By T. Ateras. Talladega College.

Test the patient’s reflexes—the biceps reflex (C5) generic depakote 250mg visa, the brachioradi- alis reflex (C6) purchase depakote 500mg without prescription, and the triceps reflex (C7) generic depakote 500mg mastercard. Elbow Pain 47 Table 1 Primary Muscles and Innervation for Elbow Movement Major muscle Primary muscles movement involved Primary innervation Elbow flexion 1. Plan Having completed your history and physical examination, you have a good idea of what is wrong with your patient’s elbow and/or forearm. Here is what to do next: Suspected lateral epicondylitis Additional diagnostic evaluation: Not generally necessary. Treatment: More than 95% of patients respond well to a combination of physical therapy—including strengthening and stretching exercises— ultrasound, electrical stimulation, iontophoresis, icing, counterforce bracing (which moves the fulcrum of pressure away from the lateral epi- condyle), wrist splinting, and/or steroid injections. The remaining refrac- tory cases may be treated surgically under local anesthesia. Treatment: The conservative modalities used are similar to lateral epi- condylitis and are considered first-line treatment. However, conservative measures are not as successful for medial epicondylitis as they are for lateral epicondylitis. Treatment: Conservative care, including physical therapy, non- steroidal anti-inflammatory drugs (NSAIDs), and rest, is considered the first-line of treatment for many patients. Surgical intervention should be considered for competitive athletes hoping to return to com- petition and patients with symptoms that do not respond to more con- servative measures. Additional diagnostic evaluation: X-rays, including AP and lateral views, should be obtained. Treatment: Conservative care, including rest, activity modification, NSAIDs, and a corticosteroid and anesthetic injection into the bursa, is generally effective. Treatment: Treating the underlying disease is important in rheuma- toid arthritis. Local symptoms may be treated with rest, intra-articular corticosteroid and anesthetic injections, and physical therapy. Elbow Pain 49 Treatment: Conservative care, including rest, physical therapy, NSAIDs, and intra-articular injection of corticosteroid and anesthetic, is appropriate treatment. Treatment: Conservative care, including activity modification, splinting, and/or steroid injection, is often successful. It includes carpal tunnel syndrome, De Quervain’s tenosynovitis, ulnar collateral ligament injury (also known as “skier’s thumb” or “game- keeper’s thumb”), “trigger finger,” fractures, and rheumatoid arthritis.

After the flap is freed 250mg depakote sale, the frac- ture is reduced depakote 250mg with visa, with the knee extended buy 500mg depakote otc, and the result fixed by lag screw osteosynthesis. Predominantly perios- teal avulsions of the patellar ligament can be managed by bone sutures, secured if necessary by tension-band wiring (⊡ Fig. Duration of immobilization Three weeks for compression fractures, 4–5 weeks for ⊡ Fig. Treatment of displaced eminence fractures: All patients with a displaced eminence fracture should be investigated arthroscopi- the other fractures. The eminence itself should be reduced is worn until the swelling subsides and the wound has arthroscopically and, wherever possible fixed by an epiphyseal screw (a). Mobilization can then begin immediately on the If this cannot be performed by arthroscopy, the fragment is resecured motorized splint. Because of the potential risk of growth disturbances, subsequent controls are justified for at least 2 years following trauma while the growth plates are still open, excluding compression fractures. If movement is restricted and/or axial asymmetry is present, the patient is monitored until physeal closure occurs. Complications Growth disturbances and posttraumatic deformities Partial growth plate closure is a possible complication of an epiphyseal fracture, but can also occur after epiphyseal separations that often appear trivial on the x-ray, even ⊡ Fig. Treatment of displaced epiphyseal separations of the proxi- after correct primary treatment. Parents and patients mal tibia: These fractures are managed by closed reduction and stabi- should be informed of this possibility even at the time lized with percutaneously inserted, crossed Kirschner wires of fracture treatment if more than 1–2 years of residual ⊡ Fig. Treatment of metaphyseal bowing fractures of the proximal tibia: By definition, every metaphyseal bowing fracture involves an axial devia- tion, usually a valgus deformity, which is reflected in the gaping fracture gap on the medial side (a). If the primary valgus can be eliminated and the medial fracture gap compressed by cast wedging (b), the consequences of the increased medial growth will not be clinically significant. If the medial fracture can- not be closed by cast wedging, the fracture must be managed by closed reduction and the resulting posi- tion secured ideally with a medially fitted external fixator (c). The surgeon must be careful to avoid injury a b c to the apophyseal plate 344 3. Treatment of a compression fracture of the proximal tibial wedging, but the medial fracture gap does not initially appear to be metaphysis: 4-year old girl with metaphyseal bowing fracture which, by compressed. During consolidation, however, the medial fracture gap is definition, shows a moderate valgus deformity (reflected in the medi- bridged by callus. The subsequent increased medial growth only result- ally gaping fracture gap). The valgus deformity was eliminated by cast ed in a moderate, clinically insignificant increase in the valgus position ⊡ Fig. Treatment of displaced tuberosity avulsion: Intra- and er types III and IV, of the proximal tibia:Since these are joint fractures, they extra-articular tuberosity avulsions are reduced in the exact anatomi- must be reduced openly in the exact anatomical position and stabilized cal position and refixed with a large-fragment screw with a small-fragment screw running parallel to the growth plate growth is expected. Depending on the size and location results in increased medial vascularity and thus asym- of the closure, this can lead to abnormal axial growth, metrical plate growth (as proven by bone scans).

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