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The manufacturer’s advice on contrainpovidone-iodine menstrual like cramping in third trimester generic 2mg ginette-35 fast delivery, and a readily applied non-adherent dications women's health center manhattan ks purchase ginette-35 2 mg free shipping. These may help the oedema and symptoms of venous hypertension and are said to breast cancer bracelets buy cheap ginette-35 2 mg online reduce leakage from capillaries by acting on the endothelial cells menstruation every two weeks causes buy ginette-35 american express. Sheets of human epidermis grown in tissue culture can be purchased and placed on granulating wound beds. Venous surgery on younger patients with varicose veins may prevent recurrences, if the deep veins are competent. Patients with atherosclerotic ulcers should see a vascular surgeon for assessment. Purpura from vasodian abnormality of the vessel wall or the surrounding latation and gravity is seen in many diseases of the dermis. It may also cause pura, often palpable and painful, but not bleeding; cold urticaria (p. To help detect a consumptive coagulopathy, Investigations a coagulation screen, including measurement of brinoThe most common cause of purpura is trauma, espegen and brin degradation products, may be necessary. The bleeding time, and a Hess tourniquet test for capWhen purpura has no obvious cause, investigations illary fragility, help less often. Skin biopsy will conrm should include a platelet count, prothrombin time, a small vessel vasculitis, if the purpura is palpable. The Infected pompholyx primary forms are developmental defects, although Lymphatic obstruction Filariasis signs may only appear in early puberty or even in Granuloma inguinale adulthood. Tumour Lymphatic destruction Surgery Treatment Radiation therapy Tumour Elevation, graduated compression bandages and stockings (p. If erysipelas recurs, long-term penicillin tongue and lymphoedema of lip) should be given. Surgery occasionally helps to remove Yellow nail syndrome an obstruction or restore drainage. Lymphangitis this streptococcal infection of the lymphatics may Treatment occur without any lymphoedema. Penicillin ucloxacillin, cephalexin levant blood constituents may be needed initially. The peak age for severity in females is 16–17 hair germs, but a few free glands arise from the epiderand in males 17–19 years. The glands themselves are multilobed and contain Cause cells full of lipid, which are shed whole (holocrine secretion) during secretion so that sebum contains Acne vulgaris their remnants in a complex mixture of triglycerides, fatty acids, wax esters, squalene and cholesterol. Free sebaceous glands may be found this alone need not cause acne; patients with acroin the eyelid (meibomian glands), mucous membranes megaly, or with Parkinson’s disease, have high sebum (Fordyce spots), nipple, peri-anal region and genitalia. Furthermore, sebum Androgenic hormones, especially dihydrotestosexcretion often remains high long after the acne has terone, stimulate sebaceous gland activity. Androgens (from the testes, ovaries and hydroxysteroid dehydrogenase, which convert weaker adrenals) are the main stimulants of sebum excretion, androgens to dihydrotestosterone, which in turn binds although other hormones. In acne, nal androgens for a short time after birth, and then the sebaceous glands respond excessively to what are lie dormant until puberty when a surge of androgens usually normal levels of these hormones (increased produces a sudden increase in sebum excretion and target organ sensitivity). Fifty per cent of females with acne have slightly raised free testosAcne terone levelsausually because of a low level of sex Acne is a disorder of the pilosebaceous apparatus hormone binding globulin rather than a high total characterized by comedones, papules, pustules, cysts testosteroneabut this is still only a fraction of the and scars. Rupture of these follicles is associated with intense inammation and tissue damage, mediated by oxygen free radicals and enzymes such as elastase, released by white cells. It colonizes the pilosebaceous ducts, breaks down triglycerides releasing free fatty acids, produces substances chemotactic for inammatory cells and induces the ductal epithelium to secrete pro-inammatory cytokines. There is a high concordance of the sebum excretion rate and acne in