By V. Murak. Florida State University.
Patients are transferred to their room where general treatment is continued and comfort measures effexor xr 75 mg visa 0800 anxiety, including warming and analgesia cheap effexor xr 37.5 mg without prescription anxiety symptoms knee pain, are instituted. A clear plan must be instituted, and repeated dressing changes to make management decisions should be avoided. Plastic wrap or Telfa clear dressings covered in warming blankets or any other material that keeps patients warm and comfortable should be used. This allows for easy inspection of the burn wound if a definitive plan of treatment is still to be outlined or a new or more senior burn surgeon needs to inspect the wound to make the final treatment plan. As soon as the initial management and resuscitation of burn patients is complete the determination of the wound treatment plan is the main focus during this phase of patient care. It is essential to outline the surgical plan in order to institute the rationale of dressing changes and the choice of dressing materials. Depending on the size and depth of the burn wound, the approach to wound care and closure will differ, and so will the rationale for wound care and dressings. Wounds of this type heal without surgical intervention; therefore, the topical treatment and choice of dress- ings will have a direct impact on the patient’s comfort and wound healing. The type of surgical intervention, especially the timing of excision and extent of the excision, will determine the type of wound care management patients require before and during burn wound closure. BURN WOUND MANAGEMENT BASED ON THE DEPTH OF THE WOUND Burn injuries damage different degrees of the epidermis, dermis, and soft tissues. Depending on the depth of the injury, wounds will present with different abilities for healing and re-epithelialization. Superficial wounds will present with good chances for complete wound healing within 3 weeks, whereas deep wounds have lost most or all possibilities for spontaneous wound healing. State-of-the-art wound care is therefore essential in superficial wounds to warrant and stimulate spontaneous wound healing. Surgery and operative wound closure will play a central role in the management of deep wounds. In general, patients can be categorized to three broad groups depending on the type of injury sustained: 1. Deep partial and full-thickness burn Patients’ local wound treatment and surgical plans are based essentially on the type of injury (see Table 1). Superficial burns include all those injuries that have destroyed the epidermis and different degrees of the papillary dermis. They are represented by first-degree TABLE 1 Management of the Burn Wound Superficial partial-thickness burns: conservative treatment Deep Partial and full-thickness burns: excision and autografting Indeterminate-depth burns: Conservative treatment (10–14 days), followed by second inspection and definitive treatment (based on healing time) Wound Management and Surgical Preparation 87 (or epidermal burns) and superficial second-degree burns (or superficial partial thickness burns). Indeterminate-depth burns include those injuries that can be classified neither as superficial nor as deep burns. Their potential for regeneration is also variable, and a period of conservative treatment followed by a second assessment and definitive treatment plan is usually required. Deep second-degree and third-degree burns represent deep partial and full-thickness burns. They do not represent any treatment problem, and surgery is normally the treatment of choice. Most or all dermal appendages have been destroyed, and regeneration proceeds slowly or never occurs. The debate continues as to the timing of surgery, especially for patients with massive injuries. Superficial burns A conservative approach is mandatory in this type of injury. When they heal in less than 3 weeks they leave minor skin changes or no scars at all. The period that these injuries require for complete healing is mandated by the speed of debridement of all devitalized tissues and the proliferation of basal cell epithelial cells. Treatment should be therefore directed to speed or promote debridement of all debris caused by burning and to provide a microenvironment that allows and promotes re- epithelialization. Many topical treatment regimens are available in the market for treatment of superficial burns. Many topical antimicrobial creams for the tempo- rary skin substitutes are available.
