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Although predominantly seen in the work dorsal than normal for de Quervain’s (as indicated by dark environment virus 68 symptoms buy cefpodoxime 100mg otc, certain athletic activities can lead to win32 cryptor virus buy 100 mg cefpodoxime inter arrow and dotted lines) rotating antibiotics for acne purchase cefpodoxime 100 mg without prescription. Release of this stenotic area allowed early return against the resistance of deep snow on withdrawal of to antibiotics metronidazole generic 200mg cefpodoxime fast delivery manual labor. Extensor Digitorum Brevis tion producing pain and crepitus with exion/extension Manus Syndrome of the wrist. Failing based on cadaveric dissections of 3404 and 559 hands, this, there are two schools of thought regarding ap respectively [21,23]. Still others maintain that it is a derivative of this approach directly addresses the site of symptoma the dorsal interosseous musculature [24]. All patients had excellent results, with origin to be the wrist capsule beneath the dorsal carpal resumption of normal activities and return to full athletic ligaments at the level of the scaphoid, lunate, capitate, or training within one week. There were no recurrences up hamate, or occasionally at the level of the distal radial to 4 years postsurgery. They propose that the basic pathology involves also inserts on the radial side of the long and ring nger tenosynovitis of the second extensor compartment [24]. Symptoms likely result symptoms in all 13 patients by decompressing the second from the associated synovitis. No inter the key to diagnosis of the syndrome is an awareness vention was performed more proximally at the site of of its existence. There more distally of the second compartments, thus further may be a hereditary component [24,27]. Operative intervention tomatic, patients are usually heavy laborers and present involving decompression of the second extensor com with dorsoradial or middorsal wrist pain and swelling partment resulted in 100% relief of symptoms at an during or after excessive use of the affected hand. All patients returned to ical exam reveals an easily identiable fusiform mass, their previous employment [22]. The Our operative technique involves a longitudinal inci mass is soft, freely mobile, and usually nontender, unless sion in line with the radial wrist extensors extending from there is signicant associated synovitis. Resisted extension of the ngers repro muscle belly is released to expose the second compart duces the pain [21], as does pressure on the palm of the ment. Only upon decompression of the second compart hand against a table with the wrist in full extension [23]. The wrist is then immobilized in ographs are usually normal, and aspiration is negative. The inciting the differential diagnosis includes ganglions, tenosynovi activity should be avoided for at least 12 weeks tis, synovial cysts, exostosis, and carpal bossing [28–30]. Hand and Wrist Tendinopathies 141 Provocative test: Pressure on palm of hand against table crepitus at the level of Lister’s tubercle. There is usually with wrist in full extension no specic traumatic event, although the patient may relate the symptoms to a new sporting activity or a repet Management and Results itive maneuver at work. The pain is reproduced at the level of is certain, then no treatment is necessary for a painless the wrist with active and resisted thumb extension. Failure will frequently associated with pain along the tendon sheath at the level lead to operative release. Nonoperative management including steroid injection and splinting is usually successful, although some authors recommend that steroids be used with caution, as increased local tissue pressure may increase the risk of Middorsal Wrist Pain tendon rupture [33,34]. All 4 cases resolved with surgical commonly seen in patients with rheumatoid arthritis. In release, one of which remained symptom free at 10 year athletes, it is generally related to racquet sports. Early diagnosis in this case is important to In the rst [6], a standard longitudinal incision is made prevent rupture at the level of Lister’s tubercle. The exten been noted in cadaveric dissections by Morgensen and sor retinaculum is then closed to prevent relocation of the Mattson. In our experience, as well as in that of other between the third and fourth compartments is quite vari authors [36], bowstringing has not been a problem with able when compared to the septum between the second this technique. Primary the patient generally presents with a several-months repair is usually impossible due to the chronic degenera history of dorsal wrist pain, swelling, and occasionally tive nature of the rupture. This synovitis surrounding both the tendon and the muscle may prevent complete attenuation of the tendon and [37]. After passing through the with diffuse pain over the fourth extensor compartment fourth extensor compartment deep to the extensor digi that is aggravated by passive wrist and nger exion. The provocative maneuver begins with the they have termed “fourth-compartment syndrome. The patient will describe a sudden pain localized and occult ganglion) that can increase pressure within the to the ulnar aspect of