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A recent meta-analysis states that epidural anesthesia may be associated with superior pain control but this does not translate into improved recovery or reduced morbidity when compared with alternative analgesic techniques when used within an enhanced recovery protocol 1000mg valacyclovir with mastercard stage 1 hiv infection timeline. It is advisable to remove epidural catheter on second postoperative day to enhance patient mobilization purchase valacyclovir 500mg online hiv infection life expectancy. Local wound infiltration or continuous infusion of local anesthetics using wound pumps has been used and found to be as efficient as epidurals in reducing pain in the first 48 hours postoperatively buy valacyclovir 500 mg low price antiviral lotion, with lower rates of urinary retention buy 1000mg valacyclovir amex hiv symptoms sinus infection. Postoperative Glycemic Control Hyperglycemia (blood sugar >180–200 mg/dL) is commonly observed in the postoperative period. It has shown to adversely affect postoperative outcome in terms of infection, length of hospital stay including increased mortality rates. Target blood sugar should be between 180 mg/dL–200 mg/dL and patients having blood glucose higher than this range should be treated with insulin therapy. It is recommended to do regular blood glucose monitoring to prevent iatrogenic hypoglycemia. Early Postoperative Mobilization There should be planned early mobilization with the involvement of physio- therapist with an aim to make the patient sit on chair same evening or the very first day of surgery. Avoidance of abdominal drains, nasogastric tubes and opioids can help in early mobilization. Early Enteral Diet Postoperatively patients are likely to develop ileus secondary to intraoperative bowel handling, use of opioids, excessive crystalloids and surgical stress. Early feeding by enteral route is shown to minimize postoperative insulin resistance, 160 Yearbook of Anesthesiology-6 hyperglycemia, nitrogen loss and enhances recovery. Oral fluids should be started as early as 2 hours postoperatively and increased as tolerated by the patient. Early Discharge Patients are usually ready to go home in 8–9 days following major abdominal surgery. With implementation of enhanced recovery program patients can be sent home in 4–5 days. Regular audits to evaluate rate of compliance, rates of complication and of readmission must be carried out. Preoperative, peri- operative and postoperative components of enhanced recovery should be used to promote early recovery in patients undergoing surgery. Implementation of such a program involves multidisciplinary effort and gradual evolution and adoption of evidence based best practices. Enhanced recovery in colorectal resections: a systematic review and meta-analysis. Fast track surgery versus conventional recovery strategies for colorectal surgery. Health-related quality of life and postoperative recovery in fast-track hysterectomy. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Preoperative alcohol consumption and postoperative compli cations: a systematic review and meta-analysis. Kotzé A, Harris A, Baker C, Iqbal T, Lavies N, Richards T, Ryan K, Taylor C, Thomas D. The ability of prehabilitation to influence postoperative outcome after intra-abdominal operation: A systematic review and meta-analysis. The effectiveness of prehabilitation or preoperative exercise for surgical patients: a systematic review. Should perioperative immunonutrition for elective surgery be the current standard of care? Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-analysis. Issues in professional practice guidelines for implementation of enhanced recovery protocols. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Effect of intraoperative fluid administration and colloid osmotic pressure on the formation of intestinal edema during gastrointestinal surgery. Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding H, Lindorff-Larsen K, et al. Effects of intravenous fluid restriction on postoperative complications: Comparison of two perioperative fluid regimens: A randomized assessor-blinded multicenter trial. Restrictive deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy reduces postoperative complications and hospitalization time. Meta-analysis of the effect of goal-directed therapy on bowel function after abdominal surgery. Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis. Determinants of outcome after colorectal resection within an enhanced recovery programme. Predictors of length of stay in patients having elective colorectal surgery within an enhanced recovery protocol. Even after delivery, it may continue to be secreted in the breast milk, which will again affect the baby. Knowledge of pharmacokinetics in obstetric patients can guide the obstetric anesthetist in finding the right balance between risks and benefits of a therapy to both the mother and baby. Only proven safe drugs must be used in the pregnant patient, but the adverse effects of many drugs is uncertain. The American Society of Anesthesiologists has established guidelines and protocols for providing safe care during obstetric anesthesia. However, during labor and after administration of opioids, the gastric emptying may be delayed. There is an increase in gastric pH, which affects absorption of drugs that are weak acids and bases. Clinically, the changes in bioavailability of a drug during pregnancy are very small. This increase in peripheral perfusion however will lead to a delay in arterial and brain anesthetic concentration. Lipophilic anesthetic agents like thiopentone and bupivacaine tend to distribute and be held in this large adipose tissue depot leading to persistently high drug concentration. While the concentration of free drug is increased, in chronic drug therapy, the increased drug clearance offsets this change. The increase in free fatty acids, placental and steroidal hormones during pregnancy at term displaces drugs from their albumin binding sites compounding the problem further.

