By H. Marcus. Husson College.

Split-skin grafts are normally used purchase sildalis 120mg overnight delivery erectile dysfunction drugs natural, but small full-thickness skin grafts may be necessary in specific areas (lips cheap sildalis 120 mg with mastercard erectile dysfunction exercises wiki, eyelids, nose, hand/fingers, toes, and genita- lia). In general, medium-thickness split-skin autografts are used (14–16/1000 inch), which provide a good color and texture to the grafted site. As soon as the burn wound has been excised, the defect is measured and a drawing that resembles the excised burn wound is created on the donor site. It must be taken into account that skin grafts will shrink after harvesting due to skin relaxation. Therefore, it is advised to make the drawing 10–15% bigger than FIGURE 4 Meshed skin grafts should be avoided in minor and medium-sized (up to 40% TBSA) burns. The scars and mesh pattern are permanent marks and re- minders of the injury. After complete hemostasis has been achieved, sheet skin grafts can be applied to the wound. Donor sites are infiltrated with normal saline with epinephrine 1/200,000. Other useful techniques include the Pipkin’s syringe and infiltration through a pressurized system (a manometer commonly used for arterial lines will suffice) (Fig. Enough tension must be obtained to immobilize the skin and produce an even surface that avoids bony structures. Although skin grafts can be taken with a hand der- matome, thickness is not as predictable as with powered dermatomes. Hand der- matomes leave also an uneven contour around the donor site that will show in the postoperative result. Zimmer and Padgett air- or electrically powered der- matomes can be used. Liquid paraffin is normally used to moisten the skin surface but it is the author’s prefer- ence to use normal saline, which provides better friction. It should not be turned on before its application on the skin to avoid uncontrolled pressure and skipping. It is very helpful to hold the body of the dermatome with one hand and apply gentle pressure with the other hand on the head of the dermatome to get perfect control of the device. The surgeon should concentrate on the harvesting while the assistant holds and fixates the donor site. An operating assistant should hold the skin graft that is being taken with a pair of forceps to prevent any rolling on the drum and to let the surgeon check the thickness of the skin graft. Tension should not be applied to prevent deepening the plane of harvest. When harvesting is complete, the angle of the dermatome is diminished to let the blade cut through the skin graft. This will leave the final portion of the skin graft thinner than the rest. If a uniform skin graft is desired, the surgeon can either discard the final part or stop the dermatome while maintaining its angle. The thickness of the drum is then opened to maximum aperture and the dermatome is gently withdrawn, exposing the final part of the skin graft. Epinephrine-soaked (1:10,000) Telfa dress- ings are then applied to the surface of the donor site to allow good hemostasis. Specific Donor Sites Patients with minor burns present with many donor sites. Choice of donor site depends on graft requirements, anatomical location, extent of burn, patient’s char- acteristics, and patient’s preference. The most commonly used donor sites for small- and medium-sized burns are: Scalp Thigh Back The Small Burn 201 A B FIGURE6 Donor sites are infiltrated with normal saline with epinephrine 1/200,000 to promote hemostasis, provide enough tension to immobilize the skin, and produce an even surface. Powered dermatomes should be used to harvest the skin, which provide the best quality of skin by a reproducible means. Donor sites are infil- trated before harvest, which provide good blood loss control. Donor sites are then dressed with epinephrine-soaked Telfa dressings for 10 min.

