William C. Dooley, MD

• Director of Surgical Oncology
• Department of Surgery
• OU Health Sciences Center Surgeon
• OU Medical Center
• Oklahoma City, Oklahoma

Traced distally the aponeurosis broadens and divides into five processes healthy cholesterol foods cheap rosuvastatin 10 mg buy on line, one for each digit why so much cholesterol in eggs rosuvastatin 10 mg order visa. Near the head of the corresponding metatarsal bone cholesterol levels range australia purchase rosuvastatin 10 mg on-line, each process divides into two slips cholesterol test results 4.5 order rosuvastatin 10 mg online. The slips pass round the sides of the flexor tendons of the digit concerned and get attached to the deep transverse metatarsal ligaments (which stretch between the heads of the metatarsals) cholesterol medication and muscle breakdown rosuvastatin 10 mg sale. Distally, the two slips of each process become continuous with the proximal end of the fibrous flexor sheath of the digit. Over each toe the deep fascia (which is thick) winds round the sides of the flexor tendons of the digit to get attached to the lateral margins of the phalanges. This canal is lined by a synovial sheath to permit smooth movement of the tendons. The fibrous sheath is closed distally by attachment to the base of the terminal phalanx. Proximally, the fibrous sheath is continuous with the distal margins of the slips of the plantar aponeurosis (as described above). In persons who have to do a lot of standing or walking pain over the sole of the foot may be caused by inflammation or injury to the plantar aponeurosis. Inflammation of the calcaneal attachment of the aponeurosis can cause considerable pain on putting the heel on the ground. Ossification of the posterior end of the aponeurosis leads to the formation of a projection from the calcaneus (calcaneal spur). These spurs have been regarded as the cause of pain, but the recent view is that the pain is of fascial origin. Bunion the term bunion is used for an inflamed adventitial bursa over the head of the first metatarsal bone. The muscles and tendons seen in the sole lie in four layers that are separated by fascia. Some fibres from plantar aponeurosis (deep aspect) Tuberosity of calcaneus (me- 1. Muscle ends in four ten- Medial side of base of proxi- Lateral side of proximal phamal phalanx of great toe lanx of fifth toe dons (for 2nd to 5th digits) 2. The slips reunite and again separate to be inserted into the sides of the shaft of the middle phalanx Contd. Helps to maintain arches of the foot the two slips of the tendon for each digit form a tunnel through which the tendon of the flexor digitorum longus passes to reach its insertion into the distal phalanx Medial plantar nerve (S2, 3) 291 Lateral plantar nerve (S2, 3) 1. Part 2 Lower Extremity Flexor digitorum accessorius (Quadratus plantae) Insertion Each muscle ends in a tendon that passes backwards on the medial side of one metatarsophalangeal joint and is inserted into the medial basal angle of the extensor expansion for that digit in the following order: 1. Other lumbricals by lateral plantar nerve (S2, 3) They maintain extension of interphalangeal joints of toes Nerve supply Action 13. It is attached to the proxipart is inserted into corresponding lateral side of base) mal phalanx of the great toe (latside of base of proximal phalanx of eral side of base) great toe Medial plantar nerve (S2, 3) 1. A palmar interosseous muscle is inserted into the base of the proximal phalanx of the digit concerned and into the dorsal digital expansion 4. They flex the metatarsophalangeal joint and extend the interphalangeal joints of the digit concerned 1. The second digit does not give origin to , or receive the insertion of any plantar interosseous muscle 4. Plantar interossei take origin from, and are inserted into the third, fourth, and fifth digits (not the second) 6. Insertion of each muscle into medial side of one digit, third, fourth and fifth Dorsal Interossei 1. A dorsal interosseous muscle is inserted into the base of the proximal phalanx of the digit concerned and into the dorsal digital expansion 4. They flex the metatarso-phalangeal joint and extend the interphalangeal joints of the digit concerned 1. The second digit gives origin to , and receives insertions of two muscles (one on each side: medial and lateral) 4. Dorsal interossei take origin from all five metatarsals and are inserted into the second, third and fourth digits (not first and fifth) 6. The various muscles in the sole perform the movements described in the relevant tables. This is necessary as the propulsive force is transmitted to the ground through the toes. In the next phase both the anterior and posterior parts of the foot touch the ground. In the third phase, the calcaneus is lifted off the ground and the anterior part of the foot exerts strong propulsive pressure on the ground. The propulsive pressure (created by the gastrocnemius and soleus) reaches the foot through the tendocalcaneus. The integrity of the arch is essential for transmitting propulsive force to the ground. The arch is maintained by all structures connecting the anterior and posterior parts of the foot. Note on Interosseous Muscles of the Foot Details of the attachments of individual interosseous muscles are easily remembered if their actions are first understood. The interossei adduct or abduct the toes with reference to an axis passing through the second digit. To understand their action note that as the axis of the second digit is the line of reference for defining abduction: movement of this digit to either the medial or lateral side is described as abduction. The 3rd muscle pulls the 3rd digit, and the 4th muscle pulls the 4th digit laterally. In addition to abduction and adduction, the interossei flex the metatarsophalangeal joints and extend the interphalangeal joints by virtue of their insertion into the dorsal digital expansions (See below). Differences from Interosseous Muscles of the Hand Note the following differences between the interossei of the hand and those of the foot. It begins behind the medial malleolus, deep to the flexor retinaculum, and runs distally along the medial border of the sole of the foot. Thereafter, it lies in the interval between the abductor hallucis medially and the flexor digitorum brevis laterally. Chapter 13 Back of Leg, and Sole Branches of Medial Plantar Artery the branches of the artery are as follows (13. Three digital branches that end by joining the first, second and third plantar metatarsal arteries. From here it runs obliquely across the sole in a lateral and distal direction to reach the base of the fifth metatarsal bone. This part of the artery is deep to the flexor digitorum brevis and lies over the flexor accessorius. The