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Distin- peutic doses proven 1000 mg valacyclovir hiv infection rates bangkok, and that are predictable and usually dose guishing between natural progression of a disease and drug- related buy valacyclovir 500 mg online anti viral pharyngitis. The der that are of importance in evaluating drug-induced majority of reactions develop soon after exposure order valacyclovir 500mg on-line hiv infection rates gay vs. straight. The term adverse ‘reaction’ Anaphylactic reactions (within minutes or hours) and is almost synonymous with adverse ‘effect’ buy generic valacyclovir 500 mg on-line antiviral drugs name, except that hypersensitivity reactions (within weeks) may readily an ‘effect’ relates to the drug and a ‘reaction’ to the suggest an association, but delayed effects such as patient. Both terms should be distinguished from an carcinogenesis or tardive dyskinesia (after years or even adverse ‘event’, which is an adverse happening that oc- decades) present more difficulty. The relationship to what is already known about the in overdose2 and overdose can be absolute or relative; drug. This of course invites questions about consistency in the latter case an ordinary dose may be administered with the established pharmacology and toxicology of but may be toxic due to an underlying abnormality in the drug or related substances. Mutagenicity, carci- Degrees of conviction for attributing adverse reactions to drugs may be ascribed as3: nogenicity and teratogenicity (see Index) are special cases of toxicity. Examples are: vitamin deficiency or drugs; event ceases on stopping the drug; event returns opportunistic infection in patients whose normal bowel on restarting the drug (rarely advisable). Individuals vary greatly in their • Possible: time sequence is reasonable; event susceptibility to drugs, those at one extreme of the normal corresponds to what is known of the drug; uncertain distribution curve being intolerant of the drugs, those at the relationship to effect of stopping the drug; event could other, tolerant. AprincipleappreciatedbyParacelsus500 yearsago,whostatedthat‘All things are poisons and there is nothing that is harmless; the dose alone • Doubtful: event not meeting the above criteria. The physician, alchemist and philosopher is regarded as the founder of chemical therapeutics; he was the first to use carefully measured doses of mercury to treat syphilis. About 80% of well people not taking any drugs illness: this effect is likely to remain undiscovered. Administration of a placebo intensifies (or dimin- increased risk did become apparent after meta-analysis ishes) these symptoms. Similarly, minor and • A drug rarely induces an otherwise rare illness: this effect is possibly transient abnormalities in laboratory results, e. The effect could be detected by informal clinical observation or during any special post-registration surveillance and confirmed by Practicalities of detecting rare a case–control study (see p. Assuming that three events effect will not be discovered by informal clinical are required before any regulatory or other action should be observation. If very common, it may be discovered in taken, it shows the large number of patients that must be formal therapeutic trials and in case–control studies, monitored to detect even a relatively high-incidence ad- but if only moderately common it may require verse effect. The challenge is to find and than aspirin); the commonest adverse reaction was avoid these, and, indeed, the present systems for detecting gastrointestinal bleeding. Many drugs possess anticholinergic activity either directly (atropine, oxybutynin) or indirectly It is important to avoid alarmist or defeatist reactions. Thefirst-generation H1-receptoran- biliary stones or hernia and to refuse to accept any risk at tihistamines (chlorphenamine, diphenhydramine) are no- all from drugs for conditions of comparable severity. Drugs wholly caused by drugs, are dangerously ill already; justifi- may also affect performance through cerebral depression able risks may be taken in the hope of helping them; ill- (antiepileptics, opioids), hypoglycaemia (antidiabetics) informed criticism in such cases can act against the interest and hypotension (antihypertensives). This is often more obvious Car driving is a complex multifunction task that in- when reviewing the conduct of treatment after the event, cludes: visual search and recognition, vigilance, informa- i. It is plain that tury, said that ‘medicine is an art founded on conjecture prescribers have a major responsibility here, both to warn and improved by murder’. Although medicine has ad- patients and, in the case of those who need to drive for their vanced rapidly, there is still a ring of truth in that statement, work, to choose medicines with a minimal liability to cause as witness