Lister’s tubercle just distal to the fourth extensor compartment, ultimately compressing extensor retinaculum [43]. If this fails, sur most common wrist tendinopathy seen in sports, and is gical decompression is indicated. The literature to date particularly associated with rowing and racquet sports provides only sporadic case reports describing operative [3]. Hand and Wrist Tendinopathies 143 Patients present with a history of chronic pain local ized to the dorsal-ulnar aspect of the wrist just distal to the dorsum of the ulna. Sometimes there is a history of trauma, but usually the pain is of insidious onset. Management A standard nonoperative approach will yield satisfactory results in most cases. All 3 patients had complete relief of symp toms at an average 16 months follow-up, with return to full activity. Crimmins and Jones [45] performed a retro spective review of 15 patients with 10 to 14 months follow-up. Seven of 15 patients failed conservative B therapy consisting of splinting and steroid injections. Surgical release of the sixth compartment is the tained direct trauma to the dorsum of the wrist 10 weeks before treatment of choice if conservative management fails. He had been treated with taping, but this is performed through a longitudinal incision over the continued to have pain on daily activities, particularly with sixth extensor compartment. He had pain radiating from the wrist up the arm, particularly with supination, and has been canal is released on the radial side of the sixth compart diagnosed with tendinopathy. The wrist is then immobilized for infolded and tacked down to the tunnel, giving the appearance 2 to 3 weeks postoperatively in a volar-based splint with of a normal tunnel. The arrow points to the sling that has been constructed from the dorsal retinaculum. It is necessary to reinforce the 4–5 interval before nal letic trauma with a fairly well-dened mechanism of suturing. This causes a volar displacement of the tendon as an acute longitudinal tear of the bro-osseous tunnel occurs on the ulnar side. Clinical examination ing these maneuvers passively will rarely reproduce the reveals minimal tenderness over the sixth extensor com symptoms. Otherwise, all dorsal-ulnar pathologies sents a predisposing factor as it does in de Quervain’s (Table 15-1) must be considered. Patients present with pain and swelling on the ulnar Provocative test: Combined forearm supination with wrist dorsal aspect of the wrist just distal to the head of the extension. It can be seen following wrist injury but generally occurs after repetitive use of the hand, such as with hand Management writing activities. The patient has pain with gripping and When acute recognition of the condition occurs, rst-line is unable to extend the little nger. On examination, there nonoperative management includes long-arm casting is reproduction of the pain with attempts to ex the wrist with the forearm in pronation and the wrist in slight after making a st. While nonoperative management is Provocative test: Flexion of the wrist after making a st. The sheath will be been achieved with operative reconstruction of the bro thickened and is completely released. Once again, these Results results are based on a limited number of case reports (11 in total for these 3 authors) but the results are encour There is only one documented case report in the last 40 aging. This is performed through a dorsoulnar, longitudi years where surgical decompression was performed for nal incision over the sixth extensor compartment. The patient’s pain completely subluxating tendon is identied, and a longitudinal rent resolved with release of the fth extensor compartment. Except in an acute situation, primary repair resulting in triggering of the little nger which, upon without augmentation will rarely be successful. Most surgical release, resulted in complete resolution of often, reconstruction using a radially based sling about symptoms [52]. Postoperatively the arm is maintained Volar-Radial Wrist Pain in a long-arm cast at 90 degrees of elbow exion, neutral forearm rotation, and 30 degrees of wrist extension for 6 1.

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They are constructed the most common reasons for mechanical valve failure are with pyrolitic carbon leaftlets with either titanium or pyrolitic pannus formation and thrombosis infection in bone purchase 100 mg cefpodoxime with mastercard. Tungsten or graphite is used as the supporting occurs on the undersurface of the valve and leads to antibiotics ear drops cheap cefpodoxime 100mg overnight delivery progres scaffolding over which the pyrolitic carbon is laid antibiotics for pustular acne 200 mg cefpodoxime amex. Thrombosis ple mechanical prostheses available worldwide are shown in is often a catastrophic event infection endocarditis 200mg cefpodoxime mastercard. Recent advances in mechanical prostheses Mechanical prostheses failure modes the most significant changes in mechanical heart valves of the Structural failure of mechanical prostheses has been observed last decade have focused on two components, namely, the with both monoleaflet (disc) and bileaflet designs. The Bjork sewing ring and the ability to rotate the valve after implanta Shiley tilting disc design