artery now turns medially and runs deep in the sole across the bases of the metatarsal bones. It ends by joining the termination of the dorsalis pedis artery (in the interval between the bases of the first and second metatarsal bones). The plantar arch is overlapped (apart from skin, fascia and plantar aponeurosis) by the flexor digitorum brevis, the tendons of the flexor digitorum longus and by the oblique head of the adductor hallucis muscle. A calcaneal branch arises near the beginning of the artery and supplies the skin of the heel. Some anastomotic branches reach the lateral border of the foot and anastomose with arteries of the dorsum of the foot. Branches of Plantar Arch the branches arising from the plantar arch are as follows: 1. Four plantar metatarsal arteries (1 to 4) run distally, one in each intermetatarsal space. Each ends by dividing into two plantar digital branches for adjacent sides of two digits. The lateral side of the little toe gets a direct branch from the lateral plantar artery. The plantar arch gives off three proximal perforating arteries (x) that pass through the second, third and fourth intermetatarsal spaces and communicate with the dorsal metatarsal arteries (branches of arcuate artery). The distal end of each plantar metatarsal artery gives off a distal perforating artery (y) which joins the distal part of the corresponding dorsal metatarsal artery. Pressure can be applied on the dorsalis pedis artery and the posterior tibial artery to stop bleeding from the foot. Arteries supplying the lower limb (like arteries elsewhere) become narrower with age and can sometimes be blocked. The level of blockage can be ascertained by feeling for the arterial pulse at different levels. Bilateral absence or feebleness of the femoral pulse may be produced by narrowing of the aorta (coarctation) or by blockage. The popliteal pulse is difficult to feel with the knee extended as this stretches the popliteal fascia. Flexion of the knee relaxes the fascia and overlying muscles, and makes it easier to feel the pulse. In case pulsation of the dorsalis pedis artery cannot be felt it should be remembered that occasionally the artery is absent, and its area of supply is taken over by an enlarged perforating branch of the peroneal artery. When an artery undergoes gradual narrowing, circulation is maintained through collateral channels. In blockage or narrowing of the proximal part of the femoral artery, circulation is maintained through the cruciate and trochanteric anastomoses. When the femoral artery is blocked in the lower part of the thigh the lower part of the limb is supplied through the perforating branches of the profunda femoris artery and its anastomoses with branches of the popliteal artery. Severe narrowing of arteries of the lower limb, with an inadequate collateral circulation, can lead to pain in muscles. As the pain appears every time the person takes a few steps it is called intermittent claudication (Claudication = limping). The pain is felt most commonly in calf muscles, but it can also occur in the thigh or in the gluteal region (depending on the level of blockage). With more serious narrowing of arteries there can be pain even at rest (rest pain); and the part becomes cold and numb. In recent years there has been considerable advance in vascular surgery and various procedures are now available for relieving symptoms arising from blockage of larger arteries and for avoiding gangrene. It may be remembered that apart from narrowing of vessels, insufficiency of blood supply can also be produced by spasm of smooth muscle in the walls of arteries. Spasm often coexists with physical narrowing, and relief can be obtained if spasm can be removed. This can be done by the use of drugs or by cutting off sympathetic nerve supply by lumbar sympathectomy. In this condition, arteries of the leg and foot are narrowed, and there is thrombophlebitis of veins. The condition can sometimes be controlled by complete abstinence from smoking, and may benefit from lumbar sympathectomy. Nerves of the Back of Leg and Sole the tibial nerve is the nerve of the back of the leg. The fibres of the tibial nerve are derived from ventral rami of spinal nerves L4 to S3. Separating from the common peroneal at the junction of the middle and lower thirds of the thigh it descends through the popliteal fossa, and passes into the back of the leg. In the lower part of the leg it passes medially and ends midway between the medial malleolus and the tendocalcaneus by dividing into the medial and lateral plantar nerves. In the upper part of the popliteal fossa, the nerve lies lateral to the popliteal artery and vein. In the leg the nerve is at first medial to the posterior tibial vessels, but crosses behind these vessels to reach their lateral side. In the upper two-thirds of the leg the nerve is overlapped by the gastrocnemius and soleus muscles. In the lower one-third of the leg (as it turns medially) the nerve is covered only by skin and fasciae. The distribution of the tibial nerve (excluding that of its terminal branches) is as follows: Muscular Branches 1. Branches given off in the lower part of the popliteal fossa supply the two heads of the gastrocnemius, the plantaris, the soleus and the popliteus. After running down superficial (posterior) to this muscle the nerve turns round its lower border to reach its anterior surface which it enters (13. Branches arising in the leg supply the soleus, the tibialis posterior, the flexor digitorum longus and the flexor hallucis longus. It arises in the lower part of the popliteal fossa and passes backwards between the two heads of the gastrocnemius. In its lower part the nerve inclines laterally and passes forwards below the lateral malleolus. The nerve supplies skin on the posterolateral part of the leg and along the lateral margin of the foot. They pass medially, become superficial by piercing the flexor retinaculum and supply the skin over the heel. The upper part of the tibial nerve gives three branches to the knee joint: they accompany the superior medial genicular, the middle genicular, and the inferior medial genicular arteries. When the nerve is completely cut the power of plantar flexion is lost, and there is loss of sensation over part of the sole. It begins on the posteromedial aspect of the ankle midway between the tendocalcaneus and the medial malleolus: here it lies under cover of the flexor retinaculum. Here the nerve is at first deep to the abductor hallucis, and then lies between this muscle and the flexor digitorum brevis. The nerve ends by dividing into one proper digital branch for the great toe, and three common plantar digital branches. Branches arising from the trunk of the nerve supply the skin of the medial part of the sole.