anyone who follows the introduction of new 11 impairment. Patients who must drive when taking a drug drugs and observes how, after the early enthusiasm, there of known risk, e. It is also essential that patients Aspects of the above appear throughout the book as is be advised of the additive effect of alcohol with prescribed indicated. How the patient feels is not a reliable guide to recovery of Age skills, and drivers may be more than usually accident prone without any subjective feeling of sedation or dysphoria. The very old and the very young are liable to be intolerant The criteria for safety in aircrew are much more stringent of many drugs, largely because the mechanisms for dispos- than are those for car drivers. The young are not Resumption of car driving or other skilled activity after simply ‘small adults’ and ‘respect for their pharmacokinetic anaesthesia is a special case, and an extremely variable variability should be added to the list of our senior citizens’ rights’. The emphasis on psychomotor and physical aspects (in- jury) should not distract from the possibility that those Sex who live by their intellect and imagination (politicians and even journalists may be included here) may suffer cog- Females are more likely to experience adverse reactions to nitive disability from thoughtless prescribing. The porphyrias comprise a number of rare, genetically de- • The known nature of the drug may forewarn. The capacity of the body to (porphyria cutanea tarda, erythropoietic protoporphyria eliminate certain drugs, e. Use of these and other drugs may raise variegate porphyria and hereditary co-proporphyria) are longer-term issues of mutagenicity, carcinogenicity and characterised by severe attacks of neurovisceral dysfunction teratogenicity. Ingredients of a formulation, rather than precipitated principally by a wide variety of drugs (also by the active drug, may also cause adverse reactions. Clinical effects arise from Examples include the high sodium content of some the accumulation of the precursors of haem synthesis, antacids, and colouring and flavouring agents. Induc- The environment and social habits tion of the haem-containing hepatic oxidising enzymes of the cytochrome P450 group causes an increased demand Drug metabolism may be increased by hepatic enzyme in- for haem. Therefore drugs that induce these enzymes duction from insecticide accumulation, e. Apparently unexplained at- bials used in feeds of animals for human consumption tacks of porphyria should be an indication for close en- have given rise to concern in relation to the spread of resis- quiry into all possible chemical intake, including tant bacteria that may affect man. Penicillin in the air of recreational substances such as marijuana, cocaine, amfeta- hospitals or in milk (see below) may cause allergy. Great care in prescribing for these patients is required if Allergic reactions to drugs are the result of the interaction of serious illness is to be avoided and it is therefore essential drug or metabolite (or a non-drug element in the formula- that patients and their clinicians have access to information tion) with patient and disease, and subsequent re-exposure. Drug Lack of previous exposure is not the same as lack of his- lists should be reviewed regularly, and a recent initiative tory of previous exposure, and ‘first dose reactions’ are in Europe has made a consensus-based list of safe drugs among the most dramatic. Immune responses If no recognised safe option is available, use of a to drugs may be harmful in varying degrees (allergy) or drug about which there is uncertainty may be justified. The clinician should assess the severity antibodies to penicillins but, fortunately, comparatively of the conditionandtheactivityoftheporphyriaandmakea few react clinically to penicillin administration. Measure porphyrin and porphobilinogen before tigens in combination with a body protein. Repeat the measuremenThat regular intervals or if the ratory tract, gastrointestinal tract, blood and blood vessels. Allergic reactions in general may be classified according If there is an increase in the precursor levels, stop the to four types of hypersensitivity, and drugs can elicit reac- treatment and consider giving haem arginate for acute tions of all types. Addi- bodies, activating but not damaging the cell to which they tionally, attention to nutrition, particularly the supply of are fixed and causing release of pharmacologically active carbohydrate, relief of pain (with an opioid), and of hyper- substances, e. We are grateful to Dr Badminton for contributing the body so that the body no longer recognises the protein section on porphyria. These reactions include serum sickness, glomerulone- Erythromycin may cause a similar reaction. Antigen- anaesthetics (intravenous), iodine-containing radio- specific receptors develop on T lymphocytes.

