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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Rui Fernandes, DMD, MD, FACS
For example muscle relaxant high blood pressure discount 50 mg voveran visa, when viewing a right shoulder from the superior to inferior direction knee spasms causes buy discount voveran 50mg on-line, a counterclockwise rotation of the humerus would be referred to as internal rotation muscle relaxant antidote cheap voveran 50 mg amex. Internal rotation with the arm in a position of 90° of abduction or 90° of flexion uses the same concept muscle relaxant jaw pain voveran 50mg for sale. The humerus rotates in the same direction in each case, regardless of the 8 2 Range of Motion. Abduction in the scapular plane allows for accurate range of motion estimation because both the anterior and posterior capsular structures are similarly lax. Abduction in the coronal plane, on the other hand, can be regarded as a position of extension in which anterior capsular structures become more tight when compared to posterior capsular structures. Measuring range of motion or joint laxity in this position may produce inaccurate results. In this case, the patient will attempt to reach as far up the spinal column as possible while the clinician determines the most superior spinal level that the patient can reach. This position maximizes internal rotation and has historically been a standard measure for internal rotation capacity. However, this method of measurement has recently been called to question since the vertebral level to which one reaches may be influenced by elbow, wrist, and hand motion rather than isolated internal rotation of the humerus [5]. The basic resting position with the arm at the side is often referred to as "simple adduction. Conversely, "horizontal extension" corresponds to the opposite motion, where the humerus is extended posteriorly beyond the scapular plane. When viewing a right shoulder from superiorly to inferiorly, external rotation would be defined as clockwise rotation of the humerus away from the midline. Again, similar to internal rotation, the rotational moment about the humeral anatomic axis does not change whether the 2. This position of neutral scapulohumeral angulation is determined by the angle between a line drawn along the center axis of the scapula and second line drawn at the same level that is perpendicular to the coronal plane. This position, which most often occurs between 20° and 30° of forward angulation relative to the coronal plane with the humerus in various degrees of abduction, minimizes the potential for acromiohumeral contact while also allowing for the theoretical isolation of the rotator cuff musculature during various clinical examination tests. In other words, some have theorized that abduction of the humerus within the scapular plane requires zero contribution from internal or external rotators to achieve full abduction capacity [6]. Maximum capsuloligamentous laxity also occurs within the scapular plane (at the glenohumeral resting position, discussed below) which facilitates examination of these structures (instability and laxity testing are discussed in Chap. Although the scapular plane is generally defined as 2030° of humeral forward angulation relative to the coronal plane in normal individuals, it must be recognized that patients with scapular malposition or dyskinesis, as which occurs commonly in overhead athletes, may have a scapular plane that differs from the rest of the population. For example, a throwing athlete with scapular malposition may display increased protraction and upward rotation in the resting position (discussed below), thus altering the position of the glenoid such that the plane of the scapula occurs with greater forward angulation of the humerus. Therefore, performing physical examination tests within the "normal" scapular plane in a patient with scapular malposition may produce inaccurate results (specific examination maneuvers for evaluation of the scapulothoracic articulation are presented in Chap. In other words, this position is considered to allow maximal glenohumeral mobility owing to an increase in joint laxity [8]. The glenohumeral resting position in normal shoulders is thought to be between 55° and 70° of abduction with the humerus in neutral rotation within the plane of the scapula. In this position, the amount of external force required to translate the humeral head is minimal. Although there is a general consensus regarding the location of the glenohumeral resting position, validation studies have seldom been conducted. In this study, maximum elevation occurred with the arm externally rotated within the plane of the scapula. They could not achieve this maximal elevation with the arm internally rotated due to the acromiohumeral impingement that occurs in this position. In other words, there was bony contact between the acromion and the greater tuberosity, thus hindering the ability to further elevate the arm. When the humerus was placed in a position of 30° of forward angulation, there was little contribution from the internal and external rotators during humeral abduction. The glenohumeral resting position was calculated as the mid-point of the confidence intervals where maximal rotational and translational motion occurred. Maximal anteroposterior translation and maximal rotational range of motion occurred at approximately 39° of humeral abduction in the scapular plane and corresponded to approximately 45 % of the maximum available abduction range of motion. They also found that the glenohumeral resting position varied according to the maximal available range of motion, possibly suggesting that patients with joint hypermobility and hypomobility should be tested at greater and lesser degrees of humeral abduction, respectively. Since this was a cadaveric study, the effect of dynamic glenohumeral stabilization (which also contributes to the resting position) could not be evaluated. In that study, translational and rotational range of motion