monozygotic, but not dizygotic, twins. Corticosteroids, androgenic and anabolic steroids, gonadotrophins, oral contraceptives, lithium, iodides, bromides, antituberculosis and anticonvulsant therapy can all cause an acneiform rash. Heat and humidity are responsible for this variant, which affects Caucasoids with a tendency to acne. Presentation Common type Lesions are conned to the face, shoulders, upper chest and back. Open comedones (blackheads), because of the plugging by keratin and sebum of the pilosebaceous orice, or closed comedones (whiteheads), caused by overgrowth of the follicle openings by surrounding epithelium, are always seen. Depressed or hypertrophic scarring and postinammatory hyperpigmentation can follow. On resolution, it leaves deeply pitted or hypertrophic scars, sometimes joined by keloidal bridges. Although hyperpigmentation is usually transient, it can persist, particularly in those with an already dark skin. Psychological depression is common in persistent acne, which need not necessarily be severe. Tars, chlorinated hydrocarbons, oils, and oily cosmetics can cause or exacerbate acne. Suspicion should be raised if the distribution is odd or if comedones predominate (. Glucose intolerance, dyslipidaemia when acne, dominated by papulo-pustules rather than and hypertension may be other features. Hyperpigmentacoincides with the prescription of a drug known to tion, ambiguous genitalia, history of salt-wasting in cause acneiform lesions (see above). Some athletes still childhood, and a Jewish background, are all clues to use anabolic steroids to enhance their performance. Congenital adrenal hyperplasia is associated with high levels of 17-hydroxyprogesterone, and androgensecreting tumours with high androgen levels. Pelvic ultrasound may reveal multiple small ovarian cysts, although some acne patients have ovarian cysts without biochemical evidence of the polycystic ovarian syndrome. Differential diagnosis Rosacea (see below) affects older individuals; comedones are absent; the papules and pustules occur only on the face; and the rash has an erythematous. Hidradenitis suppurativa (see below) is associated with acne conglobata, but attacks the • Androgen-secreting tumours. Pseudofolliculitis barbae, caused onset of virilization (clitoromegaly, deepening of voice, by ingrowing hairs, occurs on the necks of men with breast atrophy, male pattern balding and hirsutism) curly facial hair and clears up if shaving is stopped. Even Acne vulgaris clears by the age of 23–25 years in 90% those with mild acne need sympathy. An optimistic of patients, but some 5% of women and 1% of men approach is essential, and regular encouragement still need treatment in their thirties or even forties. Occasionally an underlying cause (see above) is found; this should be removed or treated. Investigations At some time most teenagers try antiacne preparaNone are usually necessary. Cultures are occasionally tions bought from their pharmacist; local treatment is needed to exclude a pyogenic infection, an anaerobic enough for most patients with comedo-papular acne, infection or Gram-negative folliculitis. Only a few although both local and systemic treatment are needed laboratories routinely culture P. Any acne, including infantile acne, which is associLocal treatment (Formulary 1, p. Benzoyl peroxide bleaches also anti-inammatory and inhibits the formation coloured materials, particularly towels and annels. It should be applied twice daily, but not (tretinoin, adapalene, tazarotene) normalize follicular used for more than 6 months at a time. Patients should be warned about skin largely been replaced by topical retinoids as aggressirritation (start with small amounts) and photosensitive scrubbing can rupture comedones. Tretinoin can be prescribed as a lotion, containing sulphur are available on both sides of the cream or gel. The weakest preparation cin, erythromycin and sulfacetamide (Formulary 1, should be used rst, and applied overnight on alternp. Some combinations work better than to be stopped temporarily because of irritation. Erythromycin with benzoyl peroxide, it may be worth increasing the combined with a zinc acetate complex (Formulary 1, strength of tretinoin after 6 weeks if it has been well p. The combination of benzoyl peroxide in the icrobial, an inhibitor of 5reductase (see above), morning and tretinoin at night has many advocates.