Lateral subluxation of the femoral head can be measured as the percentage of the femoral head not covered by the acetabulum is cholesterol in shrimp good for you 10 mg rosuvastatin otc. The acetabulum should be concave with a transverse sourcil ("eyebrow" in French) that turns down around the femoral head cholesterol quoi manger buy rosuvastatin toronto. Patients with hip dysplasia frequently have a very flat acetabulum with an upturned sourcil cholesterol free diet chart in urdu order rosuvastatin overnight. This results in shear forces on the joint cholesterol test how many hours fasting rosuvastatin 10 mg order line, leading to early degenerative joint disease total cholesterol level definition purchase genuine rosuvastatin. The normal hip joint has a spherical femoral head that is congruent with a well-formed acetabulum. Sphericity of the femoral head can be measured with Mose templates (concentric circles). First babies and babies that are large have a higher risk, thought to be secondary to inadequate space in the uterus during development. Hip dysplasia is also commonly associated with torticollis and metatarsus adductus, with each of the three abnormalities thought to be a "packaging" problem. There also appears to be a hormonal component, as girls and babies with increased laxity are at higher risk of hip dysplasia. Loss of sphericity of the left femoral head after reossification of Perthes disease has led to a noncongruent joint (left hip). A few studies have shown a possible association between passive smoking and Perthes disease. Legg-Calvé-Perthes Disease the natural history for younger patients (under age 8 years at onset) and patients with milder disease (Herring A classification) is more benign, with minimal long-term disability. Patients may have decreased abduction on examination, or pain with internal rotation of the hip. A marked loss of abduction with the hip in the fully extended position (pelvis rotates rather than hip abducting) suggests hinge abduction and is a poor prognostic sign. A dynamic arthrogram is the best way to determine the function and motion of the joint, since it allows visualization of the labrum and impingement of the femoral neck on the labrum or acetabulum. Patients age 5 to 10 can be treated with an acetabular redirecting osteotomy that bends through the triradiate cartilage (Pemberton osteotomy, Chap. From age 18 months to 5 years, abduction bracing has not been found to predictably improve dysplasia, although nighttime brace use is occasionally recommended. Most advise monitoring during this period with hope that the acetabular growth centers will mature and correct the dysplasia. Anti-inflammatory medications and activity modification can be used to decrease pain, but these do not correct the underlying problem and by masking symptoms may delay surgical correction. Instead, surgical correction should be performed to cover the femoral head and restore normal biomechanical forces. Legg-Calvé-Perthes Disease Perthes disease can be treated nonoperatively in young children. Children older than 8 years or with more severe disease can be treated with a variety of surgical procedures aimed at containing the capital femoral epiphysis during the phase of reossification when the biologically plastic femoral head is at risk for subluxation, hinge abduction, and the development of permanent femoral head deformity. The simplest surgical treatment is adductor lengthening followed by Petrie casting or bracing. This can be used alone for very mild cases, or in preparation for containment surgery. Adductor lengthening and Petrie casting improves mobility of the hip and returns the hip to a more congruous, contained position, beginning the remolding process that surgical containment will continue. A Salter innominate osteotomy can also be performed, but Rab22 has clarified that the degree of acetabular rotation achieved with the Salter procedure is often not enough to cover the femoral head in more severe Perthes disease. This procedure has the benefit of maintaining hyaline cartilage surface-to-surface contact (as compared to the shelf or Chiari procedure). A shelf (labral support) osteotomy or Chiari procedure may be a better choice for a severely deformed femoral head that cannot be congruently centered in the acetabulum. With these procedures, contact between the hyaline (head) and hyaline cartilage (acetabulum) is partially sacrificed. Legg-Calvé-Perthes Disease Children younger than 8 years and patients with hips classified as Herring A can be treated conservatively with predictable results. Children with neuromuscular disorders such as cerebral palsy, due to muscle imbalance around the hip joint and flexion contracture, often have a posterior deficiency. Overrotation of the acetabulum should be avoided, as this can cause anterolateral impingement, which may hasten degenerative changes. Also, external rotation of the acetabulum should be avoided to prevent the creation of acetabular retroversion (which in itself can predispose to hip arthritis). Legg-Calvé-Perthes Disease A preoperative dynamic arthrogram is the best study for understanding how to best contain the femoral head. We perform an arthrogram and percutaneous adductor lengthening followed by Petrie casting (for 6 weeks) before definitive containment surgery. The C-arm and screen of the image intensifier are positioned to allow a clear view for the surgeon. Using three incisions allows more precise exposure for each osteotomy cut, especially in larger patients. The second incision is distal to the groin crease, slightly below the superior pubic ramus, lateral to the adductor longus tendon origin and medial to the neurovascular bundle. The pubic osteotomy is performed through this incision with the ischial osteotomy also possible with posterior extension of the incision. The third incision (if the surgeon chooses a three-incision approach) is longitudinal, distal to the gluteal crease, and just medial to the ischial spine with the hip flexed to 90 degrees. A Foley catheter can be considered to minimize any risk for bladder injury with the pubic ramus cut. A sandbag bolster is placed under the trunk to tip the patient toward the opposite side, giving better exposure of the hip laterally. The bolster should not be placed directly behind the pelvis because it often distorts the image intensifier views. The cartilaginous iliac crest apophysis is split, starting at the anterior superior iliac spine and continuing posteriorly for 6 to 8 cm. Both sides of the iliac wing are exposed subperiosteally down to the sciatic notch using a Cobb periosteal elevator. The iliac crest apophysis is split to expose the medial and lateral aspects of the ilium down to the sciatic notch. Rang retractors are placed in the sciatic notch to facilitate passing the