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This abnormally wide gap can be diagnosed by radiologic studies such as x-ray, MRI, CT scan or bone scan. Manual testing by a healthcare professional can also be used. The patient is placed in various positions and pressure is applied in such a way that it provokes pain and maybe movement in the pubis.
Osteitis pubis may be diagnosed with an X-ray, where irregularity and widening of the pubic symphysis are hallmark findings. Similar change is also demonstrated with Computed Tomography (CT), but the multi-planar nature of CT has a higher sensitivity than conventional radiography. Though not well visualised on ultrasound (US), thickening of the superior joint capsule with cyst formation is a clue to the diagnosis, as well as secondary changes (i.e. tendinosis) of the adjacent adductor muscles - particularly the adductor longus and rectus abdominis. US is also useful for excluding a hernia, which may co-exist with osteitis pubis and warrant additional treatment.
Both US and CT may be used for injecting the pubic symphysis with corticosteroid as part of an athlete's treatment program. Magnetic resonance imaging combines the diagnostic advantages of CT and ultrasound, also shows bone marrow edema, and has the advantages of not being operator dependent (unlike US), nor using radiation (such as CT and X-rays). As such, MRI is the modality of choice for evaluation, diagnosis, and treatment planning.
X-rays are usually necessary, but this is not always the case. A physical examination will be carried out, which sometimes involves a rectal examination and/or neurologic examination.
An X-ray film will show a marked gap between the pubic bones, normally there is a 4–5 mm gap but in pregnancy, hormonal influences cause relaxation of the connecting ligaments and the bones separate up to 9 mm. To demonstrate instability of the joint the patient is required to stand in the "flamingo" position, (standing with weight on one leg and the other bent). A vertical displacement of more than 1 cm is an indicator of symphysis pubis instability. A displacement of more than 2 cm usually indicates involvement of the sacroiliac joints.
Several precautions may decrease the risk of getting a pelvic fracture. One study that examined the effectiveness of vitamin D supplementation found that oral vitamin D supplements reduced the risk of hip and nonvertebral fractures in older people. Certain types of equipment may help prevent pelvic fractures for the groups which are most at risk.
Pelvic fractures can be dangerous to one’s physical health. As the human body ages, the bones become more weak and brittle and are therefore more susceptible to fractures. Certain precautions are crucial in order to lower the risk of getting pelvic fractures. The most damaging is one from a car accident, cycling accident, or falling from a high building which can result in a high energy injury. This can be very dangerous because the pelvis supports many internal organs and can damage these organs. Falling is one of the most common causes of a pelvic fracture. Therefore, proper precautions should be taken to prevent this from happening.
If the coccyx fracture is severe enough, short-term hospitalisation may be required, although this is extremely rare. More often, self-care at home is administered.
Sitting on soft surfaces is recommended, as this reduces pressure on the coccyx. A 'donut' or 'wedge' cushion may be purchased – these are simply cushions with a hole in them to ensure that no weight is placed in the injured tailbone. Painkillers such as ibuprofen are also recommended, as is a diet high in fibre to soften stools and avoid constipation.
Doctors will not usually attempt to correct a bad alignment, as muscles in the area are powerful and can pull the bone back into the 'bad' position. The bone is also very difficult to immobilise simply due to the sheer number of muscles attached to it, as well as the position.
If the femur head is dislocated, it should be reduced as soon as possible, to prevent damage to its blood supply. This is preferably done under anaesthesia, following which, leg is kept pulled by applying traction to prevent joint from dislocating.
The final management depends on the size of the fragment(s), stability and congruence of the joint. In some cases traction for six to eight weeks may be the only treatment required; however, surgical fixation using screw(s) and plate(s) may be required if the injury is more complex. The latter treatment will be called for if bone fragments do not fall into place, or if they are found in the joint, or if the joint itself is unstable.