capacities were determined using an electromagnetic tracking device after an 80 N translational load and a 4 N-m (torque) rotational load were applied. These results suggested that testing for anteroposterior joint laxity should be conducted at lower degrees of abduction than when testing for rotational joint laxity. Considered together, these studies demonstrate the complexity and potential variability that the glenohumeral resting position can have across a population, between populations or even between individuals (dominant versus nondominant shoulders). In general, it is important to determine the maximal range of translational and rotational range of motion for each patient. In general, the rotational resting position is thought to occur at a point near 45 % of the total abduction arc [14] where half of this abduction angle is thought to represent the translational resting position [9]. In other words, when beginning the motion, the palm faces posteriorly and, at the end of the motion, the palm faces anteriorly. Alternatively, an individual can place their hand at the top of the head through either (1) forward flexion and internal rotation or (2) abduction and external rotation. This observation has traditionally been of academic interest; however, many investigators have attempted to mathematically solve the "paradox" using complex equations and algorithms [15, 16]. Some authors have suggested that scapular malposition may be involved with both external and internal impingement mechanisms, especially in overhead athletes [1924]. The first function is to dynamically position the glenoid in space to facilitate the generation of a large arc of glenohumeral motion. Second, the scapula provides a stable fulcrum upon which glenohumeral motion can arise. Third, dynamic scapular positioning allows the rotator cuff tendons to glide smoothly beneath the acromion with humeral elevation. Finally, the scapula functions to transfer potential energy through the kinetic chain, into the shoulder and, finally, to the hand thus allowing for functional overhead motion. Changes in scapular positioning as a result of alterations in the dynamic periscapular muscle force couples leads to scapular dyskinesis. Evaluation of the scapular range of motion is one of the most difficult aspects of the shoulder examination for several reasons. One reason is that scapular motion is very complex and requires the examiner to visualize motion in three dimensions. Another reason is that the relative contributions of glenohumeral and scapulothoracic motions are difficult to distinguish, especially when abnormal motions are the result of muscle compensation for some other shoulder condition outside of the scapulothoracic articulation. The scapula is also covered with large, thick muscles making it difficult to visualize or palpate the various scapular motions. In addition, there exists a change in nomenclature when referring to scapular motion (discussed below). Specific examination maneuvers used to examine the scapulothoracic articulation are presented in Chap. Rather, it represents the position of the scapular body relative to the coronal plane (discussed below). With the arm at rest, the scapula is predictably positioned in a specific orientation that can be used to detect scapular malposition before any motion measurements or evaluations are undertaken. There have only been a few studies that quantified the precise location of the scapula on the posterior thorax. The distance from the superomedial angle to the midline, the distance from the inferomedial angle to the midline and also the angle of scapular inclination were determined. In total, there are three rotational movements and two translational movements. Although it is not possible to isolate these movements, they represent the basic components that comprise threedimensional scapular motion.
A chronic spasms during mri discount voveran 50 mg with mastercard, uncomfortable muscle relaxant list order 50mg voveran mastercard, burning pain presents in the territory of the involved dermatome spasms right side under ribs discount voveran 50mg mastercard. Herpes Zoster ophthalmicus can be associated spasms muscle buy 50mg voveran visa, in the middle aged, with delayed major cerebral artery territory infarction. Stroke also occurs as a remote complication of childhood varicella, usually within 12 weeks of clinical chickenpox. Certain types of immunological deficiency tend to be associated with specific forms of infection. Fungi Aspergillus Candida Mucoraceae Parasites Toxoplasmosis B cell immunoglobulin deficiency Granulocyte deficiency Chronic lymphatic leukaemia Marrow infiltration Primary hypogammaglobulinaemia Aplastic anaemia Splenectomy Chemotherapy/ radiotherapy Measles Enteroviruses Streptococcus pneumoniae Haemophilus influenzae Pseudomonas aeruginosa, etc. Sex education, supply of clean needles to addicts, active drug-dependence programmes and specific precautions in the preparation of blood products are necessary to limit its spread. Unlike acute meningitis, the onset is insidious; cranial nerve signs and focal deficits such as hemiparesis, dementia and gradual deterioration of conscious level may predominate. The outcome depends upon aetiology and the early instigation of appropriate treatment. Amphotericin B + fluorocytosine or fluconazole Specific features Treatment Carcinomatous meningitis lung/breast/ gastrointestinal tract Leukaemia/ lymphoma Glioma Medulloblastoma Melanoma Back pain/ radicular involvement common. Hydrocephalus in 30% Consider irradiation followed by intrathecal methotrexate or monoclonal targeting (see page 314). The central nervous system is composed of neurons with neuroectodermal and mesodermal supporting cells. The oligodendrocytes, like Schwann cells in the peripheral nervous system, are responsible for the formation of myelin around central nervous system axons. One Schwann cell myelinates one axon but one oligodendrocyte may myelinate several contiguous axons, and the close proximity of cell to