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Many therapists believe children should wear ankle-foot orthotics (AFO) at night to stretch the contracted gastrocnemius buy discount nitrofurantoin 50mg online. However 50 mg nitrofurantoin for sale, if only AFOs are used generic nitrofurantoin 50mg overnight delivery, children will flex the knee and only the soleus gets stretched, further increasing the length difference many children already have between the gastrocnemius and soleus muscles (Figure 7. Stretching the gastrocnemius requires the use of a knee exten- sion splint and a dorsiflexion splint, a combination that is bulky and adds to the poor acceptance. The use of casting adds other problems, especially mus- cle atrophy. One of the most efficient ways to shrink the size of a muscle is to rigidly immobilize the joint in a cast so the muscle has no motion possible. No documentation is available to show that a muscle grows longer if im- mobilized under tension in a cast; however, based on knowledge of how muscle grows, it probably does grow longer in addition to developing severe atrophy. The severe atrophy and temporary nature of the clinical length gain make the use of casting for chronic management of short muscles in children with CP a poor choice. The major problem in the research of muscle growth is the difficulty of measuring muscle growth separate from tendon growth. The mechanical stimuli for growth of these two different anatomic structures, muscles and tendons, somewhat overlap and the effort to cause muscle growth probably causes tendon growth as well. Connective Tissue Mechanics Short muscles in CP are clinically well recognized; however, the problem of excessive length of the tendons is often not recognized. However, surgeons who operate on the tendons fre- quently see tendons that are much too long, as if these tendons were trying to make some adjustment for the very short muscles (Figure 7. Tendons grow by interstitial growth throughout, but most of the growth seems to occur at the tendon–bone interface. The stimulus for increased tendon growth and tendon cross-sectional area growth is not well defined, but depends heavily on the force environment. The regulation of length growth is heavily influenced by tension, but the 264 Cerebral Palsy Management Figure 7. Tendons have a growth plate-like structure at the tendon–bone interface and at the muscle–tendon interface, this structure is a high concentration of satellite cells that contribute to muscle growth. In addition, the muscles and tendons also have some inter- stitial growth ability. Tendons contain mechanoreceptors called Golgi tendon organs, which give feedback to the brain and also influence the sensitivity of muscle spindles. In the presence of spasticity with continuous low-level tension, this system may be altered to accommodate for chronic stimulation, possibly by the system dropping mechanoreceptors. Another connective tissue effect that has been long recognized and recently better quantified is the increase in connective tissue in the muscle in the presence of spasticity. This process of increasing connective tissue seems to get worse with increasing magnitude of spasticity, increasing exposure time to spasticity, and increas- ing age of the patient. This is another component of what is defined as the contracture, but is the least understood element of this pathology. Growth of the Muscle–Tendon Unit The current understanding of growth regulation of a muscle–tendon unit is that the muscle fibers grow in response to stretching of the sarcomeres while they are not actively firing. This stretch has to occur for some amount of time each day. The tendon grows in length by summation of the total tension over time. The specific pattern of maximum to minimum tension is unknown. Another factor that is important but not well understood is the influence of motion, which both muscles and tendons need to have for healthy growth. Defining the specific stimulus for growth of tendons compared with muscles would be a useful research project. The length of the muscle fiber di- rectly determines the active total joint range of motion; however, the muscle rest length plus tendon length defines where that active range of motion occurs. Therefore, if the active range of the ankle is from −20° of dor- siflexion to 60° of plantar flexion, there is no definitely known mechanism to lengthen the muscle fiber and create an active range of muscle activity from 30° of dorsiflexion to 60° of plantar flexion. However, by length- ening the Achilles tendon, we can move the 40° active range to 10° of dorsiflexion to 30° of plantar flexion, a much more useful position of the muscle’s active range of mo- tion.