Until recently, there was no specific treatment for osteitis pubis. To treat the pain and inflammation caused by osteitis pubis, antiinflammatory medication, stretching, and strengthening of the stabilizing muscles are often prescribed. In Argentina, Topol et al. have studied the use of glucose and lidocaine injections ("prolotherapy", or regenerative injection therapy) in an attempt to restart the healing process and generate new connective tissue in 72 athletes with chronic groin/abdominal pain who had failed a conservative treatment trial. The treatment consisted of monthly injections to ligament attachments on the pubis. Their pain had lasted an average of 11 months, ranging from 3–60 months. The average number of treatments received was 3, ranging from 1–6. Their pain improved by 82%. Six athletes did not improve, and the remaining 66 returned to unrestricted sport in an average of 3 months.
Surgical intervention - such as wedge resection of the pubis symphysis - is sometimes attempted in severe cases, but its success rate is not high, and the surgery itself may lead to later pelvic problems.
The Australian Football League has taken some steps to reduce the incidence of osteitis pubis, in particular recommending that clubs restrict the amount of bodybuilding which young players are required to carry out, and in general reducing the physical demands on players before their bodies mature.
Osteitis pubis, if not treated early and correctly, can more often than not end a sporting individuals career, or give them an uncertain playing future.
Management of shoulder dystocia has become a focus point for many obstetrical nursing units in North America. Courses such as the Canadian More-OB program encourage nursing units to do routine drills to prevent delays in delivery which adversely affect both mother and fetus. A common treatment mnemonic is ALARMER
- Ask for help. This involves preparing for the help of an obstetrician, for anesthesia, and for pediatrics for subsequent resuscitation of the infant that may be needed if the methods below fail.
- L hyperflexion (McRoberts' maneuver)
- Anterior shoulder disimpaction (pressure)
- Rubin maneuver
- M delivery of posterior arm
- Episiotomy
- Roll over on all fours
Typically the procedures are performed in the order listed above and the sequence ends whenever a technique is successful. Intentional clavicular fracture is a final attempt at nonoperative vaginal delivery prior to Zavanelli's maneuver or symphysiotomy, both of which are considered extraordinary treatment measures.
The broken bone pieces or the dislocated head of the femur may injure the sciatic nerve, causing paralysis of the foot; the patient may or may not recover sensation in the foot, depending on the extent of injury to the nerve. The posterior wall fragment may be one large piece, or multiple pieces, and may be associated with impaction of the bone. Sciatic nerve injury and stoppage of blood supply to femoral head at the time of accident or during surgery to treat may occur. Deep vein thrombosis and pulmonary embolism are other complications that may occur in any type of injury to the acetabulum.
Computed tomography is the most sensitive and specific of the imaging techniques. The facial bones can be visualized as slices through the skeletal in either the axial, coronal or sagittal planes. Images can be reconstructed into a 3-dimensional view, to give a better sense of the displacement of various fragments. 3D reconstruction, however, can mask smaller fractures owing to volume averaging, scatter artifact and surrounding structures simply blocking the view of underlying areas.
Research has shown that panoramic radiography is similar to computed tomography in its diagnostic accuracy for mandible fractures and both are more accurate than plain film radiograph. The indications to use CT for mandible fracture vary by region, but it does not seem to add to diagnosis or treatment planning except for comminuted or avulsive type fractures, although, there is better clinician agreement on the location and absence of fractures with CT compared to panoramic radiography.
A number of different conditions can cause pain in the general area of the coccyx, but not all involve the coccyx and the muscles attached to it. The first task of diagnosis is to determine whether the pain is related to the coccyx. Physical rectal examination, high resolution x-rays and MRI scans can rule out various causes unrelated to the coccyx, such as Tarlov cysts and pain referred from higher up the spine. Note that, contrary to most anatomical textbooks, most coccyxes consist of several segments: 'fractured coccyx' is often diagnosed when the coccyx is in fact normal or just dislocated at an intercoccygeal joint.
A simple test to determine whether the coccyx is involved is injection of local anesthetic into the area. If the pain relates to the coccyx, this should produce immediate relief.
If the anesthetic test proves positive, then a dynamic (sit/stand) x-ray or MRI scan may show whether the coccyx dislocates when the patient sits.
