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The of injuries are a result of athlete’s either completely or smaller the canal diameter the greater the risk of partially missing the landing pad cheap 2 mg artane amex, this rule change has recurrence cheap artane 2 mg. PREVENTION Any hard or unyielding surfaces such as concrete artane 2 mg amex, Banning spearing-tackling and teaching players to metal, wood, or asphalt around the landing pad must play “heads up” ball with no contact on the top of the be padded or cushioned. This should reduce the The development of a safety standard for the football chance of an athlete landing in the vault or planting helmet by the National Operating Committee on box. Standards for Athletic Equipment (NOCSAE) has Acoach’s box or painted square in the middle of the also been a significant factor in reducing head and landing pad is being promoted. Other safety measures include mark- management of athletic head and neck injuries and ing the runway distances so athletes can better gage guidelines for return to contact or collision sport after their takeoff, and prohibiting the practice of tapping or an injury. POLE VAULTING The value of helmets in reducing head injuries in high school pole vaulters is controversial. Without conclu- EPIDEMIOLOGY sive data as to their protective effect, the use of hel- Pole vaulting is a unique sport in that athletes often mets is optional for athletes at this time (www. SOCCER The vast majority of catastrophic pole vaulting injuries are head injuries in male athletes. The overall EPIDEMIOLOGY incidence of catastrophic pole vault injuries is two per Injuries to the head, neck, and face in soccer account year, while the incidence of fatalities is one per year. Most head and Most injuries occurred at the high school level (Boden neck injuries occur when two players collide, espe- et al, 2001). The most common mech- CPSC identified at least 21 deaths over a 16-year anism occurs when a pole vaulter lands with his body on period associated with movable goalposts (www. The second most common letes is approximately one per team per season (Boden mechanism occurs when the vaulter releases the pole et al, 1998). There is a 50% chance for a professional prematurely or does not have enough momentum and athlete to sustain a concussion over a 10-year span. The third most Most concussions occur as a result of contact with an common mechanism occurs when the vaulter completely opposing player, not with the soccer ball. CHAPTER 6 CATASTROPHIC SPORTS INJURIES 27 There is no evidence that an isolated episode of head- predominance of any one type of takedown hold that ing a soccer ball can cause any head injury; however, contributes to wrestling injuries. During the off-season, goals head, sustaining an axial compression force to the cer- should either be disassembled or placed in a safe stor- vical spine. Goals should be moved only by trained per- sonnel, and should be used only on flat fields PREVENTION (www. The use of padded goalposts may Aminimum body fat for high school and college also reduce the incidence of impact injuries with the wrestlers has been established to reduce weight loss goalposts (Janda et al, 1995). The NFHS also instituted a rule that com- Children should use smaller soccer balls to reduce the petitors cannot lose more than 1. Both the NCAA and NFHS have banned the soccer balls should never be used. Proper heading use of laxatives, diuretics, and other rapid weight loss techniques should be employed: contact on the fore- techniques such as rubber suits. Soccer play- Referees should strictly enforce penalties for slams ers should be trained to hit the ball, not to be hit by the and gain more awareness of dangerous holds (Boden ball. There is particular vulnerability for the effects of heading a soccer ball is currently underway. Stringent penalties for intentional slams or WRESTLING throws are encouraged. The referee should have a low threshold of tolerance to stop the match during poten- EPIDEMIOLOGY tially dangerous situations. Proper rolling wrestling injuries per year at the high school and col- techniques, with avoidance of landing on the head, lege levels (Boden et al, 2002). The major- ity of injuries occur in match competitions, where CHEERLEADING intense, competitive situations place wrestlers at a higher risk (Boden et al, 2002; Jarrett et al, 1998; EPIDEMIOLOGY Pasque and Hewett, 2000). In the same year is trained to be directed vertically and not allow the there were 1814 neck injuries with 76 fractures in head to drop backward out of alignment with the torso cheerleaders that initially presented to an emergency or below a horizontal plane with the body. The by proper supervision, progression to complex tum- majority of injuries occur during the winter months, bling only when simple maneuvers are mastered, and because cheerleaders perform on indoor hard surfaces. The cheer- Coaches are encouraged to complete a safety certifi- leader at the top of the pyramid is most frequently cation, especially for any teams that perform pyra- injured. A basket toss is a stunt where a cheerleader is mids, basket tosses, and/or tumbling.

