles. Orthopedic Emergencies 211 Injury Classification Description Treatment Disposition Complications Transcondylar Fracture line Analgesia, Immed. Condylar Fracture of the Ulnar nerve articular and impingement, nonarticular nonunion, surface of cubitus valgus or either condyle: varus, arthritis. Articular Capitellum Analgesia, Arthritis, 8 posterior splint decreased range Reduction of motion, if displaced. Elbow Anterior; Immediate re- Emergent Anterior: Dislocation Posterior, duction with orthopedic High incidence Lateral, conscious sedation consultation. Due to this complex interconnection, energy can be transmitted both above and below and injury site. Joints above and below a site of trauma should be included in radiographic evaluations of the forearm. Orthopedic Emergencies 213 Motor Sensory Ulnar nerve Intrinsic hand muscles Small finger and Ulnar side of ring finger Median nerve Finger flexion, innervation of Most of palm thenar eminence Radial nerve-proximal Wrist, finger and thumb No sensory extension Radial nerve-distal (aka. A detailed neurovascular exam is essential because defi- cits can help pinpoint specific injuries. A widened radioulnar joint suggests disruption of this complex and subluxations at the wrist or elbow must be carefully noted. The lateral projection of the distal radius usually demonstrates a volar tilt of 10-25 degrees. Diagnosis, Treatment, Disposition and Complications Diagnosis of forearm injuries in usually straightforward and based on the physi- cal and radiographic findings.
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