Use of dynamic x-rays on 208 patients who gave positive results with the anesthetic test showed:
- 31% Not possible to identify the cause of pain
- 27% Hypermobility (excessive flexing of the coccyx forwards and upwards when sitting)
- 22% Posterior luxation (partial dislocation of the coccyx backwards when sitting)
- 14% Spicule (bony spur) on the coccyx
- 5% Anterior luxation (partial dislocation of the coccyx forwards when sitting)
This study found that the pattern of lesions was different depending on the obesity of the patients: obese patients were most likely to have posterior luxation of the coccyx, while thin patients were most likely to have coccygeal .
There are various classification systems of mandibular fractures in use.
A compound elevated skull fracture is a rare type of skull fracture where the fractured bone is elevated above the intact outer table of the skull. This type of skull fracture is always compound in nature. It can be caused during an assault with a weapon where the initial blow penetrates the skull and the underlying meninges and, on withdrawal, the weapon lifts the fractured portion of the skull outward. It can also be caused the skull rotating while being struck in a case of blunt force trauma, the skull rotating while striking an inanimate object as in a fall, or it may occur during transfer of a patient after an initial compound head injury.
Scoliosis is well established and even evaluated at an early age. It is typically quantified using the standardized Cobb angle method. This method consists of measuring the degree of deformity by the angle between two successive vertebrae. The Cobb method was accepted by the Scoliosis Research Society (SRS) in 1966. It serves as the standard method for quantification of scoliosis deformities. Sagittal plane posture aberrations such as cervical and lumbar lordosis and thoracic kyphosis have yet to be quantified due to considerable inter-individual variability in normal sagittal curvature. The Cobb method was also one of the first techniques used to quantify sagittal deformity. As a 2D measurement technique it has limitations and new techniques are being proposed for measurement of these curvatures. Most recently, 3D imaging techniques using computed tomography (CT) and magnetic resonance (MR) have been attempted. These techniques are promising but lack the reliability and validity necessary to be used as a reference for clinical purposes.
Posture assessment has also become quite popular in many practical environments like the personal training and sports conditioning settings. The need for reliable methods of posture assessment as a screening tool is warranted. Current available programs such as those through the National Posture Institute (NPI) and Posture Print are recommended for the practical setting but cost close to $1000 and are clearly a profiteering scam by individuals not at all concerned with human well-being.
Chronic deviations from neutral spine lead to improper posture, increased stress on the back and causes discomfort and damage. People who sit for long hours on the job are susceptible to a number of misalignments.
"Neutral spine" is ideally maintained while sitting, standing, and sleeping.
About 16% of deliveries where shoulder dystocia occurs will have conventional risk factors.
There are well-recognized risk factors, such as diabetes, fetal macrosomia, and maternal obesity, but it is often difficult to predict, despite recognised risk factors. Despite appropriate obstetric management, fetal injury (such as brachial plexus injury) or even fetal death can be a complication of this obstetric emergency.
Risk factors:
- Age >35
- Short in stature
- Small or abnormal pelvis
- More than 42 weeks gestation
- Estimated fetal weight > 4500g
- Maternal diabetes (2-4 fold increase in risk)
Factors which increase the risk/are warning signs:
- the need for oxytocics
- a prolonged first or second stage of labour
- turtle sign
- head bobbing in the second stage
- failure to restitute
- No shoulder rotation or descent
- Instrumental delivery
Recurrence rates are relatively high (if you had shoulder dystocia in a previous delivery the risk is now 10% higher than in the general population).
A fracture in conjunction with an overlying laceration that tears the epidermis and the meninges—or runs through the paranasal sinuses and the middle ear structures, putting the outside environment in contact with the cranial cavity—is a compound fracture.
Compound fractures may either be clean or contaminated. Intracranial air (pneumocephalus) may occur in compound skull fractures.
The most serious complication of compound skull fractures is infection. Increased risk factors for infection include visible contamination, meningeal tear, loose bone fragments and presenting for treatment more than eight hours after initial injury.