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Such lengthening man with a grotesquely deformed skull who was the subject of a play occurs in approx artane 2mg cheap. However order artane 2mg, more recent investigations of his Neurological lesions: Discrete neurological changes purchase 2 mg artane overnight delivery, skull have revealed that John Merrick had suffered not from neurofi- particularly sensory abnormalities, occur in 15% of bromatosis, but rather from Proteus syndrome. In addition to the neurofibromatosis solitary at least two must be present, the following additional neurofibromas are also present in Proteus syndrome, al- changes can occur: though these do not usually affect children and adoles- ▬ Elephantiasis (pachydermatocele): hypertrophy of the cents, but patients aged between 20 and 40 years. Within the population of neuro- Patients with neurofibromatosis have a largely normal life fibromatosis patients, however, tibial pseudarthrosis expectancy. A detailed description A very important prognostic indicator is the malig- of congenital tibial pseudarthrosis can be found in nant degeneration of the neurofibromas. We have observed three such ▬ Paravertebral soft tissue tumors: These are usually as- cases. Isolated reports of degeneration into malignant sociated with scoliosis. They are readily viewed on the schwannomas or rhabdomyosarcomas are also described MRI scan and must be differentiated from ganglio- in the literature. The spinal changes must The diagnosis of neurofibromatosis is confirmed clini- be diagnosed as soon as possible and then monitored very cally. The scolioses are usually strongly progressive and history is present in only a minority of patients and most corset treatments are not very effective. X-rays are needed for diag- surgical treatment is often indicated ( Chapter 3. The MRI scan can reveal severe – cutaneous changes, and also with sensory ab- paravertebral, intraspinal and intracerebral tumors. The thickened, flabby skin on the Differential diagnosis sole of the foot can lead to pronounced trophic problems Neurofibromatosis can be confused with the very rare Pro- and pressure sores. Removal of the excess skin by the teus syndrome (see above: »Historical background«). From the orthopaedic standpoint, can also occur in this condition, and the patients may as soon as a discrepancy exceeds 2 cm, leg length equal- also show macrodactyly. But the nodules do not consist ization by means of epiphysiodesis should be attempted. In view of the prevailing soft tissue changes, the risk of vein thrombosis and other complications is very high. The surgical leg length equalization procedure is described in Chapter 4. Since the course of congenital tibial pseudarthrosis in patients with neurofibromatosis is not different from that in other patients, the therapeutic principles are completely identical ( Chapter 3. Neurofibromatosis type II This type of neurofibromatosis is characterized by mul- tiple tumors (schwannomas) of the cranial and spinal nerves. The initial symptom is central hearing loss, since cranial nerve VIII is usually affected. Poor eyesight, sen- sory abnormalities and weakness of the facial muscles can also occur. This type is also known as »bilateral acoustic neurofibromatosis« or »central type«. The syndrome is characterized by macrosomia, which in- variably affects individual structures and never the whole body. Thus, individual fingers or toes, a whole limb or even one half of the body may be enlarged. Tumorous thickening of the fatty or connective tissues can also oc- cur. The skin may show areas of striated thickening or vascular markings (⊡ Fig. Over time, such changes can lead to functional problems of the affected organs. These can be alleviated by early diagnosis and careful fol- low-up and, if specifically required, by surgical measures.

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The advantages of fascial excision over tangential excision include the following: FIGURE 5 Large flaps raised during fascial excision purchase 2mg artane. The incidence of distal edema is higher when excision is circumferen- tial buy artane 2 mg fast delivery. Skin graft loss may occur from the relatively avascular fascia over joints cheap artane 2mg mastercard, may lead to an ungraftable bed, and may require eventual flap coverage. FIGURE6 One-year follow-up of a child with a 75% TBSA burn who required fascial excision. Principles of Burn Surgery 145 The risks and benefits must be weighed carefully, and each burned area on each patient reviewed to identify the optimal excision technique to provide the best result. Donor sites When treating a patient with extensive burns, the decision of where to create donor sites is easy: You take what you can get. Since all donor sites scar to some degree, it is best to take skin from an area that will be otherwise hidden under most circumstances. Donors should also be taken from an area that allows ease in harvesting and donor site care. Our first choice of donor site for children still in diapers is the buttocks. This allows for a hidden donor site and use of the diaper to hold the silver sulfadiazine in place for wound care. The use of the buttocks in others is not forbidden, but we have found that it is more painful in older patients than other sites and wound care is more difficult. It is less difficult to harvest because the femur provides excellent support during harvesting and there is minimal motion even with ambulation so that the dressings remain intact during the healing period. The lower back is another area that is less difficult to harvest and provides ample skin. The difficulty with using the lower back is that most often it requires a patient to change position during the operation. The use of clysis can help provide support to the area to be excised so that the best donor may be harvested. We use lactated Ringer’s solution to inject and use clysis on any site that needs additional support, especially the abdomen and chest. Using assistants to provide traction to the skin and surgical soap for lubrication can also help. Donor site dressings Before we started our process of early excision of indeterminate burns, many patients endured weeks of daily debridement and donor sites were not a problem. With the pain of daily debridements gone, since the burns were excised, this left larger donor sites to cover the excised wound and now the patients focused on their donor site pain. Over the past 20 years, our institution has used many donor site coverings. We also went through periods using petroleum-jelly-impregnated gauze, adhesive polyurethane sheets, calcium alginate, Biobrane (Bertek Pharmaceuticals, Inc), and others. We 146 Heimbach and Faucher now most commonly use Acticoat (Smith and Nephew) for most donor sites. We use silver sulfadiazine cream on buttock donors of children in diapers and on donor sites near unexcised burns treated with silver sulfadiazine. We have found Acticoat to be more cost-effective, provide better patient tolerance, and better pain control than other dressings we have tried. To use Acticoat effectively, we follow the application technique for small donor sites as follows: 1. Cut Acticoat to cover the entire donor site to include at least a 2 inch border covering normal skin and place the dry Acticoat on the donor site. Spray the edges of Acticoat and skin with tincture of benzoin or Masti- sol and allow to dry.

