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Radiographs of the limb at the distal end of the femur and the proximal end of the tibia show Neuroblastoma abnormal areas of radiolucency buy cheap residronate 35mg online medicine 9 minutes. Neuroblastoma is a malignant tumor that usually oc- curs in children under 5 years of age purchase residronate 35mg on-line treatment yeast infection women. It originates from Sickle Cell Disease cells in the sympathetic ganglia and adrenal medulla Sickle cell disease is a genetic disorder characterized by but can arise from any part of the sympathetic nervous production of hemoglobin S buy discount residronate 35mg on-line medications zofran, an anemia secondary to system and metastasize to the bone purchase residronate 35 mg overnight delivery keratin treatment. The presenting short erythrocyte survival, and sickle-shaped erythro- complaint may be varied, but bone pain, limp, pallor, cytes. In the urine, The child presents with painful or vaso-occlusive crises 3-methoxy-4-hydroxymandelic acid and homovanillic characterized by symmetrical, painful swelling of the acid levels are elevated. Older people report pain in long bones and joints, abdominal pain, decreased appetite, fever, Osteogenic Sarcoma and malaise. The laboratory fndings reveal a hemoglo- Osteogenic sarcoma occurs in people 10 to 25 years bin S genotype and anemia, but fndings can vary de- old, with the most common site being the distal femur pending on the hemoglobin genotype, age, gender, and or the proximal tibia. Sickle cell disease of local intermittent pain that quickly progresses to a is associated with osteonecrosis of the hip. Chapter 22 • Lower Extremity Limb Pain 271 Nerve Entrapment Syndromes Neuritis Peroneal Nerve Compression Vascular metabolism affected by systemic disorders, Peroneal nerve compression can be caused by a cast, such as diabetes mellitus, can cause a nerve to become sports injury, or trauma. Pain is felt across the head of ischemic, producing toxins that can directly damage the fbula and can result in footdrop. Soft tissue infammation contribut- Tarsal Tunnel Syndrome ing to neuropathy can be caused by collagen disorders Tarsal tunnel syndrome is occasionally associated (e. The Diabetes mellitus is commonly associated with posterior tibial nerve is involved, and the pain is felt sensory peripheral neuropathy and results in pain across the ankle and proximal foot. Patients may not and sensory loss that is more intense in the lower remember a specifc onset but report pain and weak- extremities. Tapping the posterior tibial Alcoholism is associated with distal, demyelinating nerve posterior and inferior to the medial malleolus neuropathy that may resolve with cessation of alcohol elicits pain. References and Readings Logan K: Stress fracture in the adolescent athlete, Pediatr Ann 36:738, 2007. It is helpful to distinguish between limb pain that affects the bones, muscles, and tendons. Key Questions Pain at the base of the thumb that occurs with grip or l Have you had a recent injury? If the injury does not warrant urgent attention, obtain l Were you able to use the limb after the injury? Constitutional Symptoms Strain The presence of generalized symptoms, such as fever, A strain is an injury to a muscle or tendon (fbrous weight loss, general malaise, or hot, swollen joints, cords that connect muscles to bone). Strains usually suggests the presence of a systemic disorder such as involve repetitive trauma. Treat- thritis include bacterial endocarditis, Lyme disease, ment usually consists of rest, splinting, ice, and nonste- syphilis, and such viruses as hepatitis B, rubella, cyto- roidal antiinfammatory medicines. Golfers will often megalovirus, human immunodefciency virus, Epstein- have wrist and elbow strain. Sprain Severity of Pain A sprain is a stretch or tear of a ligament (fbrous bands Unrelenting diffuse pain, often occurring at night, is an that connect bone to bone across a joint). Sprains of the indication of bone involvement, either through bone fngers are common. Humeral fracture is fairly common after a for the Type and Severity of Humeral blow to the arm. Obese children