Marc Kenneth Halushka, M.D., Ph.D.

• Deputy Director of Education, Department of Pathology
• Professor of Pathology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0016668/marc-halushka

This ventricle com m unicates with the subarachnoid space via m edian and lateral apertures (cf diabetic quinoa salad recipes generic irbesartan 300 mg buy line. The largest ventricles are the lateral ventricles diabetic diet watermelon purchase irbesartan now, each of which consist s of an anterior diabetes scientific definition irbesartan 300 mg order fast delivery, inferior diabetic diet 3 day buy irbesartan 150 mg otc, and posterior horn and a central part diabetes symptoms toes irbesartan 300 mg buy on-line. Certain portions of the ventricular system can be assigned to speci c part s of the brain: the anterior (frontal) horn to the frontal lobe of the cerebrum, the inferior (temporal) horn to the temporal lobe, the posterior (occipital) horn to the occipital lobe, the third ventricle to the diencephalon, the aqueduct to the m idbrain (m esencephalon), and the fourth ventricle to the hindbrain (rhom bencephalon). The anatom ical relationships of the ventricular system can also be appreciated in coronal and transverse sections (see pp. Cerebrospinal uid is form ed m ainly by the choroid plexus, a net work of vessels that is present to som e degree in each of the four ventricles (see p. The next unit will trace the path of the cerebrospinal uid from it s production to its reabsorption. The last unit on the cerebrospinal uid spaces will deal with the specialized functions of the ependym a, the circumventricular organs, and the physiological tissue barriers in the brain. Ventricular System a nd Cerebrospinal Fluid Interventricular foram en Anterior horn of lateral ventricle Suprapineal recess Pineal recess Left lateral ventricle Collateral trigone Posterior horn of lateral ventricle Anterior horn of lateral ventricle Third ventricle Inferior horn of lateral ventricle Right lateral ventricle Cerebral aqueduct Third ventricle Supraoptic recess Infundibular recess Inferior horn of lateral ventricle a Lateral recess, ends in lateral aperture of fourth ventricle Cerebral aqueduct Fourth ventricle Median aperture of fourth ventricle Central canal of the spinal cord b Fourth ventricle Collateral trigone Lateral recess Posterior horn of lateral ventricle B Cast of the ventricular system Left lateral view (a) and superior view (b). Cast specim ens are used to dem onstrate the connections bet ween the ventricular cavities. Each lateral ventricle com m unicates with the third ventricle through an interventricular foram en. The third ventricle com m unicates through the cerebral aqueduct with the fourth ventricle in the rhom bencephalon. The ventricular system has a uid capacit y of approxim ately 30 m l, while the subarachnoid space has a capacit y of approxim ately 120 m l. Note the three apertures (paired lateral apertures [foram ina of Luschka] and an unpaired m edian aperture [foram en of Magendie]), through which cerebrospinal uid ows from the deeper ventricular system into the m ore super cial subarachnoid space. It s anterior portions with the hippocam pal digitations protrude into the ventricular cavit y. The lateral wall of the third ventricle is form ed by structures of the diencephalon (epithalam us, thalam us, hypothalam us). Protrusions of the thalam i on both sides m ay touch each other (interthalam ic adhesion) but are not functionally or anatom ically connected and thus do not constitute a com m issural tract 303 Neuroanatomy 12. It ows through the m edian aperture and paired lateral apertures (not shown; see p. The cerebrospinal uid drains from the subarachnoid space through the arachnoid villi (and/or granulations) in the cranial cavit y or along the spinal nerve root sleeves into the venous plexuses or lymphatic pathways of the epidural space in the spinal cord. Surrounding brain tissue has been rem oved down to the oor of the lateral ventricles, where the choroid plexus originates. The plexus is adherent to the ventricular wall at only one site (see D) and can thus oat freely in the ventricular system. C Choroid plexus in the fourth ventricle Posterior view of the partially opened rhom boid fossa (with the cerebellum rem oved). Portions of the choroid plexus are at tached to the roof of the fourth ventricle and run along the lateral aperture. The choroid plexus is form ed by the ingrowth of vascular loops into the ependym a, which rm ly at tach it to the wall of the associated ventricle (see F). When the plexus tissue is rem oved with a forceps, it s lines of at tachm ent, called taeniae, can be seen. The epithelium of the choroid plexus consists of a single layer of cuboidal cells and has a brush border on it s apical surface (to increase the surface area). F Schematic diagram of cerebrospinal uid circulation As noted earlier, the choroid plexus is present to som e extent in each of the four cerebral ventricles. Olfactory cistern Carotid cistern Interpeduncular cistern Crural cistern (encloses the anterior choroidal artery) Trigem inal cistern Median pontine cistern Basilar artery Posterior inferior cerebellar artery Vertebral artery Cistern of corpus callosum Cistern of lam ina term inalis Chiasm atic cistern Cistern of lateral cerebral fossa (encloses m iddle cerebral artery) Posterior com m unicating artery Middle cerebral artery Am bient cistern (encloses posterior cerebral artery and superior cerebellar artery) Anterior inferior cerebellar artery Flocculus Pontocerebellar cistern Posterior spinal cistern Anterior spinal cistern Lateral cerebellom edullary cistern G Subarachnoid cisterns (after Rauber and Kopsch) Basal view. They contain the proxim al portions of som e cranial nerves and basal cerebral arteries (veins are not shown). The circumventricular organs include the following: · · · · Posterior hypophysis with the neurohem al region (see p. The bloodbrain barrier is usually absent in these organs (see C and D; except the subcom m issural organ). Choroid plexus Tuber cinereum Dura m ater B Summary of the smaller circumventricular organs In addition to the four regions listed below, the circumventricular organs include the posterior hypophysis, choroid plexus, and pineal body. The functional descriptions are based largely on experim ental studies in anim als. The upper drawings show an inferior view of a transverse section through a rabbit brain, and the lower drawings show the brainstem from the basal aspect. The function of these barriers is to protect the brain from harm ful substances in the bloodstream. These include m acrom olecular as well as sm all m olecular pharm aceutical compounds. Faint blue staining is noted in the tuber cinereum (neurohem al region of the posterior hypophysis), area postrem a, and spinal ganglia (absence of the blood-brain barrier in these regions). The sam e pat tern of color distribution occurs naturally in jaundice, where bile pigm ent stains all organs but the brain and spinal cord, analogous to trypan blue in the rst Goldm ann test. The di usion barrier shifts from the vascular endothelium to the cells of the ependym a and choroid plexus. A needle is inserted precisely in the m idline bet ween the spinous processes of L3 and L4 and is advanced into the dural sac (lum bar cistern). Lumbar puncture is contraindicated if the intracranial pressure is m arkedly increased because it m ay cause a precipitous cranial to spinal pressure gradient, causing the brainstem and/or cerebellar tonsils to herniate through the foram en m agnum. This would exert pressure on vitally im portant centers in the m edulla oblongata, with a potentially fatal outcom. Thus, the physician should always check for signs of increased intracranial pressure. The mortalit y risk results from the need to pass a needle through the cerebellom edullary cistern (cisterna m agna), which m ay endanger vital centers in the m edulla oblongata. The largest structures of the cerebrum (telencephalon) are the frontal and temporal lobes. The falx cerebri separates the t wo cerebral hem ispheres in the m idline (not visible here). In the brainstem, we can iden- tify the pons and m edulla oblongata on both sides of the m idline below the telencephalon. The anterior horns of the t wo lateral ventricles are projected onto the forehead. Ventricular System a nd Cerebrospinal Fluid Lateral ventricle Anterior (frontal) horn Inferior Central part (body) (temporal) horn Posterior (occipital) horn Superior sagit tal sinus Inferior sagit tal sinus Interventricular foram en Third ventricle Frontal bone Ethm oid bone Straight sinus Confluence of the sinuses Transverse sinus Occipital bone Occipital sinus Fourth ventricle Sigm oid sinus b Cerebral aqueduct Cavernous sinus Inferior petrosal sinus Bulb of internal jugular vein Superior petrosal sinus Orbit Nasal bone Lacrim al bone Zygom atic bone Maxilla Viewed from left (b), the additional relationship bet ween individual brain lobes and the cranial fossae becom es visble. The frontal lobe lies in the anterior cranial fossa, the tem poral lobe in the m iddle cranial fossa, and the cerebellum in the posterior cranial fossa. The following dural ve- nous sinuses can be identi ed: the superior and inferior sagit tal sinus, straight sinus, transverse sinus, sigm oid sinus, cavernous sinus, superior and inferior petrosal sinus, and occipital sinus. Although, m orphologically both hem ispheres are roughly sym m etrical, textbooks m ore com m only depict the left hem