US is more difficult if local anaesthetic in a syringe con- nected to the needle flows into the joint; there will then a be no local collection seen on US buy effexor xr 150mg without prescription anxiety examples. For retrospective confirmation of intra-articular injection it is possible to add some radiographic con- trast and then take a plain radiograph to follow purchase effexor xr 37.5 mg line anxiety symptoms leg pain. For example, fluoroscopy is most often used for spinal root blocks and US is ideal for pain- ful soft tissue lesions. Typically the pain is at night and responds dra- matically to prostaglandin-blocking drugs such as aspirin. Treatment used to be by surgical exci- sion of the tiny nidus which is a few millimetres in diameter. It is not necessary to excise the scle- rotic reaction around the nidus. Iowa State Press, a Blackwell Publishing Company, Includes bibliographical references and index. No part of this publication may Printed and bound in Great Britain by be reproduced, stored in a retrieval system, or Ashford Colour Press Ltd, Gosport transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or For further information on otherwise, except as permitted by the UK Blackwell Publishing, visit our website: Copyright, Designs and Patents Act 1988, without www. Consequently, the aim of Paediatric Radiography is to provide a reference text for radiographers and student radiographers working within general imaging departments and highlights aspects of paediatric healthcare that may inﬂuence paediatric radio- graphy practice. Importantly, when writing this text, we have not sought to provide a descrip- tion of all paediatric imaging techniques or provide answers to all imaging dilemmas, because many of these will be dependent upon local expertise, radiographic equipment and availability of alternative imaging modalities. Instead we have attempted to raise important aspects of paediatric healthcare that should inform radiographic practice and hope that these will be discussed openly within imaging departments. As a consequence of the current shortage of paediatric radiography texts we have considered literature from other health professions, particularly nursing, and have attempted to adopt some of their good practice models. Therefore this text may also be useful for nurses, physio- therapists and junior doctors interested in the imaging of children and its role in current paediatric healthcare practice. The development of this book has enriched our understanding of paediatric healthcare and the role of diagnostic imaging within the discipline. Our hope is that this book will help enhance paediatric radiographic practice to ensure that children attending imaging departments will receive informed and appropriate paediatric care. Maryann Hardy and Stephen Boynes ix Acknowledgements We are particularly grateful to Jonathan McConnell of St Martin’s College, Lancaster and Anne-Marie Dixon of the University of Bradford for willingly sharing their knowledge of trauma and abdominal ultrasound respectively. In addition, we would like to thank Sue Watson, Andy Scally and Gary Culpan for critically reading appropriate chapters and providing comments and suggestions. Special thanks are also due to Dr Rosemary Arthur, paediatric consultant radi- ologist at the General Inﬁrmary at Leeds for providing information and images for inclusion within the text, and Dr Leanne Elliott, consultant radiologist at Bradford Royal Inﬁrmary, who willingly gave us regular access to the paediatric ﬁlm library housed within her ofﬁce! We would also like to offer our thanks to Gill Marles, Superintendent Radiographer, Clarendon Wing X-ray Department, the General Inﬁrmary at Leeds, for allowing us access to the department for photographic purposes, and also to those patients and their families who consented to being photographed. In addition, thanks must go to the young models who were patient with us during very long photographic sessions; Benjamin Hardy, Peter Hardy, Robin Errington, Eve Errington, Alexander Errington, Benjamin Lodge, Jody Lodge and Theo Scally. Thanks are also due to the staff of the following imaging departments who allowed us to watch them work and were open in discussions around techniques: Clarendon Wing X-ray Department, The General Inﬁrmary at Leeds Shefﬁeld Children’s Hospital Manchester Children’s Hospital (Booth Hall) Hull A&E Department Bradford Royal Inﬁrmary xi Chapter 1 Understanding childhood A child is, as deﬁned by English law, any person under the age of 18 years. It is assumed that by the age of 18 a person has reached such a level of maturity as to be capable of making fully informed decisions. However, it is the process of growth and development during childhood and adolescence that results in maturity and not chronological age alone. Growth is the progressive development of a living being, or any part of it, from its earliest stage to maturity1. In health care we usually restrict the term to mean the physiological and anatomical changes that occur. Different parts of the human body grow at different rates and the growth of one system can be affected by the activity of another (e. In contrast, the term development is commonly used to describe the psychological and cognitive advancement of a child and the acquisition of motor and sensory skills. Growth and development are variables of childhood and children of the same age can be at different growth and developmental stages. Consequently, when deciding the most appropriate health care approach it is important to allow for a child’s individuality and to avoid making assumptions about a child based upon preconceived ideas pertaining to speciﬁc chronological ages. However, although children of the same age can be at different developmental stages, the order in which growth and development occurs is generally consistent for all 2 children. For example, ossiﬁcation of the carpus occurs in the same order for all children, but the exact age at which the carpal bones ossify can vary markedly. As a result of predictable developmental staging, many texts, including this one, have provided general growth and development charts that are loosely linked to chronological age.