axon may not be obvious by light microscopy. Oligodendrocytes are present in grey matter near neuronal cell bodies and in white matter near axons. The lipid fraction may be divided into: cholesterol glycophosphatides (lecithins) sphingolipids (sphingomyelins). The laying down of myelin in the central nervous system commences at the fourth month of fetal life in the median longitudinal bundle, then in frontal and parietal lobes at birth. Myelin is inherently abnormal or was never properly formed these disorders generally present in infancy and early childhood and have a biochemical basis. Myelin which was normal when formed breaks down as a consequence of pathological insult. The disease occurs most commonly in temperate climates and prevalence differs at various latitudes: Latitude (°N) Orkneys and Shetland. The lesions lie in close relationship to veins (postcapillary venules) perivenous distribution. Breakdown of bloodbrain barrier occurs and may be essential for myelin destruction. Within these plaques bare axons are surrounded by astrocytes Axon loss accounts for increasing disability. Thoracic spinal cord showing established plaques of demyelination Immune deficiency has been suggested. T lymphocytes and macrophages found in plaques may be sensitized to myelin antigens. Viruses may be important in the development of multiple sclerosis, infection perhaps occurring in a genetically/ immunologically susceptible host. Biochemical: No biochemical effect has been demonstrated myelin appears normal before breakdown and the proposed excess of dietary fats or malabsorption of unsaturated fatty acids is unproven. Vague symptoms: lack of energy, headache, depression, aches in limbs may result in diagnosis of psychoneurosis. Precise symptoms: (initial symptom of multiple sclerosis expressed as a %) Sensory disturbance Retrobulbar neuritis Limb weakness Diplopia Vertigo Ataxia Sphincter disturbance 40% 17% 12% 11% 20% Trigeminal neuralgia may be an early symptom of multiple sclerosis, and this should be considered in the young patient with paroxysmal facial pain. Paraesthesia is more often due to posterior column demyelination than to spinothalamic tract involvement. Paraparesis is the result of spinal demyelination, usually in the cervical region. Signs: Increased tone Hyperactive tendon reflexes, extensor plantar response and absent abdominal reflexes Pyramidal distribution weakness. The visual loss develops over several days and is often associated with pain on ocular movement (irritation of the dural membrane around the optic nerve). Typically only one eye is affected, although occasionally both eyes simultaneously or consecutively are involved. Visual field Macular area Macular fibres Optic disc Retina Blind spot Central scotoma 20° 30° On examination: Disturbance of visual function ranges from a small central scotoma to complete loss. Fundal examination reveals swelling papillitis in up to 50% of patients, depending upon the proximity of the plaque to the optic nerve head. Abnormality of eye movements with or without diplopia occurs when supranuclear or internuclear connection are involved. The latter results from a lesion in the medial longitudinal fasciculus internuclear ophthalmoplegia (I. It is unusual in multiple sclerosis when the eyes are in the primary position, and is commonly seen on lateral gaze. Limb inco-ordination, intention tremor and dysarthria indicate cerebellar involvement. Sphincter disturbance with urgency or precipitancy of micturition and eventual incontinence occurs. Conversely urinary retention in a young person may be the first symptom of disease. Emotional lability: Uncontrolled outbursts of crying or laughing, result from involvement of pseudobulbar pathways. Paroxysmal (symptoms occurring momentarily throughout any stage of the disease): paraesthesia, dysarthria, ataxia, pain. Converting from relapsing and remitting to secondary progressive occurs on average 610 years after the initial symptoms. Symptoms and signs are usually spinal and relapses absent in the context of insidious progression. The true incidence of such cases is difficult to define and patients may still progress in time to major disability. Cerebrospinal fluid examination by lumbar puncture A mild pleocytosis (25 cells/mm3), mainly lymphocytes, is occasionally found. Research criteria have been developed for clinical studies which combine clinical features with investigation findings. Check for infection beforehand, monitor blood glucose and consider an H2 blocker for ulcer prophylaxis. The evidence that this reduction translates into reduced disability is less clear. Natalizumab, a monoclonal antibody, reduces the relapse rate by over 60% with reduction in disability but is associated with a risk of developing progressive multifocal leucoencephalopathy (1 in 1000). Mitoxantrone is a chemotherapy agent which can be used in aggressive disease with risk of cardiotoxicity and leukemia. Pathologically demyelination is associated with marked cavitation and necrosis (possibly due to severe oedema confined and compressed by the pia of the optic nerves and spinal cord). When recurrent attacks occur, this results in an aggressive course with a high fatality. Examination Optic neuritis with or without papillitis Reduced visual acuity and bilateral central scotoma Sensory loss extending up to mid thorax Reduced lower limb reflexes initially Reduced power in lower limbs Extensor plantar response Left Right 30 20 20 30 Investigations Anti-aquaporin 4 antibody is positive in over 90% of patients. There appears to be a case for using immunosuppressive drugs (azathioprine, cyclophosphamide) to prevent relapses though evidence is as yet limited. This disorder may follow upper respiratory and gastrointestinal infections (viral), viral exanthems (measles, chickenpox, rubella, etc. Measles is the commonest cause occurring in 1 per 1000 primary infections; next Varicella zoster (chickenpox), 1 per 2000 primary infections.
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Syndromes