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Beitr Klin Chir 38: 874–87 boy with a stress fracture beneath the center of the tibia with anterior 19 cheap rogaine 2 60 ml on line man health daily shopping category. Sinding-Larsen MF (1921) A hitherto unknown affection of the cortical thickening purchase rogaine 2 60 ml visa prostate 0270-4137. Acta Radiol 1: 171–3 ing fracture and should not be confused with the nidus of an osteoid 20. Stanitski CL (1993) Anterior knee pain syndromes in the adoles- osteoma cent. The shape of the loose body allows certain sport will soon drive it from there. In many chil- dren, for example, isolated ossification centers or islands are observed, and these can subsequently develop into a case of osteochondritis dissecans. Classification, occurrence We make a distinction between a more common juvenile form of the disease (with open epiphyseal plates at the start) and a rarer adult form (with closed or premature plates). The juvenile type rarely begins before the age of 10 and has a better prognosis than the adult form. Since the prognosis deteriorates even a year before plate closure, we include boys up to the age of 14 and girls up > Definition to the age of 13 in the juvenile form. A systemic form with Necrotic focus usually localized on the lateral curve (fac- multiple lesions affecting several joints also exists. In the latter case, the condition then become detached and remain in the joint as a loose is known as Panner’s disease. European Paediatric Orthopaedic Society directed by the author, the male:female ratio in 798 cases of osteochon- Historical background dritis dissecans was approx. Both sides were af- 1558: Ambroise Paré observes loose joint bodies in the knee. Site The typical site is the lateral curve, facing the intercondy- Etiology lar notch, of the medial femoral condyle. This is a concave The most important etiological factors are: surface with a relatively small curve radius. Generally ▬ hereditary factors, speaking, osteochondritis dissecans only occurs on con- ▬ trauma. In the above-mentioned multicenter study of 798 cases, 70% were located at this site (⊡ Fig. Other factors such as endocrine dysfunction, collagen disorders and epiphyseal anomalies (e. Other authors report a familial occurrence of the disease in several joints. Other studies showed an increased incidence among very physically active patients, suggesting that trauma also plays a role in its development. One biomechani- cal study with a three-dimensional model showed that high shear forces, particularly around the medial femoral a b c condyle, occur during flexion under load. Osteochondrosis dissecans: Typical site on the lat- reach a peak at 60° flexion. The deformation of the carti- erodorsal section of the medial femoral condyle 295 3 3. This is a harmless variant of normal ossification of the epiphysis and not a case of osteochondrosis dissecans ⊡ Fig. Lateral x-ray of a 16-year old boy with osteochondrosis dissecans of the patella condyle, 16% on the lateral femoral condyle, 6% on the not be confused with ossification irregularities, which are patella (⊡ Fig. The 99technetium bone scan was used in the past for monitoring progression, but Diagnosis has superseded by the MRI scan with its wide range of The symptoms in osteochondritis dissecans are non-spe- possibilities. Exercise-related pain is usually present, and possibly The MRI investigation always shows the osteochon- pseudolocking as well. While the intact appearance are observed particularly in the presence of loose joint of the cartilage can also be seen on the MRI scan, this bodies. During clinical examination, the test described evaluation is not always reliable in view of the inadequate by Wilson is helpful in establishing the diagnosis.