There is no definite way to fully prevent coccyx pain because an accident can occur at any given time. However, people who are obese are at a higher risk for developing coccyx pain. Carrying excessive weight contributes to more stress on the coccyx while sitting down causing increased chances of pain.
Prevention of carrying excessive weight gain can help reduce the tension and pressure on the coccyx. In other words, the coccyx for obese people may be more posteriorly outward when they are sitting down. Avoidance of contact sports like basketball, football, and or hockey can decrease the risks of coccyx pain, because it can help reduce the chances of falling.
Another method is proper safety equipment for sports is to prevent coccyx pain. For example, there are hockey pants that provide extra cushion that protect the thigh, coccyx, and buttocks. These results will lead to less falls that can cause trauma to the coccyx.
For most women, PGP resolves in weeks after delivery but for some it can last for years resulting in a reduced tolerance for weight bearing activities. PGP can take from 11 weeks, 6 months or even up to 2 years postpartum to subside. However, some research supports that the average time to complete recovery is 6.25 years, and the more severe the case is, the longer recovery period.
Overall, about 45% of all pregnant women and 25% of all women postpartum suffer from PGP. During pregnancy, serious pain occurs in about 25%, and severe disability in about 8% of patients. After pregnancy, problems are serious in about 7%. There is no correlation between age, culture, nationality and numbers of pregnancies that determine a higher incidence of PGP.
If a woman experiences PGP during one pregnancy, she is more likely to experience it in subsequent pregnancies; but the severity cannot be determined.
Radiography, imaging of tissues using X-rays, is used to rule out facial fractures. Angiography (X-rays taken of the inside of blood vessels) can be used to locate the source of bleeding. However the complex bones and tissues of the face can make it difficult to interpret plain radiographs; CT scanning is better for detecting fractures and examining soft tissues, and is often needed to determine whether surgery is necessary, but it is more expensive and difficult to obtain. CT scanning is usually considered to be more definitive and better at detecting facial injuries than X-ray. CT scanning is especially likely to be used in people with multiple injuries who need CT scans to assess for other injuries anyway.
A number of treatments have some evidence for benefits include an exercise program. Paracetamol (acetaminophen) has not been found effective but is safe. NSAIDs are sometimes effective but should not be used after 30 weeks of pregnancy. There is tentative evidence for acupuncture.
Some pelvic joint trauma will not respond to conservative type treatments and orthopedic surgery might become the only option to stabilize the joints.
Measures to reduce facial trauma include laws enforcing seat belt use and public education to increase awareness about the importance of seat belts and motorcycle helmets. Efforts to reduce drunk driving are other preventative measures; changes to laws and their enforcement have been proposed, as well as changes to societal attitudes toward the activity. Information obtained from biomechanics studies can be used to design automobiles with a view toward preventing facial injuries. While seat belts reduce the number and severity of facial injuries that occur in crashes, airbags alone are not very effective at preventing the injuries. In sports, safety devices including helmets have been found to reduce the risk of severe facial injury. Additional attachments such as face guards may be added to sports helmets to prevent orofacial injury (injury to the mouth or face); mouth guards also used.
No treatment is necessary for women while they are still pregnant. In children, complications include development of an umbilical or ventral hernia, which is rare and can be corrected with surgery.
Alerting a medical professional is important when an infant displays signs of vomiting, redness or pain in the abdominal area.
Typically the separation of the abdominal muscles will lessen within the first 8 weeks after childbirth; however, the connective tissue remains stretched for many postpartum women. The weakening of the abdominal muscles and the reduced force transmission from the stretched linea alba may also make it difficult to lift objects, and cause lower back pain. Additional complications can manifest in weakened pelvic alignment and altered posture.
Different features of the dysostosis are significant. Radiological imaging helps confirm the diagnosis. During gestation (pregnancy), clavicular size can be calculated using available nomograms. Wormian bones can sometimes be observed in the skull.
Diagnosis of CCD spectrum disorder is established in an individual with typical clinical and radiographic findings and/or by the identification of a heterozygous pathogenic variant in RUNX2 (CBFA1).