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Patients with central nervous system symptoms should receive urgent treatment with hypertonic saline (3%); 1 mL/kg (which is equal to womens health zone natural remedies health ginette-35 2mg free shipping 0 womens health specialists cheap 2 mg ginette-35 fast delivery. Infusions of hypertonic saline at a rate of 3 mL/kg every 10 to menstrual incontinence ginette-35 2mg cheap 20 minutes are generally safe menstrual 3 days late purchase 2 mg ginette-35 amex. Increasing the serum sodium by only 5 to 10 mEq/L is usually sufficient to stop hyponatremic seizures. A combination of history, clinical assessment of the patient’s volume status, and urinary sodium concentration measurement is helpful for establishing the diagnostic categories. Children with severe hyponatremia usually seize before treatment is started, whereas those with hypernatremia may develop seizures in response to therapy. In patients with hypernatremic dehydration, the increased extracellular tonicity draws fluid from the intracellular compartment, and cells shrink in size, including those in the brain. However, the brain can generate “idiogenic osmoles” to minimize the loss of fluids. These idiogenic osmoles are principally amino acids and other organic solutes that cause the brain to reabsorb some of that water. It takes about 24 hours to begin to generate or dissipate these idiogenic osmoles. If the correction of chronic (>24 hours’ duration) hypernatremia is too rapid, water flows from the extracellular compartment back into the cerebral intracellular compartment, thereby causing cerebral edema. To prevent this situation, in patients with chronic hypernatremia, the serum Na should not be allowed to fall faster than 0. The first step is to make certain that water is always available to avoid dehydration. Warn parents that these children can become dehydrated quickly during an episode of gastroenteritis, and medical intervention with intravenous fluid will be needed sooner than in an unaffected child. Decreasing the solute load for urinary excretion by modestly lowering salt and protein intake will decrease urine volume. If the volume of urine and frequency of urination is still intolerable, treatment with hydrochlorothiazide may be necessary. This drug is thought to decrease urine volume by establishing some degree of volume contraction, which stimulates proximal tubular reabsorption of sodium and water and decreases distal delivery and final urine volume. Because hydrochlorothiazide often produces hypokalemia, combined therapy with the potassium-sparing diuretic amiloride may be helpful. In patients with alkalosis, potassium moves into cells as hydrogen moves out of cells in response to the alkalinity. This is true in individuals and laboratory animals with acidosis as a result of mineral acids. Ideally, if potassium supplementation or replacement is needed, the concentration of potassium in the intravenous fluids should not exceed 40 mEq/L if given through a peripheral vein, or 80 mEq/L if given through a central vein. Faster delivery can lead to local irritation of the veins, paresthesias, and/or weakness, and cardiac arrest because of changes in transmembrane potentials. Increased intake: this is rarely a primary cause because the ability to dispose of a potassium load is so great. It is only important when renal excretion is compromised (renal failure with oliguria). If the patient’s serum potassium level is higher than 8 mEq/L or cardiac dysrhythmia is present. Calcium is the quickest way to treat an arrhythmia that is associated with hyperkalemia, but it has no effect on serum potassium concentrations. Hyperkalemia leads to an increase in the cell’s membrane potential, thereby making cells more arrhythmogenic. Hypercalcemia raises the cell’s threshold potential, restores the voltage difference between these two potentials, and decreases the likelihood of an arrhythmia. The effect of calcium infusion is transient, whereas potassium concentrations remain unchanged. Which children with acute renal failure are at the greatest risk for hyperkalemia The two most important determinants of potassium excretion are the rate of urine flow and aldosterone. It is those with oliguria who are at the greatest risk for hyperkalemia because of low urine flow. The anion gap is the difference between the serum sodium concentration and the sum of chloride plus bicarbonate. It represents those anions that are not normally measured in clinical practice, such as sulfate, various organic anions, negatively charged albumin, and phosphate, which often is measured but is not included in the calculation of anion gap. An increased anion gap reflects the addition of an acid with its anion that is not normally measured. In methanol poisoning, it is formic acid with accumulation of formate causing the increased anion gap. In ethylene glycol ingestion (antifreeze), it is oxalate; in lactic acidosis, it is lactate. In the presence of metabolic acidosis, the calculation of