has been withdrawn from the market tion. To gain insight into the failure mech series, the cuff fabric is shifted to an entirely supra-annular anism, a metallurgical analysis was carried out on the fractured position. This demonstrated that welding imperfec bon rim from intra-annular to entirely supra-annular. While tions and metal fatigue were the major determinants of strut these modifications have resulted in better hemodynamics, fracture. The hinges are the area of CarboMedics Top Hat valve has a modified sewing ring that highest stress. Factors that influence wear are the geometry of allows for the placement of the device in a supra-annular posi the coupling elements undergoing impact wear (flat to flat ver tion. This modification allows for the implantation of a valve sus curved to flat), the mechanism of kinetic coupling between on average one size larger for any given annulus. This results in the moving parts that are subjected to wear (sliding versus improved hemodynamics. The safety and efficacy of the St Jude Medical In the case of the Duromedics valve, a cavitation injury of Silzone (silver nitrate incorporated in the sewing cuff) was the disc and housing or pivot ball was found to occur with result under evaluation in the Artificial Valve Endocarditis ant fracture of the pivot ball and embolization of the disc (1). The design mod silver metal influenced healing at the sewing cuff of the pros ifications undertaken by Edwards Lifesciences (Baxter thesis. The extensive study of mucopolysaccharide matrix by the fixation process, which this prosthesis failure by the manufacturer identified studies for induces molecular crosslinks, and the tissue therefore becomes flow fields within the hinge region of a bileaflet prosthesis and more resistant to the axial compressive forces that accompany serves as a standard for assessment of future prosthesis designs. The microstructural flow analysis within the hinge pocket was Once buckling begins, it returns to the same spot with each made possible by the creation of an optically clear, dimension successive heart beat and the collagen fibres may fatigue until ally accurate reproduction of the prosthesis. Tissue buckling is particularly prominent when the of the bileaflet prosthesis was made possible by a clear epoxy valve is mounted onto a stent. This replica of the prosthesis facilitated flow stent-mounted valves do not open fully. Stent mounting not visualization, computational fluid dynamics modelling, laser only produces higher transvalvular gradients but also causes Doppler velocimetry measurements and laser Doppler premature valve failure. In the brief period in which hinge mechanism of the Medtronic Parallel prosthesis corre homografts were stented, the average life expectancy of the lated with multiple zones of stagnation, distributed flow and valve was less than 10 years. In sharp contrast, nonstented elevated shear stresses during the leakage flow phase. There is the likelihood Tissue buckling promotes calcification that predictably of reduced thromboembolism and thrombosis with future pros begins and increases in areas of leaflet flexion where deforma theses and the potential for reduction of anticoagulation levels. This in turn minimizes tissue buckling and serve biological tissue, both porcine aortic and bovine peri should increase valve longevity. However, the fixa valve degeneration was less with a stentless bioprosthesis than tion process also alters the mechanical and viscoelastic charac with a stented bioprosthesis. These results support the hypothe teristics of the leaflets, producing abnormal valve function, sis that valve leaflets are subjected to less bending when normal leading to overstressing and eventually to valve degeneration valve and root interactions are maintained. This concept can be understood by an analysis of Stentless porcine xenografts were reintroduced into clinical the internal mechanical stress that bioprosthetic valves are practice a decade ago in the hope that elimination of the subjected to: (i) tensile stress which results primarily from sewing ring and supporting stent would produce a device with hydrostatic forces applied while the valve is closed, (ii) inter superior hemodynamics and enhanced longevity (15-17). There is a large and compelling body of evidence Can J Cardiol Vol 20 Suppl E October 2004 93E Jamieson et al that these devices are hemodynamically superior to conven (25). Furthermore, to date, in two large inter content of the leaflets, reduces cholesterol uptake and increases national trials, no Medtronic Freestyle (Medtronic Inc) and the resistance to collagenase digestion. However, cation agent and zero pressure fixation may produce optimal few patients have yet to reach the 10 to 12-year follow-up results with the technology currently being employed in clini interval. Ethanol pretreatment when combined with alu determine whether these valves will function longer than con minum chloride has been shown in investigative endeavours to ventional stented bioprostheses. These There have been other strategies introduced over the past approaches are being evaluated clinically. These There are several alternatives to glutaraldehyde fixation in have related primarily to normalization