isphere because of the functional asym m etry of the brain: som e functions ­ for instance speech production and speech comprehension ­ are localized in only one hem isphere and m ore often in the left than in the right. The sulci and gyri which are visible on the hem ipsheres increase the cortical surface area to roughly 2200 cm 2. Som e anatom ic landm arks are well suited to serve as reference points: · Precentral and postcentral gyri are separated by the central sulcus. This distinction is based in part on phylogenetic grounds but is also arbitrary in a topographical sense · Topographically: the central sulcus separates the frontal and parietal lobes (a); the lateral sulcus de nes the superior border of the temporal lobe (a); the insular lobe (Insula, Ba) is located deep within the lateral sulcus; the parietooccipitalis sulcus separates the occipital and parietal lobes (b). Precentral gyrus Postcentral gyrus Parietal lobe Frontal lobe Supram arginal gyrus Lateral sulcus Temporal lobe a Lim bic lobe Cingulate gyrus Central sulcus Occipital lobe Central sulcus Frontal lobe Corpus callosum Septum pellucidum Temporal lobe b Fornix Frontal pole Parietal lobe Parietooccipital sulcus Occipital lobe Frontal lobe Olfactory bulb Optic nerve Pituitary Longitudinal fissure Mam m illary body Mesencephalon Temporal lobe Occipital lobe c Occipital pole 310 Neuroa natomy 13. Telencephalon Parietal operculum Corpus striatum Caudate nucleus Putam en Cerebral cortex White m at ter Globus pallidus Claustrum Amygdala Frontal operculum a Insular lobe (= insula) Temporal operculum b Insula B Gray and w hite matter in the telencephalon a Left cerebral hem isphere, lateral view, lateral sulcus spread open; b Coronal section of the brain. Based on the division of the pallium, the cortex is divided into neo-, archi- and paleocortex. The archi- and paleocortex (collectively called allocortex) consist of fewer layers. Due to their location at the base of the telencepahlon, the caudate nucleus (tail), putamen (or shell, owing to the striation collectively called corpus striatum [or striped body]) and globus pallidus (pale globe) are also referred to as basal nuclei and are often misnamed basal ganglia. Additional nuclei, which anatomically are part of the basal nuclei, are the amygdala (an almond-shaped structure) in the temporal lobe and the claustrum (front wall) a subcortical structure found deep to the insular lobe. Thus the insula, the previsously mentioned nuclei, and the exposed lateral ventricles dominate the cross section. Neopallium Archipallium Ventricle Neopallium Archipallium Ventricle C Development of cerebral cortex and basal nuclei a Em bryonic brain; b Adult brain; frontal sections. Phylogenetically, the entire telencephalon can be roughly divided into 3 part s of varying age. For this purpose, white m at ter and the overlying gray m at ter (cortex) are collectively referred to as m antle or pallium. In chronological order, a distinction is drawn bet ween paleopallium, archipallium and neopallium (for further detail see D). During em bryonic developm ent, a large part of the neopallium is invaginated to form the insula (see a). Additionally, neurons from the neopallium m igrate into the deeper regions where they form a portion of the basal nuclei (the striatum, see p. Insula and basal nuclei are thus anatom ical reference structures on a frontal section. This explains why the surface morphology of the brain is not the sam e in every textbook. The following illustrations show the gyri and sulci, that are o cially recognized by the Terminologia Anatom ica. Introduction Morphologically, the surface of the telencephalon is de ned by num erous ridges or gyri which are separated from one another by furrows or sulci. This form follows a basic pat tern in hum ans which can vary signi cantly from one individual to another. Som e brains even show dif- Precentral sulcus Precentral gyrus Superior frontal sulcus Superior frontal gyrus Middle frontal gyrus Inferior frontal sulcus Inferior frontal gyrus Frontal pole Triangular part (of the inferior frontal gyrus) Orbital part (of the inferior frontal gyrus) Temporal pole Opercular part (of the inferior frontal gyrus) Central sulcus Postcentral gyrus Postcentral sulcus Supram arginal gyrus Superior parietal lobule Intraparietal sulcus Parieto-occipital sulcus Inferior parietal lobule Angular gyrus Occipital pole Lunate sulcus Medial tem poral gyrus Inferior temporal gyrus Lateral sulcus Superior temporal gyrus Superior tem poral sulcus Inferior temporal sulcus A Gyri and sulci of the convex surface Left hem isphere, lateral view. The important reference point of the brain is the central sulcus, which is cleary visible here. Often three morphological characteristics are ascribed to the central sulcus: · it is the longest sulcus of the brain, · it extends across the superior m argin of the brain, · it is joined by the lateral suclus, which is also clearly visible here. In actualit y, the central sulcus rarely exhibits all these three characteristics. In this case, it helps to use the "t wo nger rule" to locate the central sulcus on the surface of the brain. With the index and m iddle nger of one hand held close together, they are placed above the hem isphere so that the ngers are above the convolutions which most closely correspond to the longitudinal direction of the ngers and as such run m ore or less parallel. The index nger is located on the precentral gyrus and the middle nger lies on the postcentral gyrus. Telencephalon Longitudinal cerebral fissure Olfactory bulb Orbital sulci Straight gyrus Olfactory sulcus Olfactory tract Medial olfactory stria Lateral olfactory stria Orbital gyri Uncus (of the parahippocampal gyrus) Parahippocam pal gyrus Medial occipitotemporal gyrus Inferior temporal gyrus Lateral occipitotemporal gyrus Occipitotemporal sulcus Collateral sulcus Lingual gyrus Longitudinal cerebral fissure B Gyri and sulci at the base of the brain Basal view of the telencephalon (from below). The gyri at the base of the temporal lobe are som etim es topographically barely distinguishable. In contrast, the straight gyri are located in the frontal lobe and the orbital gyri, are situated in the cranium directly above the roof of the orbit. The comparison with Aa shows the "edge position" of the inferior temporal gyrus: it is visible in both the lateral view (as the lower border of the temporal lobe) and the basal view (as lateral border of the tem poral lobe). What is apparent at the base of the brain, is a paleocortical part of the telencephalon, which m orphologically resem bles a nerve rather than a part of the cortex since it does not have any gyri: the olfactory bulb and tract. Histologically, this part of the paleocortex does not exhibit a cortical structure. Note: In the occipital lobe very close to the logitudinal cerebral ssure lies the lingual gyrus. It s shape, which resem bles the tongue, is only visible when viewed from m edial aspect (see A, p. Although m orphologically, it seem s to be the posterior extension of the parahippocam pal gyrus (which is the m ost m edial of the gyri) functionally these gyri have nothing to do with each other: the parahippocampal gyrus is part of the lim bic system, while the lingual gyrus is part of visual cortex. Clearly visible are the following structures: · Located directly above the corpus callosum and surrounding it like a clamp (= cingulum: clamp, yoke) is the cingulate gyrus, which is part of the lim bic system. They are the hippocampus proper (and the dentate gyrus with it s tooth-like surface. To provide an unobstucted view of the dentate gyrus, in this specim en the neighboring gyri would either have to be rem oved or pushed out of the way. The dentate gyrus lies above and som ewhat m edial to the hippocampus proper, which is why the lat ter is still not visible here. The dentate gyrus and in particular the hippocampus proper are alm ost rolled up in the temporal lobe of the brain; both structures are part of the lim bic system and process inform ation related to learning, m em ory, and em otions (for a description of the hip- pocampus proper see pp. The fornix, which is also clearly visible, is a tract of the lim bic system which extends from the hippo campus to the diencephalon. The m idsagit tal section also shows additional m orphological characteristics, which are less clearly visible when looking at the convex or basal cerebral surfaces: · the cingulate gyrus has a tongue-like shape. It s superior border is m arked by the calcarine sulcus which separates it from the cuneus (= wedge). At the superior border of the lingual gyrus and the lower m argin of the cuneus- thus dem arcating the calcarine sulcus- lies the prim ary visual cortex (see p. Both gyri are connected through a long association tract- the cingulum - which is located in the white m at ter of the gyri and therefore not visible here. Telencephalon Long gyrus of insula Parietal operculum Short gyri of insula Central sulcus of insula Frontal operculum Circular sulcus of insula Superior temporal gyrus Transverse temporal gyri Temporal operculum B Gyri and sulci of the insula Left hem isphere, lateral view; lateral sulcus spread open by retractors. As a result, the following structures becom e visible: · the insula (not visible in an intact brain) along with the insular gyri as well as · the transverse temporal gyri (transverse gyri of Heschl- prim ary the auditory cortex) on the surface of the superior temporal gyrus at it s posterior end.

