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Nene AV purchase 60 ml rogaine 2, Evans GA, Patrick JH (1993) Simultaneous multiple operations for spastic diplegia. Outcome and functional as- movement, thereby helping to produce the indirect ex- sessment of walking in 18 patients. Severe equinus deformities, however, 488–94 require correction but only to -5° to 0° of dorsiflexion. Dev Med Child Neu- A slight hyperextension of the knee of up to 5° is ac- rol 29: 153–8 ceptable, whereas a more pronounced hyperextension can 15. Rethieften S, Tolo VT, Reynolds RAK, Kay R (1999) Outcome of hamstring lengthening and distal rectus femoris transfer sur- overstretch the knee capsule and lead to later problems in gery. Reimers J (1990) Functional changes in the antagonists af- prevented indirectly by corresponding orthotic provision ter lengthening the agonists in cerebral palsy. Quadriceps for the lower leg and foot, and the forward or backward strength before and after distal hamstring lengthening. Outcome of bilizing the knee are difficult to produce and hardly ever hamstring lengthening and distal rectus femoris transfer sur- produce the desired result. J Pediatr Orthop B 8: 75–9 able during the day with a high-fitting orthosis, a low-fit- 18. Rideau Y (1986) Prophylactic surgery for scoliosis in Duchenne ting orthosis should always be used if possible. Dev Med Child Neurol 28: 398–9 have unjustified and unproven concerns about possible 19. Rideau Y, Duport G, Delaubier A, Guillou C, Renardel-Irani A, Bach deformities, e. Roberts A, Evans GA (1993) Orthopedic aspects of neuromuscu- useful to provide excessive treatments, but rather to solve lar disorders in children. Saw A, Smith PA, Sirirungruangsarn Y, Chen S, Hassani S, Harris G, Kuo KN (2003) Rectus femoris transfer for children with cerebral palsy: long-term outcome.

Erken EH order rogaine 2 60 ml line, Bischof FM (1994) Iliopsoas transfer in cerebral palsy: the J Pediatr Orthop 10: 583–7 long-term outcome. Fabry G, Liu XC, Molenaers G (1999) Gait pattern in patients with 158 patients followed for 15 years. Acta Orthop Scand 61: 3–6 spastic diplegic cerebral palsy who underwent staged operations. Samuelsson L, Skoog M (1988) Ambulation in patients with myelo- J Pediatr Orthop 8: 33–8 meningocele: a multivariate statistical analysis. Fraser RK, Bourke HM, Broughton NS, Menelaus MB (1995) Unilat- 569–75 eral dislocation of the hip in spina bifida. Saraph V, Zwick EB, Zwick G, Steinwender C, Steinwender G, Lin- Bone Joint Surg 77-B: 615–9 hart W (2002) Multilevel surgery in spastic diplegia: evaluation by 20. Fraser RK, Bourke HM, Broughton NS, Menelaus MB (1995) Unilat- physical examination and gait analysis in 25 children. Fraser RK, Hoffman EB, Sparks LT, Buccimazza SS (1992) The un- of established dislocation and refractory progressive subluxation stable hip and mid-lumbar myelomeningocele. Frischhut B, Krismer M, Sterzinger W (1992) Die Hüfte bei der dislocations in ambulatory myelomeningoceles. Z Kinderchir 42: infantilen Zerebralparese, natürlicher Entwicklungsverlauf und Supl 1 48–9 Behandlungskonzepte. Heimkes B, Stotz S, Heid T (1992) Pathogenese und Pravention der psoas release, and proximal hamstring release in cerebral palsy. Song HR, Carroll NC (1998) Femoral varus derotation osteotomy fecting the incidence of hip dislocation in cerebral palsy. J Bone with or without acetabuloplasty for unstable hips in cerebral Joint Surg (Br) 67: 530–2 palsy.

