Acupuncture

A recent systematic qualitative review concluded that there is no evidence to show that acupuncture is more effective than no treatment, moderate evidence to show that acupuncture is not more effective than trigger point injection or TENS, and limited evidence to show that acupuncture is not more effective than placebo or sham procedure for the treatment of chronic low back pain.51 Therefore, acupuncture is not recommended as a regular treatment for patients with low back pain. Early treatment...

Myofascial Pain Syndrome

Myofascial pain syndrome (MPS) is the name given to the common clinical syndrome of persistent regional or local pain in muscle(s) accompanied by trigger points on palpation of the involved muscles. The trigger point has local tenderness, the presence of a taut band, and a twitch response. Palpation of the trigger point characteristically produces pain referred beyond it.11 The syndrome may be acute and is often seen after strain or trauma to a muscle. Nonmusculoskeletal symptoms, such as...

Orthopedic Referral

Indications for orthopedic referral include the following factors fracture, dislocation, evidence of neurovascular compromise, penetrating wound into the joint space, and grade 3 sprain with tendon rupture. All patients with ankle injuries should begin early rehabilitation exercises, including passive range of motion and graduated strength training immediately after the injury. It has been estimated that during each week of the fall football season at least 6000 high school and college players...

Malignant Bone Tumors

Malignant tumors of bone may originate in the bone or metastasize to the bone. There are definite patterns in tumor type based on the age of the patient. Ewing's sarcoma is a tumor of uncertain origin. It is most common in children and young adults. It is more common in whites than blacks. The tumor may occur in any bone but has some predilection for long tubular bones and the pelvis. The presenting complaints include pain, swelling, tenderness, and erythema, which makes it resemble...

Radiology

Plain radiographs are usually not helpful in diagnosing acute low back pain, because they cannot demonstrate soft tissue sprains and strains, or an acute herniated disc. However, plain radiographs are useful in ruling out conditions such as vertebral fracture, spondylolisthesis, spondylolysis, infection, tumor, or inflammatory spondyloarthropathy5,19 (Fig. 1.1). In the absence of neurologic deficits, plain radiographs in the evaluation of low back pain should be reserved for...

Unproven Treatments

Traction is not recommended for the treatment of acute low back pain.45 No scientific evidence supports the efficacy of corsets or braces in the treatment of acute low back pain, and these treatments Table 1.2. Nonoperative Treatment Considerations for Low Back Pain and Sciatica Orthoses Cryotherapy (ice) Thermotherapy Symptomatic pain relief, time-limited Symptomatic pain relief, time-limited Optimal 1 Optimal 1-3 days maximum 2-3 weeks No No Selected pre-surgical cases avoid Selected cases...

Stimulators of Bone Formation

PTH is the most promising anabolic agent that stimulates bone formation. It is still undergoing clinical trials. Even though it increases the BMD of the lumbar spine,41 there are no data on fracture risk. One disadvantage is that it must be administered by subcutaneous injection. It is not yet approved by the FDA. Fluoride stimulates bone formation but does not decrease the risk of a fracture. A meta-analysis showed that fluoride increases bone mineral density at the lumbar spine and does not...

Inhibitors of Bone Resorption

Hormone Replacement Therapy (HRT) In the PEPI trial, HRT increased BMD at the hip by 1.7 and at the spine by 3.5 to 5.0 over a 3-year period compared to placebo. HRT inhibits bone loss for the duration of the therapy, which recurs once therapy is discontinued. In premenopausal women with osteoporosis secondary to hypoestrogenic stages, early intervention with estrogen to achieve return of menses, is critical since bone loss may be irreversible. Observational studies consistently suggest that...

Raynauds Disease

During the late nineteenth century Maurice Raynaud described digital vasospasm that seemed to be cold-induced. He believed that this phenomenon, now known as Raynaud's disease, was due to changes in the CNS control over vascular innervation. Raynaud's phenomenon is classically described in patients who develop extremity blanching and numbness with cold exposure, followed by cyanosis and then erythema on rewarming. The fingers are affected most commonly, but the toes and ears may also be...

Wound Preparation

Proper preparation of a wound can improve the success of aesthetically acceptable healing. The wound should be closed as soon as possible, although most lacerations heal well if closed within 24 hours after the injury. After anesthesia, proper cleansing should be accomplished by wiping, scrubbing, and irrigating with normal saline using a large syringe with or without a 22-gauge needle, which produces enough velocity to clean most wounds. Antiseptic soaps such as hexa-chlorophene (pHisoHex),...

Miscellaneous Bone Conditions

A common condition, nonossifying fibroma is also called a fibrous cortical defect. It is considered a developmental aberration rather than a neoplasm. It is seen primarily in children and occurs most commonly in the femur, tibia, and fibula. The diagnosis can usually be made by the radiographic picture, and a large number of these lesions are found while obtaining a radiograph for another purpose. The lesions are sharply demarcated, lobular, radiolucent defects in the metaphyseal cortex. There...

Hip Fractures

Aging is associated with reductions in muscle strength, increased inactivity, and a diminished sense of balance. Moreover, the presence of concomitant medical disorders and their treatments are increased, which are factors that contribute to the increased incidence of falls and fracture of the hip in those 65 years and older (see Reference 56, Chapter 24). Although hip fractures are a common malady of the elderly, anyone subjected to sufficient forces to the hip can be affected. The overall...

Problems of the Spine

Spondylolysis is an acquired condition in which there is a bony defect on one or both sides of the pars interarticularis (Fig. 7.10), usually at the L5-S1 level. The incidence of spondylolysis is about 5 in preadolescent North American children and rises to 12 in gymnasts and divers.42 The defect is not apparent at birth but develops usually between 5 and 10 years of age.43 Thus vigorous athletic activity in children may produce repetitive stress on the developing pars. When bilateral pars...

Skin Anatomy

Figure 11.1 represents a model of the skin and the underlying tissue down to structures such as bone or muscle. Two additional features of skin anatomy that affect the repair of injuries are cleavage lines and wrinkles. Lines of cleavage are also known as Langer's lines. These lines are formed by the collagen bundles that lie parallel in the dermis. An incision or repair along these lines lessens disruption of collagen bundles and decreases new collagen formation and therefore causes less...

Apophyseal Injuries

Apophyseal injury involving the anterosuperior and anteroinferior iliac spines, iliac crest, and ischial tuberosity typically occurs in active adolescents. Major abdominal and hip muscles either insert or originate at these sites of bone growth. The condition is most common in distance runners and dancers and is associated with muscle-tendon imbalance and rapid growth (see Chapter 10). Adolescents present with vague, dull pain related to activity located near the hip. Should a single traumatic...

Plantar Fasciitis

Plantar fasciitis refers to disorders involving insertion of the plantar fascia into the medial tubercle of the medial calcaneus. It can present Table 3.4. Disorders of the Foot and Ankle Navicular stress fracture Midtarsal joint sprain Extensor tendonitis Tibialis posterior tendonitis Plantar fascia strain Calcaneal fracture traumatic, stress Compression of the medial branch of the lateral plantar nerve Medial calcaneal nerve entrapment Tarsal tunnel syndrome Talar stress fracture...

Aspirated or Swallowed Foreign Body

More deaths in the United States result from suffocation by foreign bodies than from burns or from firearms accidents. Children younger than 3 years of age have a natural tendency to place objects in their mouths, putting them at high risk of choking injury. In children younger than 1 year, asphyxiation is an important cause of unintentional death. The foreign bodies most often aspirated are food, including nuts, vegetable or fruit pieces, seeds, and popcorn. Small items such as pen caps,...