the anion gap determines which of two diagnostic pathways is more likely. Metabolic alkalosis occurs when a net gain of alkali or loss of acid leads to a rise in the serum bicarbonate concentration and pH. In metabolic alkalosis (as in metabolic acidosis), there is a measure of respiratory compensation in response to the change in pH. This response, which is accomplished by alveolar hypoventilation, is limited by the overriding need to maintain an adequate blood oxygen concentration. What is the differential diagnosis in a child presenting with symptoms of primary metabolic alkalosis Metabolic alkalosis can be divided into two major categories on the basis of the urinary ClA concentration and the response to volume expansion with a saline infusion. The salineresponsive metabolic alkaloses usually involve a urine ClA concentration that is less than 10 mEq/L and significant volume depletion. Treatment with intravenously administered normal saline usually corrects the metabolic alkalosis; the classic example is pyloric stenosis. The saline-resistant alkaloses are associated with a high urine ClA and often hypertension. The administration of normal saline tends to aggravate rather than correct the metabolic alkalosis. In most cases, mineralocorticoid excess plays the central role in the generation of the acid-base disturbance. Prolonged vomiting results in metabolic alkalosis because of loss of hydrogen ions as well as volume depletion (dehydration). The volume depletion stimulates the release of aldosterone, resulting in increased distal reabsorption of sodium and increased excretion of hydrogen ions and potassium. To make matters worse, the resulting hypokalemia stimulates proximal tubular reabsorption of bicarbonate. Only when volume is repleted, resulting in suppression of aldosterone, can the retained bicarbonate be excreted with sodium and the urine pH become alkaline (pH 6. This is sometimes referred to as the “paradoxical aciduria of metabolic alkalosis, ” and your attending may use this term as well. If you are feeling courageous, you could respond that it is not paradoxical at all, once you understand the pathophysiology. In an effort to standardize definitions, the 1998 International Children’s Continence Society recommended the following: n Enuresis: A normal void occurring at a socially unacceptable time or place n Nocturnal enuresis: Voiding in bed during sleep that is socially unacceptable n Primary nocturnal enuresis: Monosymptomatic (no other urinary symptoms) bed-wetting in an individual who has never been dry at night for an uninterrupted period of 6 months n Dysfunctional voiding: Functional disturbances of voiding owing to overactivity of the pelvic floor during micturition (dysfunctional voiding is characterized by variable urinary stream, prolonged voiding, and incomplete bladder emptying, and it may be accompanied by daytime incontinence. At the age of 5 years, about 20% of children (boys more than girls) wet the bed at least once monthly. By the age of 7 years, the overall rate is down to 10%, and by the age of 10 years, it is down to 5%. As a general rule, after age 7 years, nocturnal enuresis resolves at a rate of 15% per year so that by age 15 years, about 1% to 2% of teenagers still have nocturnal enuresis. This is a familial condition; 70% of enuretic children have a parent who has had the condition.

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This disease follows viral illnesses breast cancer uggs boots effective ginette-35 2 mg, such as measles womens health 092013 generic 2mg ginette-35 otc, mumps women's health diet tips purchase ginette-35 2mg on-line, rubella menstruation pills cheap ginette-35 2 mg with mastercard, and chickenpox, and is often known as postinfectious encephalitis. This disease is often preceded by viralinfection, immunization, or allergic reactions. Neurofibrillary tangles: intracytoplasmic bundles of fi laments, derived in part from microtubules and neurofilaments, occur within neurons, especially in the cerebral cortex. Patients with Down syndrome who survive to 40 years of age and older often exhibit Alzheimer-like findings. Other genetic abnormalities (1) Inheritance of the E4 allele of apoprotein E (chromosome 19). The brain content ofthe enzyme and its product, acetylcholine, is decreased, especially in the cerebral cortex and hippocampus. Acetyl­ choline plays a role in learning, and drugs that block its action adversely afect short term memory. Multi-infarction dementia is the second most frequent cause of dementia after Alzheimer disease; it is caused by cerebral atherosclerosis. Binswanger disease (subcortical leukoencephalopathy) is associated with hyperten­ sion. Histologic manifestations include depigmentation of the substantia nigra and locus ceruleus; damaged cells contain highly characteristic eosinophilic intracytoplasmic inclusions (lewy bodies). Morphologic characteristics include degeneration and atrophy of the lateral corti­ cospinal tracts, as well as ofthe anteriormotor neurons ofthe