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Therapeutic strategies that of oral or nail candidiasis were identifed at a follow-up exami- augment the immune response can be very benefcial buy generic valacyclovir 500 mg on line hiv infection potential long term effects, including nation more than a year later safe 1000mg valacyclovir hiv infection blood test. The drug was very well transfer factor (orally or parenterally) or high-dose cimetidine discount valacyclovir 1000 mg visa account for hiv infection cycle. Clinical and mycologic remissions Thyroid-stimulating hormone were achieved in all patients after a mean of 10 days discount 500mg valacyclovir overnight delivery symptoms hiv infection first week. Three Fasting blood glucose patients relapsed within 4 months (mean 56 days), but all Plasma cortisol level responded to fuconazole 50 mg daily for 3 days. Voricon- thymoma patients correlates with autoimmunity to Th17- azole can be given intravenously (6 mg/kg every 12 hours for two associated cytokines. J Exp Med 2010; 207: or orally (200 mg every 12 hours for individuals over 40 kg and 299–308. N Engl J Successful treatment of chronic mucocutaneous candidia- Med 2011; 365: 54–61. She was treated with amphotericin B 50 mg/day intravenously for 2 weeks fol- Systemic azole antimycotics C lowed by posaconazole 400 mg twice daily. After 2 months the 158 Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports 48 dose was reduced to 200 mg/day without a relapse in symptoms. Arch Dermatol 1971; When posaconazole was discontinued, a relapse of oral candidia- 104: 45–56. Of note, the serum levels were signifcantly higher in the frst two patients than the latter two. Echinocandins E In all four patients the oral amphotericin B was free of side effects Oral amphotericin B E both clinically and in laboratory studies. Intravenous amphotericin B D Chronic mucocutaneous candidiasis treated with ampho- tericin B. East Afr Med J Activity of amphotericin B, anidulafungin, caspofungin, 1983; 60: 588–91. All isolates Transfer factor C were highly susceptible to amphotericin B and echinocandins. Cimetidine and zinc sulfate E Posaconazole and voriconazole were active against all isolates, but more active in the fuconazole-susceptible group, suggesting Case report: successful treatment with cimetidine and a possibility that patients may develop some cross-resistance to zinc sulphate in chronic mucocutaneous candidiasis. Am J Med Sci 1996; 311: Successful treatment of azole-resistant chronic mucocuta- 189–90. Jayasinghe M, Schmidt The clinical effcacy of high-dose cimetidine, 400 mg, three S, Walker B, Rocken M, Schaller M. Acta Derm Venereol 2006; 86: times daily, and zinc sulfate, 200 mg daily (subsequently adjusted 563–4. All but one patient Prolonged oral treatment of chronic mucocutaneous can- experienced signifcant improvement during treatment with didiasis with amphotericin B. The Weronika Szczecinska, Anthony Abdullah disappearance of pruritus was reported after 2 to 3 days and skin lesions after 5 to 7 days of therapy. The authors concluded that this regimen was very effective and had no severe side effects. Cutaneous larva migrans: clinical features and manage- ment of 44 cases presenting in the returning traveler. Thirty-one patients received oral albendazole 400 mg daily for 3 to 5 days and 24 were cured (77%). Five patients received 10% thiabendazole cream topically for 10 days and four were cured (80%). A randomized trial of ivermectin versus albendazole for the treatment of cutaneous larva migrans. Twenty-one patients were ease caused by percutaneous penetration and migration of ani- randomly assigned to receive ivermectin (n=10) or albendazole mal hookworm larvae in the human skin, most commonly (n=11). All patients who received ivermectin responded and none Ancylostoma braziliense, Ancylostoma caninum, Uncinaria stenoceph- relapsed (cure rate 100%). People at risk are the inhabit- the group receiving albendazole responded, but fve relapsed ants and returning travellers from tropical and subtropical after a mean of 11 days (cure rate 46%; p=0. The authors suggest that a single can vary between a few days to 7 months after exposure to con- dose of ivermectin is more effective than a single dose of taminated soil or sand. Houze S, Schiemann R, Durand R, Ralaimazava P, Ruggeri C, Rare complications include pulmonary eosinophilic infltrates, et al. Single-dose Hookworm-related cutaneous larva migrans is self-limiting: most ivermectin therapy appears to be effective and well tolerated. However, the lesions are extremely pruritic, can be extensive and can signifcantly reduce the quality of life, so treat- Treatment of cutaneous larva migrans. An alternative is ivermectin given as a single dose of patients (94%) healed within 5 days. One patient had repeated relapses, notwith- takes the form of thiabendazole