Gigli saw. A Gigli saw (arrow) is passed through the sciatic notch and is brought through the ilium to create the osteotomy. In older, larger patients, we make this cut slightly more proximal than in a Salter osteotomy, which allows room to place a temporary Schanz screw to guide the acetabular segment. The iliopsoas muscle is identified and rotated to expose the psoas tendon, which lies posterior and medially in relation to the muscle mass of the iliopsoas. Because the femoral nerve lies just anterior to the psoas muscle, care should be taken to identify the psoas ten- don. A right-angled hemostat is placed around the tendon and the tendon is sectioned, leaving the muscle belly intact. The Salter incision can now be packed with a damp sponge and the wound edges pulled together with a towel clip while the other osteotomies are completed. For the three-incision technique, a 2- to 3-cm transverse incision (parallel to the inguinal ligament) is made just lateral to the adductor longus and 1 cm distal to the groin crease. For the two-incision technique, this incision would subsequently be extended medially and distally to allow exposure of the ischium. The pectineus muscle is identified just lateral to the adductor longus origin and is partially elevated off the superior pubic ramus. The saphenous vein, which often crosses the field, should be maintained and retracted laterally. The extraperiosteal approach allows easier periosteal sectioning since the periosteum is strong in this area and may prevent movement of the pubic segment of the acetabuloplasty. Care must be taken to avoid the obturator nerve, which courses just below the superior ramus. Those new to the operation might be advised to begin with a subperiosteal approach to the pubic ramus. The closer the surgeon is to the acetabulum, the easier it will be to rotate the acetabulum. Once position is confirmed, a narrow rongeur or osteotome can be used to make a slightly oblique osteotomy of the pubis. The cut can be angled slightly to allow subsequent superomedial acetabular displacement. If a rongeur is used (the safest method), the bits of excised bone should be maintained and returned to the osteotomy site to avoid the risk for pseudarthrosis. After elevating the medial border of the pectineus off the pubic ramus, Hohmann retractors are placed above and below the pubis extraperiosteally. When first performing this procedure, the surgeon should have a skeletal model of the pelvis in the operating room and the circulating nurse should hold it for him or her to inspect as needed. One error that we have seen is palpation of a deep bony prominence, thought to be the ischial spine, which was in fact the greater trochanter. Two-Incision Technique Through the adductor incision, blunt dissection is carried out subcutaneously down to the ischial spine. The electrocautery is used to take down the posterior portion of the adductor magnus muscle origin just anterior to the proximal origin of the hamstrings. The ischial tuberosity is identified and then an initial sharp Hohmann retractor is placed inside the obturator foramen. A Cobb elevator is then used to clear the ischium up to its origin just below the acetabulum. Blunt Hohmann retractors are then placed extraperiosteally around the ischium, with one retractor in the obturator foramen and the other lateral to the ischium. This is a very deep exposure, and the neophyte will be surprised at the depth of the ascending ischium. Thus, there are a total of three Hohmann retractors- one medial, one lateral, and a sharp-tipped tapped into the bone proximally. The ischial cut should be just below but not in the acetabulum (about 1 cm below the lower end of the "teardrop"). A third sharp Hohmann is driven into the ischium in the proximal end of the wound (just below the acetabulum) to help with retraction. When the osteotome enters the posterior cortex, it is rotated medially to displace the ischium. Once position is confirmed, a rongeur can be used to start the osteotomy, creating a groove for the osteotome to prevent the osteotome from slipping. To encourage proper displacement of the osteotomy, the large wooden handle of the osteotome is used to radically rotate the acetabular segment medially before the osteotome is withdrawn. Using a very long (about 20 inch) wooden-handled osteotome makes this essential rotational maneuver easier. This is pushed upward and inward while the Schanz screw is levered downward and laterally to rotate the entire acetabulum around the femoral head. A Cobb elevator is placed in the Salter (iliac) cut and rotated to encourage lateral positioning of the acetabular fragment in the coronal plane. Care must be taken not to externally rotate the acetabular segment (this is easy to do in a triple osteotomy and will cause undesired acetabular retroversion). This triangular graft is only about half as large as in a Salter osteotomy for the same-size patient since a good deal of the rotation should have occurred in the pubic and ischial cuts. Acetabular position is checked with fluoroscopy to confirm the amount of coverage that has been obtained. A Schanz screw is placed just above the hip (arrow); it can be used as a lever to help rotate the acetabulum. A ballpoint pusher can be used to push the pubic portion upward and inward while the Schanz screw levers the superior acetabulum anterolaterally. Fluoroscopic image showing ballpoint pusher (white arrow) and Schanz screw (black arrow). Bone graft is taken from the iliac crest and fashioned to fit into the iliac osteotomy. The osteotomy is temporarily fixed using smooth Kirschner wires to confirm position with fluoroscopy before final screw fixation. Using fully threaded screws minimizes the tendency for loss of correction that can occur when a partially threaded screw is tightened too much, overcompressing the graft and pulling the acetabular edge upward. Threaded Kirschner wires can be used in smaller patients in whom the bone may not be thick (strong) enough to hold the 4. Any remaining bone graft fragments can be packed into the pubic and ischial osteotomies to prevent nonunion. The iliac crest apophysis is reapproximated and closed with a running absorbable suture. If both iliac and pubic fixation is secure in a cooperative patient, we sometimes use a removable bivalve plastic "spica-type" orthosis (made before surgery) or trust the patient with no immobilization (rare). Acetabular positioning Proper rotation of the acetabulum is the most important part of this procedure. A: the acetabular segment if the ilium should be positioned 8 to 10 mm lateral to the inner wall of the ilium above. B: the acetabular segment of the pubis should be displaced slightly superior and medial. E: the ischial spine should be only a little (if any) more prominent than on the opposite side.