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Joint Fluid Analysis Property Normal Noninflammatory Inflammatory Septic Viscosity High High Low Variable Color Colorless Straw Yellow Turbid-Yellow Clarity Transluscent Transluscent Transluscent Opaque WBC < 200 < 5000 1000–75000 > 100 cheap rogaine 2 60 ml online,000 PMN% < 25 < 25 > 50 > 85 Culture Negative Negative Negative Positive Mucin clot Good Good Fair Poor Glucose Equal to blood Equal to blood < 50 mg/dl > 50 mg/dl lower than lower than blood blood OTHER INFECTIOUS CAUSES OF ARTHRITIS Viral Infections—Rubella, infectious hepatitis Fungi—Seen in Immunocompromised adults Mycobacterium—tuberculosis of the spine (Pott’s disease) – Thoracic involvement – TB arthritis—Hips and knees Monoarticular Radiologic findings—Phemister’s triad Juxta-articular osteoporosis Marginal erosions Joint space narrowing Lyme Disease – Tick borne—Borrelia burgdorferi – Classic presentation Erythema migrans—bull’s eye rash Cardiac, neurologic, articular manifestations – Intermittent migratory episodes of polyarthritis – Commonly affects the knee – Synovial fluid—Inflammatory – Diagnosis—ELISA, Western blot analysis – Management—First-line antibiotics: Adults: Doxycycline Children: Amoxicillin – Pattern of Onset: Bite Rash Systemic dz. Neurologic involvement RHEUMATOLOGY 119 DEPOSITION AND STORAGE DISEASE HEMOCHROMATOSIS Organ damage and tissue dysfunction secondary to excessive iron stores and the deposi- tion of hemosiderin Organs → Hepatic cirrhosis, cardiomyopathy, DM, pituitary dysfunction Skin pigmentation Chronic progressive arthritis – Occurs commonly in second and third MCP, PIP joints. It may also affect the hip joints Males ~40–50 years old Treatment: Phlebotomy, NSAIDs ALKAPTONURIA (OCHRONOSIS) Autosomal recessive Deficiency in the enzyme homogentisic acid oxidase leads to its increase Alkalinization and oxidation causes darkening of tissue parts termed ochronosis – Blueish discoloration of the urine, cartilage, skin, sclera secondary to the accumulation of homogentisic acid Progressive degenerative arthropathy – Onset—in the fourth decade – Spinal column involvement – Arthritis of the large joints, chondrocalcinosis, effusions, osteochrondral bodies WILSON’S DISEASE Autosomal recessive Deposition of copper leads to destruction: – Liver leading to cirrhosis – Brain – Kidneys – Ocular—Kayser-Fleischer rings OA—wrists, MCP, knees, spine Osteoporosis Treatment: Copper chelation with penicillamine, dietary restriction GAUCHER’S DISEASE Autosomal recessive—Ashkenazi Jews Glucocerebroside accumulates in the reticuloendothelial cells of the spleen, liver, and bone marrow Monoarticular hip and knee degeneration 120 RHEUMATOLOGY OTHER SYSTEMIC DISEASES SARCOIDOSIS Systemic chronic granulomatous disease—can affect any organ system Pathogenesis: disseminated noncaseating granulomatous Eight times more common in blacks, females > males Clinical features: – Pulmonary – Hilar adenopathy – Fever, weight loss, fatigue – Arthritis: polyarthritis, 4-6 joints Knees, PIP, MCP, wrists – Skin—Lofgren’s Syndrome – Arthritis, Hilar adenopathy, Erythema nodosum AMYLOIDOSIS Homogeneous eosinophilic material seen with Congo red dye Deposition of amyloid in the kidneys, liver and spleen Clinical features: – Renal disease is primary clinical feature – Cardiomyopathy – Median neuropathy – Pseudoarthritis—periarticular joint inflammation – Effusions: Arthrocentesis—“Shoulder-pad” sign HEMOPHILIA ARTHROPATHY X-linked recessive disorder, predominately in males—associated with HIV 2° to transfu- sions of factor and blood Blood coagulation disorder caused by Factor VIII deficiency (classic hemophilia A) and Factor IX deficiency (Christmas disease, hemophilia B) Bleeding into bones and soft tissue causes hemarthrosis, necrosis and compartment syn- drome Elbow, knee, wrist are common Arthritis is caused by the remaining blood in the joint depositing hemosiderin into the synovial lining → proliferation of the synovium and pannus formation Radiologic: Joint space narrowing, subchondral sclerosis and cyst formation Treatment: Conservative care (immobilization, rest, ice), Factor VIII replacement, reha- bilitation, joint aspiration as a last resort SICKLE-CELL DISEASE Biconcave RBC changes to an elongated crescent sickle-shape causing obstruction of the microvasculature Musculoskeletal complications: – Painful crisis—Most common event Abdomen, chest, back Pain in the large joints from juxta-articular bone infarcts with synovial ischemia RHEUMATOLOGY 121 – Dactylitis—“Hand-Foot” Syndrome Painful non-pitting swelling of the hands and feet – Osteonecrosis Local hypoxia with occlusion to the venous system by the sickled cells 1/3 femoral heads and 1/4 humeral heads go on to osteonecrosis – Osteomyelitis—most commonly caused by Salmonella NEUROPATHIC ARTHROPATHY (CHARCOT’S JOINT) DEFINITION Chronic progressive degenerative arthropathy, secondary to a sensory neuropathy with loss of proprioception and pain sensation, leading to instability and joint destruction CAUSES → “STD” “SKA” → SHOULDER, KNEE, ANKLE Syringomyelia → Shoulder Tabes dorsalis # 2 → Syphilis → Knee Diabetic Neuropathy → # 1 cause → Ankle CLINICAL Early findings: Painless swelling, effusion and joint