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Others best 2 mg artane, such as the AAPM 2 mg artane mastercard, have fashioned consensus statements col- laboratively with other professional groups as evidence-based as the literature permits discount artane 2mg with amex. And finally, there are a multitude of Internet sites pre- pared and maintained by for-profit and nonprofit groups, ranging from patient organizations (www. By drawing on the knowledge, judgment, and wisdom of earnest and current clinical authori- ties and by asking them to “bullet” their messages, the editors have squeezed an immense amount of material into a very small space! Wallace and Staats are known for their work in translating pre- clinical advances into improved therapies, in large part through conducting rigorous clinical studies that have had great impact on their peers and med- icine in general. This perspective is evident in their having assembled for this text an extremely talented and diverse group of contributors whose accom- plishments span preclinical research to clinical medicine to health policy and economics. It would be dangerous to single out any single contributor by name, because nearly all are of international status and those that are not yet, will certainly become so. The authors and editors alike should be proud of this volume, which will prove useful not only in passing examinations but also in rendering high-quality, up-to-date clinical care. Carr, MD Diplomate, American Board of Internal Medicine, with subspecialty qualification in Endocrinology & Metabolism Diplomate, American Board of Anesthesiology, with added qualification in Pain Management Diplomate, American Board of Pain Medicine Honorary Fellow, Faculty of Pain Medicine, Australia and New Zealand College of Anaesthetists PREFACE The latter part of the 20th century produced great achievements in our understanding of pain mechanisms and treatment. Now, with the increased awareness and better understanding of pain, the pain practitioner has a full armamentarium for the management of pain and suffering. There are numerous textbooks focusing on various aspects of pain management including pharmacologic, psychologic, interventional, and rehabilitative aspects; however, with the vastness of knowledge, much detail must be sifted through to get to the facts. This book, Pain Medicine and Management: Just the Facts, is intended to be a study guide for the pain physician who is studying for the board certi- fication or recertification exam. The unique format of the book also allows it to be used as an effective clinical aid when time is tight and authoritative information is needed quickly. We have invited experts from all over the country to contribute to this important book. Each chapter contains information that in the author’s opin- ion were the most important points for the chosen topic. We are confident that the resulting book will be an important contribution to your pain library. We would like to thank all of the authors for their commitment and ded- ication to this book. We are also grateful to numerous individuals who assisted us with this project, especially Linda Sutherland at the UCSD School of Medicine. We would also like to thank our families who are always there for us and whose understanding made this project possible. MSW would like to thank his wife, Anne, and his two sons, Zachary and Dominick. PSS would like to thank his wife, Nancy, his parents, and his children, Alyssa, Dylan, and Rachel, for their unyielding support and for taking the pain out of his life. Section I TEST PREPARATION AND PLANNING ing the first 5 years of the examination system. Abram, MD specialty certification by their respective boards, not by the ABA, on successful completion of the examination. SUBSPECIALTY CERTIFICATION With the expansion of the examination system to EXAMINATION IN PAIN MEDICINE diplomates of the other two boards, there was a broaden- ing of the scope of the examination. Question writers and The American Board of Anesthesiology offers a written editors from Neurology, Psychiatry, and PM&R were examination in pain medicine designed to test for the added to the examination preparation process. Although presence of knowledge that is essential for a physician previous examinations included material from all aspects to function as a pain medicine practitioner. Certification of pain management practice, the infusion of new expert- awarded by the ABA on successful completion of the ise produced a more diverse question bank. For nation should, and does, contain information from all that reason, the ABA offers a pain medicine recertifica- of the disciplines involved in the multidisciplinary treat- tion examination as well. The areas of knowledge that are tested can The examination required for the Certificate of be found in the ABA Pain Medicine Certification Added Qualifications in Pain Management was initially Examination Content Outline. This document is revised offered in 1993 by the ABA, 1 year after the periodically and can be found on the ABA web site, Accreditation Council for Graduate Medical Education http://www. An approximation of the distribu- approved the first accredited pain fellowship programs. The A-type question is a the 1998 exam, ABA diplomates were required to com- “choose the best answer” format with four or five possible plete an ACGME-approved pain fellowship.

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