of tissue collagen con the experimental phases of investigation. The agents being figuration at the time of glutaraldehyde fixation, as well as to studied are either incorporated into the tissue (eg, epoxide or control of tissue calcification with the use of surfactant treat glutaraldehyde) or act as promoters of the crosslinking process ment (18). The the pressure the tissue is subjected to during the fixation epoxide compounds, such as denacol, form strong crosslinks process significantly alters the normal architecture of the aor with the carboxyl and amino protein groups (37,38). Examination of the cuspal tissue of commer the compounds acyl azide and carbodiimide facilitate cially processed xenografts demonstrate near complete loss of crosslinking without incorporating the agents into the fixed transverse cuspal ridges and collagen crimp in valves fixed at tissue (26,39). The Ultifix fixed at zero pressure retain a collagen architecture virtually method (carbodiimide) uses a coupler to link the amine and identical to that of native unfixed porcine aortic valve cusps carboxyl moities by the formation of a Schiff base (26). It is thought that the role of the collagen crimp is to pre treated tissue is not exposed at any time to glutaraldehyde, vent tissue buckling that, in turn, will retard mineralization of only the valve cusps and not the wall will show significant the cuspal tissues (7). Medtronic Intact (Medtronic Inc) (zero pressure fixed) valve Dye mediated photo-oxidation is also a promoting process has been reported (19). The tissue, either pericardium or cases of primary structural degeneration in patients over porcine, is treated with an aqueous solution including the photo 60 years of age and only one case of valve failure in individuals oxidative dye and light irradiated. Considerable effort has been made by both industry and Photo-oxidation has been proposed to replace glutaraldehyde, investigators to develop compounds that will retard or possibly and has been used to fix both bovine pericardial tissue and completely eliminate leaflet calcification. Surfactants, particularly sodium dodecyl glutaraldehyde cross-linking of heterographic tissue. While these compounds do not alter the collagen carditis similar to that of allografts (40-43). Investigative clinical trials of at least some of these agents the control of residual aldehydes, following glutaralde should commence within the next few years. The premise is to create a living valve that will not be rejected Of the antimineralization compounds currently in clinical by the patient’s own immune system. These tissue engineering techniques are it does not prevent calcification of the aortic wall. Finally, the focused on fabricating the intricate architecture of the valve No-React detoxification process has been proposed as a leaflets. Scaffolds have been developed from synthetic and nat method of preventing calcification of glutaraldehyde fixed tis urally occurring polymers and then cellularized from host sue (24). Detoxification with homocysteic acid is used in Sorin endothelial cells in tissue culture. These cells would then be cultured and Pretreatment of the tissue with ethanol before glutaraldehyde incorporated into the scaffold. A living valve with recipient fixation may play a role in future anticalcification strategies specific endothelial cells would then be implanted at the time 94E Can J Cardiol Vol 20 Suppl E October 2004 Surgical management of valvular heart disease of surgery. On a theoretical basis, these approaches are the thermoplastic biopolyesters that have been studied to mould a most attractive. The disadvan allograft bioprosthetic valves that have been fabricated from tages of these synthetic polymers are stiffness, thickness and acellular tissues, cryopreserved and implanted as pulmonary root nonpliability. After 150 days, the grafts matrix is conducted with fibroblasts, smooth muscle cells and showed intact leaflets with ingrowth of host fibroblastoid cells in endothelial cells. The xenogenic or allogenic biological extra all explanted porcine valves and no evidence of calcification. These modalities provide the opportunity for a use of glutaraldehyde for collagen crosslinking to limit physiological environment that is nonimmunogenic with the xenograft antigenicity. There is extensive research on polyetherurethane polymer In summary, the current status of achieving tissue engi alternatives for valve prostheses. Polyurethane flexible pros neered heart valves with autologous cells is to have scaffolds of theses are being evaluated in sheep models (63). There is also either biodegradable polymers or biological extracellular matri preliminary investigation on percutaneous aortic valves, as ces.

