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Rea JA buy discount azulfidine 500 mg on-line pain treatment center meridian ms, Steiger P, Blake GM, Fogelman I (1998) Optimizing Comparison of methods for the visualisation of prevalent ver- data acquisition and analysis of morphometric X-ray absorp- tebral fracture in osteoporosis. Smyth PP, Taylor CJ, Adams JE (1999) Vertebral shape: auto- fracture assessment using a semi-quantitative technique. Mughal M, Ward K Adams J (2004) Assessment of bone sta- Radiographics 16:335-348 tus in children by densitometric and quantitative ultrasound 80. Jergas M (2003) Conventional radiographs and basic quantita- techniques. Peh WC, Gilula LA (2003) Percutaneous vertebroplasty: indi- childhood and adolescence: An approach based on bone’s bio- cations, contraindications, and technique. Marshall D, Johnell O, Wedel H (1996) Meta-analysis of how 20:561-583 well measures of bone mineral density predict occurrence of 90. Semin plication to screening for postmenopausal osteoporosis (1994) Musculoskelet Radiol, 6(4):307-312 IDKD 2005 The Radiology of Hip and Knee Joint Prostheses I. Weissman2 1 Department of Radiology, Leiden University Medical Centre, Leiden, The Netherlands 2 Department of Radiology, Brigham & Women’s Hospital, Boston, MA, USA Introduction density polyethylene is radiolucent and cannot be readily visualized non-invasively. Currently, approximately 800,000 total Other Articulations hip arthroplasties are performed each year worldwide, with the USA accounting for more than 200,000 of them In an effort to decrease articular wear and the shedding. The most frequent causes of failure are loosening and of particles, which can cause loosening, other articular particle disease. Up to 20% of both the acetabular cup and the femoral head made of patients will need revision surgery over 20 postoperative alumina ceramic. Good to excellent results are Main Types of Devices Used expected in 95% of appropriately selected patients. Hip Currently Used Materials Unipolar: Usually a femoral component only (or a mod- ular femoral component). Used mainly in older patients Metal following a femoral-neck fracture in whom the acetabu- lum is relatively normal. A number of combinations are in current use, designed to be long-wearing and inert biologically. The principle Bipolar arthroplasty: Comprising both a fixed femoral alloys used are cobalt-chrome-molybdenum, cobalt- component and an acetabular component that moves chrome-tungsten and titanium-aluminium-vanadium. Thus, motion should occur The prosthesis may be inserted with cement (to trans- between the native acetabulum and the acetabular com- fer stress from the prosthesis to bone) or have a sin- ponent and between the femoral component and the ac- tered irregular (“porous”) coating, allowing bone in- etabular liner. Bone in-growth fixation of the femoral stem can be performed if necessary. Acetabular fixation is generally by This is the most commonly used device in patients with bone in-growth. Ultra-High-Molecular-Weight Polyethylene Hybrid total hip replacement: The acetabular compo- nent is fixed by bone in-growth while the femoral com- This hard, high-density material provides a low-friction ponent is cemented. Furthermore, it allows Customised: Following tumor resection or difficult revi- plastic deformity increasing congruity. The Radiology of Hip and Knee Joint Prostheses 107 Knee The joint-line height is drawn from the tibial tubercle to the superior surface of the tibial component (the infe- Unicompartmental: Used when only one compartment rior edge of the femoral component) on the lateral radi- needs replacement; both the femoral and tibial sides of ograph. A joint line 8 mm higher than in the preoperative ex- amination is associated with a poorer clinical outcome. Total knee replacement: Posterior-cruciate-sparing or A low joint line causes a low patella and may result cruciate-substituting designs may be inserted. Unicompartmental arthroplasty: The femoral and tibial Mobile tibial polyethylene bearings: Rotating platform components should parallel each other, with no rotatory allows rotation, meniscal bearings allow rotation and an- element, and lie parallel to floor. Constrained: Reserved for revision surgery, severe bone loss or after tumor resection. These devices do not permit knee rotation and are subject to failure (loosening) in pa- Bone In-growth and Porous Coating tients whose activity level is high. Porous coating, while significantly adding to the cost of Patellofemoral: Either as part of a total knee replacement, joint replacement, may significantly improve implant when a polyethylene “button” is cemented into the articu- longevity. Beads of a similar alloy are sintered onto the lar surface of the patella, or as a specific patellofemoral metallic components, permitting bony in-growth to occur joint replacement when the major knee compartments are without the need for intervening cement. Clearly, this requires stability to allow in-growth to occur, with implications for the postoperative period. Normal Appearances Anticipated normal plain-film appearances include re- sorption of medial femoral cortex at the calcar femoris Hip Replacements (98%), reduced bone density where it is unloaded, the ab- sence of a thin lucent rim around the implant, although The following features on plain film suggest an ideal po- such a lucency with a sclerotic margin is common (79%) sition for a total hip replacement. A lucent line of more than 2 mm implies unacceptable tion angle should be about 40±10° on an AP view.