cord. Werdnig-Hoffmann syndrome (infantile progressive spinal muscular atrophy) is an autoso­ malrecessive lower motor neuron disease that manifests clinically ininfancy. The disease is due to toxicity oftherapeutic oxygen, most often administered because of neonatal respiratory distress syndrome (hyaline membrane disease). Manifestations include microaneurysms, dilation ofveins, hemorrhages, soft (cotton­ wool) exudates (microinfarcts), and hard exudates (deposits ofprotein thathaveleaked from damaged capillaries), all ofwhich can be viewed with the ophthalmoscope. The retinopathy also includes increased capillary permeability, edema, and diffuse thickening of basement membranes (microangiopathy). The disorder is related to the duration ofthe disease, occurring in most patients with diabetes mellitus after 10 years. The tumor is sporadic in approximately 60% ofcases; sporadic cases are unilateral and monocentric in origin. It is familial in approximately 40% of cases; familial cases are frequently bilateral and multicentric in origin. First deletion ("hit") is inherited in germ line cells in familial cases or occurs as a somatic mutation in sporadic cases. Second deletion ("hit") results from somatic mutation in both familial and sporadic cases. Benign intracranial tumors can result in devastating clinical consequences due to com­ pression phenomena. Metastatic tumors to the brainare found more frequently than primary intracranial neo­ plasms; in orderoffequency, themost commonprimary intracranial tumors in adults are glioblastoma multiforme, meningioma, and acoustic neuroma. The most common pri­ mary intracranial tumors in children are cerebellar astrocytoma and medulloblastoma. This neoplasm is associated with marked anaplasia and pleomorphism; pronounced vascular changes with endothelial hyperplasia occur. Areas ofnecrosis and hemorrhage are surrounded by a "pseudopalisade" arrangement oftumor cells. Closely packed cells with large round nuclei surrounded by a clear halo of cytoplasm ("fried egg" appearance) b. Histologic characteristics include tubules or rosettes with cells encircling vessels or pointing toward a central lumen; tumor cells characteristically demonstrate blepharo­ plasts, rod-shaped structures near the nucleus representing basal bodies of cilia. This neoplasm occurs as solitary or multiple tumors of peripheral nerves derived from Schwann cells. When questioned, (e) Multiple areas of necrosis and hemor she says that she does not remember rhage within the tumor the fall. Subsequently she complains (0) Origin in arachnoidal cells of the ofpersistent headache and confusion. A newborn girl is found to have association or characteristic of this herniation of both the spinal cord and disorder One or two the most likely etiologic agent is minutes later, he had again lost conscious­ (A) Escherichia coli. These clinical fndings are appearance of an autopsy specimen highly suggestive of a specific diagnosis. The patient is diagnosed weakness of her right arm, drooping of the with multiple sclerosis. Assuming that normal protein the lesion has been caused by embolization (8) Albumino-cytologic dissociation, with from the left atrium, which vessel is the markedly increased protein but only most likely site of embolic arrest Which ofthe following taking short, shufing steps and losing is the most likely diagnosis A 45-year-old man presents with invol­ untary facial grimaces and movements of 12. Her disorder had progressed to danc­ that he had an extremely aggressive brain ing movements, writhing of the arms and tumor. Which of the follOwing is most neoplasm invading the cerebral hemi­ characteristic ofthis disease The venous hemorrhage typically arrests early, but the volume of the hematoma gradually increases because of osmotic imbibing ofwater. This results in a slowly enlarging tumor-like mass characterized clinically by gradual signs of cerebral compression occurring hours to days or even weeks after head injury. Pyogenic meningitis in older infants and young children is most fre­ quently caused by Streptococcus pneumoniae or Neisseria meningitidis. In older adults, especially those with impaired resistance to infection, the most common etiologic agents are S. Because this slowly growing benign tumor arises from the arachnoidal cells of the meninges, it is actually external to the brain and is frequently amenable to surgical resection and complete cure. An epidural hematoma is an arterial hemorrhage between the dura and the skull, most often resulting fromskull fracture and laceration of the middle meningeal artery. Characteris­ tic features include the intracerebral location, prominent hemorrhage and necrosis, and the pseudopalisading appearance of the pleomorphic tumor cells. Although characterized by exacerbations and remissions, the course is progressive, lead­ ing to increasing disability. Alzheimer disease is a major cause ofdementia and is characterized by relatively slow, progressive memory loss followed in later stages by motor