destruction Late findings: Crepitation, destruction of cartilage and bones, intra-articular loose bodies Subtle fractures RADIOLOGIC Joint destruction Hypertrophic osteophytes Loose bodies caused by micro fractures Disorganization of the joint—Subluxation and dislocation TREATMENT Immobilization Restriction of weight bearing Charcot Joint vs. Osteoarthritis May mimic OA early in the disease— Both have: Soft tissue swelling Osteophytes Joint effusion Charcot joints have: Bony fragments Subluxation Periarticular debris 122 RHEUMATOLOGY TABLE 3–8. Hip Pain in Children (Janig and Stanton-Hicks 1996; Kaggs and Tolo 1996; Koop Quanbeck 1996; Jensen et al. Growth arrest— Proximal and lateral epiphysis avascular stage migration of the femoral Grade I: < 33% 2. Subchondral fracture— head from the Grade II: 33–50% “Crescent sign” acetabulum Grade III: > 50% 3. Healed RHEUMATOLOGY 123 TABLE 3-8 (Continued) Congenital Slipped Capital Femoral Legg-Calve-Perthes Hip Dislocation Epiphysis (SCFE) Disease (LCPD) Treatment Goal—return the hip into Bed rest—weight relief 1. Prevent femoral head pathologic changes Surgery is the preferred collapse Closed Reduction— method of treatment— Containment techniques < 6 mo Knowles pinning Permit weight bearing Position devices Nonsurgical—traction, of the femoral head to Triple diapers body casts, hormonal assist healing and Frejka pillows therapy remodeling Splints: Craig, Von Greater than 6 years old Rosen-Pavlik harness: Abduction braces allows hip motion Petrie casts, Toronto within the safe zone brace, Salter stirrup while maintaining Surgical— abduction Epiphysiodesis Traction, casting, surgical Valgus Osteotomy Complication 1. OA Thomas Test: To detect flexion contractures of the hip and evaluate range of hip flexion 1. Have patient hold one leg on chest, lower other leg flat Indicators of fixed flexion contracture/deformity: 1. Emotional stress May be associated with Irritable Bowel Syndrome, RA, Lyme, hyperthyroidism ARA CLASSIFICATION: 1. Widespread pain—pain in the left and right side of the Classification body above and below the waist.

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MRI/CT Internal rotation best 60 ml rogaine 2, extension, Juvenile rheumatoid Laboratory (infection parameters, abduction arthritis of the hip rheumatoid factors), ultrasound, AP x-ray Internal rotation, extension, Septic arthritis of the hip Laboratory (infection parameters), abduction AP x-ray, poss. Indications for imaging procedures for the hip Age Circumstances/Indication Tentative clinical Imaging procedures 3 diagnosis Infant Positive family history, positive clinical exam- Hip dysplasia Ultrasound, AP hip x-ray ination findings, additional malformations Infant, toddler, child Fever, restricted movement, pain, limping, Septic arthritis of the hip Ultrasound (effusion? Indications for physical therapy in hip disorders Disorder Indication Goal/type of treatment Duration Additional measures Septic arthritis of the Defective healing and Improve mobility, partic- As long as mobility is Poss. Frequent if movement is restricted, as swimming and cycling long as progress is possible Developmental In the older child with Improve gait As long as mobility is – dysplasia of the hip persistent dysplasia, poss. Improve mobility restricted and prog- (DDH) postoperatively ress is still possible Intoeing gait None Encouragement of sport- – Operation very rarely ing activity more useful indicated; watch for than physical therapy tibial torsion Slipped capital Postoperatively Strengthen the muscles Until the patient No strenuous sport femoral epiphysis (extensors/abductors), walks without a limp, until completion of improve mobility mobility is unre- growth stricted or no further progress is possible Femoral fractures If gait pattern is not normal Walking exercises As long as patient is – after 3 months symptomatic 279 3 3. The examination protocol for the knees is shown in – Did anything »give way« during the trauma, or was ⊡ Table 3. Is the pain load-related, movement-related, If so: or does it also occur at rest (e. If so, does the pain only occur when the – During what type of activity (sport, play, daily rou- patient changes position or does the patient awake at tine)? Lateral contours of the supine patient with 90° Lesion of the posterior cruciate ligament? Palpation Palpation of the patellar margins, shifting of Anterior knee pain? Ligamentous Lachman test (drawer test with almost full Lesion of the anterior and/or posterior cruciate ligament? Drawer test in 60° flexion Lesion of the anterior and/or posterior cruciate ligament? Meniscal signs Palpation of the joint space Backward migration of tenderness during increasing flexion? External rotation with increasing flexion Lesion of the medial meniscus? Lateral contours of the tibial tuberosity with 90° flex- ▬ Does locking or pseudolocking occur? If genuine ion of the knee with the patient in the supine posi- locking is present, the knee can neither be flexed nor tion (posterior displacement of the tibial tuberosity extended from a particular position for a prolonged compared to the other side is a sign of a lesion of the period (occurs particularly after a bucket-handle tear posterior cruciate ligament; ⊡ Fig.