The region supplied by the inferior rectal nerve (somatic) is much more sensitive to pain than the region supplied by autonomic nerves yolk cholesterol in eggs from various avian species generic 10 mg rosuvastatin overnight delivery. Internal or true haemorrhoids are located in the part of the anal canal lined by mucosa cholesterol alcohol order genuine rosuvastatin. They are located in relation to anal columns above the level of anal valves cholesterol chart seafood 10 mg rosuvastatin with amex, and are formed by dilatation of radicles of the superior rectal vein cholesterol test results vary order 10 mg rosuvastatin amex. Some anatomical considerations relevant to the formation of internal haemorrhoids are as follows: a cholesterol levels in fresh eggs cheap rosuvastatin 10 mg otc. However, the tributaries located in the left lateral, right posterior, and right anterior positions are largest and the first to enlarge. When the anal canal is viewed with the patient lying supine with the thighs raised (lithotomy position) the position of primary piles is often described with reference to a clock. Submucous connective tissue at the anorectal junction is very loose and the radicles of the superior rectal vein lie unsupported in this tissue. The veins pierce the muscle coat and are pressed upon when the muscle contracts during defecation. The tributaries of the these veins in the anal columns, therefore, bear the pressure of the entire column of blood right up to the portal vein. This explains why haemorrhoids are more liable to occur in persons who have to stand for long periods. This also explains why the tendency to formation of piles is increased in portal hypertension (as mentioned above). It has been observed that persons who have haemorrhoids also frequently have varicose veins, suggesting the possibility of some inherent weakness in the walls of veins. The relationship of haemorrhoids to portal hypertension has been contested and some authorities believe that there is no such correlation. In some cases haemorrhoids can be caused by pressure on, or blockage of, veins caused by a rectal carcinoma. The most important clinical feature of piles is painless bleeding which may take place every time the patient passes stools. Second degree when they prolapse out of the anus during defecation, but get reduced by themselves. Treatment of haemorrhoids can be conservative but when this is unsuccessful the haemorrhoids can be removed surgically (haemorrhoidectomy). In contrast to internal haemorrhoids, external haemorrhoids are formed by dilatation of tributaries of the inferior rectal veins. Some haemorrhoids may extend partly under mucosa and partly under skin (interno-external haemorrhoids). Rupture of a small tributary of the inferior rectal vein can give rise to a perianal haematoma. Because of constant contact with fecal material the anal canal is a frequent site of infection. When an abscess opens in both directions it leads to formation of a fistula that is a narrow inflamed tract of communication between the lumen of the anal canal and outside. From the point of view of treatment it is necessary to know the locations of perianal abscesses and fistulae as follows. A fistula lying above the level of the anorectal ring is a high level anal fistula. In doing so it has to be remembered that excision of a high level fistula requires division of the anorectal ring, and special procedures are necessary to ensure that division of the ring does not result in anal incontinence. Here the ureter crosses several structures that lie between it and the lateral pelvic wall. Here the ureter forms the posterior wall of a depression (ovarian fossa) in which the ovary lies. Lateral to the cervix, the ureter is crossed by the uterine artery and the broad ligament. The terminal part of the ureter passes obliquely through the thickness of the wall of the urinary bladder to open into its posterior wall. The openings lie at the lateral angles of a triangular area of the posterior wall of the urinary bladder called the trigone (33. Pain starts on the back over lower ribs and shoots downwards and forwards to the inguinal region, scrotum, and sometimes to front of thigh. The clinical correlations of the ureter have been considered in Chapter 30 along with those of the kidneys. However, when distended with urine, part of it extends above the level of the pubic symphysis and comes in contact with the anterior abdominal wall. Urine is formed continuously in the kidneys and is conveyed to the urinary bladder through the ureters. The apex of the bladder gives attachment to the lower end of the median umbilical ligament (33. The superior surface of the bladder is separated by peritoneum from part of the sigmoid colon and from coils of small intestine (33. They are separated from these bones by a mass of fat and by the puboprostatic ligaments (see below). The base of the bladder lies in front of the rectum, but is partly separated from it by the right and left seminal vesicles and the right and left ductus deferens (33. Traced anteriorly this peritoneum becomes continuous with that lining the anterior abdominal wall. In the middle line this peritoneum is raised into a fold called the median umbilical fold because of the presence here of the median umbilical ligament. Traced laterally the peritoneum of the superior surface is reflected on to the lateral pelvic wall. Traced posteriorly the peritoneum on the superior surface of the bladder passes on to the upper part of the base. The peritoneum lined depression between the urinary bladder and the rectum is called the rectovesical pouch (37. In the fetus the rectovesical pouch is much deeper and extends up to the pelvic floor. The lower part of the pouch is obliterated by fusion of the layers of peritoneum lining it. The remains of this peritoneum persist as the rectovesical fascia that separates the lower part of the base of the bladder, and lower down the prostate, from the rectum. Chapter 33 Pelvic Viscera and Peritoneum Relations of Urinary Bladder in the Female 653 1. The