This rules and a surgical procedure possibly postponed or even out the option of visual compensation for any impaired avoided sildalis 120 mg mastercard erectile dysfunction treatment in tampa, by injecting botulinum toxin A into the affected sensory function and considerably aggravates the use muscle groups generic sildalis 120mg amex erectile dysfunction treatment options-pumps. The position of the wrist can be Surgical measures are more difficult to plan for the improved functionally by a splint. The aim of orthosis extends from the forearm to the metacarpus, but an operation on the upper extremities is to restore the should not extend beyond the distal flexion crease other- muscle equilibrium and thus improve the use of the hand, wise it will interfere with free finger function. The ideal preconditions for an opera- geal joint counteracts the dislocation of the 1st metacarpal tion are: patient’s willingness to cooperate, predominantly in this joint. This appliance can also be used to test how a pyramidal signs and symptoms, minimal emotional effect patient would react to a corrective, stabilizing procedure on spasticity, good voluntary control of the spastic muscles in which the flexor carpi ulnaris muscle is transferred, in and the necessary willpower to concentrate and cooperate one of various ways, to the extensor carpi radialis brevis or. In all cases, the patient must at least understand the longus muscles (Operation according to Green). These extensive conditions are rarely fulfilled clude any functional deterioration resulting from a loss in patients with spastic tetraparesis since they are almost of power of the transferred muscle. A wrist arthrodesis invariably retarded to a greater or lesser extent, difficult can also produce a functional improvement by providing to motivate and unable to provide sufficient cooperation. This corrects the position at the wrist Additional sensory changes further diminish the prospects and the grasp function of the hand. An intervention is ideally implemented operation are also good in the long term. For all the above reasons, surgical corrections muscle may be indicated at the same time, particularly if of the upper extremity are relatively rarely indicated. If active supination up to the neutral level, which can pose a problem in respect of nursing care position only is possible, the pronator quadratus muscle particularly in severely disabled patients. If ac- botulinum toxin A or muscle lengthening procedures may tive supination is absent, but free movement is possible resolve this problem. Osteotomies and arthrodeses have passively, transfer of the pronating muscles is indicated. If movement restriction without pronatory activity is Flexion contractures at the elbow are relatively com- present, the pronator quadratus is lengthened and can be mon. However, since these are usually slight or moderate, transferred at a later date (⊡ Table 3. The results and as long as they do not hinder the patient, surgical are better after transfer than after lengthening. Nocturnal splints can be used for alternative to muscle weakening by surgical lengthening is patients with significant progression of the contractures. We have only encountered very troublesome flexion con- For fixed flexion deformities of the wrist or a concur- tractures in severely tetraspastic patients. Elbow extension rent troublesome instability, an arthrodesis of the wrist orthoses are difficult to use, particularly if spastic counter- can produce good results. In such cases, the injection of botulinum this procedure can also be employed for young patients toxin A can slacken the countertension. In addition to the prona- to distinguish between a contracture that is merely func- tion-flexion position of the wrist, the whole hand is often 489 3 3. Braces can be used to prevent and improve flex- the simple Green operation combined with procedures for ion contractures. No negative results have surgery, however, and severe finger deformities persist, been noted to date. In the swan-neck deformity of the operations for correcting the finger function and position fingers (see above) it is usually sufficient to correct the must be considered as a supplement to the transfer of the wrist contracture. In severe cases, a release of the pronator flexor carpi ulnaris muscle (⊡ Table 3. Muscle surgery is gener- The options for correcting the adduction-pronation ally inadvisable in patients with athetotic atactic-dystonic deformity of the thumb are listed in ⊡ Table 3. Protocol for the treatment of pronation vative measures tend to be more appropriate than surgical contracture. It is technically Functional deficiency Surgical treatment difficult, however, to provide sufficient stability by internal Active supination bey- No operation fixation until the arthrodesis has consolidated. In one pa- ond the neutral position tient, for example, we have had to stabilize a wrist arthrod- Active supination up to Release of the pronator quadratus esis with two plates instead of just one.

