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The examiner grasps the knee later- ally with the thumb posterior to the fibular head and the fingers resting on the patella 20 mg vasodilan otc blood pressure chart age nhs. In contrast to the other dynamic subluxation tests generic 20mg vasodilan with mastercard arrhythmia light headed, the exam- iner does not internally rotate the lower leg but instead moves it into slight external rotation. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Note: Traditionally, the external rotation of the lower leg has marked out the Losee test among the dynamic subluxation tests. However, it is important for the examiner not to force this external rotation, but to hold the lower leg in a relaxed way in external rotation with the knee flexed. Extending the knee causes the lateral portion of the tibia to subluxate anteriorly, meaning that the entire lower leg moves into internal rotation. Slocum Test Procedure: The patient lies on the unaffected side with the hip and knee flexed, holding the injured upper leg in slight internal rotation with the foot extended where possible. Assessment: In an injury to the anterior cruciate ligament, the lateral tibial head will subluxate anteriorly with the knee in a position ap- proaching extension. Subsequent flexion will then lead to posterior reduction of the tibial head at about 30° of flexion. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. The patient then crosses the normal leg over the injured leg, rotat- ing the pelvis and trunk toward the injured side. Assessment: The contraction of the quadriceps causes the immobilized leg to reproduce the lateral pivot shift phenomenon. The patient will experience an unpleasant sensation and report that the knee is about to dislocate. Note: In muscular patients, this test usually provides more useful diagnostic information than the other dynamic anterior cruciate liga- ment tests. With the knee in about 20° of flexion, the Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. The distal femur will drop into external rotation and slightly recede posteriorly (subluxation). Assessment: In contrast to other dynamic anterior subluxation tests, it is not the lateral portion of the tibia but the distal femur that is tested for reduction and subluxation relative to the tibial head, which the exam- iner immobilizes and guides posteriorly. The test is positive when knee flexion results in palpable internal rotation of the distal femur (reduc- tion). Note: The Noyes test is suitable for assessing cruciate ligament insuf- ficiency in an apprehensive patient who has dif• culty relaxing the hamstrings. Jakob Giving Way Test Procedure: The patient leans against the wall on the normal side and distributes his or her body weight over both legs. The examiner places one hand each proximal and distal to the injured knee and applies a valgus stress while the patient flexes the knee. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Assessment: In an anterior cruciate ligament tear, the examiner will observe anterior subluxation of the lateral tibial head as the knee approaches extension. Note: This test method was described first by Lemaire and subse- quently by Galway and McIntosh; it is often referred to by the latter names. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. In an anterior cruciate ligament tear, the lateral portion of the tibial head will abruptly subluxate anteriorly at about 20° of flexion. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. A positive test in external rotation indicates generalized anterior instability, which will not necessarily be present in every patient with an anterior cruciate tear. Function Tests to Assess the Posterior Cruciate Ligament Posterior Drawer Test in 90° Flexion (Posterior Lachman Test) Procedure: The posterior drawer test is performed with the knee in flexion and in a position approaching extension. It is similar to the anterior drawer test except that it is used to evaluate posterior trans- lation in neutral, internal, and external rotation. Assessment: Isolated posterolateral instability exhibits maximum pos- terior translation with the knee in a position approaching extension.

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Case Study Treatment of Coronary Vasospasm 60-year-old man comes into the office com- ANSWER: Treat the patient with sublingual nitroglyc- Aplaining of chest pains that primarily occur in erin for the acute attacks because of its rapid onset the early morning and do not appear to be associ- of action and its powerful vasodilating effect on the ated with stress or exercise vasodilan 20 mg on line arrhythmia frequency. Following coronary an- large epicardial conductance coronary arteries cheap vasodilan 20mg without prescription blood pressure medication dehydration, giography and a positive ergonovine test you deter- which are normally the primary site of the spasm. How would you (1) treat ties, an oral calcium channel blocker, such as am- the patient to alleviate the acute attacks when they lodipine or verapamil, or a long-acting nitrate occur and (2) treat chronically to prevent their re- preparation, such as the transdermal form of nitro- occurrence? Cassis DRUG LIST GENERIC NAME PAGE GENERIC NAME PAGE Benzapril 212 Losartan 213 Candesartan 213 Moexipril 212 Captopril 210 Quinapril 212 Enalapril 212 