The drill guide will need to be readjusted to penetrate the articular surface at a near perpendicular angle of entry managing diabetes kit irbesartan 150 mg order online. A single suture anchor is often used and a simple suture configuration is chosen due to thinning tissue along the middle and inferior capsular ligament junction managing gestational diabetes with diet purchase discount irbesartan online. Step 10: Rotator Interval Plication the rotator interval closure has been added to select shoulders that are considered lax prior to their dislocation history diabetes foot care buy genuine irbesartan on line. A monofilament suture can be selected as this will come in contact with the humeral head articular surface during extension blood glucose exercise effect discount irbesartan on line. The larger cannula is partially withdrawn and a penetrating retriever is placed through the superior glenohumeral ligament the suture is retrieved diabetes type 1 epidemiology buy cheap irbesartan on-line, creating a vertical mattress suture. Step 11: Bracing Portals are closed with monofilament nylon sutures and dressings are secured. A pillow splint is applied in the operating room, placing the arm in modest internal rotation. Postoperative Protocol Initial week: Protective sling brace Elbow flexion and extension Forearm, wrist, and grip strength Scapular posturing exercise 26 Chapter 2 Weeks 2 through 5: Pendulum exercises Scapular retraction External rotate assist to 20 degrees with elbow at the side Lower body conditioning Weeks 5 through 8: Begin forward flexion to 150 degrees External rotate at side to 40 degrees Scapular stabilizing exercises Core strength Wean from sling Weeks 8 through 12: Approach terminal elevation Increase external rotation to 50 degrees Rotator cuff strengthening Scapular strengthening Increase general conditioning Weeks 12 through 16: Critical increases in motion to apply to desired sports Closed-chain exercises for strength and coordination Overhead throwing motion allowed, but without the ball Week 16 through 6 months: Begin weightbearing loads, gradual and not ballistic Avoid contact and collision until shoulder approaches symptom free. May begin overhead throwing as maturity of healing is confirmed Months 4 through 8: Return to sport if symptoms free, with protective strength and appropriate conditioning Potential Complications Surgical complications can follow operative stabilization of the unstable shoulder. This includes subluxation with a spontaneous reduction or a complete dislocation that requires assistance with reduction apprehension in abduction and external rotation. There are several identified risk factors for a failed Bankart procedure, including but not limited to younger age, significant bone loss, contact sports, associated ligamentous laxity, and the male gender. Balg and Boileau have introduced the instability severity index score as a means of quantifying the risk of recurrence after an arthroscopic Bankart procedure. Although loss of maximal external rotation is a common outcome of any surgical repair of the anterior capsular ligaments, severe restriction is not an anticipated outcome. On occasion, a surgical release of adhesions or overtightening may be appropriate. Inadvertent stabilization of an anatomic variant such as a sublabral foramen in the anterosuperior quadrant can result in significant and disabling losses in external rotation and the overhead-throwing motion. Sutures and suture anchors are required in repairing the damaged, avulsed capsulolabral tissue. Special attention to the placement of sutures and knots can reduce the risk of this phenomenon. Utilizing mattress sutures or alternating mattress and simple sutures can help prevent migration of suture material to the articular margin. Multiple suture anchor holes can create a stress-riser structural weakness, leading to this vulnerability. Maintaining appropriate spacing of the anchors while using implants with narrow diameter drill holes can mitigate this risk. If suspected, the appropriate evaluation would include x-rays, 3D computed tomography imaging, as well as testing for occult infection. In symptomatic patients, an arthroscopic debridement and hardware removal might be prudent, although uncommon. Avoid cannula crowding, which can limit working space around the 2 anterior cannulas. Insert the cannulas at the most superior and inferior borders of the rotator interval. The inferior cannula is placed immediately adjacent to the superior border of the subscapularis, while the superior cannula enters the joint directly behind the biceps tendon. Adequate capsulolabral mobilization includes liberation of the tissue from the glenoid margin while visualizing the underlying subscapularis muscle belly. The accessory posteroinferior portal allows placement of this suture anchor, while subsequent suture hook passage through the inferior capsule can be accomplished through either the anteroinferior or standard posterior working portals. The remplissage can be a significant addition to the "at risk" shoulder due to bone loss. In patients with mild changes to the glenoid width and more significant deficiency of the humeral head due to a large, deep Hill-Sachs lesion, this additional step can reduce the risk of recurrence. The rotator interval closure can be added to create additional capsular tension and reduce anterior translation. This is not recommended in overhead-throwing athletes due to undesirable loss of terminal external rotation. Edpidemiology of shoulder dislocations presenting to emergency departments in the United States. Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger: a prospective twenty-five year follow-up. Can the need for future surgery for acute traumatic anterior shoulder dislocation be predicted Functional outcome and risk of recurrent instability after primary traumatic anterior shoulder dislocation in young patients. Management of primary acute anterior shoulder dislocation: systematic review and quantitative synthesis of the literature. Outcome of the open Bankart procedure for shoulder instability and development of osteoarthritis: a 5- to 20-year follow-up study. Evolution of lesions of the labrum-ligament complex in posttraumatic anterior shoulder instability: a prospective study. Recurrent anterior dislocation of the shoulder after surgical repair: apparent causes of failure and treatment. Open capsular repair without bone block for recurrent anterior shoulder instability in patients with and without bony defects of the glenoid and/or humeral head. The treatment of traumatic anterior instability of the shoulder: nonoperative and surgical treatment. Return to sports after arthroscopic anterior stabilization in patients aged younger than 25 years. A randomized clinical trial comparing open and arthroscopic stabilization for recurrent traumatic anterior shoulder instability. Traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repairs: significance of the inverted pear glenoid and the humeral engaging HillSachs lesion. Hill-Sachs remplissage: an arthroscopic solution for the engaging Hill-Sachs lesion. Primary versus revision arthroscopic reconstruction with remplissage for shoulder instability with moderate bone loss. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from "engaging/non-engaging" lesion to "on-track/off-track" lesion. A simple pre-operative score to select patients for arthroscopic or open shoulder stabilization. Typically, this pathology is attributed to separation of the labrum from the anteroinferior glenoid (Bankart lesion) or to plastic deformation of the capsule. Indications Patients with limited function or athletic performance secondary to symptoms of pain and/ or instability and who have failed a trial of conservative treatment should be considered surgical candidates. Surgeons should have a high index of suspicion for younger patients after a shoulder injury with persistent pain, shoulder dysfunction, and complaints that the shoulder is not working well. Note arthrogram fluid extending down the humeral neck indicating compromise in the capsular attachments to the humerus. The patient is then prepped and draped in the usual sterile fashion and the arm is placed in 10 lbs of balanced suspension. The limb is positioned in 15 degrees of forward flexion and 50 degrees of abduction in order to gently expose the glenohumeral joint. Portals Posterior portal: A standard posterior viewing portal is initially created by identifying the interval between the infraspinatus and the teres minor, which is usually located 1. Anterosuperior portal: this portal is created using an outside-in technique under direct visualization. It is located approximately 1 cm laterally to the anterolateral border of the acromion, often just above biceps. It is typically located 4 cm directly lateral to the posterior corner of the acromion. Anterior mid-to-low glenoid portal: With the camera switched back to the posterior portal, the anterior mid-to-low glenoid portal is established directly above the subscapularis tendon. An 18-gauge spinal needle is used to identify the proper trajectory and angle of approach to the humeral bed and anterior glenoid as needed. An intraoperative exam under anesthesia is then performed to confirm the diagnosis of instability or to access additional pathology. The patient is then placed in the lateral decubitus position with a well-padded roll under the down-facing axilla. The patient is then