in a suitable lipophilic vehicle. All seven were cured with a single dose of 150–200 µg/kg ivermectin, with no signifcant adverse effects. In Systemic albendazole B the authors’ experience ivermectin is a safe and effective alterna- Systemic ivermectin B tive treatment for cutaneous parasitosis in children. Topical thiabendazole in a lipophilic vehicle D Two 2-year-old patients were treated with a 10% albendazole ointment, prepared by crushing three 400 mg tablets of albenda- Effcacy and tolerability of thiabendazole in a lipophil zole in 12 g of petroleum jelly. Epidemiological and clinical characteristics of hookworm- The ointment was prepared by crushing the tablets of thiabenda- zole in the lipophilic base. Treatment with topical thiabendazole ointmenThat 10–15% concen- tration in a hydrophilic vehicle has shown 98% effcacy within a median of 10 days of treatment. Painful nodules on the lower extremi- ties, with edema and swelling, were the most common clinical fnding; 22% of patients had some evidence of neuropathy. There was no evi- dence for hepatitis B infection in the 37 patients tested, and hepatitis C infection was present in only one of the 20 patients tested. Five patients had infammatory bowel disease (four had Crohn disease and one had ulcerative colitis). The ulcerative and weakness, arthralgias or arthritis, neuropathy, abdominal form of disease was more prolonged and frequently associated pain, ischemic bowel, testicular pain, hypertension, and renal with neuropathy. Obser- vessels as well as smaller vessels, and is manifest clinically as a vations suggested that agents such as corticosteroids, azathioprine, glomerulonephritis and a pulmonary capillaritis with alveolar pentoxifylline, and hydroxychloroquine were effective in indi- hemorrhage. A careful focused history is the preferred demonstrated that interleukin-6 is elevated in roughly 40% of method of evaluation. Some cases have occurred in patients treated with High titer of phosphatadylserine–prothrombin complex propylthiouracil and minocycline. Although it is generally benign, there Kawakami T, Yamazaki M, Mizoguchi M, Soma Y.

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Spine Abnormalities of the chest wall with angulation of ribs and hypoplasia of the ischial bones were reported [4] buy valacyclovir 500 mg on line antiviral diet. Craniofacial Cup-shaped generic valacyclovir 1000 mg otc hiv infection from kissing, low-placed small buy generic valacyclovir 1000mg hiv infection stages, round discount valacyclovir 500 mg line hiv infection from dried blood, and protruding ears are common fndings [6] as well as inner ear dysplasia with hearing loss. Cleft lip and palate [11] as well as hypoplasia of the alae nasi may be encoun- tered [4]. Many other terms had been used previously sifcation as up to three or four separate rays or components in the literature. The term balanced thumbs suggests the parts thereof may be found on the radial side of the hand. They to be identical or “duplicate” partners whereas unbalanced may or may not be arranged as separate rays and the best thumbs indicates that the two partners are not true duplicates; way to designate them is to individually assign the apparent most are unbalanced and the radial is usually the more def- rays and the number of distal phalanges. Thumb polydactyly cases do not all have biphalangeal and practical system involving the digits has been developed components, some are triphalangeal in nature and some are by three generations of German hand surgeons and is good rudimentary or foating and do not have well-developed pha- for the strict constructionist [6]. Those with triphalangeal components are discussed the six types into A and B with A being the two components elsewhere. With three bones and three joints there are polydactyly is more common among Caucasian and Asian six levels (. The system includes: Type I, bifd populations than ulnar polydactyly with an incidence of 1 in Fig. Polydactyly (extra parts) occur throughout the entire hand and is defned as radial, the involving thumb ray; central involving the index, long and ring rays, and ulnar involving the ffth ray. Both partners share with the clinical and radiologic appearance of a Type I duplication with- a common articular surface and epiphysis (With kind permission from in the distal phalanx. The overall incidence of polydactyly in the general population is defcient in the unbalanced types, the ulnar component is often estimated between 2 and 19 per 10,000 live births. Interphalangeal joint motion is usually defcient tion can be four times more common in males than females. In these cases there are two separate developed interphalan- Radial polydactyly most probably results from an imbal- geal joints and each distal phalanx has its own separate nail. The frst genetic mutation responsible for the cause of most common