problems, contractures, and paralysis. This is a case of Huntington disease, which is an autosomal dominant, fatal, progressive degeneration and atrophy of the striatum (caudate nucleus and puta­ men). Parkinson disease, orparkinsonism, is characterized by a resting pill-rolling tremor, masked facies, slowness of movements, muscular rigidity, and a festinating (shufing) gait. These can be further divided into true-positive results and false-positive results. Specificity measures the extent to which a laboratory test is negative in healthy persons. For most analytic procedures, the point ofmaximum specificity is the highest test value that correctly identifies all subjects without the disease. This value is a measure ofthelikelihoodthata person with a negative test resultis actually free ofthe disease. In some instances, it is infuenced by variable factors, such as diet, exercise, posture, or the efects of smoking, alcohol, or medications. This type of variation describes the variability of repeated laboratory measurements on identical specimens over a specified time span. Review The st Directions: Each of the numbered items or incomplete statements in this section is followed by answers or by completions of the statement. What is the likelihood that the S test will he develops a diagnostic procedure for the correctly identif a potential firefighter as disorder. What is the likelihood that the S test will (e) 75% correctly identif a potential firefighter as (0) 80% one with an unacceptable sensitivity to (E) 85% smoke inhalation damage if the applicant is blue-eyed (prevalence ofsusceptibility is Questions 10-12: Questions 10 through 12 known to be 1 in 10)

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Reasons (both postulated and confirmed) for this observation include the fastidious nature of some less common etiologies of infectious arthritis women's health clinic alaska order 2mg ginette-35 amex. How have the initial antibiotic choices for suspected bacterial bone and joint infections changed during the past decade Saphyakhajon P: Empiric antibiotic therapy for acute osteoarticular infections with suspected methicillin-sensitive Staphylococcus aureus or Kingella breast cancer radiation buy ginette-35 2 mg, Pediatrics 27:765–767 breast cancer 5k miami trusted 2 mg ginette-35, 2008 women's health center hudson ny order ginette-35 2mg amex. How long should antibiotics be continued in patients with osteomyelitis and septic arthritis A minimum of 4 to 6 weeks is likely necessary for the former group, and 2 to 3 weeks are needed for the latter. Traditional teaching has been to treat acute osteomyelitis for 4 to 6 weeks with intravenous antibiotics, usually through a central venous catheter. Evidence is increasing that the use of prolonged intravenous therapy and the use of early transition to oral therapy are equally effective. Factors that can contribute to the decision to opt for oral therapy include an identified organism, patient compliance, and the use of surgical debridement. Concentrations in joint fluid may actually exceed peak serum concentrations, whereas those in bone may be significantly less than serum concentrations. How do the features of osteomyelitis in the neonate differ from those seen in the older child and adult Diskitis, which is the infection and/or inflammation of the intervertebral disk, most commonly occurs inchildren betweenthe agesof4and 10years. The diagnosis can be difficult because the symptoms can be vague and vary greatly. Symptoms include generalized back pain with or without localized tenderness; limp; refusal to sit up, stand, or walk; back stiffness withlossoflumbarlordosis;abdominal pain;andunexplainedlow-grade fever. Some things appear to be destined to be learned, forgotten, and relearned many times as a rite of passage: the Krebs cycle is one; this is another. For example, in patients with knock knees, the lower portion of the deformity points away, so the term is genu valgum. All angles conforming to the curve of the circle are varus; all angles going against the circle are valgus. Bowleggedness conforms to the circle around the body and is, therefore, genu varum. Most children at birth are bowlegged (genu varum) up to 20 degrees, but this tendency progressively diminishes until about 24 months, when the trend toward knock knees (genu valgum) begins. Knock knees are most noticeable at about 3 years of age (up to 15 degrees) and then begin to diminish. By 8 years of age, most children are—and will remain—in neutral alignment, meaning that with their Figure 16-11. Radiographs should be considered if bowleggedness demonstrates any of the following features: n Present after 24 months (the time of normal progression to physiologic genu valgum) n Worse after age 1 year as the infant begins to bear weight and walk n Unilateral deformity n Visually >20 degrees of varus angulation across the knee It is important to remember that clinical or radiographic evaluation of alignment in the legs requires the knees to be pointed straight ahead. If