prepped and draped in the usual sterile fashion with the arm hanging in 10 lbs of balanced suspension. The limb is positioned in 15 degrees of forward flexion and 50 degrees of abduction in order to distend the joint and separate the humeral head from the glenoid. Two horizontal sutures are placed (4 passes into the capsule) to be utilized for capsular repair back to the humerus. The standard posterior portal is made and a diagnostic arthroscopy is then initiated. An anterior portal is established in the superior aspect of the rotator interval using an outside-in or inside-out technique. The needle insertion and portal site is typically located 4 cm directly lateral to the posterior corner of the acromion. Next, the arthroscope is returned to the posterior portal and a mid-to-low glenoid portal is established directly above the subscapularis tendon. The proper position for this portal is determined using an 18-gauge spinal needle. The anterior glenohumeral ligaments are inspected from their glenoid/labral origin to their attachment on the humeral neck. A 70-degree scope in the posterior portal provides excellent visualization of the humeral insertion of this complex. A probe is then placed through the anterior midto-low glenoid portal to assess the competency of the ligaments. Concomitant Pathology: Bone Loss or Labral Injury If a large, engaging Hill-Sachs lesion or significant glenoid bone defect is identified, the treatment plan is changed to an alternative procedure to address the area of bone deficiency. The Bankart repair is completed in standard fashion using glenoid suture with care taken not to overtension the repair so there is sufficient tissue left to anchor the capsule to the humeral neck avulsion site. Note the rotator cuff (infraspinatus) muscle now exposed due to the capsular tear (arrow). Steps for Humeral Avulsion of the Glenohumeral Ligament Repair Attention is then turned toward percutaneous suture anchor insertion onto the medial neck of the humerus at the previously prepared footprint. Under direct visualization, an 18-gauge needle is used to establish the correct path for suture anchor placement. This is obtained in a percutaneous fashion with the anchor-inserting device and drill. Once the appropriate path is established, an appropriate suture anchor is placed and one of the suture limbs is retrieved from the anterosuperior portal. As the repair continues anteriorly, an accessory low anterior portal is required for correct anchor placement. This portal is created in a trans-subscapularis fashion, staying lateral to the humerus to minimize the risk of axillary nerve injury. This portal can be used to place an anchor percutaneously or a small 5-mm cannula can be used. It is important to use the rotation 36 Chapter 3 of the humerus to help control access to all areas of the humeral capsular avulsion site. Once the anchor is in place, sutures are passed through the torn capsule in a similar fashion as described previously using a corkscrew suture-passing device. Postoperative Protocol Initially, the arm is placed into a sling for approximately 4 weeks, during which the patient is instructed to perform supine well-arm forward elevation to 90 degrees; passive external rotation with arm at the side to 30 degrees; grip strength; and hand, wrist, and elbow range of motion exercises. From 4 to 6 weeks postoperatively, active and active-assisted forward elevation to 140 degrees and external rotation with arm at the side to 40 degrees is begun, deltoid/rotator cuff isometrics are progressed, and scapular-stabilizing exercises are begun. At 8 weeks, full range of motion in all directions, gentle stretching at end range of motion, and progressive light resistance training is permitted. External rotation in 45 degrees of abduction is started at 10 to 12 weeks postoperatively. After 3 months, or when the patient has pain-free symmetric active range of motion, a strengthening program is initiated and progressed as tolerated. Return to sport is determined after completing an isokinetic and functional test assessment, but is usually 5 to 6 months postoperatively. The tear itself may predispose to having a capsular constriction after the surgery because sometimes, in order to incorporate quality tissue into the repair, one moves medially into the capsule, thus creating a tension and the potential for overconstraint. A grasping device can be used to access tissue mobility and the goal should be anatomic repair. Care should be taken to avoid anteroinferior and deep anterior or inferior portals where the axillary nerve is at highest risk. It is also at risk laterally, approximately 5 cm lateral to the acromion, although this is highly variable and individualized in patients. Positioning in the lateral decubitus position may afford some protection; however, avoiding injury to the axillary nerve is paramount. Implant complications: the humeral head bone is softer than that of the glenoid and care should be taken to choose an anchor that provides adequate fixation into the humeral head for optimized pullout strength. Tap-in type of compression implants may also provide adequate fixation but should be of sufficient diameter (usually greater than 3. Arthroscopic Humeral Avulsion of the Glenohumeral Ligament Repair 37 Top Technical Pearls for the Procedure 1. Assess the anterior labrum for a Bankart lesion, significant glenoid bone loss, or an anterior labroligamentous periosteal sleeve avulsion lesion.

Orga ns and Their Neurovascula r Structures Malleus Sebaceous and cerum en glands Bony part of external auditory canal Cartilaginous part of external auditory canal Incus Lateral ligam ent of m alleus Stapes Handle (m anubrium) Tym panic m em brane C External auditory canal diabetes in older dogs uk discount generic irbesartan uk, tympanic membrane diabetes medications nclex buy generic irbesartan 300 mg, and tympanic cavity Right ear blood glucose 5 hours after eating 150 mg irbesartan buy with visa, coronal section diabetes mellitus prevalence irbesartan 300 mg purchase line, anterior view blood sugar fasting discount 300 mg irbesartan with mastercard. The t ympanic m em brane (eardrum, see E) separates the external auditory canal from the t ym panic cavit y, which is part of the m iddle ear (see p. The external auditory canal is an S-shaped tunnel (see D) that is approxim ately 3 cm long with an average diam eter of 0. The inner t wo-thirds of the canal are osseous, the wall being form ed by the t ympanic part of the temporal bone. The cartilaginous part in particular bears num erous sebaceous and cerum en glands beneath the keratinized strati ed squam ous epithelium. The cerum en glands produce a watery secretion that com bines with the sebum and sloughed epithelial cells to form a protective barrier (cerum en, "earwax") that screens out foreign bodies and keeps the epithelium from drying out. When the t ympanic m em brane is inspected with an otoscope, the auricle should be pulled backward and upward in order to straighten the cartilaginous part of the ear canal so that the speculum of the otoscope can be introduced (c). Note the proxim it y of the cartilaginous anterior wall of the external auditory canal to the tem porom andibular joint. This allows the exam iner to palpate m ovem ents of the m andibular head by inserting the sm all nger into the outer part of the ear canal. The healthy t ympanic m em brane has a pearly gray color and an oval shape with an average surface area of approxim ately 75 m m 2. It consists of a lax portion, the pars accida (Shrapnell m em brane), and a larger taut portion, the pars tensa, which is drawn inward at its center to form the um bo ("navel"). The um bo m arks the lower tip of the handle (m anubrium) of the m alleus, which is at tached to the t ym panic m em brane all along it s length. It is visible through the pars tensa as a light-colored streak (m alleolar stria). The boundary lines of the quadrants are the m alleolar stria and a line intersecting it perpendicularly at the um bo. The quadrant s of the t ym panic m em brane are clinically important because they are used in describing the location of lesions. A triangular area of re ected light can be seen in the anteroinferior quadrant of a norm al t ympanic m em brane. The location of this "cone of light" is helpful in evaluating the tension of the t ympanic m em brane. The m iddle ear (light blue) is located within the petrous part of the temporal bone bet ween the external ear (yellow) and inner ear (green). The t ym panic cavit y of the m iddle ear contains the chain of auditory ossicles, of which the m alleus (ham m er) and incus (anvil) are visible here. The t ym panic cavit y com m unicates anteriorly with the pharynx via the pharyngot ympanic (auditory) tube, and it com m unicates posteriorly with the m astoid air cells. Infections can spread from the pharynx to the m astoid cells by this route (see C). Auricle Aditus (inlet) to m astoid antrum Malleus Incus Chorda t ympani Tensor t ym pani Lesser petrosal nerve Facial nerve Prom inence of lateral sem icircular canal Prom inence of facial canal Stapes Tendon of insertion of stapedius Tympanic m em brane External auditory canal Prom ontory Tympanic plexus Tympanic nerve B Walls of the tympanic cavity Anterior view with the anterior wall rem oved. The t ympanic cavit y is a slightly oblique space that is bounded by six walls: · Lateral (m em branous) wall: boundary with the external ear; form ed largely by the