greater part of the superior surface of the bladder is lined by peritoneum that separates it from the body of the uterus (33. When traced backwards this peritoneum is reflected on to the front of uterus at the junction of the body with the cervix. The posterior part of the superior surface of the bladder is in direct contact with the upper part of the cervix. The relations of the inferolateral surfaces of the bladder are the same as in the male except that the puboprostatic ligaments are replaced by the pubovesical ligaments. Ligaments of the Urinary Bladder the urinary bladder is kept in place by a number of so-called ligaments. The median umbilical ligament connects the apex of the urinary bladder to the umbilicus. It is the remnant of an embryonic structure the urachus that is derived from the allantoic diverticulum. The fascia over the upper surface of the levator ani (pelvic fascia) is thickened anteriorly to form the medial and lateral puboprostatic ligaments (in the male) or the pubovesical ligaments (in the female). Laterally the same fascia stretches from the bladder to the fascia covering the obturator internus. The lateral margins of the base of the bladder are joined to the lateral pelvic wall by fascia surrounding the veins that pass from the bladder to the internal iliac veins. The median umbilical ligament raises up a median fold of peritoneum called the median umbilical fold (33. In the fetus the right and left umbilical arteries pass from the internal iliac arteries to the umbilicus (on their way to the placenta). Their distal parts become obliterated and form the medial umbilical ligaments that connect the superior vesical arteries to the umbilicus. They raise up folds of peritoneum called the right and left medial umbilical folds. Peritoneum reflected from the superior surface of the bladder to the lateral wall of the pelvis is referred to as the lateral false ligament of the bladder. Two folds of peritoneum (right and left) pass backwards from the lateral margin of the base of the bladder to the sacrum. These folds pass lateral to the rectum and form the lateral boundaries of the rectovesical pouch. These folds are called the sacrogenital folds or the posterior ligaments of the bladder (33. On the posterior wall of the bladder, however, there is a triangular area where the mucosa is relatively fixed. The ureters open into the urinary bladder at the upper lateral corners of the trigone while the upper end of the urethra opens at the lower angle. The upper margin of the trigone forms a ridge stretching between the openings of the two ureters. The urinary bladder is supplied (in the male) by the superior and inferior vesical arteries. In the female the inferior vesical artery is replaced by the vaginal artery and the uterine artery also gives branches to the bladder. Veins from the bladder pass backwards in the posterior ligaments of the bladder to reach the internal iliac veins. Parasympathetic nerves stimulate the detrusor muscles and are inhibitory to sphincters. However, it is now believed that normal bladder function is controlled only by parasympathetic nerves and that sympathetic nerves only have a vasomotor effect. Sensations of bladder filling and pain travel through both sympathetic and parasympathetic nerves. Within the central nervous system pathways for sensations of bladder filling and for pain are different. Pain from the bladder can be abolished by anterolateral cordotomy without affecting sensations of bladder filling. Fibres travel through pelvic splanchnic nerves, inferior hypogastric plexus and vesical plexus. The overlying anterior abdominal wall is also absent so that the posterior wall of the bladder (trigone) appears on the surface of the body. The lumen of the bladder may be divided completely (by septa) or partially (by a constriction) into upper and lower compartments. In an infant the urinary bladder is partially in contact with the anterior abdominal wall. In the adult the empty bladder does not come in contact with the anterior abdominal wall. However, when it is distended its upper part is in contact with the abdominal wall above the pubic symphysis. It is important to note that as the distended bladder ascends the fold of peritoneum passing from the anterior abdominal wall to the superior surface of the bladder also rises so that no peritoneum intervenes between a distended bladder and the anterior abdominal wall. In a patient with urinary obstruction, and consequent distension of the bladder, the distension can be relieved by passing a needle into the bladder through the anterior abdominal wall (just above the pubic symphysis). The bladder can be approached surgically through a suprapubic incision (after distending it). This operation is used for removal of stones from the bladder (suprapubic lithotomy). Chapter 33 Pelvic Viscera and Peritoneum Effect of Spinal Cord Injury on Bladder 657 1. This leads to distension of the bladder, the urine dribbling out when pressure rises to a level that cannot be opposed by the sphincters. A few days after injury the bladder begins to contract reflexly when it is full (as in an infant). If these segments are damaged reflex emptying does not occur, and there is dribbling when the bladder is distended. Two important causes are enlargement of the prostate (in the elderly), and a stricture of the urethra. Retention is relieved by passing a suitable catheter into the bladder through the urethra. Congenital malformations resulting in abnormal communications of the bladder have been mentioned above. The urethra is a tube that connects the lower end (or neck) of the urinary bladder to the exterior. The urethra is much longer in the male (about 20 cm) as compared to the female (4 cm). The first part starts at the internal urethral orifice and descends through the prostate to reach the urogenital diaphragm. This part of the urethra is embedded within the prostate gland and is, therefore, called the prostatic part. Between the two layers there is the sphincter urethrae externus that surrounds this part of the urethra.