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Employability *Note: measuring cognitive skills only in these categories order 120mg sildalis mastercard impotence curse. The change as a percentage of total score was greater for the CRS than for the GCS or DRS (Horn and Zasler 1996) Neuropsychological Testing Prior to the development of the CT Scan order sildalis 120 mg on-line impotence meds, neuropsychological assessment was targeted at determining whether a brain lesion was or was not present, and, if present, discerning its location and type This diagnostic approach supported the development of the Halstead-Reitan Neuropsychological Battery (HRNB). This battery was initially designed to assess frontal-lobe disorders by W. Halstead (1947) and subsequently used by Reitan (1970 1974), who added some tests and recommended its use as a diagnostic test for all kinds of brain damage. Most examiners administer this battery in conjunction with the WAIS-R (Wechsler Adult Intelligence Scale—Revised) and WMS (Wechsler Memory Scale) or the Minnesota Multiphasic Personality Inventory (MMPI) Wechsler Adult Intelligence Scale—Revised (WAIS-R): eleven subtests (6 determine verbal IQ and 5 determine performance IQ), WAIS-R is the most frequently used measure of general intellectual ability. It is the most widely and thoroughly researched objective measure of personality. MEDICAL COMPLICATIONS AFTER TBI Posttraumatic Hydrocephalus (PTH) Ventriculomegaly (ventricular dilation) is common after TBI , reported in 40%–72% of patients after severe TBI. It should remain > 60 mmHg to ensure cerebral blood flow CPP = MAP—ICP Fever, hyperglycemia, hyponatremia, and seizures can worsen cerebral edema by ↑ ICP Indications for Continuous Monitoring of Intracranial Pressure and for Artificial Ventilation 1. Patient in coma (GCS < 8) and with CT findings of ↑ ICP (absence of third ventricle and CSF cisterns) 2. Severe chest and facial injuries and moderate/severe head injury (GCS < 12) 4. After evacuation of IC hemorrhage if patient is in coma (GCS < 8) beforehand Factors that May Increase ICP Turning head, especially to left side if patient is completely horizontal or head down Loud noise Vigorous physical therapy Chest PT Suctioning Elevated blood pressure Methods Used to Monitor ICP Papilledema: papilledema is rare in the acute stage after brain injury, despite the fact that ↑ ICP is frequent – Usually occurs bilaterally – May indicate presence of intracranial mass lesion – Develops within 12 to 24 hours in cases of brain trauma and hemorrhage, but, if pro- nounced, it usually signifies brain tumor or abscess, i. However, it may negatively impact outcome – Hyperventilation should be used with caution as it reduces brain tissue PO2 this may cause brain tissue hypoxia ⇒ this may lead to ischemia ⇒ ischemia may cause further damage in the CNS tissue of the head injury (HI) patient – Optimal PaCO2 ~ 30 mmHg Osmotic agents (e. Marion (1997)—treatment with hypothermia for 24 hours in severe TBI patients (GCS 5–7) associated with improved outcome Steroids—not proven to be beneficial management of ICP Temporal Lobe—Tentorial (UNCAL) Herniation Uncal herniation results when the medial part of one temporal lobe (uncus and parahip- pocampal gyrus) is displaced over the edge of the ipsilateral tentorium so as to compress the third cranial nerve, midbrain, cerebral cortex, and subthalamus Occurs as a result of increased supratentorial pressure. It is commonly associated with hematoma (subdural or epidural) secondary to trauma or to a brain tumor Uncal herniation of the medial temporal lobe produces: 1. Stretching of the third cranial nerve (oculomotor nerve) causes ipsilateral pupillary dilation; this may lead to complete ipsilateral third nerve palsy (with fixed pupil dila- tion, ptosis, and later, ophthalmoplegia) 2. Ipsilateral hemiparesis results due to pressure on the corticospinal tract located in the contralateral crus cerebri 3. Contralateral hemiparesis may result due to pressure (from edema or mass effect) on the precentral motor cortex or the internal capsule In uncal herniation, reduced consciousness and bilateral motor signs appear relatively late. Central hyperventilation may also occur late in uncal herniation FIGURE 2–5. Temporal Lobe—Tentorial (Uncal) Herniation 66 TRAUMATIC BRAIN INJURY Heterotopic Ossification (HO) HO is the formation of mature lamellar bone in soft tissue Common in TBI, with an incidence of 11%–76% (incidence of clinically significant cases is 10%–20%) Risk factors: Prolonged coma (> 2 weeks) – Immobility – Limb spasticity/↑ tone (in the involved extremity) – Associated long-bone fracture – Pressure ulcers – Edema Period of greater risk to develop HO: 3 to 4 months post injury Signs/Symptoms – Most common: pain and ↓ range of motion (ROM) – Also: local swelling, erythema, warmth joint, muscle guarding, low-grade fever In addition to pain and ↓ ROM, complications of HO include bony ankylosis, peripheral nerve compression, vascular compression, and lymphedema Joints most commonly involved: 1. Knees Differential Dx: DVT, tumor, septic joint, hematoma, cellulitis, and fracture Diagnostic Tests/Labs Serum Alkaline Phosphatase (SAP) SAP elevation may be the earliest and least expensive method of detection of HO It has poor specificity (may be elevated for multiple reasons, such as