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I am honored to join you and thousands of our colleagues from around the globe who share in our Society’s mission of advancing knowledge, awareness, and education to advance the discovery and clinical application of gene and cell therapies for alleviation of human disease. This scientifc and educational program refects the wonderful advancements that have occurred in gene and cell therapy over the past year. Our invited faculty includes nearly 150 investigators in our feld, presenting cutting edge research in the 23 Scientifc Symposia and overviews of important concepts and technologies in the seven Education Sessions. Michel Sadelain, who will present the George Stamatoyannopoulos Lecture on Tuesday. On Wednesday morning, the presentation of the Outstanding Achievement Award to Dr. We are also thrilled to share 1,000 abstracts featuring groundbreaking scientifc and clinical advances across the breadth of our feld that will be presented as oral presentations or at poster sessions. I look forward to the Annual Meeting program with an immense sense of excitement and pride in our feld. The reception takes place in the National Portrait Gallery of the Smithsonian Institute, where we will enjoy live music and dancing as well full access to the museum’s collections including the Orchids, American Presidents, and Henrietta Lacks exhibitions. Be sure to visit our Exhibit Hall to fnd out about the products and services offered by more than 100 partner companies, via conversations at their booths and more formal presentations in the Tools & Technologies Forum. Finally, I would like to thank everyone involved in the planning and execution of our Annual Meeting, especially the Program Committee, Scientifc and Education Committees, abstract reviewers, staff and all of our volunteers. Their sustained support, dedication and hard work throughout the year now comes to fruition in what is sure to be a spectacular meeting. I sincerely hope you enjoy the science, technology, networking, and camaraderie that we have built together! Attendees are able to access a copy of the supplement online at the Molecular Therapy website, or have access to the abstracts through the Mobile App. Name badges should be worn at all times inside the Hilton, as badges will be used to control access to sessions and activities. It is open Monday – Friday from 7:00 am to 7:00 pm and on Saturday from 9:00 am – 3:00 pm. A Concierge Desk is located in the Main Lobby of the Washington Hilton, with Hilton staff who can help you with your city needs and reservations. Better instruct their students in medical school and other health venues using the state of-the-art basic science and clinical trials data presented at the meeting. Use the latest advances in gene and cell therapy to enhance their research mission, as physician scientists conducting basic and clinical research. Oligonucleotide Therapies, Novel Vector Development, Host-Vector Interactions and Vaccine Therapies will be discussed as well as many other scientifc topics. This meeting will provide an educational forum for scientists and clinicians to expand their knowledge about the broad developments in these felds. If you have open positions, bring a printed copy of your job posting to the meeting. If you would like more information about this service, please contact Samantha Kay at skay@asgct. All participants are urged to allow adequate time daily to visit the exhibits, as they are an integral part of the success of the meeting. Exhibitors may ask to scan attendee name badges with a hand held scanner in order to obtain attendee contact information. Registration will be located at the Registration Desk on the Terrace Level of the Washington Hilton Hotel. Interview space, computers and internet services are available for the convenience of media representatives covering the meeting. Assistance will be provided to members of the media that would like to schedule interviews. To schedule a time to use the press room, contact Alex Wendland at awendland@asgct. All speakers, including oral abstract presenters, must deliver their presentations to the Speaker Ready Desk the day before their session or at least four hours prior to their presentations. Equipment is available at the Speaker Ready Desk for faculty to review their materials. Please mark your materials (your name, session and speaker order) so the materials can be returned to you. The Society strongly encourages faculty to pre-load presentations at the Speaker Ready Desk; those faculty who load presentations in the meeting rooms during the sessions will have that time deducted from their presentation time by the Chair. Join now for access to: • Annual Meetng Discounts • Molecular Therapy Subscripton • Opportunity for Commitee Involvement • Grants & Awards and more! Schaffer, PhD University of California Berkeley Shen Shen, PhD Editas Medicine Arun Srivastava, PhD University of Florida College of Medicine Junghae Suh, PhD Rice University Jude J. Rossi, PhD Beckman Research Institute City of Hope Bruce Sullenger, PhD Duke University Medical Center Paul N. Davidson, PhD Children’s Hospital of Philadelphia Jane Farrar, PhD Trinity College Dublin Guangping Gao, PhD University of Massachusetts Medical School Jeffrey H. Sinai School of Medicine Alessio Cantore, PhD San Raffaele Telethon Institute for Gene Therapy Conrad Russell Y. Herzog, PhD Indiana University Denise Sabatino, PhD the Children’s Hospital of Philadelphia Brandon K. To get involved in this important initatve, contact Alison Kujawski at akujawski@asgct. Shuttle buses will leave from the T-Street Entrance (Terrace Level) of the Washington Hilton Hotel. In 2019, 6 recipients will receive grants of $50,000, with grant funds totaling $300,000. 