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When she was discharged 500mg azulfidine for sale pain medication for cancer in dogs, she was able to walk with a wheeled walker and she used a motorized tricart for longer distances. Her ability to walk has diminished, she is able to stand and pivot for transfers, and only take a few steps to and from chairs and her bed. She continues to experience attacks of her MS and, despite treatment with steroids, she has had incomplete recovery (secondary progressive MS). She uses a tub transfer chair to bathe and grab bars to get up and down from her commode. She uses a long-handled reacher in her kitchen and bedroom to reach items on high shelves. She has had a ramp installed at her front door and has widened the doorways in her home to accommodate her scooter. She is subject to fatigue and finds that if she rests in the after- noons, she is able to stay up until 9 or 10 PM before going to bed. Sally and her family have had frequent contact with the National Multiple Sclerosis Society (NMSS), participating in several education- al programs, family weekends, and support groups. Sally receives her care at an MS Center where, in addition to neurologic care, she has had nursing care for bladder and bowel management, counseling to assist her to adjust to her changing physical condition, and rehabili- tation services. She has had physical therapy for mobility and to develop a home program, and occupational therapy for upper extrem- Answers to the questions asked in these case studies can be found on page 112. Her current medications consist of Ditropan® and Hiprex® for her bladder, Cylert® for fatigue, and Neurontin® for pain. Sally’s condition contin- ues to worsen and her neurologist has discussed immunomodulating therapy, but has not suggested a particular product. Sally is unsure about what to do and comes to you for advice and education. What should one consider in assisting Sally with her decision regarding therapy? What types of education will Sally and her family need should she decide to begin therapy? What strategies have shown to facilitate adherence to complex protocols (select all that apply)? Assisting patients with injections until they are able to accomplish the task b. Sally has occasional short-term memory problems, particularly when she is fatigued. All of the above CHAPTER 21: CASE STUDIES 103 Case Study 2 Roberta is a fifty-five-year-old woman with a twenty-two-year history of multiple sclerosis. In the early 1980s she began to experience grad- ual weakness in her legs, and was using a walker by 1985. She showed signs of spasticity in her legs at that time and was started on a low dose of oral baclofen. She began using increasing doses of oral baclofen with some symptom relief. By 1994, she was triplegic and experienc- ing severe neurogenic bowel and bladder dysfunction. By 1997, she was unable to feed herself, her speech was hypophonic, and she need- ed a highly regimented bladder and bowel management program. She was taking baclofen 160 mg per day, and Zanaflex® was added starting with 2 mg. Roberta’s physician had suggested that she consider an intrathecal pump for delivery of baclofen but she refused. The most influential factor in choosing intrathecal baclofen might be: a. Insurance coverage 104 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM Case Study 3 William is a thirty-five-year-old executive who works 50 to 60 hours per week and travels frequently.

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The broken portion of the bone is driven in- cantly reducing the time of immobilization order azulfidine 500 mg online treatment of chronic pain guidelines. A fracture in which the bone fragments are not ultimate repair of the bone occurs naturally within the bone it- in anatomical alignment. When a bone is fractured, the surrounding periosteum is main in anatomical alignment. A disrupted aligning the broken ends and then immobilizing them until new blood supply to osteocytes and periosteal cells at the frac- bone tissue has formed and the fracture has healed. This is followed by severity of the fracture and the age of the patient determines the swelling and inflammation. The methods of immobilization include Colles’ fracture: from Abraham Colles, Irish surgeon, 1773–1843 Pott’s fracture: from Percivall Pott, British surgeon, 1713–88 hematoma: Gk. Skeletal System: The © The McGraw−Hill Anatomy, Sixth Edition Appendicular Skeleton Companies, 2001 Chapter 7 Skeletal System: The Appendicular Skeleton 191 (e) FIGURE 7. The traumatized area is “cleaned up” by the activity of velops around the periphery of the fracture. A healed frac- phagocytic cells within the blood and osteoclasts that re- ture line is frequently undetectable in a radiograph, except sorb bone fragments. As the debris is removed, fibrocarti- that for a period of time the bone in this area may be lage fills the gap within the fragmented bone, and a slightly thicker. The bony callus becomes the precursor of bone formation in much the same way that hyaline cartilage serves as the precursor of developing bone. The remodeling of the bony callus is the final step in the healing process. The cartilaginous callus is broken down, a The injury involves the cartilaginous epiphyseal growth plate, which is new vascular supply is established, and compact bone de- the site of linear growth in long bones. At cessation of growth, this plate disappears as the epiphysis and diaphysis fuse. Until this occurrence, however, disruption of the growth plate can adversely affect growth of the bone. Skeletal System: The © The McGraw−Hill Anatomy, Sixth Edition Appendicular Skeleton Companies, 2001 Developmental Exposition Initially, the developing limbs are directed caudally, but The Appendicular Skeleton later there is a lateral rotation in the upper extremity and a me- dial rotation in the lower extremity. As a result, the elbows are directed backward and the knees directed forward. EXPLANATION Digital rays that will form the hands and feet are apparent The development of the upper and lower extremities is initiated by the fifth week, and the individual digits separate by the end of toward the end of the fourth week with the appearance of four the sixth week. The superior pair are the arm buds, whose development precedes that of the infe- A large number of limb deformities occurred in children born between 1957 and 1962. Each limb bud consists of a tive thalidomide was used by large numbers of pregnant women mass of undifferentiated mesoderm partially covered with a layer to relieve “morning sickness. The malformations ranged from As the limb buds elongate, migrating mesenchymal tissues micromelia (short limbs) to amelia (absence of limbs). Primary ossifica- tion centers soon form in each bone, and the hyaline cartilage tissue is gradually replaced by bony tissue in the process of endo- micromelia: Gk. Skeletal System: The © The McGraw−Hill Anatomy, Sixth Edition Appendicular Skeleton Companies, 2001 Chapter 7 Skeletal System: The Appendicular Skeleton 193 CLINICAL PRACTICUM 7. On examination, you note a markedly deformed forearm with an open wound. You note that the patient has mildly weakened strength in the hand, normal sensation, as well as normal capil- lary refill and normal radial pulse. Why is it important to evaluate neuromuscular and vascular function in the hand in this case? At the current appointment, she complains of a new pain in her right hip. This pain began approxi- mately one month before and has been slowly progressing. On physical exam, you find nothing remarkable with the exception that the patient is now walking with a no- ticeable limp. A conventional radiograph (left) and a CT scan (right) of the hip are shown here.

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