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The tooth must first be located; it may be in the upper teeth protrudes past the lower teeth cheap 1 mg finasteride hair loss network, also the patient’s mouth buy finasteride 1mg low cost hair loss in male rabbits, on their clothing, or near the called an overbite or buck teeth), having an overjet injury site. The avulsed tooth should be handled very greater than 4 mm, having a short upper lip, incompe- carefully-only by the crown/enamel therefore not tent lips or a mouth breather will increase chance of causing further damage to the root surface. A referral to an orthodontist to evaluate should be implanted within the first 20 min of injury to for orthodontic correction to reduce such risks is very increase success of reimplantation. The tooth should be gently cleansed complication of the tooth fracture would involve with saline and repositioned in the socket, if the patient 172 SECTION 3 MEDICAL PROBLEMS IN THE ATHLETE is alert. The tooth will click into place, but make sure performed whether cellulitis is indurated or fluctuant the tooth is properly positioned. The athlete should These patients will need surgical drainage and IV broad then follow up with a dentist immediately for defini- spectrum antibiotics immediately. The PDL and alveolar bone are destroyed by most suitable transport medium is Hank’s balanced bacterial plaque. Athletes with evidence of periodontal salt solution (HBSS) because of its pH-preserving disease should be referred to the care of a periodontist. Save-a-Tooth Dental decay or caries is caused by oral bacterial dem- (Biologic Rescue Products, Conshohacken, PA) is one ineralizing tooth enamel and dentin. HBSS should be readily avail- tion from the fermentation of dietary carbohydrates able at schools, emergency rooms, athletic coach by oral bacteria demineralizes the tooth. Cool milk has been shown to work as a better medium than PREVENTION warm milk. Also, getting the tooth into a medium within the first 15 min increases cell survival and Aproperly fitted mouth guard should be protective, com- reimplantation success (Trope, 2002). Mouth guards are worn in greater than 30 min decreases chance of survival. On the contrary in basketball where mouth 90% chance the tooth will be retained for life guards are not routinely worn oral facial injuries are 34% (Douglas and Douglas, 2003). The American Dental Association (ADA) Primary avulsed teeth should not be reimplanted estimates mouth guards have prevented 200,000 injuries because this could injure the permanent tooth follicle per year. A properly fitting mouth guard will protect the (Douglas and Douglas, 2003). The tooth will then have localized pain and considered bulky and have little retention. Referral to Boil and bite mouth guards are the most common on dentist for either a root canal or extraction is needed. The mouth guard is immersed in boiling Pain medication may be given but antibiotics are not water and formed in the mouth by fingers, tongue, and necessary (Douglas and Douglas, 2003). This mouth guard does not cover all An apical abscess is localized, but if not treated a cel- the posterior teeth decreasing the protective qualities lulitis may follow. This infection may spread into the fascial Custom mouth guards are made by a dentist after a spaces of the head and neck possibly causing airway complete dental examination and proper questioning. The infection may spread to the periorbital An impression is taken of the athlete’s mouth allow- area with complications such as loss of vision, cav- ing the dentist to make a stone cast of the mouth. A ernous sinus thrombosis, and central nervous system single layer thermoplastic mouth guard material is (CNS) involvement. A vacuum custom mouth guard be placed on antibiotics and incision and drainage can be made in the office. CHAPTER 31 INFECTIOUS DISEASE AND THE ATHLETE 173 Increased evidence has shown that a multilayer guard or laboratory pressure laminated may be preferred to REFERENCES a single layer. These can either be made by the dentist in office if proper materials are available or need to be Cohen S. Louis, MO, When properly worn helmets and facemasks will Mosby, 2002, p 605. Am Fam sports: acrobatics, basketball, boxing, field hockey, Phys 67:3, 2003. Kenny DJ Barrett EJ: Recent developments in dental traumato- football, gymnastics, handball, ice hockey, lacrosse, logy. J Public Health Dent 58:289, squash, surfing, volleyball, water polo, weightlifting, 1998. Lee JL, Vann WF, Sigurdsson A: Management of avulsed perma- Injury rates in football rates have gone from 50% to nent incisors: A decision analysis based on hanging concepts. Phys Sportsmed Compliance can be a problem with mouth guard use— 28:1, 2000. DENTAL MAINTENANCE Trope M: Clinical management of the avulsed tooth: Present strategies and future directions. An initial compre- hensive dental examination should be performed, including chief complaint, health history, intraoral and extraoral examination, and radiographs where appli- cable; then the dentist will recommend a recall sched- 31 INFECTIOUS DISEASE ule as needed dictated by the evaluation. AND THE ATHLETE Oral jewelry has become a recent fad with the youth of this country. Dental professionals are advised to John P Metz, MD give these patients information about the problems that can occur with the jewelry.