Syndromes

• The wrong dose of medicine
• Limit or avoid oranges and orange juice, nectarines, Kiwis, raisins, or other dried fruit, bananas, cantaloupe, honeydew, prunes, and nectarines
• Endoscopic esophageal ultrasound (EUS) with biopsy
• Tricuspid regurgitation
• 4,500 to 10,000 cells/mcL
• Aortic stenosis
• Passing worms in stool
• Nausea and vomiting (the vomit may contain blood)
• The toes disappear into the cast

The femoral shaft is palpated laterally on this line; this point is marked as 0 degrees cholesterol membrane fluidity discount 10 mg rosuvastatin otc. The neck-to-head angle is measured cholesterol medication guidelines 2015 buy rosuvastatin amex, and the point at which a line through the center of the head and perpendicular to the physis intersects the neck is noted cholesterol ratio of 3.9 rosuvastatin 10 mg buy free shipping. If the head­neck angle measured is cholesterol levels on paleo diet buy rosuvastatin 10 mg, for example cholesterol examples 10 mg rosuvastatin buy fast delivery, 30 degrees, the entry point on the skin should be 30 degrees from the lateral palpable femoral shaft toward the femoral head. Helpful hint: this position can be obtained by taking a length of suture that goes from the femoral head mark to the lateral femur mark (representing 90 degrees) and dividing it into thirds (30 degrees). The surgeon then measures from the lateral femoral shaft (0degree mark) toward the head along the drawn line. A 1-cm incision is made along the drawn line at the number of degrees from the lateral femur (0 degrees). The guide pin is inserted into this incision along the marked line but at the measured neck­head angle. The point of the guide pin should be positioned on the anterolateral femoral neck where the entry was estimated above. Inserting the Guidewire the guide pin is drilled into the femoral neck to the midneck and then additional image views are taken to confirm and fine-tune the position. When satisfactory, the guide pin is drilled to within 3 mm of the articular surface and measured, and a bone screw is chosen. Multiple image views should confirm the guide pin position be- fore inserting the bone screw to avoid stress risers from too many holes in the bone. Helpful hint: the surgeon can rotate the hip to prevent bending of the guide pin while flexing to get multiple views. Helpful hint: If the end of the guide pin is threaded, the bone screw may advance the guide pin through the articular surface. The hip must not be moved because of the risk of breaking off the end of the guide pin in the hip joint. Instead, the surgeon can retract the guide pin partially into the bone screw and then continue to advance the bone screw to the appropriate position. Again, multiple views are obtained to ensure that the bone screw does not penetrate the articular surface. The drill should stop 1 or 2 mm before the tip of the guidewire to keep the guidewire in place. The approach-and-withdraw technique allows evaluation of the screw tip to ensure that it remains within the femoral head. With live fluoroscopy, the hip is ranged from internal to external rotation at varying degrees of flexion and the screw tip is observed to approach and withdraw from the subchondral bone. The closest point is observed and the screw should remain within the femoral head. The guidewire should be placed into the center of the epiphysis parallel to the physis to obtain maximum fixation, like the handle of an umbrella. When the hip is moved from resting position to frog-leg lateral position or back again, the quadriceps fascia must be meticulously retracted to prevent guidewire bending. Guidewire bending Guidewire pullout Drilling should stop 1 to 2 mm before the end of the guidewire to keep it seated in bone. The surgeon should check spot fluoroscopy as the drill is backed out to make sure the guidewire remains in place. Guidewire binding During drilling, tapping, or screw placement, the instrument can bind the guidewire and cause unwanted advancement of the guidewire. The cannulated instrument must remain perfectly colinear with the guidewire during advancement. The surgeon should check spot fluoroscopy to make sure the guidewire is not advancing. Patients should remain non-weight bearing or touch-down weight bearing on crutches on the affected leg for about 6 weeks to allow healing. Patients should be followed at regular intervals until the proximal femoral physis closes completely on radiographs. Overall, patients may have cartilage recovery and good midterm functional outcomes. Further slippage after in situ fixation occurs most frequently with improper screw placement outside of the desired middle third of the epiphysis and insufficient thread purchase into the epiphysis. Risk factors include unrecognized pin or screw penetration, spica cast treatment, more severe slips, and female sex. The joint space appears narrowed to less than 3 mm on radiographs, and treatment involves revision of prominent hardware, limited weight bearing until symptoms improve, physical therapy, and nonsteroidal anti-inflammatories. Slipped capital femoral epiphysis: a prospective study of fixation with a single screw. The demographics of slipped capital femoral epiphysis: an international multicenter study. The "approach­withdraw phenomenon" in the pinning of slipped capital femoral epiphysis. The first part of the procedure is a surgical hip dislocation with femoral head­neck osteoplasty. If additional deformity correction is needed, the flexion intertrochanteric osteotomy is performed. Pain is elicited with hip flexion, adduction, and internal rotation stress (impingement test). The physical examination should include flexion and internal rotation range-of-motion tests. Normal, physiologic hip flexion needed for activities of daily living is at least 90 degrees. However, because it occurs mainly in adolescent boys (80%), hormonal factors are thought to be involved. Corrective osteotomies have been described through the femoral neck at the growth plate (cuneiform), at the base of the femoral neck, or subtrochanteric. A flat-top cushion placed beneath the operative side is helpful to stabilize the leg during the approach. A hip drape with a sterile side bag is used, which will capture the leg during the dislocation maneuver. Approach the incision from the surgical hip dislocation is extended slightly distal, along the lateral aspect of the thigh, in line with the femoral shaft. The lateral approach to the proximal third of the femur is required for the intertrochanteric osteotomy. The posterior angulation of the affected side determines the angle of the lateral osteotomy template. The vastus lateralis, supplied by the femoral nerve, is reflected anteriorly from the vastus ridge distally. The anterolateral aspect of the femoral shaft is then exposed subperiosteally, and the lesser trochanter is identified. This is placed parallel to the floor in the axial plane and perpendicular to the shaft of the femur in the coronal plane. In the coronal plane, the Kirschner wire is placed with an appropriate amount of valgus, determined from the anterior head­shaft angle difference on preoperative radiographs. A slot for the blade plate should now be made in the trochanteric fragment to allow for anatomic fixation of the trochanter after the osteotomy. The amount of flexion is based on the preoperative lateral head­shaft angle measurement. Using an oscillating saw, the proximal femur is cut using the Kirschner wire as a guide. If necessary, the distal fragment