the knees are pointed in or out, flexion at the knee can be easily mistaken for bowing of the legs. What are the causes of pathologic genu varum (bowleggedness) or genu valgus (knock knees) Tibia vara, or Blount disease, is a medial angulation of the tibia in the proximal metaphyseal region as a result of a growth disturbance in the medial aspect of the proximal tibial epiphysis. In the infantile type, the child is usually an obese early walker, and he or she develops pronounced bowlegs during the first year of life. In the adolescent variety, the onset occurs during late childhood or early adolescence, and the deformity is usually unilateral and milder. Although bracing can be effective in infantile cases diagnosed in the first 2 years of life, correction of severe deformity usually requires surgical intervention. Tibial torsion, the most common cause of in-toeing in children between the ages of 1 and 3 years, gradually rotates externally with age. For excessive internal rotation, bracing was used extensively in the past, but its efficacy is questionable because the natural history of the condition is self-resolution. Measurement is done by measuring the angle made by the long axis of the foot and the thigh when the knee is flexed 90 degrees. The splint consists of a metal bar connected to shoes and holds the feet in varying degrees of external rotation. However, there is absolutely no scientific evidence that this device alters the natural history of tibial torsion, and the use of this device for treatment of tibial torsion is rapidly fading. In children, ligaments tend to be stronger than the cartilaginous growth plates, and thus the growth plate will often fail. Between 80% and 90% of ankle sprains are the result of excessive inversion and/or plantarflexion causing injury to the lateral ligaments (anterior talofibular and calcaneofibular). A grade 1 ankle sprain is a mild, partial tear of the ankle ligament and results in no instability. This will result in some instability of the ankle, which can be detected with the ankle drawer test. This test is performed by immobilizing the lower tibia with one hand as the other hand grasps the heel and pulls the foot forward. There is always some motion (test the unaffected side to get an idea of what is normal for that patient), but with a complete tear, there is marked laxity with a poor end point. More than 5, 000, 000 radiographs are estimated to be taken annually in children and adults for ankle injuries, yet there are no widely accepted guidelines. When these simple criteria were used in studies involving children and adults, no fractures were missed, and unnecessary radiographs were reduced by 25%. If inversion ankle sprains are not complicated by a fracture or peroneal tendon dislocation, casting is not warranted. It has no benefit over early immobilization with a wrap, such as commercially available air stirrups. Acute hemarthrosis is most commonly the result of the following: n Rupture of the anterior or posterior cruciate ligaments n Peripheral meniscal tears n Intratrabecular fracture n Major disruption or tear in the joint capsule 118. A discoid meniscus is a congenitally abnormal meniscus that is shaped like a hockey puck instead of a “C. Meniscal tears in children not associated with a discoid meniscus are typically associated with a significant injury. A 5-year-old boy with a painless swelling in the back of his knee has what likely condition Also called Baker cysts, these occur more frequently in boys, are usually found on the medial side of the popliteal fossa, and are painless. The mass should transilluminate on physical examination, confirming the fluid-filled nature of the lesion. The natural history is for the cyst to disappear spontaneously after 6 to 24 months. Surgery is not required except in extraordinary circumstances such as unremitting pain. Seil R, Rupp S, Jochum P, et al: Prevalence of popliteal cysts in children: a sonographic study and review of the literature, Arch Orthop Trauma Surg 119:73–75, 1999. A teenager has chronic knee pain, swelling, and occasional “locking” of the knee joint, and his radiograph reveals increased density and fragmentation at the weight-bearing surface of the medial femoral condyle. In this disease, there is focal necrosis of a region of subchondral bone, typically in the lateral half of the medial femoral condyle. These cases present with activity-related pain; locking, buckling, and stiffness may be seen as well. Extended immobilization and activity restriction are the primary treatment in skeletally immature patients who have a favorable natural history—the lesions typically heal without surgery. For older adolescents and skeletally mature individuals, surgery is frequently required to stabilize the lesion and encourage healing. This is a major problem because the lost articular cartilage cannot be replaced, and the risk for arthritis is high. This major cause of chronic knee pain in teenagers results from malalignment of the extensor mechanism of the knee.