have an increased risk of sustaining mus- culoskeletal injuries compared with normal-weight peers If there is no history of trauma or a precipitating event, and are at greater risk of sustaining forearm fractures, what else is causing the pain? Activities A person may adapt to chronic musculoskeletal prob- Pain associated with fracture is often severe. Bursitis pain is duce symmetrical discomfort and pain with inactivity often associated with swelling and limited joint motion while noninfammatory conditions are often associated (see Chapter 22). In upper extremity (shoulder, wrist, elbow) joint pain with injury, what do I need to know about the specifc Key Questions l Is there any swelling? Generally, swelling secondary to trauma such as a l Did you engage in any activities that required over- strain develops immediately or within 2 hours after an use of one or more joints? Swelling 6 to 24 hours after an injury is usually of synovial origin, such as a subluxation, dislocation, Pain in the dominant hand may indicate repetitive mi- or ligamentous damage (sprain). Chapter 23 • Upper Extremity Limb Pain 277 Severe ligament sprain is manifested as an immedi- Night Pain ately disabling pain at the moment of the injury. Pain Rotator cuff tears can cause shoulder pain and upper experienced hours after an injury or physical activity is extremity numbness when sleeping on one’s affected usually caused by acute extensor injury or overuse. Patients may report noticing pain, weakness, or diff- culty in activities of daily living, such as using a hair Chronic diseases, such as sickle cell anemia, infam- dryer, opening jars, holding a pen, or handling eating matory bowel disease, Crohn disease, hypothyroidism utensils. Gonorrhea disseminates to the musculoskeletal system in 1% to 3% of infected individuals. Exposure to Key Questions other infectious agents, such as Chlamydia trachoma- l Have you had any joint stiffness? Stiffness is a common feature of any infammatory ar- Viral infections may cause diffuse myalgia. With most in- fammatory arthropathies, stiffness and pain are allevi- Figures 23-1 to 23-3 depict anatomic landmarks of the ated by activity; in contrast, mechanical problems are shoulder, elbow, hand, and wrist. Musculoskeletal tumors com- monly present with mild joint stiffness because of Observe Patient Walking, Removing Coat/Jacket muscle involvement but rarely demonstrate instability. People who have septic joints appear ill, and move- ment of the joint will increase pain. Shoulder pain from rotator cuff tendinitis is felt Medications over the lateral aspect of the deltoid. Transient arthralgia may occur 6 to 8 weeks after receiv- Swelling of the elbow may compress the ulnar ing immunizations. Recurrent or permanent arthritis may nerve, producing a tingling sensation in the fourth and follow rubella vaccination, especially in adult women. Inspect the Skin and Nails Osteoarthritis typically involves the distal interpha- Inspect the skin for redness and infammation. Joints are swollen with a fusiform- distends the joint in a smooth, symmetrical manner. Assess Vital Signs Elevated temperatures are seen with neoplastic, sys- Measure Limb Circumference and Length temic, and infectious processes such as osteomyelitis, Use a tape measure to locate points at which to mea- septic arthritis and septic hip in children, and rheu- sure and compare limb circumference. Chapter 23 • Upper Extremity Limb Pain 279 Heat over the affected joint can indicate infamma- tion or infection. Tendonitis can produce a grat- Humerus ing sensation on palpation of the ligament or a grating sound with movement. Test for Muscle Strength Test for upper extremity fexor and extensor strength Articular against resistance of both the proximal and distal capsule muscle groups. Distal muscle weakness is seen collateral ligament Medial secondary to a neuropathic process. Generally, if the collateral opposite side is normal, strength should be compared Annular ligament ligament with it. Perform a Neurological Examination Oblique cord Assessment of sensory and motor function and deep tendon refexes should be done on the affected and contralateral limbs.