Type III is additionally characterized Treatment of the underlying disorder by muscle hypotonia with gait abnormalities buy 60 ml rogaine 2 fast delivery mens health survival of the fittest, strabismus A breakthrough was made some years ago in the treat- and psychomotor retardation buy rogaine 2 60 ml with mastercard androgen hormone x and hair. These are soon followed ment of Gaucher disease, following the production of the by anemia, bleeding tendency and repeated infections. The The following skeletal changes are observed: Infiltration missing enzyme can now be substituted with Ceredase of the bone marrow, bone necroses, »bone crises«,. The treatment is very expensive, but is capable of pathological fractures, osteolysis and osteomyelitis. The metaphysis and diaphysis of the affected bone are widened and the corti- Orthopaedic treatment cal bone becomes thinner (⊡ Fig. The orthopaedic treatment depends on the nature of the These changes often remain asymptomatic for a fairly complication. The storage of Gaucher cells can ultimately lead logical fractures and osteomyelitis. The fracture manage- to impairment of the blood supply and thus to necrosis. Long periods of immobilization tial confusion with Legg-Calvé-Perthes disease, although are frequently required. The osteomyelitis is treated by the necrosis can also occur in the head of the humerus or local clearance and the administration of antibiotics. This is characterized by intense ing kyphosing at the thoracolumbar junction (⊡ Fig. The frequently occurring femoral head necrosis can warmth, redness and occasionally fever as well. During result in premature osteoarthritis of the hip and the need the crisis, an increased uptake is apparent on the techne- for a total hip replacement. AP x-ray of the pelvis in a 7-year old girl with Gaucher disease and an intertrochanteric fracture of the right femur 699 4 4. The proliferating cells are derived either from the Schwann cells or accompanying cells. Viewed macroscopically the neurofibromas are bright, relatively compact nod- ules that are connected to the peripheral nerves. Neurofibromas also occur in the central nervous system (brain, spinal cord). Occurrence After Down syndrome, neurofibromatosis is the most common hereditary disease. In Israel, prevalence figures of 104/1,000,000 males and 119/1,000,000 females have been reported. Type II neurofibromatosis is much less common (1/1,000,000 inhabitants). Neurofibromatosis type I Clinical features, diagnosis At least two of the following clinical characteristics are required before a diagnosis of neurofibromatosis can be made: ⊡ Fig. X-ray of the spine of a 9-year old boy with Gaucher disease ▬ Café-au-lait spots: Light brown, regular pigmented le- and a low thoracic kyphosis sions that can cover large areas. Dystrophic scoliosis sues associated with the central and peripheral nervous is short-curved and has a kyphotic component. Typical or- vertebral bodies show a curved indentation, the ribs thopaedic problems include leg lengthening, congenital are thinned on the concave side facing the spine and tibial pseudarthroses and short-curved progressive sco- markedly rotated (⊡ Fig. In 1918 Gould mentioned nection with substantial accumulations of subcutane- the occurrence of scolioses in connection with neurofibromatosis. Such lengthening man with a grotesquely deformed skull who was the subject of a play occurs in approx. However, more recent investigations of his Neurological lesions: Discrete neurological changes, skull have revealed that John Merrick had suffered not from neurofi- particularly sensory abnormalities, occur in 15% of bromatosis, but rather from Proteus syndrome. In addition to the neurofibromatosis solitary at least two must be present, the following additional neurofibromas are also present in Proteus syndrome, al- changes can occur: though these do not usually affect children and adoles- ▬ Elephantiasis (pachydermatocele): hypertrophy of the cents, but patients aged between 20 and 40 years. Within the population of neuro- Patients with neurofibromatosis have a largely normal life fibromatosis patients, however, tibial pseudarthrosis expectancy. A detailed description A very important prognostic indicator is the malig- of congenital tibial pseudarthrosis can be found in nant degeneration of the neurofibromas. We have observed three such ▬ Paravertebral soft tissue tumors: These are usually as- cases. Isolated reports of degeneration into malignant sociated with scoliosis.