t ympanic m em brane. Orga ns and Their Neurovascula r Structures Anterior sem icircular canal Posterior sem icircular canal Lateral sem icircular canal Oval window Facial canal Sigm oid sinus Prom ontory Posterior wall of t ym panic cavit y Mastoid air cells Chorda t ympani Facial nerve Round window niche Roof of t ympanic cavit y (tegm en t ympani) Geniculate ganglion Facial nerve Cochleariform process Greater petrosal nerve Lesser petrosal nerve Sem icanal of tensor t ympani Internal carotid artery Pharyngot ym panic (auditory) tube Internal carotid plexus Anterior wall of t ympanic cavit y Floor of t ym panic cavit y Tympanic plexus Internal jugular vein Tympanic nerve C Tympanic cavity: clinically important anatomical relationships Oblique sagit tal section showing the m edial wall of the t ympanic cavit y (cf. The anatom ical relationships of the t ympanic cavit y are particularly im portant in treating chronic suppurative otitis m edia. During this in am m ation of the m iddle ear, pathogenic bacteria m ay spread upward to adjacent regions. Internal carotid artery Sphenoid sinus Superior m eatus Middle m eatus Inferior m eatus Pharyngot ympanic tube, bony part Tym panic m em brane Pharyngeal tonsil Levator veli palatini Pharyngot ym panic tube, cartilaginous part Pharyngeal orifice of pharyngot ympanic tube Pharyngot ympanic tube, m em branous lam ina Tensor veli palatini Salpingopharyngeus D Pharyngotympanic (auditory) tube Medial view of the right half of the head. The pharyngot ym panic tube (auditory tube) creates an open channel bet ween the m iddle ear and pharynx. The bony part of the tube is located in the petrous bone, and the cartilaginous part continues onward to the pharynx, where it expands into a funnel-shaped ori ce. Air passing through the tube serves to equalize the air pressure on the t wo sides of the t ympanic m em brane. This equalization is essential for m aintaining norm al t ym panic m em brane m obilit y, which, in turn, is necessary for norm al hearing. The pharyngot ympanic tube is opened by the m uscles of the soft palate (tensor veli palatini and levator veli palatini) and by the salpingopharyngeus, which is part of the superior pharyngeal constrictor. The bers of the tensor veli palatini arising from the m em branous lam ina of the pharyngot ympanic tube are of special signi cance: When the tensor veli palatini tenses the soft palate during swallowing, it s bers at tached to the m em branous lam ina sim ultaneously open the pharyngot ympanic tube. The tube is lined with ciliated respiratory epithelium whose cilia beat toward the pharynx, thus inhibiting the passage of m icroorganism s into the m iddle ear. If this nonspeci c protective m echanism fails, bacteria m ay m igrate up the tube and incite a purulent m iddle ear infection (cf. The ossicular chain transm it s the vibrations of the t ym panic m em brane (and thus the sound waves) to the oval window, which in turn com m unicates them to an aqueous m edium, the perilymph. While sound waves encounter very lit tle resistance in air, they encounter considerably higher im pedance when they reach the uid interface of the inner ear (perilymph). The difference in surface area bet ween the t ympanic m em brane and oval window increases the sound pressure by a factor of 17, and this is augm ented by the 1. Thus, in passing from the t ympanic m em brane to the inner ear, the sound pressure is ampli ed by a factor of 22. If the ossicular chain fails to transform the sound pressure bet ween the t ympanic m em brane and stapes base (footplate), the patient will experience conductive hearing loss of m agnitude approxim ately 20 dB. The m ovem ent s of the stapes base against the m em brane of the oval window (stapedial m em brane) induce corresponding waves in the uid colum n in the inner ear. Two m uscles a ect the m obilit y of the ossicular chain: the tensor t ym pani and the stapedius (see C). The ossicular chain consist s of three sm all bones in the m iddle ear (chain function is described in B). It establishes an articular connection from the t ym panic m em brane to the oval window and consist s of the following bones: · Malleus ("ham m er") · Incus ("anvil") · Stapes ("stirrup") a, b c, d e, f g Malleus: posterior view and anterior view Incus: m edial view and anterolateral view Stapes: superior view and m edial view Medial view of the ossicular chain Note the articulations bet ween the m alleus and incus (incudom alleolar joint) and bet ween the incus and stapes (incudostapedial joint). Orga ns and Their Neurovascula r Structures Posterior ligam ent of incus Incus Superior ligam ent of incus and superior ligam ent of m alleus Incudom alleolar joint Annular stapedial ligam ent Stapedial m em brane Incudostapedial joint Pyram idal em inence Stapedius Malleus Tendon of tensor t ympani Tensor t ympani Internal carotid artery Petrot ym panic fissure Anterior ligam ent of m alleus Chorda t ympani Anterior t ym panic artery St ylom astoid artery Facial nerve Posterior t ympanic artery Chorda t ympani Tympanic m em brane Anterior process of m alleus C Ossicular chain in the tympanic cavity Lateral view of the right ear. The t wo m uscles of the m iddle ear- stapedius and tenthe sor t ym pani- can also be identi ed. The stapedius (innervated by the stapedial branch of the facial nerve) insert s on the stapes. When it contract s, it sti ens the sound conduction apparatus and decreases sound transm ission to the inner ear. This ltering function is believed to be particularly important at high sound frequencies ("high-pass lter"). When sound is transm it ted into the m iddle ear through a probe placed in the external ear canal, one can m easure the action of the stapedius (stapedius re ex test) by m easuring the change in acoustic im pedance. Note: the chorda t ympani, which contains gustatory bers for the anterior t wo-thirds of the tongue, passes through the m iddle ear without a bony covering (m aking it susceptible to injury during otological surgery). Incus Epit ympanum Stapes Superior m alleolar fold Chorda t ym pani Stapedius tendon Malleolar stria Um bo Malleus Lateral ligam ent of m alleus Superior recess of t ympanic m em brane Malleolar prom inence Tympanic m em brane Incus Malleus External auditory canal Tympanic m em brane Mesot ympanum Hypot ympanum Pharyngot ympanic tube Tendon of tensor t ympani D Mucosal lining of the tympanic cavity Posterolateral view with the t ympanic m em brane partially rem oved. The t ympanic cavit y and the structures it contains (ossicular chain, tendons, nerves) are covered with m ucosa that is raised into folds and deepened into depressions conform ing to the covered surfaces. The epithelium consists m ainly of a sim ple squam ous t ype, with areas of ciliated colum nar cells and goblet cells. Because the t ym panic cavit y com m unicates directly with the respiratory tract through the pharyngot ym panic tube, it can also be interpreted as a specialized paranasal sinus. E Clinically important levels of the tympanic cavity the t ym panic cavit y is divided into three levels in relation to the t ym panic m em brane: · the epit ympanum (epit ympanic recess, at tic) above the t ympanic m em brane · the m esot ympanum m edial to the t ympanic m em brane · the hypot ym panum (hypot ympanic recess) below the t ympanic m em brane the epit ym panum com m unicates with the m astoid air cells, and the hypot ympanum com m unicates with the pharyngot ym panic tube. It comprises a membranous labyrinth contained within a sim ilarly shaped bony labyrinth. The auditory apparatus consist s of the cochlear labyrinth with the m em branous cochlear duct. The m em branous duct and it s bony shell m ake up the cochlea, which contains the sensory epithelium of the auditory apparatus (organ of Corti). The vestibular apparatus includes the vestibular labyrinth with three semicircular canals (sem icircular duct s), a saccule, and a utricle, each of which contains sensory epithelium. While each of the m em branous sem icircular duct s is encased in it s own bony shell (sem icircular canal), the utricle and saccule are contained in a com m on bony capsule, the vestibule. The cavit y of the bony labyrinth is lled with perilymph (perilymphatic space, beige), whose composition re ect s it s being an ultra ltrate of blood. The perilymphatic space is connected to the subarachnoid space by the cochlear aqueduct (= perilym phatic duct). The membranous labyrinth " oats" in the bony labyrinth, being loosely at tached to it by connective-tissue bers. It is lled with endolymph (endolymphatic space, blue-green), whose ionic composition of which corresponds to that of intracellular uid. The endolymphatic spaces of the auditory and vestibular apparatus com m unicate with each other through the ductus reuniens and are connected by the endolymphatic duct to the endolym phatic sac, an epidural sac at the outer surface of the petrous bone between internal acoustic opening and sigm oidal sinus sulcus in which the endolym ph is absorbed. The apex of the cochlea is directed anteriorly and laterally- upward not as m ight be intuitively expected. The bony sem icircular canals are oriented at an approxim ately 45° angle to the cardinal body planes (coronal, transverse, and sagit tal). Note: the location of the sem icircular canals is of clinical importance in therm al function test s of the vestibular apparatus. The lateral (horizontal) sem icircular canal is directed 30° forward and