Perindopril 212 Eprosartan 213 Ramipril 212 Fosinopril 212 Spironolactone 214 Irbesartan 213 Telmisartan 213 Lisinopril 212 Valsartan 213 THE RENIN–ANGIOTENSIN SYSTEM duction of a family of structurally related peptides (e. Sites for pharmacological inter- regulation of vascular smooth muscle tone, fluid and vention in this system include the enzymatic steps cat- electrolyte balance, and the growth of cardiac and vas- alyzed by renin, angiotensin-converting enzyme (ACE), cular smooth muscle. A normally functioning renin– and angiotensin receptors that mediate a particular angiotensin system contributes to the routine control of physiological response. A variety of basic and clinical investigations have resulted in a broader understanding Renin of the role of the renin–angiotensin system in the car- diovascular pathophysiology of hypertension, conges- Renin is an enzyme that is synthesized and stored in the tive heart failure, and more recently, atherosclerosis. Renin has a narrow substrate of these diseases, pharmacological inhibition of the specificity that is limited to a single peptide bond in an- renin–angiotensin system has proved to be a valuable giotensinogen, a precursor of angiotensin I. Renin is therapeutic strategy in the treatment of hypertension and considered to control the rate-limiting step in the ulti- congestive heart failure. Control of renin se- The classical renin–angiotensin system comprises a cretion by the juxtaglomerular apparatus is important series of biochemical steps (Fig. Angiotensinogen Renin 1 4 Angiotensin I NH2–(Asp-Arg-Val-Tyr-Ile-His-Pro-Phe-His-Leu)–COOH Prolylendopeptidase Aspartylaminopeptidase Peptidyldipeptide hydrolase (converting enzyme) 1 Angiotensin I-7 (Asp-Arg-Val-Tyr-Ile-His-Pro) 2 (des-Asp1) Angiotensin I (Arg-Val-Tyr-Ile-His-Pro-Phe-His-Leu) Angiotensin II (Asp-Arg-Val-Tyr-Ile-His-Pro-Phe) Peptidyldipeptide hydrolase Aspartylaminopeptidase 2 Angiotensin III (Arg-Val-Tyr-Ile-His-Pro-Phe) Carboxypeptidase Endopeptidase Aminopeptidase Endopeptidase Carboxypeptidase 3 Angiotensin IV (Val-Tyr-Ile-His-Pro-Phe) Inactive peptide fragments FIGURE 18. Three generally accepted mechanisms are involved innervation of the juxtaglomerular cells in the afferent in the regulation of renin secretion (Fig. The first arteriole; renin release is increased following activation depends on renal afferent arterioles that act as stretch of 1-adrenoceptors by the neurotransmitter norepi- receptors or baroreceptors. The second mechanism is renin–angiotensin system, acts on the juxtaglomerular the result of changes in the amount of filtered sodium cells to inhibit the release of renin; this process is there- that reaches the macula densa of the distal tubule. The half-life of Plasma renin activity correlates inversely with dietary renin in the circulation is 10 to 30 minutes, with inacti- sodium intake. Small amounts of anism is neurogenic and involves the dense sympathetic renin are eliminated by the kidneys. Increased pressure in Increased NaCl at macula Decreased sympathetic afferent arteriole leads to densa in distal tubule leads nerve activity in afferent decreased renin release by to decreased renin release arteriole leads to decreased JG cells. Low-molecular-weight orally effective renin in- the proximal tubule and small intestine, male germinal hibitors are under development. The lung vascular endothelium contains the highest concentration of Angiotensinogen ACE, and therefore, the lung serves as the major organ for the production of circulating angiotensin II. Human plasma contains a glycoprotein called an- Although ACE was originally thought to be specific for giotensinogen, which serves as the only known substrate the conversion of angiotensin I to II, it is now known to for renin. Angiotensinogen must undergo proteolysis be a rather nonspecific peptidyl dipeptide hydrolase before active portions of the protein are sufficiently un- that can cleave dipeptides from the carboxy terminus masked to exert biological effects. Its gene transcription and plasma con- are not cleaved by converting enzyme; this accounts for centrations increase following treatment with adreno- the biological stability of angiotensin II. Inhibition of corticotropic hormone (ACTH), glucocorticoids, thy- converting enzyme results in an elevated pool of an- roid hormone, and estrogens, as well as during giotensin I. The Angiotensins The amino acid composition of the peptides and en- zymes involved in the synthesis and metabolism of the Angiotensin-Converting Enzyme: angiotensins is shown in Figure 18. Angiotensin I is be- A Peptidyl Dipeptide Hydrolase lieved to have little direct biological activity and must be Metabolism of angiotensinogen by renin produces the converted to angiotensin II or angiotensin 1-7 before decapeptide angiotensin I. This relatively inactive pep- characteristic responses of the renin–angiotensin system tide is acted on by a dipeptidase-converting enzyme to are manifested. In their animo terminus by aspartyl aminopeptidase, an en- addition to converting enzyme, angiotensin I can be zyme in plasma and numerous tissues. Angiotensin II is acted on by prolyl endopeptidase, an enzyme that re- rapidly metabolized by aspartyl aminopeptidases, en- moves the first amino acid to form angiotensin 1-7, a dopeptidases, and carboxypeptidases, while angiotensin peptide primarily active in the brain.