fractures, hepatic dys- function, etc. Useful to confirm maturity of HO Prophylaxis ROM exercises Control of muscle tone Non Steroidal Anti-inflammatory Drugs (NSAIDs) Radiation—used perioperatively to inhibit HO in total hip replacement patients; concerns about ↑ risk of neoplasia limit its use in younger patient populations (e. Also, as radiation is used prophylactically to prevent HO formation of a particular joint, to use it in TBI patients would require essentially irradiation of the whole body (as HO can develop practically at any joint), which is not practical TRAUMATIC BRAIN INJURY 67 Treatment Diphosphonates and NSAIDs (particularly indomethacin) have been used on patients to arrest early HO and to prevent postop recurrence, but their efficacy has not been clearly proven (TBI population) ROM exercises—used prophylactically to prevent HO and also used as a treatment for developing HO (to prevent ankylosis) Surgery—surgical removal of HO indicated only if ↑ in function is a goal (to ↑ hygiene, sitting, etc. IVC filter used when anticoagulation is contraindicated Posttraumatic Epilepsy/Posttraumatic Seizures (PTS) Posttraumatic epilepsy is classified as: 1. Partial (simple, if consciousness is maintained, or complex, if not) The majority of PTS are of the partial type Posttraumatic seizures are further classified as: Immediate PTS—occur within the first 24 hours post injury Early PTS—occur within the first week (24 hours to 7 days) Late PTS—occur after the first week – Immediate PTS has better prognosis than early epilepsy; early PTS associated with increased risk of late PTS Incidence Varies greatly according to the severity of the injury, the time since the injury, and the pres- ence of risk factors (see below) 5% of hospitalized TBI patients (overall, closed-head injury) have late PTS 4%–5% of hospitalized TBI patients have one or more seizures in the first week after the injury (early PTS) (Rosenthal et al. A group of 4541 patients with TBI {characterized by loss of consciousness (LOC), posttraumatic amnesia (PTA), SDH or skull fracture}, were divided into three categories: Mild TBI—LOC or amnesia < 30 minutes Moderate TBI—LOC for 30 minutes to 24 hours or skull fractures Severe TBI—LOC or amnesia > 24 hours, SDH or brain contusion Incidence of seizures in the different categories: Mild TBI—1. There is no proof of change in outcome with prophy- lactic use of phenytoin (Temkin et al. TABLE 2–10 Anticonvulsant Medications: Uses and Adverse Reactions Medication Uses Adverse Reactions Carbamazepine Partial seizures Acute: stupor or coma, hyperirritability, Tonic-clonic; generalized convulsions, respiratory depression seizures Chronic: drowsiness, vertigo, ataxia, diplopia, Stabilization of agitation blurred vision, nausea, vomiting, aplastic anemia, and psychotic behavior agranulocytosis, hypersensitivity reactions Bipolar affective disorder (dermatitis, eosinophilia, splenomegaly, Neuralgia lymphadenopathy), transient mild leukopenia, transient thrombocytopenia, water retention with decreased serum osmolality and sodium, transient elevation of hepatic enzymes Gabapentin Partial seizures Somnolence, dizziness, ataxia, fatigue Lamotrigine Partial seizures Dizziness, ataxia, blurred or double vision, Tonic-clonic; generalized nausea, vomiting, rash, Stevens-Johnson seizures syndrome, disseminated intravascular coagulation Phenobarbital Partial seizures Sedation, irritability, and hyperactivity in Tonic-clonic; generalized children, agitation, confusion, rash, exfoliative seizures dermatitis, hypothrombinemia with hemorrhage in newborns whose mothers took phenobarbital, megaloblastic anemia, osteomalacia Nystagmus and ataxia at toxic doses Phenytoin Partial seizures Intravenous administration: cardiac Tonic-clonic; generalized arrhythmias, hypotension, CNS depression seizures Oral administration: disorders of the cerebellar Neuralgia and vestibular systems (such as nystagmus, ataxia, and vertigo), cerebellar atrophy, blurred vision, mydriasis, diplopia, ophthalmoplegia, behavioral changes (such as hyperactivity, confusion, dullness, drowsiness, and hallucination), increased seizure frequency, gastrointestinal symptoms, gingival hyperplasia, osteomalacia, megaloblastic anemia, hirsutism, transient liver enzyme elevation, decreased antidiuretic hormone secretion leading to hypernatremia, hyperglycemia, glycosuria, hypocalcemia, Stevens-Johnson syndrome, systemic lupus erythematosus, neutropenia, leukopenia, red cell aplasia, agranulocytosis, thrombocytopenia, lymphadenopathy, hypothrombinemia in newborns whose mothers received phenytoin, reactions indicative of drug allergy (skin, bone marrow, liver function) Valproic Acid Partial seizures Transient gastrointestinal symptoms such as Tonic-clonic; generalized anorexia, nausea, and vomiting; increased seizures appetite; sedation; ataxia; tremor; rash; alopecia; Myoclonic seizures hepatic enzyme elevation, fulminant hepatitis Absence seizures (rare, but fatal); acute pancreatitis; Stabilization of agitation hyperammoniemia and psychotic behavior From Rosenthal M, Griffith ER, Kreutzer JS, Pentland B. Rehabilitation of the Adult and Child with Traumatic Brain Injury 3rd ed.