ETHNOCULTURAL VARIATIONS IN PAIN 169 Some recent papers have started to correct the problem of small sample size purchase rogaine 2 60 ml free shipping prostate cancer x-ray bone. Ho and Ong (2001) used Singapore order rogaine 2 60 ml otc prostate 3 3, a large multiethnic society, to ex- amine the influence of group membership (Chinese, Malay, Indian, and other) on headache morbidity. No significant ethnic differences were found for lifetime or current headache prevalence within a sample of over 2,000 in- dividuals, although there were some group differences in average headache intensity and frequency, with the Chinese lowest. Non-Chinese were also more likely to seek medical attention for their headaches and to have taken medical leave during the preceding year. The data do not allow one to de- termine whether genetic factors may have influenced the outcome of this study. For the age range 45–64 years, musculo- skeletal pain prevalence was higher in all ethnic groups (about 70 to 90%) than in White subjects, with the latter being about 53% for both males and females. When asked whether they had pain in “most joints,” about 6 to 8% of Whites agreed compared to about 30 to 45% in the ethnic minority groups. The authors cautioned that comparable studies need to be done in other geo- graphical locations, because the data do not permit one to readily distin- guish between differences in pain sensitivity or expression, the effects of change of culture and migration, and mental health issues. With respect to the last point, a study (Nelson, Novy, Averill, & Berry, 1996) with a relatively small sample of Black, White, and Hispanic patients in a southern U. McCracken, Matthews, Tang, and Cuba (2001), in one of the few studies of ethnic or racial group differences in the experience of chronic pain, asked 207 White and 57 African American patients seeking treatment at a pain management center about their physical symptoms, depression, dis- ability, health care use, and pain-related anxiety. The two groups did not differ in age, education, or chronicity of their pain complaint. African Ameri- cans rated their pain higher and reported more avoidance of pain and activ- ity, more fearful thinking about pain, and more pain-related anxiety. As well, they were higher on physical symptom complaints and on physical, psycho- social, and overall disability. The authors noted that many factors may ex- plain these findings, including less social support, differences in social cir- cumstances, beliefs about pain, and self-management strategies, and the 170 ROLLMAN possibility that African Americans may not seek or be referred for treat- ment unless they are suffering from high levels of distress. A study by Jordan, Lumley, and Leisen (1998) compared pain control be- liefs, use of cognitive coping strategies, and status of pain, activity level, and emotion among 48 African American and 52 White women with rheuma- toid arthritis, controlling for the potentially confounding influence of in- come, marital status, and education. There were no group differences in pain, but the African American patients were less physically active and more likely to cope with pain by praying and hoping and diverting atten- tion, whereas Whites were more likely to make coping statements and ig- nore the pain. Bill-Harvey, Rippey, Abeles, and Pfeiffer (1989) had earlier noted that 92% of low-income, urban African American arthritis patients used prayer to relieve their pain and discomfort. Cognitive behavior ther- apy and other treatments that encourage the use of increased coping at- tempts and decreased negative thinking can aid African Americans to man- age experimentally induced pain (Gil et al. Waza, Graham, Zyzanski, and Inoue (1999) found that Japanese patients who had been newly diagnosed with depression reported more total symp- toms, particularly physical ones, than patients in the United States. Twenty seven percent of the Japanese patients reported only physical symptoms, whereas only 9% of the patients in the United States presented in this man- ner. A large proportion of the Japanese had pain complaints (generally ab- dominal pain, headache, and neck pain); comparable figures for the Ameri- can patients were about 60 to 80% less. The authors propose that pain at specific body areas may arise because of cultural influences, possibly to avoid the stigma in Japan associated with emotional disorders. For exam- ple, many Japanese expressions use the term hara (abdomen) to verbalize emotion, and digestive-system complaints are the primary reason for out- patient medical visits in that country. Njobvu, Hunt, Pope, and Macfarlane (1999), in a review of pain among in- dividuals from South Asian ethnic minority groups who live in the United Kingdom, observed that they more frequently attend medical clinics and re- port greater musculoskeletal pain. This leads to the question of whether South Asians also suffer greatly from pain in their countries of origin. Hameed and Gibson (1997) provided relevant data in a study of pain com- plaints among Pakistanis living in England and in Pakistan. Those living in England reported more arthritic symptoms and more nonspecific musculo- skeletal pain, particularly among females. There are numerous possible ex- planations including the colder British climate, adjustment to life in a new 6.