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Next finasteride 5 mg without prescription hair loss growth products, have the patient bring the ankle underneath the table (flexing the knee) against resistance (Photo 4) cheap finasteride 1mg amex hair loss in men quotes. This tests the patient’s ham- string muscles, which are innervated primarily by the tibial portion of the sciatic nerve (L5, S1). The common peroneal portion of the sciatic nerve (L5–S2) innervates the short head of the biceps femoris. Table 1 lists the major movements of the knee, along with the involved muscles and their innervation. Knee Pain 97 Table 1 Primary Muscles and Innervation for Knee Movement Major muscle movement Primary muscles involved Primary innervation Knee flexion Hamstrings Primarily tibial, but also (semimembranosus, peroneal portion of semitendinosus, biceps sciatic nerve femoris). Knee extension Quadriceps (vastus Femoral nerve lateralis, vastus medialis, (primarily L4). With the patient still seated, test for stability of the medial collateral ligament (MCL). Next, secure the patient’s ankle in one hand and cup the patient’s knee with the other hand so that your thenar eminence is against the patient’s fibular head. Place a firm valgus stress on the patient’s knee by push- ing medially against the patient’s knee and pulling laterally against the patient’s ankle—this maneuver is performed in an attempt to open the medial side of his knee (Photo 5). If there is an MCL injury, there will be medial joint-line gapping that you will appreciate with the fingers that are cupped around the patient’s knee. When the valgus stress on the patient’s leg is relieved, the patient’s knee may be felt to “clunk” back together if there is an MCL tear. To test for a lateral collateral ligament (LCL) tear, apply a varus stress to the patient’s joint by pushing the patient’s ankle medially while pulling the patient’s knee laterally. Remember to keep your hand cupped around the lateral aspect of the joint in order to appreciate gap- ping, if present (Photo 6). Next, have the patient lie in the supine position while you check for an effusion. Look for a large effusion by pushing the patient’s patella superiorly and then quickly releasing it. If there is a large amount of fluid, the fluid will redistribute and push the patella into its former position. Knee Pain 99 you may need to milk the fluid from the suprapatellar pouch and the lat- eral side of the knee over to the medial side of the knee. Then, you would release the fluid and tap the medial aspect of the knee. In the next few seconds, if an effusion is present, then the fluid will redistribute laterally and a fullness will develop on the lateral side of the knee. The Lachman test is performed by flexing the patient’s knee to 20° and sta- bilizing the patient’s femur with one hand and pulling the tibia toward you with the other hand. This is important because a few degrees of anterior glide of the tibia on the femur may be normal. The anterior drawer test is a similar test that should also be per- formed to evaluate for an ACL injury. In this test, the patient’s knee is flexed to 90° with the feet flat on the table. The examiner sits on the patient’s foot to stabilize it, and with the examiner’s hands cupped around the back of the patient’s upper calf, the tibia is pulled toward the examiner (Photo 7). If the tibia slides forward from under the femur more than a few degrees, there may be a tear in the ACL. If the patient has a positive anterior drawer sign or Lachman test, repeat the maneuver with the patient’s leg in external and internal rota- tion. Repeating the maneuver with the leg in external rotation should tighten the posteromedial portion of the capsule. If the patient’s tibia glides forward as much as it did with the leg in the neutral position, an MCL tear may be accompanying the potential ACL tear. Repeating the test with the leg in internal rotation tightens the posterolateral capsule. If the patient’s tibia again glides forward as much as it did with the leg in the neutral position, an LCL tear may be accompanying the poten- tial ACL tear. To test for a posterior cruciate ligament (PCL) tear, the examiner stays seated on the patient’s foot as for the anterior drawer test. However, instead of pulling the patient’s tibia toward the examiner, the tibia is pushed posteriorly (Photo 8). If the patient’s tibia glides posteriorly on the femur, it is likely torn, although the PCL is rarely torn. In this sign, the patient’s hip is flexed to 45° and the knee is flexed to 90°. The examiner supports the limb by holding the patient’s ankle (Photo 9). In a patient with a PCL tear, the tibia will posteriorly translate on the femur. Tenderness to palpation at the joint line (which you have already assessed) is a good indication that Knee Pain 101 Photo 9.