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Diseases
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If there is a greater than 5-mA difference purchase 35 mg residronate with mastercard treatment xdr tb, the circuit is broken buy generic residronate 35 mg medicine net, thus preventing electrocution residronate 35mg low cost medications zovirax. Thus discount residronate 35mg free shipping medicine vial caps, in most cases of electrocution, the house fuse is unaffected by the electrocution. Electrocution in water could also be caused by defective lights in a swimming pool. Lightning A lightning bolt is produced when the charged undersurface of a thunder- cloud sends its electrical charge to the ground. Since the undersurface is usually negatively charged, virtually all discharges are also negative. A lightning bolt may injure or kill an individual by a direct strike, a side flash, or conduction through another object. An example of the last instance Electrocution 417 would be a lightning bolt’s hitting a crane, with the electricity’s flowing down the metal structure and striking a grounded worker who is touching the crane. The injuries produced would be the same as if the crane had hit a high-power electrical line, that is, burns at the entrance and exit sites, often multiple and severe. In a side-flash strike, the bolt of lightning hits an object, such as a tree, and then ricochets, striking the individual. In a direct strike or a side-flash strike where the individual is relatively close to the object from which the bolt jumps, the current can either spread over the surface of the body or enter it, or it can follow both routes. In most cases seen by the forensic pathologist, the current has both flowed over the surface of the body and entered. In such cases, it is quite common to find the clothing torn, shoes burst, hair seared, burns on the skin caused by zippers and other metal objects heated by the lightning, and burns caused by the entrance and exit of current. The torn clothing and burst shoes sometimes have led to misinterpretation of the nature of the injuries. People struck by lightning and found next to a road have been thought to be hit-and-run victims. If one is inside a metal vehicle, such as a car or train, when it is struck by lightning, the probability of injury is extremely small. On rare occasions, death or injury has been reported when an individual was using a telephone and the line was hit by lightning. With a direct hit by lightning, death is probably inevitable, because of burns and injury to the respiratory center of the brain. If the electrocution is secondary to a close point of impac- tion, survival may be possible. One of the lesions considered pathognomonic for lightning injury is the “arborescent” or fern-like injury of the skin called Lichtenberg figures (Figure 16. This lesion is a patterned area of transient erythema that appears within 1 h of the accident and then gradually fades within 24 h. Another pos- sibility is that it represents an entrance point in an individual struck by a positively charged lightning bolt. Both explanations, neither of which are exclusive of the other, would explain the relative rarity of the arborescent lesion in individuals struck by lightning. Hyperthermia and Hypothermia: the 17 Effects of Heat and Cold Normal body temperature is generally considered to be 98. Body temperature, however, can vary from individual to individual, by age, time of day, physical exertion, etc. Maintenance of normal body temperature is a delicate balance between heat load and heat loss. Heat load is the sum of heat generated by oxidation of metabolic products and heat acquired from the environment. For example, if an indi- vidual sits in a chair, heat conducted from the body will raise the temperature of the chair to that of the body. In contrast to limited heat loss by direct conduction, sizable quantities of heat can be lost by conduction to air. The molecules composing the skin transfer heat to contiguous air molecules, producing a thin zone of heated air adjacent to the skin. Once 419 420 Forensic Pathology this layer of air absorbs heat until it is equal to the temperature of the body, heat loss ceases. If, however, this layer of heated air is continually removed and new air introduced (by a fan or wind), the loss of heat by conduction will continue. This movement of air around the body, with resultant contin- ued loss of heat, is known as convection. Winds will blow away the layer of air immediately adjacent to the skin, thus accounting for the feeling of cold and increased heat loss when the wind blows. Once the wind has cooled the skin to a certain temperature, the rate at which heat flows from the core of the body to the skin is the limiting factor in heat loss, rather than the rate of conduction and convection. If the environment becomes hotter than the body, radiant heat given up by the surroundings will exceed the loss of heat from the body by radiation. It occurs at a rate of about 600 mL per day, that is, a continual heat loss of 12-16 cal/h. The more important of the two methods of evaporation that produce cooling of the body is sweating. In hot weather, the maximum rate of sweat production varies from 700 mL/h in the unacclimatized person to 1. Dehydration, in turn, predisposes an individual to the development of hyperthermia and heat stroke. To prevent this, individuals exposed to high temperatures are urged to increase their fluid intake. This is especially necessary in those engaging in strenuous activities such as man- ual labor or jogging. Symptoms occur when serum sodium levels decrease to <130 mmol/L, becoming severe at levels <125 mmol/L. When serum sodium drops below 120 mmol/L, more than 50% of individuals have seizures. When people are exposed to hot weather for several weeks, they begin to progressively sweat more and more. This Hyperthermia and Hypothermia: the Effects of Heat and Cold 421 doubles within 10 days, increasing up to three times as much within 6 weeks. When the rate of sweat secretion is very low, the sodium chloride concentration of the sweat is also very low because sodium and chloride are reabsorbed before they reach the surface of the body. As the rate of secretion becomes progressively greater, the rate of sodium chloride re-absorption does not increase equally, so that the concentration of sodium in the sweat can rise almost to the level of the plasma. Extreme sweating can deplete the extracellular fluids of electrolytes, particularly sodium and chloride. Thus, extra sodium and chloride must usually be added to the diet in tropical climates.