Treatment: Conservative care generic 150mg effexor xr with mastercard anxiety otc medication, including physical therapy generic 150 mg effexor xr free shipping anxiety symptoms 4 weeks, non- steroidal anti-inflammatory drugs (NSAIDs), heat, and trigger point or tender point injections, is usually effective in treating muscle strains. Provocative cervical discography should be performed and is the gold standard diagnosis of cervical discogenic pain. As this is an invasive procedure, it should only be performed when the index of suspicion is sufficiently high. Treatment: Physical therapy, including stretching and strengthen- ing exercises and heat, and NSAIDs are considered first-line treatment. Patients who do not respond to conservative therapy may require sur- gical intervention. Radiographic findings of cervical osteoarthritis do not reliably correlate with clinical symptoms and therefore, the value of X-rays is in ruling out more serious underlying pathology. Neck and Shooting Arm Pain 17 Treatment: Physical therapy, including stretching and strengthening exercises of the surrounding muscles. NSAIDs, rest, and an appropri- ate pillow for better neck support may also be helpful. Treatment: Most cases of cervical radiculopathy respond very well to conservative care, including physical therapy, NSAIDs, and fluoro- scopically guided epidural steroid injections. In refractory cases or severe cases with progressive neurological deficiencies (i. Additional diagnostic evaluation: X-ray—including AP and lateral views—may be obtained. Treatment: Conservative care includes physical therapy, collar, NSAIDs, and fluoroscopically guided epidural steroid injections. Sur- gical decompression may be necessary depending on the severity of symptoms and the patient’s response to more conservative interventions. Imaging: X-ray, including AP, lateral, and odontoid views, and/or computed tomography or MRI. Treatment: Neck immobilization with a collar or halo and/or possi- ble surgery. Related complaints of stiffness or of the shoulder “giving way,” expand your differential diagnosis to include adhesive capsulitis (frozen shoulder) and shoulder instability, respectively. A history of trauma expands the diagnosis to include acromioclavicular (AC) injury and fractures. A careful history and physical examination will narrow your differential diagnosis. Patients with rotator cuff tendonitis and rotator cuff calcific ten- donitis will generally point directly beneath their acromion process. Patients with bicipital tendonitis will point slightly more distal along their arm over the bicipital sheath. This is a high-yield question for shoulder pain that should confirm your diagnosis. Patients with biceps tendonitis, rotator cuff tendonitis, or rotator cuff calcific tendonitis all complain of pain exacerbated by overhead movements. Patients with biceps tendonitis or SLAP lesions From: Pocket Guide to Musculoskeletal Diagnosis By: G. Patients with shoulder instability will complain of their shoulder repeatedly “giving way. This question specifically targets patients with adhesive capsulitis (frozen shoulder). Patients with adhesive capsulitis classically report a history of shoulder pain that gradually resolves and is replaced with stiffness. How long have you had your shoulder pain and have you tried anything to help it? These two questions are more useful for when you are ready to order imaging studies and decide treatment. Physical Exam Having completed the history portion of your examination, you are ready to perform the physical exam. Next, palpate along the biceps tendon as it runs in the bicipital groove (tenderness over a tendon may reflect tendonitis). To find the bicipital groove, palpate lateral to the coracoid process onto the lesser tuberosity of the humerus.