Occupational therapy is indi- sults of treatment of the medial humeral epicondyle in children purchase 60 ml rogaine 2 amex prostate cancer in men. Fowles JV generic rogaine 2 60 ml man health customer main customer public, Slimane N, Kassab MT (1990) Elbow dislocation with ▬ Posttraumatic deformities can be safely avoided by the avulsion of the medial humeral epicondyle. J Bone Joint Surg (Br) correct clinical recording of the rotational situation 72: 102–4 and observance of the limits of spontaneous correc- 23. Gartland JJ (1959) Management of supracondylar fractures of the humerus in children. Gibbons CL, Woods DA, Pailthorpe C, Carr AJ, Worlock P (1994) The management of isolated distal radius fractures in children. Gilchrist AD, McKee (2002) Valgus instability of the elbow due to ulnar nerve palsy caused by cubitus varus deformity. J Hand Surg medial epicondyle non-union: treatment by fragment excision (Am) 20: 5–9 and ligament repair- a report of 5 cases. Archibeck MJ, Scott SM, Peters CL (1997) Brachialis muscle en- 11: 493–7 trapment in displaced supracondylar humerus fractures: a tech- 26. Goldfarb CA, Bassett GS, Sullivan S, Gordon JE (2001) Retrosternal nique of closed reduction and report of initial results. J Pediatr displacement after physeal fracture of the medial clavicle in chil- Orthop 17: 298–302 dren treatment by open reduction and internal fixation. Clin Orthop 376: 32–8 closed intramedullary pinning (Metaizeau Technique). Bortel DT, Pritchett JW (1993) Straight-line graphs for the predic- Orthop 17: 325–31 tion of growth of the upper extremity. Graves SC, Canale S (1993) Fractures of the olecranon in children: 885–92 long-term follow-up. Gurkan I, Bayrakci K, Tasbas B, Daglar B, Gunel U, Ucaner A (2002) Rokkanen P (1986) Radial palsy in shaft fracture of the humerus. Posterior instability of the shoulder after supracondylar fractures Acta Orthop Scand 57: 316–9 recovered with cubitus varus deformity. Bould M, Bannister GC (1999) Refractures of the radius and ulna 198–202 in children. Calder JD, Solan M, Gidwani S, Allen S, Ricketts DM (2002) Man- erten Frakturen des Condylus radialis humeri im Wachstumsalter. Cannata G, De Maio F, Mancini F, Ippolito E (2003) Physeal frac- after fractures of the lateral condyle in children. J Pediatr Orthop tures of the distal radius and ulna: long-term prognosis. Carsi B, Abril JC, Epeldegui T (2003) Longitudinal growth after omy and external fixation for chronically displaced radial heads. Caterini R, Farsetti P, D’Arrigo C, Ippolito E (2002) Fractures of the 33. Hill JM; McGuire MH; Crosby LA (1997) Closed treatment of dis- olecranon in children. J Pediatr placed middle-third fractures of the clavicle gives poor results. Inoue G, Horii E (1992) Case report: Combined shear fractures of diatric age groups: A study of 3350 children. J Orthop Trauma 7: the trochlea and capitellum associated with anterior fracture-dis- 15–22 location of the elbow. J Pediatr Orthop B 8: 84–7 intra-articular entrapment of the lateral epicondyle. Josefsson PO, Gentz CF, Johnell, Wendeberg B (1987) Surgical Edinb 38: 112–3 versus nonsurgical treatment of ligamentous injuries following 58. Mehlman CT, Strub WM, Roy DR, Wall EJ, Crawford AH (2001) The dislocations of the elbow joint. Kallio PE, Foster BK, Paterson DC (1992) Difficult supracondylar Joint Surg (Am) 83: 323–7 elbow fractures in children: analysis of percutaneous pinning 59. Nimkin K, Spevak MR, Kleinman PK (1997) Fractures of the hands techniques.