form of thumb duplication. Soft tissue bulk on certain types of radial polydactyly with triphalangeal thumb both partners is less than normal. The metacarpal head is often and for triphalangeal thumb alone has been localized on chro- broad with bifd, asymmetric condyles. When the proximal diver- underlying skeleton may often gives clues to the associated gence is great the distal portions deviate toward one another. They present a nail which may be either fused tendons onto the side of the distal phalanges instead of the with a longitudinal ridge or have a smooth conjoined surface. With rebalancing during surgical correction the ab- low soft tissue in the hyponychium. Pulp surfaces are often fat normal joint surfaces will not necessarily correct themselves but stable. The pollex abductus anomaly in which there radial side attach to the radial thumb. There is often a very is a soft tissue connection between the extrinsic fexor and thick fbrous band over the adductor pollicis aponeurosis. In addition, the origin of the extrinsic fexor (fexor thumbs are always smaller than normal and one thumb may pollicis longus) is often anomalous with a very limited excur- be triphalangeal with an extra phalanx (. Because the meta- the anatomic variations become greater and more compli- carpals are small and the phalangeal segments deviated, these cated. A rudimentary or fouting thumb may be attached to thumbs are shorter and smaller than normal. All degrees of intrinsic muscle anomalous attachments In contrast to isolated thumb polydactyly, the association are seen; often the adductor pollicis may have components of triphalangeal components (i. Congenital malformations of the hand: Indica- tions, operative treatment and results. Clinical and genetic studies on 12 preaxial polydactyly families and refnement of the localization of the gene responsible to a 1. Pre-axial Polydactylie in fünf Generationen einer on the far right in which the metacarpal head of the ulnar thumb is not schwedischen Sippe. Classifcation and treatment of triphalangeal radial thumb with a phalangeal deviation toward the ulnar partner (With thumbs. Approximately half of the triphalangeal thumbs recorded in Shoen and Upton’s registry are associated with thumb polydactyly [14]. The triphalangeal rays can be either balanced or unbalanced and are always longer than normal. Presentation Most symptoms occur between 20 and 30 years of age through the onset of diabetes, and visual, skin, and hair manifestations. Metastatic subcutaneous calcifcations and atherosclerosis are also common [2] along with short stature. Upper extremity Digital hypoplasia, radial polydactyly, soft tissue calcifcation, and osteoporosis were all reported. Observa- acteristically rests tightly fexed against the palm of the hand tion of the resting posture of the thumb and the position of its beneath the four digits (. Newborns normally three joints will help localize the specifc anatomic problem tend to maintain the thumb beneath the fexed fngers for in many cases (. When extension is lacking at all three often bilateral than unilateral [2] and is seen in males twice thumb joints with added defciency of the abductor pollicis as often as females [2]. Congenital clasped thumb is not very longus tendon, as in the typical clasped thumb, the latter common and typically the result of hypoplasia or absence of will extend across the entire palm and rests at the base of the a portion of the extensor musculotendinous unit. The contribution of the intrinsic thenar muscula- skin defciencies both palmar and frst web space, collateral ture on either side of the thumb must also be considered as Fig. Lower extremity anomalies may also be present Two classifcation systems have been described with clini- such as clubfeet. The spastic thumb-in-palm posture and all space contracture, volar skin shortage, and thenar muscle ab- the secondary problems related to a long-standing contracture normality. Congenital digital fexion defor- mity is also caused by defciency of the extensor mecha- nism of the fngers. This is typically present in Freeman-Sheldon syndrome, arthrogryposis multiplex congenita, and the congenital ulnar drift deformity “wind- blown” hand. Note the wrist has been fused to correct severe fexion defor- a patient with cerebral palsy with a common thumb presentation of ad- mity. The thumb extensors are intrinsic muscles, most often the frst dorsal interosseous and adductor not absent as in clasp thumb but rather attenuated and weak References Associated Syndromes 1. Congenital clasped thumb (congenital Stuve-Wiedemann syndrome fexion-adduction deformity of the thumb): a syndrome, not a spe- cifc entity. Characteristics of patients with congenital clasped thumb: a prospective study of 40 pa- Waardenburg syndrome tients with the results of treatment.

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