Segal LS sildalis 120 mg discount erectile dysfunction doctors austin texas, Weitzel PP order 120 mg sildalis with amex erectile dysfunction quick natural remedies, Davidson RS (1996) Valgus slipped capital femo- 563–7 ral epiphysis. Kallio PE, Paterson DC, Foster BK, Lequesne GW (1993) Classification 47. Southwick WO (1967) Osteotomy through the lesser trochanter in slipped capital femoral epiphysis. Vrettos BC, Hoffman EB (1993) Chondrolysis in slipped upper femo- study after corrective Imhauser osteotomy for severe slipped capital ral epiphysis. Yngve DA, Moulton DL, Burke Evans E (2005) Valgus slipped capital tribution of slipped capital femoral epiphysis in Connecticut and femoral epiphysis. If a teratological dislocation is suspected, an x-ray and MRI scan are indicated as de- Classification formities of the femoral head (e. The localized disorders include: ▬ teratological dislocation of the hip, Treatment ▬ proximal femoral focal deficiency, The treatment of teratological dislocations is essentially ▬ coxa vara and femoral neck pseudarthrosis. An open Typical changes in this area are found in association with reduction is usually unavoidable, and deformities of the the following systemic illnesses: soft tissues and the bony and cartilaginous skeleton also ▬ multiple epiphyseal dysplasia, have to be taken into account (see chapter 3. The risk of redislocation is much ▬ dysplasia epiphysealis hemimelia, greater than with dysplasia-related dislocation. If a deformity or defect of the femur exists, the proximal part is always affected as well, hence the description of These diseases are discussed in chapter 4. At this point ▬ proximal femoral focal deficiency (abbreviated to we shall restrict ourselves to the specific changes in those PFFD) or congenital femoral deficiency (CFD) forms of multiple epiphyseal dysplasia that are manifested in the hip only. Classification Various classifications have been proposed for proximal 3. The classification Teratological hip dislocation most commonly used is that of Aitken (⊡ Fig. This is a purely radiological classification and thus in- > Definition complete. The condition frequently has to be reclas- Dislocation of one, or usually both, hips at birth as a sified during the course of growth. A comprehensive result of malformations rather than immaturity of the classification of congenital anomalies of the femur has joints, and associated with other deformities. More Occurrence recently Paley proposed a classification with 3 types Since teratological hip dislocation is not a systemic illness (⊡ Table 3. In particular, these techniques ring deformities are: can show whether a femoral head is present or not, a find- Torticollis, plagiocephaly (32%), arthrogryposis, ing that is important for correct classification. Larsen syndrome, general ligament laxity, flat feet, club feet, proximal femoral focal deficiency, congenital Occurrence knee dislocation, pyloric stenosis, renal agenesis and or- The incidence of proximal femoral focal deficiency cal- chidocele. Compared to dysplasia-related hip dislocation, culated in an epidemiological study was found to be 2 teratological dislocation of the hip is extremely rare. If all femoral anomalies are taken into account, the frequency is undoubtedly much Diagnosis greater since mild forms of femoral hypoplasia in par-! If an abnormality of any kind exists at birth, an ticular are very numerous and usually not yet diagnosed ultrasound scan of the hips is invariably indicated. Classification of a proximal focal femoral deficiency (PFFD) (I–IX) accord- ing to Pappas (see text) ⊡ Table 3. Classification of congenital femoral anomalies of the femur after Pappas deficiency (CFD) after Paley Class Characteristics Type I Complete absence of the femur 1 Intact femur with mobile hip and knee a) normal ossification of proximal femur II Proximal femoral deficiency combined with lesion of b) delayed ossification of proximal femur the pelvis 2 Mobile pseudarthrosis (hip not fully formed, a false III Proximal femoral deficiency without bone connection joint) with mobile knee between the femoral shaft and head a) femoral head mobile in acetabulum IV Proximal femoral deficiency with poorly organized b) femoral head absent or stiff in acetabulum fibro-osseous connection between the femoral shaft 3 Diaphyseal deficiency of femur (femur does not reach and head the acetabulum) V Femoral deficiency in the middle of the shaft with a) knee motion > 45° hypoplastic proximal or distal bony development b) knee motion < 45° VI Distal femoral deficiency VII Hypoplastic femur with coxa vara and sclerosis of diaphysis VIII Hypoplastic femur with coxa valga IX Hypoplastic femur with normal proportions 227 3 3. Arthrography of the hip of the same patient shown in femur is completely missing Fig. Sometimes the shortening Proximal femoral focal deficiency occurs as a result of a of the extremity in the infant is so severe that the foot is at noxious event (viral infection, drug, radiation, mechanical the level of the knee on the opposite side. A recent report has provided evidence of is always required at birth since, as has already been men- a possible hereditary variant. Associated anomalies Treatment The incidence of associated anomalies is very high, with The treatment of congenital anomalies of the femur is figures of up to 70%. A longitudinal defect of the very time-consuming and requires a lot of experience.

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