US identifies a broad with posterior acoustic shadowing from avulsed sleeve of cartilage buy discount effexor xr 75 mg on line anxiety related to, often associated with an osseous bone fragments and local haematoma (Fig buy discount effexor xr 75mg line anxiety knot in stomach. In doubtful or difficult cases, MR minimal displacement, high-resolution US may imaging may be a useful adjunct to US. The main demonstrate a “double cortical sign” as a result of Ultrasonography of Tendons and Ligaments 45 a b c d Fig. Traction injury at the lower pole of the patella of a 14-year-old boy following a kick during a soccer game. Longitudinal 12-5 MHz US images obtained over the dorsal aspect of the distal left (a) and right (b) quadriceps tendon in a 8-year-old child with complete inability to knee extension after an acute injury. In the left quadriceps tendon (a), the normal contralateral tendon (arrowheads) shows well-deﬁned borders and normal internal echo texture; P upper pole of the patella. In the right quadriceps tendon (b), the affected quadriceps tendon (arrowheads) appears swollen and hypoechoic. The tendon attaches to a hyperechoic bony structure (arrows) that lies deep and cranial to the upper pole of the patella (P). This ﬁnding indicates a posttraumatic avulsion injury at the upper pole of the patella. Note the intra-articular effusion located inside the suprapatellar synovial pouch (asterisk). When a traction injury is strongly suspected on clini- A tendon abnormality that may be encountered in cal grounds and US is negative, MR imaging is the the adolescent is the so-called “snapping hip”. This study of choice to identify the lesion by observing disease is often bilateral and presents with an audible marrow oedema with widening and irregularity of snap produced during walking or hip movement. The degree of fragment displacement is due to snapping of either the iliopsoas tendon over is critical in therapeutic planning. Most cases will the iliopectineal eminence or the iliotibial band over require surgery with the possible exception of those the greater trochanter (Fig. Dynamic US is an ideal means to identify this condition by showing the iliopsoas Ultrasonography of Tendons and Ligaments 47 Fig. Double cortical sign in a 14- year-old sprinter with a recent acute traction trauma and pain over the tibial tuberosity. Longitudinal 12- 5 MHz US image shows a thickened patellar tendon (arrowheads) and the elevation and fragmentation of the cortical bone of the tibial tuberos- ity forming two hyperechoic layers (arrows) tendon or the iliotibial band which suddenly display amyloid deposits can be seen both in the paraarticu- an abrupt abnormal lateral displacement during hip lar tissues and within the tendon substance. Conservative treatment with rest loid deposits cause swelling of the involved tendon and antiinflammatory drugs is sufficient in most and a more heterogeneous appearance of the fibrillar patients. Occasionally, a hyperaemic pattern can tendon, surgical lengthening of the tendon may be be found at colour and power Doppler examination. Differing from traumatic and degenerative lesions, the inflammatory involvement of tendons invested by synovial sheath is commonly encoun- 3. Degenerative and Inflammatory Conditions The US appearance of the affected tendons varies depending on the stage of synovial involvement Degenerative disorders of tendons are rare in children (acute vs chronic). In the early stages, the tendon has and usually follow mechanical stress related to foot a normal size and echotexture and is surrounded by disorders, including clubfoot and flat foot (Fig. In chronic renal failure treated by haemodialysis, In more advanced disease, synovial hypertrophy Fig. When the hip is ﬂexed (a), the iliotibial band is present as a hyperechoic stripe (arrows) posterior to the trochanter (asterisk) and superﬁcial to the gluteus medius tendon (Gm). During extension of the hip (b), an abrupt displacement (dotted arrow) of the iliotibial band occurs as it gets closer to the trochanter, coinciding with the snapping sensation 48 M. Degenerative changes in the Achilles tendon of a 10-year-old boy who was previously operated upon for ﬂat foot. Longitudinal (a) and transverse (b) grey-scale 12-5 MHz US images obtained over the Achilles tendon demonstrate diffuse fusiform hypoechoic swelling (asterisks) of the tendon extending from its insertion to approximately 3 cm above the calcaneus due to microtears and mucoid degeneration. The colour Doppler image (c) shows an increased depiction of intratendinous ﬂow signals.