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Open reduction and inter- nal fixation through a deltopectoral approach is usually preferred discount vasodilan 20 mg heart attack get me going extended version. In 3- part greater tuberosity displacements cheap vasodilan 20 mg on-line blood pressure and caffeine, a prosthesis may be preferred when the soft-tissue attachments to the head are found at surgery to be frail or the patient is elderly. The exception is the valgus-impacted type 4-part fracture, which, as will be discussed, is a less-displaced, border- line lesion. When the head has no significant soft-tissue attachments, prosthetic replacement is preferred with careful reattachment of the tu- berosities and rotator cuff and meticulous aftercare. Both tuberosities are fractured and displace enough to make room for the articular segment 130 11 Classifications of proximal humeral fractures to be impacted on the shaft and to be tilted into at least 458 valgus. In the valgus-impacted 4-part fracture there is no lateral displacement of the articular segment, so the medial periosteum may remain intact to allow some blood supply to the head. The prognosis for survival of the head is better than in true 4-part fractures (lateral fracture-disloca- tions). As stated above, my preferred treatment is nonoperative for the minimal displacement category and prosthetic replacement for true 4- part fractures (later fracture-dislocations). A marginal lesion of this type between these two categories with enough angulation of the head to justify surgery, is explored by extending the tear in the rotator inter- val, with care taken to avoid injury to the blood supply, and if enough soft tissue is attached to the head, disimpaction and internal fixation is considered. When the 4-segment system criteria for exploring and in- traoperative findings for decision making are used, the diagnosis of im- pacted valgus 4-part fracture and disimpaction has been infrequent. It is difficult for surgeons to agree on the incidence and treatment of a borderline displacement, such as the valgus-impacted 4-part fracture. Accurate measurement of angulation on plain films is difficult because of angle of valgus or varus is altered by rotation the humeral and be- cause of the round shape of the head. In the 4-segment system, angula- tion of less than 458 is in the minimal displacement category. Transitory subluxation, as occurs at time with minimal displacements, can be mis- leading as to the height of the head in reference to the tuberosities and glenoid. In the valgus-impacted 4-part fracture, the articular segment should be angulated without lateral displacement, causing the upper hu- merus to resemble an ice cream cone. True 4-part fractures (lateral frac- ture-dislocations) are easy to distinguish in plain films except in mar- ginal displacements, where the final decision between performing disim- paction and using a prosthesis depends on the quality of the soft-tissue attachments on the articular segment observed intraoperatively. With anterior dislocations, the greater tuberos- ity is displaced prier to lesser tuberosity displacement, and with poste- rior dislocations, the lesser tuberosity is displaced prior to greater tu- a 11. In 4-part fracture-dis- locations, both tuberosities are fractured, and although the tuberosities may be held together by the soft-tissue rather than retracted, the head is detached and dislocated. The authors preferred treatment is closed or open reduction for 2-part fracture-dislocations; open reduction and in- ternal fixation for 3-part fracture-dislocations, unless as discussed above, the soft-tissue attachments to the head are frail and the patient is elderly; and a prosthesis for 4-part fracture-dislocations. Axillary views are the key to avoid missing them, and CT scans are helpful in evaluating them. Treatment depends upon the size of the head defect and duration of the dislocation. To quote from the initial description of the 4- segment classification, head-splitting fractures usually result from a cen- tral impact which may extrude fragments of cartilage both anteriorly and posteriorly. A recently published ar- ticle misstated that the splitting of the head fracture was not included in the original 4-segment classification. The standard AO alpha numerical sys- tem has been adopted to this application following the interrelated themes of fracture anatomy and vascular status of the articular segment. The classification recognizes both displaced (Neer criteria) and undis- 132 11 Classifications of proximal humeral fractures placed fractures and provides adequate specificity for documentation as part of the AO documentation system for all fractures. In addition, it provides a framework for more detailed therapeutic and prognostic guidelines. General considerations The principle of the comprehensive classification of fractures of long bones The fundamental principle of this classification is the division of all fractures of a bone segment into three types and their further subdivi- sion into three groups and their subgroups, and the arrangement of these in an ascending order of severity according to the morphologic complexities of the fracture, the difficulties inherent in their treatment, and their prognosis. These three questions and the three possible answers to each are the key to the clas- sification. The colours green, orange, and red, as well as the darkening arrows, indicate the increasing severity: A1 indicates the simplest fracture with the best prognosis and C3 the most difficult fracture with the worst prognosis. Thus when one has classified a fracture one has established its severity and obtained a guide to its best possible treatment (Fig.

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