upward (see b). Since warm uids tend to rise, irrigating the auditory canal with warm (44° C) or cool (30° C) water (relative to the norm al body temperature) can induce a therm al current in the endolym ph of the sem icircular canal, causing the patient to m anifest vestibular nystagm us (jerky eye m ovem ent s, vestibulo-ocular re ex). Because head m ovem ent s always stim ulate both vestibular apparatuses, caloric testing is the only m ethod of separately testing the function of each vestibular apparatus (im portant in the diagnosis of unexplained vertigo). Orga ns and Their Neurovascula r Structures Anterior sem icircularis duct Vestibular aqueduct Anterior ampullary nerve Vestibular ganglion, superior part Vestibulocochlear nerve, vestibular part Facial nerve Vestibular ganglion inferior part Cochlear com municating branch Nervus interm edius Vestibulocochlear nerve, cochlear part Saccular nerve Posterior ampullary nerve Modiolus Spiral ganglion of cochlea Dura mater Endolymphatic sac Lateral ampullary nerve Com m on crus Auricular nerve Lateral sem icircular duct Posterior sem icircular duct Posterior am pulla Oval window Round window C Innervation of the membranous labyrinth Right ear, anterior view. A erent impulses from the receptor organs of the utricle, saccule, and sem icircular canals. Their central processes form the vestibular part of the vestibulocochlear nerve through the internal acoustic m eatus and the cerebellopontine angle to the brainstem. Note also the section of the facial nerve with it s parasympathetic bers (nervus interm edius) within the internal auditory canal (see D). Greater petrosal nerve Transverse crest Facial nerve Nervus interm edius Geniculate ganglion D Passage of cranial nerves through the right internal acoustic meatus Posterior oblique view of the fundus of the internal acoustic m eatus. The approxim ately 1 cm long internal auditory canal begins at the internal acoustic m eatus on the posterior wall of the petrous bone. It contains · the vestibulocochlear nerve with it s cochlear and vestibular part s, · the m arkedly thinner facial nerve with it s parasympathetic bers (nervus interm edius), and · the labyrinthine artery and vein (not shown). Given the close proxim it y of the vestibulocochlear nerve and facial nerve in the bony canal, a tum or of the vestibulocochlear nerve (acoustic neuroma) m ay exert pressure on the facial nerve, leading to peripheral facial paralysis (see also p. Acoustic neurom a is a benign tum or that originates from the Schwann cells of vestibular bers, and so it would be m ore accurate to call it a vestibular schwannoma (see also p. Tum or growth always begins in the internal auditory canal; as the tum or enlarges it m ay grow into the cerebellopontine angle. Acute, unilateral inner ear dysfunction with hearing loss (sudden sensorineural hearing loss), often accom panied by tinnitus, t ypically re ects an underlying vascular disturbance (vasospasm of the labyrinthine artery causing decreased blood ow). The bony canal of the cochlea (spiral canal) is approxim ately 30­35 m m long in the adult. It m akes 2½ turns around it s bony axis, the modiolus, which is permeated by branched cavities and contains the spiral ganglion (cell bodies of the a erent neurons). A cross-section through the cochlear canal displays three m em branous com partm ent s arranged in three levels (b). The upper and lower compartm ent s, the scala vestibuli and scala tympani, each contain perilymph, while the m iddle level, the cochlear duct (scala m edia), contains endolymph. The perilym phatic spaces are interconnected at the apex by the helicotrema, while the endolymphatic space ends blindly at the apex. The cochlear duct, which is triangular in cross-section, is separated from the scala vestibuli by the vestibular (Reissner) membrane and from the scala t ym pani by the basilar membrane. High frequencies (up to 20,000 Hz) are perceived by the narrow portions of the basilar m em brane while low frequencies (down to about 200 Hz) are perceived by its broader portions (tonotopic organization). The basilar m em brane and bony spiral lam ina form the oor of the cochlear duct, upon which the actual organ of hearing, the organ of Corti, is located. This organ consist s of a system of sensory cells and supporting cells covered by an acellular gelatinous ap, the tectorial membrane. The sensory cells (inner and outer hair cells) are the receptors of the organ of Corti (c). These cells bear approxim ately 50­100 stereocilia, and on their apical surface synapse on their basal side with the endings of a erent and e erent neurons. They have the abilit y to transform m echanical energy into electrochem ical potentials (see below). A m agni ed cross-sectional view of a cochlear turn (c) also reveals the stria vascularis, a layer of vascularized epithelium in which the endolymph is form ed. This endolymph lls the m em branous labyrinth (appearing here as the cochlear duct, which is part of the labyrinth). It transform s the energy of the acoustic traveling wave into electrical im pulses, which are then carried to the brain by the cochlear nerve.

My indications for fixation of midshaft fractures are open fractures diabetes symptoms and diagnosis irbesartan 300 mg order without a prescription, skin risk over the fracture site diabetes mellitus dictionary definition buy irbesartan 150 mg low price, superior displacement/shortening of 2 cm or more diabetes symptoms urinary tract infection buy cheap irbesartan 150 mg on-line, neurovascular compromise diabetes type 1 rash irbesartan 150 mg buy without a prescription, or high-energy injuries with gross fragmentation diabetes mellitus levels buy irbesartan 300 mg with amex. I would also consider fixation in multitrauma patients if it allowed early mobilization of other joints/limbs. In 2007 the Canadian Orthopaedic Trauma Society published the results of a randomized controlled study of non-operative treatment compared with plate fixation of midshaft clavicle fractures. It was concluded that those treated with plate fixation had better functional scores and less chance of non-union and malunion at 1-year follow-up compared with those in the non-operative group. There were weaknesses to the study, particularly the large number lost to follow-up in the non-operative group. I always consent patients as to the general risks of surgery relating to the anaesthetic, infection, and thromboembolic events. Specific to fixation of clavicle fractures, I would mention the risk of neurovascular damage, numbness below the scar site, prominent hard wear, re-operation to remove metal work, non-union, and hypertrophic scar formation. The restoration of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle. This is an anteroposterior view of the right shoulder demonstrating a three- to four-part fracture of the proximal humerus. There is fragmentation medially at the neck of the humerus and the humeral head is in valgus. Neer classified displacement as separation >1 cm or 45° angulation between the fragments. This is at least a three-part fracture with displacement of the greater tuberosity and humeral head from the shaft of the humerus. However, the Level 1 evidence for operative treatment and type of operative treatment is sparse. A Cochrane review published in 2012 states that there is insufficient evidence to suggest that surgery is better for three- or four-part fractures of the proximal humerus, although surgery is associated with a requirement for further surgery. It also stated that there is not enough evidence to suggest a best method of treating fractures of this type. However, there are Level 3 studies demonstrating that locking plates have good function with this type of injury, and from my experience I would treat this with a locking plate. Assuming that the patient is adequately prepared for theatre, including being starved, marked, consented, and having had the appropriate anaesthetic investigations, I would place the patient in the beach chair position. I would perform the procedure through the deltopectoral approach under image intensification. The deltopectoral approach is an extensile approach based proximally on the coracoid process and distally along the deltopectoral groove. The incision is 10­15 cm based proximally on the coracoid following the deltopectoral groove. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. Fracture displacement and screw cut-out after open reduction and locked plate fixation of proximal humeral fractures [corrected]. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Answers this is an anteroposterior view of the distal humerus of a skeletally mature patient, showing a displaced intra-articular distal humeral fracture. There is some comminution, especially of the medial column and possibly of the articular surface itself, although the joint appears to be in two principal fragments. Although displaced, this is most likely a type C fracture as it has the characteristic Y-shaped pattern. In my department these injuries may get referred on to the specialist trauma centre, but the principles of management are to achieve anatomical articular reduction and preserve the blood supply while providing rigid stable internal fixation that is strong enough to withstand early functional motion. Several surgical approaches have been described: triceps sparing is useful for extra-articular or simple articular fractures; triceps splitting is useful for exploiting skin lesions; and triceps reflecting preserves triceps function in the event of need for total elbow replacement. Olecranon osteotomy is still considered to be the approach best suited for articular visualization, but it risks non-union and involves prominent hardware, and should also be avoided if elbow arthroplasty is likely in the future. Locking plates appear to provide optimal biomechanical fixation, and recent cadaveric studies have shown that parallel and perpendicular plates both provide adequate biomechanical strength. Postoperative immobilization is associated with stiffness and should generally only be used to allow the soft tissues a chance to heal for 7­10 days. It is very important to be sure that the fixation provided will be sufficient to allow early mobilization. Total elbow replacement should be considered in patients with osteoporosis if there is any doubt as to whether fixation will be possible. In patients over 65 the results of total elbow replacement are more predictable and better at 2 years, and there is less need for re-operation. Unfortunately there is generally a residual degree deficiency of flexion, extension, and pronosupination, with figures quoted for the flexion contracture of up to 25°. Other complications of distal humeral fractures include failure of fixation, non-union, infection, and heterotopic ossification. Surgical treatment of intra-articular fractures of the distal part of the humerus: functional outcome after 12­30 years. A multicenter, prospective, randomized, controlled trial of open reduction internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. Answers these are lateral and anteroposterior views of the distal humerus of a skeletally mature patient showing a displaced capitellar fracture. Reduction must be anatomical and fixation must be rigid and stable as these are articular fractures. Outcome after open reduction and internal fixation of capitellar and trochlear fractures. Answers this lateral elbow radiograph demonstrates a posterior elbow fracture dislocation. Primary restraints include the ulnar­humeral articulation and the collateral ligament complexes. Secondary restraints include the radiocapitellar articulation and the common flexor and extensor origins. Most elbow dislocations occur as a result of axial load, valgus force, and forearm supination. The radial head then dislocates or fractures and the continuing force then tears the capsule (front and back) from lateral to medial as the elbow hinges out of joint. Having taken a brief history from the patient, I would document whether the distal neurovascular supply is intact. This injury requires urgent reduction and I would do this under sedation in the emergency department. I would then re-examine the patient for neurovascular status, place the elbow in a plaster backslab at 90°Flexion, and obtain further radiographs to confirm reduction. This represents a terrible triad injury-an elbow dislocation with a fracture to the coronoid and the radial head. These are unstable and, unlike simple dislocations, they are best treated with early surgery. I am careful to emphasize the gravity of this injury to the patient when gaining consent for surgery as long-term stiffness and reduced function are common. My goals in surgery are to restore the bony anatomy of the elbow and address the capsuleligamentous injuries such that early mobilization of the elbow is possible. I would adopt a stepwise approach to restoration of anatomy as described by McKee and colleagues in 2004 from their series of 36 cases. Ideally I would try and fix this fracture, but I would have a radial head replacement available. Having prepared the patient for surgery I would place him lateral with the injured arm over a bolster and fit a high-arm tourniquet. After two more weeks I would allow extension to 30°Flexion and at 6 weeks full extension would be allowed. There should be no resistance training for 3 months to allow healing of the ligaments and capsule. On examination the patient would typically hold his or her arm in internal rotation in the adducted position. The arm is locked in internal rotation and neither active nor passive external rotation is possible from this position. Rowe and Zairns described a test in which there is inability to supinate the forearm when the arm is flexed forwards because of the internal rotation deformity of the shoulder. There is increased prominence of the coracoid process anteriorly and of the humeral head posteriorly. This type of injury is usually caused during an epileptic seizure, an electric shock, or by trauma such as a fall on an outstretched arm. In the case of involuntary muscle contraction, the strong internal rotators (latissimus dorsi, pectoralis major, subscapularis, and teres minor) simply overpower the weak external rotators (infraspinatus and teres minor). Clinical suspicion of such an injury is imperative, because although they account for less than 2% of all dislocations of the shoulder most are missed on initial examination. Djurdjevic reported that in a series of 24 patients with posterior dislocation, 21 had not been recognized initially. Appropriate management of a posterior glenohumeral dislocation depends upon the size of the defect, the duration of the dislocation, and the age and activity of the patient. Non-operative treatment must be considered for patients with uncontrolled seizures or any patient unable to comply with a post-operative rehabilitation programme. Reduction of acute traumatic posterior dislocation should be carried out under general anaesthetic as soon as possible. Under general anaesthetic and muscle relaxation gentle reduction is attempted by flexion and adduction with axial traction on the arm. If closed reduction is unsuccessful open reduction is performed under the same general anaesthetic. Such an injury would be deemed chronic when the duration is longer than 3 weeks and closed reduction is usually impossible. A small impression defect of up to 25% of the articular surface of the head can be treated by closed or open reduction. A medium defect, between 25% and 50% of the articular surface, can be treated by transfer of the lesser tuberosity. McLaughlin described the transfer of subscapularis for a defect between 20% and 40%. Rotational osteotomy of the surgical neck of the humerus may be considered to ensure the defect remains anterior to the glenoid throughout the entire range of motion. The defect may be filled with an allograft from the femoral head which is contoured to fit the segmental defect and restore sphericity of the head. A large defect of more than 50% of the articular surface can be treated by shoulder arthroplasty. Retroversion of the humeral component should be decreased from approximately 35° to 20°. An axial image is useful to confirm the direction of dislocation and my diagnosis, although from this radiograph that is not necessary. As his has fallen off a fence he may have other injuries, some of which could be life threatening. Assuming this is an isolated injury, my primary goal would be to reduce the left glenohumeral joint. I would perform a neurovascular examination of the patient before any reduction was attempted and document the findings in the notes. Specifically, I would check for axillary nerve sensation over the regimental badge area and musculocutaneous nerve sensation over the lateral edge of the forearm. I would also test distal pulses and medial, ulnar, and radial nerve sensation and document all my findings. There are several methods for reducing an anterior dislocation of the glenohumeral joint. The principles involve applying gentle traction or leverage with adequate pain relief and muscle relaxation. The patient is asked to lie face down on the bed with the injured shoulder hanging off the bed towards the floor while holding a 4. This allows for gentle traction, and often the shoulder will fall back into joint. The arm is then adducted and slowly externally rotated until the glenohumeral joint reduces. After manipulation, I would obtain anteroposterior and axial radiographs and repeat a neurovascular examination of the affected limb. The risks include proximal humeral fracture (including greater tuberosity fracture), rotator cuff injury, nerve injury (particularly the axillary nerve), vascular injury, and inability to reduce the dislocation. Robinson and colleagues performed a prospective study of over 3000 patients presenting with an anterior glenohumeral dislocation. Over 30% had either a rotator cuff injury, a greater tuberosity fracture, or neurological injury. Static factors include the humeral head and glenoid version, conformity of the joint, the labrum, the glenohumeral ligaments and joint capsule, and negative intra-articular pressure. If there is a significant glenoid fracture or significant capsular labral injury, the humeral head may not remain reduced. Dynamic factors include the rotator cuff muscles, long head of biceps, and the deltoid muscle. The long head of biceps can get caught posterior to the humeral head and prevent reduction. An iatrogenic fracture of the humeral head during reduction may also prevent reduction of the glenohumeral joint. Assuming you have achieved a satisfactory reduction, how do you plan to manage this patient I would manage this patient in a broad arm sling for comfort and allow a gentle range of movement as pain allows. Historically, patients were advised to remain in a broad arm sling in internal rotation for 3 weeks.