Reynolds R finasteride 5 mg with amex hair loss wikipedia, Browning G generic finasteride 1mg fast delivery hair loss 7 months postpartum, Nawroz I, Campbell I (2003) Von Reck- correction in Marfan syndrome. Spine 27: 2003–12 linghausen’s neurofibromatosis: neurofibromatosis type 1. Joseph KN, Kane HA, Milner RS, Steg NL, Williamson MB Jr, cet 361: 1552–4 Bowen JR (1992) Orthopedic aspects of the Marfan phenotype. Roth DA, Tawa NE Jr, O’Brien JM, Treco DA, Selden RF (2001) Clin Orthop 277: 251–61 Nonviral transfer of the gene encoding coagulation factor VIII in 25. Journeycake J, Miller K, Anderson A, Buchanan G, Finnegan M patients with severe hemophilia A. Sotos JF, Dodge PR, Muirhead D, Crawford JD, Talbot NB (1964) with hemophilia. J Pediatr Hematol Oncol 25: 726–31 Cerebral gigantism in childhood: a syndrome of excessively 26. Katz K, Mechlis-Frish S, Cohen IJ, Horev G, Zaizov R, Lubin E rapid growth with acromegalic features and a nonprogressive (1991) Bone scans in the diagnosis of bone crisis in patients who neurologic disorder. Katz K, Sabato S, Horev G, Cohen IJ, Yosipovitch Z (1993) Spinal racolumbar spine in Marfan syndrome. J Bone Joint Surg 77-A: involvement in children and adolescents with Gaucher disease. Katz SG, Nelson IW, Atkins RM, Duthie RB: Peripheral nerve le- Orthopaedic manifestations of Ehlers-Danlos syndrome. Stevens D, Fink B, Prevel C (2000) Poland’s syndrome in one iden- (1995) Hip arthroplasty in hemophilic arthropathy. Klippel M, Trénaunay P (1900) Du naevus variqueux ostéo-hyper- foot: our experience in seven cases. Knudson AG Jr, Kaplan WD (1962) Genetics of the sphingolipi- of neurofibromatosis in children: an update. Kullmann F, Koch R, Feichtinger W, Giesen H, Schmid M, Grimm T how well do these correlate to subjective pain status and daily (1993) Holt-Oram Syndrom in Kombination mit reziproker Trans- activities? Weaver DD, Graham CB, Thomas IT, Smith DW (1974) A new over- 205: 185–9 growth syndrome with accelerated skeletal maturation, unusual 33. Lebel E, Itzchaki M, Hadas-Halpern I, Zimran A, Elstein D (2001) facies, and camptodactyly. J Arthroplasty 16: 7–12 capital femoral epiphysis associated with endocrine disease. Legroux-Gerot I, Strouk G, Parquet A, Goodemand J, Gougeon Pediatr Orthop 13: 610–4 F, Duquesnoy B (2003) Total knee arthroplasty in hemophilic 56. Joint Bone Spine 70: 22–32 (2001) Pseudo-osteomyelitic crisis upon presentation of Gau- 35. Leonard NJ, Cole T, Bhargava R, Honore LH, Watt J (2000) Sacro- cher disease. Skeletal Radiol 30: 407–10 coccygeal teratoma in two cases of Sotos syndrome. Lipton G, Guille J, Kumar S (2002) Surgical treatment of scoliosis Syndrom Exomphalos-Makroglossie-Gigantismus, über gener- in Marfan syndrome: guidelines for a successful outcome. J Pedi- alisierte Muskelhypertrophie, progressive Lipodystrophie und atr Orthop 22: 302–7 Miescher-Syndrom im Sinne diencephaler Syndrome. Wynne-Davies R, Gormley J (1985) The prevalence of skeletal in children with hemophilia. The motor and sensory systems influ- ence each other: The less an extremity is used, the less the R. Brunner sensory functions develop, and the less the extremity is used again. Motor training is important therefore for the development of sensory functions. At the same time, stretching during everyday life disorders and structural deformities of the muscu- ensures that the muscles are long enough to preserve ad- loskeletal system. If high heels are worn con- problems cannot usually be resolved at causal level, stantly, for example, the triceps surae muscle is shortened, they act permanently on the musculoskeletal system. Spastic and flaccid pare- Since the growing skeleton is more plastic than the ses and the necessary compensatory mechanisms change fully-grown counterpart, secondary skeletal deformi- the loading on the muscles, which then exert power in ties occur particularly during childhood. These can positions that differ from the physiological situation in further aggravate the functioning of the locomotor healthy individuals. Neuro-orthopaedics is concerned with the The use of muscles with modified lengths and forces consequences of neuromuscular disorders on the mus- and the presence of spasticity interfere with their ex- culoskeletal system. Some muscles become too short (contracted), Historical background whereas others are too long, a situation that alters the Even at the start of the last century appliance-based treatment for extent of joint movement. Moreover, the optimal operat- cases of paralysis, often after poliomyelitis, together with procedures ing length for both muscles in relation to the optimal for improving function, formed an important part of orthopaedics as a whole.

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