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If the pneumothorax is relatively small and minimally symp- tomatic generic nitrofurantoin 50mg with visa, it may be carefully monitored cheap 50mg nitrofurantoin overnight delivery. However discount 50 mg nitrofurantoin mastercard, if children are having significant respiratory problems or the pneumothorax involves more than 30% of the volume of the chest, it should be drained with a tube. The ori- gin of these pneumothoraces may come from positive pressure ventilation, incidental opening of the chest during posterior spinal surgery, or from the insertion of the central line. However, these pneumothoraces are usually rel- atively minor and insignificant in the overall recovery of children. Reflux and Aspiration Many children with CP have gastroesophageal reflux and chronic aspiration. The presence of scoliosis has also been associated with an increased incidence of these problems. Some children will have a dramatic postoperative improvement in the reflux; however, some will have no change and some will become significantly worse. These outcomes are in approximately equal proportions, although we do not have good objective data to make this evaluation. Clearly these children can be managed safely through the spinal fusion, and then the response can be as- sessed and appropriate treatment instituted following recovery from the spine surgery. These children need to be monitored very carefully, especially in the intensive care unit immediately after extubation and then again when feeding is begun. Feeding should be with the children in an upright position with careful monitoring to make sure there is no reflux and aspiration. If there is any evidence of reflux, feeding should be stopped immediately and the respiratory status should be monitored carefully. If there is any sugges- tion of aspiration of the stomach contents, children should be treated for aspiration pneumonia. Most children with severe quadriplegic pattern CP have some posterior aspiration and run a risk of aspiration during the initi- ation of feeding. This aspiration can lead to very severe and rapid respira- tory compromise. Some children with tracheal malacia develop a redundant and collapsing trachea as the scoliosis increases, sometimes with collapse and compression between the sternum and spine. In two of our patients, the response to cor- recting the spinal deformity was complete resolution of the symptoms of tracheal collapse and compression. There was concern that these children might have been made worse. Pancreatitis Chemical pancreatitis, as expressed by a rise in the serum amylase, is rela- tively common and is present in approximately 50% of children in the post- operative period. A much smaller number, approximately 15% to 20%, has some symptomatic pancreatitis that may rarely become very severe. One of the deaths in our patients was from acute hemorrhagic pancreatitis. The cause of pancreatitis is unknown; however, it has been recognized as a risk of most spine surgery even in otherwise healthy adolescents who have idio- pathic adolescent scoliosis. Colicystitis Most of our children are managed with aggressive postoperative nutrition with central venous hyperalimentation on day 2 or 3, and by day 5 or 7, when they have bowel sounds but are not tolerating feeding, the workup should 486 Cerebral Palsy Management include an ultrasound of the gallbladder. Often, some sludge is noted in the gallbladder, occasionally with some inflammation of the wall of the gall- bladder. Sometimes stones are found as well, leading to this inflammation. Children with severe disabilities are at increased risk of developing colicys- titis and cholangitis. When colicystitis is diagnosed in the postoperative period, medical management includes gastrointestinal rest and antibiotics. Following full recovery, children may be scheduled for colicystectomy. Duodenal Obstruction Obstruction at the second part of the duodenum where it is trapped between the superior mesenteric artery and the spine may occur in malnourished chil- dren with CP, even without any surgical insult. These children present with good bowel sounds; however, their stomachs become very distended when fed. Severe stomach distension leading to death can occur.

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As he entered puberty trusted nitrofurantoin 50mg, he was doing well with a right it was 11° discount nitrofurantoin 50 mg with mastercard. The kinematics demonstrated low nor- nearly symmetric gait pattern generic 50mg nitrofurantoin. When the hamstring contracture is causing pro- gressive knee flexion contracture, surgical lengthening should be performed. If the gastrocsoleus contractures need to be addressed, the hamstrings should also be lengthened at the same time, or knee flexion in midstance will draw these children to either toe walk again or stand with a crouched gait on the affected side, which also draws the unaffected side into a crouched gait pat- tern with increased knee flexion in stance. Stiff Knee Gait Some children with type 3 hemiplegia have involvement of the rectus. This involvement will be noted by the parents as a complaint of toe dragging, frequent tripping, and rapid shoe wear, especially on the anterior aspect of the shoes. The physical examination may or may not demonstrate increased rectus tone and a positive Ely test. The kinematic evaluation will show swing phase peak knee flexion to be less than the normal, usually less than 50°, and the peak is often late, close to midswing. For children with late or low knee flexion in swing, when the EMG