In my centre these injuries are referred to our regional specialist arthroplasty and complex trauma service raspberry ketone diabetes type 2 purchase generic irbesartan. If the femoral stem from the total hip replacement is well fixed it should be left in situ diabetes type 1 jokes 150 mg irbesartan buy overnight delivery, especially as there appears to be poor bone stock around the stem diabete 97 irbesartan 300 mg with mastercard. The presence of a stem on the femoral component of the knee would make any attempt at extramedullary fixation using a plating system difficult diabetes medications from cuba cheap 300 mg irbesartan free shipping, and proximal fixation will have to rely on cables alone managing diabetes in cats purchase 150 mg irbesartan mastercard. Conservative management with a long period in traction would be a difficult but viable option. This risks bed sores, pulmonary complications, and thromboembolic events, and may actually carry a higher risk of morbidity and mortality than surgical management. Other options include total femoral replacement, although this would be a huge undertaking and one that would carry significant risks in an elderly patient. All options should be discussed with the patient and his or her family with the seriousness of the injury being explained. In 2002 Campbell and McWilliams published a comprehensive editorial describing the epidemiology, prevention, classification, and treatment of periprosthetic fractures of the hip and knee. In 2004 Professor Learmonth from Bristol published aspects of current management of fractures around the femoral stem. There is no foot drop, but due to head and chest injuries and concerns about the airway the anaesthetists have intubated the patient and she is now fully sedated. What are your priorities for repair or reconstruction and the timing of these surgeries There is a dislocation of the tibiofemoral joint of the knee with the tibia dislocated anteriorly in relation to the tibia. While the primary survey is being completed I would assess the neurovascular status of the distal limb, which I would record carefully. If there are no other life-threatening injuries, the patient is stable, and appropriate analgesia is given, I would attempt closed reduction of the knee. I would perform this with gentle in-line traction on the foot and posterior pressure on the anterior part of the proximal tibia. I would reassess the neurovascular status and document my findings; if I was happy there was distal blood flow I would arrange immobilization of the limb in a backslab or brace and then request radiographs. There has been a recent shift from routine arteriography to selective arteriography in knee dislocation. Selective arteriography would suggest the need in cases of abnormal distal examination findings. Recent animal and human studies have shown that non-flow-limiting intimal tears rarely progress to occlusive thrombi. With the patient supine a blood pressure cuff is placed proximal to the ankle of the injured limb. Systolic pressure is determined with a Doppler probe at either the posterior tibial artery or the dorsalis pedis artery. The literature advises that repair of structures is easiest to perform and has the best outcome if performed within 2 weeks. I would thus liaise with the anaesthetists and plan for this surgery to be performed at a time that is safe for the patient. It is hard to predict the need for a graft, thus having one available is my priority. The role of arteriography in assessing popliteal artery injury in knee dislocations. Controversies in the treatment of knee dislocation and multiligament reconstruction. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. Surgical treatment of multiple knee ligament injuries in 44 patients: 2­8 years follow-up results. What would your rehabilitation programme be, and when would you allow her to return to playing netball I would recommend the application of ice twice a day and gentle range-of-movement exercises. Autograft in the form of hamstring tendon, bone­patellar tendon­bone, quadriceps tendon. Allograft should preferably be non-irradiated and is usually Achilles tendon, patellar tendon, or tibialis anterior. Bone­patellar tendon­bone is reliable with good 15-year results too, but some people have concerns over pain in the anterior knee and on kneeling. They have been shown to be reliable, have low morbidity, and combined with hamstring tendon graft have excellent 15-year results. I would not use a brace, and would allow her to fully weight-bear and to begin gentle exercise such as cycling after the first week. Gentle running can begin at 8 weeks, and I would see her at 3 and 6 months with a view to allowing netball training to start at 6 months. She should not return to competition before 9 months, and then only if she had met the rehabilitation goals. Answers this radiograph demonstrates a completely displaced transverse patella fracture in a skeletally mature patient. This injury requires operative fixation to restore the extensor mechanism of the knee joint. I would immobilize the patient in a cast or brace for comfort and provide adequate analgesia. I would then arrange to admit the patient for surgery on the next available trauma list. Talk me through your fixation technique, concentrating on the biomechanical principles. In an appropriately consented and anaesthetized patient, exposure to the patella should be achieved through a midline longitudinal incision. Fracture haematoma should be thoroughly washed to clearly expose the fracture fragments. With the knee in full extension the patella can then be reduced anatomically and temporarily held with large pointed reduction forceps with their tips on the inferior and superior poles. The K-wires can then be driven through the inferior poles and out of the soft tissue. This can be achieved with the help of a curved large-bore injection needle to pass the wire through the soft tissue. Tensioning is achieved through a single loop which should be buried in the medial or lateral retinacular tissue as best as possible to minimize later discomfort. I would bend the superior ends of the K-wires over and bury them in the patella and then cut the inferior ends flush with the soft tissue of the patellar tendon. The biomechanical principles of this technique are that the greatest tension through the fracture occurs on the most anterior aspect while the quadriceps muscle exerts a force on the tendon and the patella within. Steel wire, which is strong in tension, resists this force and transfers the energy via the fixation from the K-wires at the superior and inferior poles and to the posterior aspect of the patella, where it acts as a compressive force at the articular surface. It is also essential to augment the tension band with a strong repair of the extensor retinaculum. This is almost always torn in these cases, and repairing this will protect my fixation and allow for improved outcomes. I would perform a second procedure to remove the wires at 6 months, as symptomatic hardware is among the most common complications of this procedure. Intermediate complications include symptomatic hardware, quadriceps weakness, knee stiffness, and non-union (rare). Late issues would be conditions such as extensor lag and late-onset osteoarthritis of the patellofemoral joint from inadequate reduction. What will you tell your patient regarding the likely outcome and need for knee replacement in the future These are anteroposterior and lateral views showing a displaced bicondylar tibial plateau fracture. The fibula is fractured at the same level as the diaphyseal­metaphyseal dissociation of the tibia. Initial management would include appropriate analgesia and immobilization of the limb in an above-knee backslab. The patient requires admission and, depending on the degree of soft tissue injury and the position of the knee on a radiograph, he might also benefit from bridging external fixation. The knee is grossly swollen and the depression of the joint surfaces has not improved with simple splintage. I would prepare the patient for surgery by gaining informed consent, ensuring he is starved, and by arranging the theatre and anaesthetic support. Once supine and prepared for operation, with no tourniquet, I would place two anteroposterior Schanz pins in the distal femoral diaphysis. I tend to start the pin on power and then complete it manually to optimize feedback on the far cortex. In the tibia I would place my pins distal to the zone of injury, aiming anterior-to-posterior with my entry at the lateral aspect of the palpable tibial crest. This ensures the pins will not impede the later placement of plates if internal fixation is proposed. The frame is built off these pins and the fracture reduced manually under fluoroscopic control before the construct is tightened with the knee in slight flexion. I would add bars and pins as needed to ensure a stable construct, and ideally use a system that offers 11- or 12-mm bars for optimal stability. It may take several days for the soft tissues to settle, so I would anticipate performing definitive fixation a week or more after injury. Outcomes appear to be comparable between circular frame fixation and internal fixation. The key feature to aid decision-making about what implant to use is the state of the soft tissues. In this case, in my practice, the pattern would be amenable to limited internal fixation of the articular surface with screws, and circular frame fixation for the meta-diaphyseal component. Assuming the patient is adequately prepared for theatre, I would remove the fixator under clean conditions. The prepared patient would then be set up supine with a radiolucent bolster behind the thigh to flex the knee by about 40°. I would have the C-arm approach from the opposite side and use a radiolucent table. I would use a tourniquet for the joint fixation, and release this before applying the circular frame. This fracture line can be used to allow a punch or elevator to be inserted below the depressed fragments, and elevate them gradually under image control. It is important to use the lateral film to gauge the need for anterior or posterior joint elevation. Once the articular surface has been sufficiently elevated, I would support it in position with one or two K-wires. I would then apply a large pelvic reduction clamp across the articular block to reduce the condylar width and compress the articular fracture lines. If the articular surface does not reduce I would extend my incision proximally, allowing me to open the joint and release any entrapped meniscus. On completion of this step I would release the tourniquet and apply my circular fixator. I would use a ring just below the articular screws and a double ring block in the tibial diaphysis, allowing me to restore the axis of the tibia. If the knee was unstable after this (on examination under anaesthesia), I would cross the knee with the ring fixator and plan to remove the femoral ring at 6­8 weeks. Assuming I have restored the joint line and mechanical axis and achieved good fixation, I would explain to him that although the cartilage surface of the joint was damaged at the time of injury he is likely to achieve a good return of function. Rademakers and colleagues studied 109 patients for post-traumatic arthritis from tibial plateau fractures over 5­2 years: if good alignment was achieved, the incidence of osteosrthritis was 9% (versus 27% if the axis deviation is >5°). Weigel and Marsh looked at outcome of high-grade injuries and found a low rate of symptomatic joint arthrosis even if there was some articular incongruity. The need for meniscal resection will increase the risk of arthrosis, as will instability from cruciate dysfunction. Operative treatment of 109 tibial plateau fractures: five to 27-yr follow-up results. High-energy fractures of the tibial plateau: knee function after longer follow-up. This is a closed injury with no gross neurovascular concerns but significant soft tissue injury. There is a complex, intra-articular, multifragmentary fracture extending proximally into the metaphysis. There is no obvious air in the soft tissues, indicating that this is an open injury, although the soft tissue component and zone of injury will be extensive. I would take full history and examination, concentrating on important risk factors, for example smoking, diabetes, and peripheral vascular disease. Examination would assess soft tissue integrity and neurovascular status with full documentation. This injury requires reduction and skeletal stabilization to allow resolution of soft tissue before definitive fixation. If the patient remains stable and there are no concerns about anaesthesia I would take the patient to theatre to apply an external fixation, focusing on correction of length, alignment, and rotation. Once soft tissues have recovered I would consider definitive fixation depending upon the fracture configuration. This is the staged management protocol described by Sirkin, and represents the gold standard management algorithm for complex intra-articular fractures of the tibial plafond. The scan improves recognition of fracture fragments as described by Topiliss, and helps in planning incisions to minimize additional trauma to soft tissues and maintain their viability.

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