may be internally rotated to match the alignment of the normal side. If there is greater than 60 degrees of posterior slippage, the femoral head­neck osteoplasty performed through a surgical hip dislocation can reduce the amount of flexion needed to relieve anterior impingement. After fully inserting the seating chisel, the surgeon should remove and replace it by hand before making the osteotomy. Control of the proximal fragment is gained with a Weber bone-holding clamp instead of using the inserted blade plate for fragment manipulation, which could weaken the fixation. Subclinical slipped capital femoral epiphysis: relationship to arthrosis of the hip. Early results of treatment for hip impingement syndrome in slipped capital femoral epiphysis and pistol grip deformity of the femoral head-neck junction using the surgical dislocation technique. Nonunion of the greater trochanteric osteotomy or the intertrochanteric osteotomy Sciatic or femoral nerve neurapraxia Heterotopic ossification Chapter 81 Triple Arthrodesis Om Prasad Shrestha, David A. The procedure is most commonly indicated for salvage in severe, rigid deformities of the hindfoot that are unresponsive to less invasive methods of treatment. This procedure is typically considered in adolescents but has been reported in children as young as 8 years of age. As the ankle joint is oriented along the transmalleolar axis, dorsiflexion is associated with outward deviation of the foot, while plantarflexion is associated with inward deviation. While there is considerable variation, this joint is oriented 23 degrees medially in the transverse plane and 42 degrees dorsally in the sagittal plane. The subtalar joint thus functions as a hinge along an inclined axis and serves as the linkage between the ankle and the distal articulations of the foot. During the gait cycle, the subtalar joint is everted at heel strike and then inverts progressively until the time of push-off. The talonavicular and calcaneocuboid joints are known as the transverse tarsal joints. When the calcaneus is everted, these joints become parallel, and there is greater flexibility at the articulation. In contrast, the transverse tarsal joints become nonparallel (more rigid) when the calcaneus is inverted. Functionally, the calcaneus becomes inverted during late stance phase, which locks the transverse tarsal joints and provides a rigid lever for push-off. From a functional standpoint, the muscles crossing the ankle and subtalar joints may be classified based on their location with respect to each joint axis. There is plantarflexion (gastrocnemius and soleus, tibialis posterior, flexor digitorum longus, flexor hallucis longus) and dorsiflexion (tibialis anterior, extensor digitorum longus, extensor hallucis longus) at the ankle. The movements of inversion (tibialis anterior and posterior, flexor digitorum longus, flexor hallucis longus) and eversion (peroneus longus, brevis, tertius, extensor digitorum longus, extensor hallucis longus) occur across the subtalar axis. This spectrum of deformities may result from soft tissue contractures, from bony malalignment, or from both. While some deformities have a structural component at birth, most develop gradually, are initially flexible, and become fixed or rigid only over time. While a loss of passive motion may result from contracture of the soft tissue elements, progressive adaptive changes in the osteocartilaginous structures subsequently result in fixed bony malalignment. The equinovarus deformity is present at birth in a congenital clubfoot, or may result from spastic muscle imbalance in patients with cerebral palsy (most often spastic hemiplegia) or flaccid muscle imbalance (poliomyelitis). While the cause of congenital clubfoot remains debated, and is most likely multifactorial, the pathogenesis in neuromuscular diseases involves muscle imbalance (strong inversion­plantarflexion and weak eversion­dorsiflexion). An equinovalgus deformity is most common in patients with a congenital vertical talus or cerebral palsy (most commonly spastic diplegia). The cavovarus foot is most common in the hereditary motor and sensory neuropathies (Charcot-Marie-Tooth disease) and results from muscle imbalance. Weakness of the tibialis anterior (relative to the peroneus longus) is associated with plantarflexion of the first ray (forefoot valgus), a deformity that is initially flexible. Over time, a contracture of the plantar fascia and neighboring intrinsic muscle groups develops. To compensate for forefoot valgus, the hindfoot aligns in varus during stance phase. The hindfoot also appears to be in equinus because of plantarflexion of the midfoot on the hindfoot. A common mistake is to assume that the equinus occurs at the ankle and to perform an Achilles tendon lengthening. Deformities associated with the neuromuscular diseases will usually progress (and become rigid) over time and will have a significant chance of recurrence despite treatment owing to the underlying disease process. In the latter, the cause involves muscle weakness or imbalance, and examples include either flaccid or spastic neuromuscular dysfunction (cerebral palsy, poliomyelitis, myelomeningocele, hereditary motor and sensory neuropathies, other). The history focuses on the presence of symptoms, including functional limitations, cosmetic concerns, and shoe wear, the family history (similar deformities, neuromuscular diseases), and previous treatment. A detailed history is especially important in children of walking age, as a foot deformity may be the first clue to the presence of an underlying neuromuscular problem. While unilateral foot deformities may be seen with tethering of the spinal cord (or other problems such as a spinal cord tumor), bilateral deformities may be the initial finding in patients with a hereditary motor and sensory neuropathy. The location and character of pain should be determined, in addition to the activities that produce discomfort. The spine should be examined to rule out any deformity or evidence of an underlying dysraphic condition, and a careful neurologic examination should be performed. The shoes should be inspected for patterns of wear, which indicate weight distribution during stance phase. The physical examination of the foot and ankle focuses on the skin (presence and location of callosities, points of tenderness), the overall appearance in both the weight-bearing and non-weight-bearing positions (relationship between the forefoot and hindfoot), the range of motion of the hindfoot joints, the relationship between the forefoot and the hindfoot, and the neuromuscular assessment. Tests to perform during the physical examination include: Range of motion at the ankle joint (plantarflexion and dorsiflexion) to diagnose and determine the magnitude of equinus contracture Range of motion at the subtalar joint (inversion and eversion), which quantifies motion at the subtalar joint. Range of motion at the transverse tarsal joints Relationship between forefoot and hindfoot alignment, which identifies any coexisting deformity of the forefoot, either varus (the lateral aspect of the forefoot axis is more plantarflexed than the medial aspect) or valgus (medial aspect of the forefoot axis is more plantarflexed than the lateral forefoot axis) Coleman block test, which determines if hindfoot varus is flexible or rigid Manual muscle testing, which assesses relative strengths of motor units across the ankle and subtalar joints.

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