activity of the rectus muscle in swing phase is increased and evidence of complaints of toe dragging is present, then a distal transfer of the rectus is indicated. This transfer is almost always per- formed with hamstring lengthening and gastrocnemius or tendon Achilles lengthening. Similar to type 2 hemiplegia, approximately 25% of the children will need two tendon lengthenings, one at age 4 to 7 years, and a second at adolescence. These tend to be children who needed the first lengthening very early, sometimes as early as the third year of life. The goal of delaying the first tendon lengthening is to try to avoid the second or third tendon lengthening, although there is no physical documentation that this strategy is effective. Rotational Deformities Transverse plane deformities are more common with type 3 hemiplegic involvement. If tibial torsion or femoral anteversion are causing increased tripping or are very cosmetically objectionable by 5 to 7 years of age, surgi- cal correction can be considered. If children have a very asymmetric pelvic rotation as an adaptation for unilateral femoral anteversion, correction should be considered as early as age 5 to 7 years. Because the functional impairment is greater, the limb length discrepancy tends to be slightly greater than for type 2 hemiplegia, often between 1 and 2 cm at maturity. For most children, this limb length discrepancy works perfectly well to help with foot clearance during swing phase in a limb that does not have as good ability to shorten during preswing and initial swing phase. A shoe lift should not be used, and radiographic monitoring of limb length is needed only with a discrepancy of over 1. If the knee flexion contracture is more than 10°, additional shortening will occur. To prevent further leg shortening, knee flexion con- tracture prevention is important. Like type 2 hemiplegia, there is no role for the global treatment of spasticity in type 3 hemiplegia. Type 4 Type 4 hemiplegia is the third most common pattern; however, it is relatively rare, probably making up less than 5% of all children with hemiplegia. It is relatively common to find type 4 hemiplegia that overlaps with asymmetric diplegia or mild quadriplegia, and it is uncommon to find a child with type 4 hemiplegia who is completely normal on the contralateral side. Children with type 4 involvement usually walk later, between the ages of 2 and 3 years. Many children will use a walker during the learning period of walking. Gait 351 walker usually needs to be fitted with an arm platform on the involved side.

Prevention of infec- When the cause is not known buy cheap nitrofurantoin 50mg on-line, shock is classified ac- tions cheap 50 mg nitrofurantoin with visa, early activity to promote circulation after an injury 15 cording to its severity order 50 mg nitrofurantoin overnight delivery. Constriction of small blood vessels and the detouring of blood away from cer- tain organs increase the effective circulation. Mild shock may develop into a severe, life-threatening circulatory failure. Severe shock is characterized by poor circulation, which causes further damage and deepening of the shock. Symptoms of late shock include clammy skin, anxiety, low blood pressure, rapid pulse, and rapid, shallow breathing. Heart contractions are weakened, owing to the decrease in the heart’s blood supply. The blood vessel walls also are weakened, so that the vessels dilate. The capillaries become more permeable and lose fluid, owing to the accumulation of metabolic wastes. The victim of shock should first be placed in a hori- zontal position and covered with a blanket. The patient’s head should be kept turned to the side to prevent aspiration (breath- ing in) of vomited material, an important cause of death in shock cases. Further treatment of shock depends largely on treatment of the causative factors. For example, shock resulting from fluid loss, as in hemorrhage or burns, is best treated with blood products or plasma ex- Figure 15-17 Varicose veins. Bates’ Guide to Physical Examination and His- ure should be treated with drugs that improve heart mus- tory Taking. Philadelphia: Lippincott Williams & cle contractions. In any case, all measures are aimed at Wilkins, 2003. This condition is found frequently in people is called thrombophlebitis (throm-bo-fleh-BI-tis). Pregnancy, with its accompanying pressure on the Varicose Veins pelvic veins, may also be a predisposing factor. Varicose Varicose veins are superficial veins that have become veins in the rectum are called hemorrhoids (HEM-o-royds), swollen, distorted and ineffective. The general term for varicose veins is varices (VAR- esophagus or rectum, but the veins most commonly in- ih-seze); the singular form is varix (VAR-iks). Word Anatomy Medical terms are built from standardized word parts (prefixes, roots, and suffixes). Learning the meanings of these parts can help you remember words and interpret unfamiliar terms. WORD PART MEANING EXAMPLE Systemic Arteries brachi/o arm The brachiocephalic artery supplies blood to the arm and head on the right side. The Physiology of Circulation sphygm/o pulse A sphygmomanometer is used to measure blood pressure. Disorders Involving the Blood Vessels -ectomy surgical removal Endarterectomy is a procedure for removing plaque from the lin- ing of a vessel. Blood vessels (2) Middle—thicker layer of smooth muscle and A. Arteries—carry blood away from heart elastic connective tissue B. Arterioles—small arteries (3) Outer—connective tissue C. Capillaries—allow for exchanges between blood and tis- b.

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