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Pulp Multiple septa antibiotic eye ointment for dogs purchase cefpodoxime 200mg without a prescription, nerves infection after wisdom tooth extraction quality cefpodoxime 200 mg, arteries Felon is an infection of the pulp Paronychia Radial and ulnar nail folds Common site of infection Eponychia Proximal nail fold Common site of infection • the digital artery is supercial/volar to infection headache order cefpodoxime 200 mg with amex the nerve proximally but runs dorsal to antibiotic 101 generic cefpodoxime 100mg on line the nerve in the nger. Use 22 gauge or smaller needle, and insert into joint (if available use an image intensier to conrm needle is in joint). Palpate the exor tendon at the distal palmar crease over metacarpal head/A1 pulley. Insert 25 gauge needle into exor tendon at the level of the distal palmar crease. Withdraw needle very slightly so that it is just outside tendon, but inside sheath. Insert 25 gauge needle between metacarpal necks (metacarpal block) or on either side of proximal phalanx (digital block) in digital web space. Inject 1-2ml of local anesthetic (without epinephrine) on both sides of the bones. Care should be taken not to inject too much uid into the closed space of the proximal digit. Trauma Fall, sports injury Fracture, dislocation, tendon avulsion, ligament injury Open wound Infection 8. History of arthritides Multiple joints involved Rheumatoid arthritis, Reiter’s syndrome, etc. Bouchards nodes seen of other fingers in proximal interphlangeal joints of the ring and small finger. Scaphoid Ulnar nerve compression Interosseous muscle wasting from ulnar nerve compression Median nerve compression Rotation displacement of ring Atrophy of thenar muscles finger. It can be extended passively, and extension occurs with distinct and painful snapping action. Circle indicates point of tenderness where nodular enlargement of tendons and sheath is usually palpable Purulent tenosynovitis. Slight flexion near flexion crease of palm at base of involved fingers with cordlike formations extending to proximal palm 4. This nerve continues into the dorsal aspect of the ulnar digits as dorsal digital nerves. Ulnar nerve enters Guyon’s canal, then divides into supercial (sensory) and deep (motor) branches. The deep branch bends around the hook of the ha mate and runs with the deep arterial arch. The supercial branch continues into the palmar aspect of the ngers as the palmar digital nerves. The deep branch runs thru the bellies of the 1st dorsal interosseous muscle & terminates as the deep palmar arch. Cartilage destruction and wrist joint, osteoporosis, and finger deformities nodes) at articular margins of distal marginal osteophytes (Heberden’s phalanx. Lines of incision indicated for tendon sheaths of other fingers (A); radial and ulnar bursae (B); and Parona’s subtendinous space (C) Felon Begins as small nodule and From focus in thumb spreads spreads to hand, wrist, fore through radial and ulnar bursae arm (even systemically). Line of incision indicated Infection of thenar space from tenosynovitis of index finger due to puncture wound. Dupuytren’s Stenosing Tenosynovitis (Trigger Finger) Disease Partial excision Inflammatory thickening of fibrous sheath (pulley) of of palmar fascia flexor tendons with fusiform nodular enlargement of with care to avoid both tendons. Mild: no treatment • Radial deviation of small nger #1 metic and functional complaints 2. Gener Type 4 is most common pending on which type of duplication ally, retain ulnar thumb/ • Autosomal dominant or sporadic structures & reconstruct • Associated with some syndromes radial side. Complete amputations if necrosis or diminished growth/ level of diminished growth needed development. Landmark used for measuring the “Q” angle of the knee Symphysis pubis Site of osteitis pubis; uncommon cause of anterior pelvic pain Inguinal ligament External iliac artery becomes femoral artery here; femoral pulse can be palpated just inferior to the ligament in the femoral triangle. Posterior superior iliac spine Site of bone graft harvest in posterior spinal procedures. Ischial tuberosity Avulsion fracture (hamstring muscles) or bursitis can occur here. Strong, weight-bearing region Gluteal lines 3 lines: anterior, inferior, posterior • Separate origins of gluteal muscles Gtr. Superior gluteal nerve • Superior gluteal nerve and artery exit superior to the 2. Nerve to the Obturator internus • Sciatic nerve (especially peroneal division) may exit 7. Posterior Cutaneous nerve of thigh pelvis above or through the piriformis as an anatomic 8. Safe screw placement Inferior gluteal nerve, artery, vein can be achieved with care if necessary. Pain may Transverse fracture of the sacrum that is minimally displaced persist for a long time. Complete neuro Zone 2: through cutaneous xation • Nerve root injury very com exam including rectal foramina Open reduction, internal mon exam. Age Young Ankylosing spondylitis Middle aged–elderly Sacroiliitis, decreased mobility 2. Onset Acute Trauma: fracture, dislocation, contusion Chronic Systemic inammatory, degenerative disorder b. Occurrence In/out of bed, on stairs Sacroiliac etiology Adducting legs Symphysis pubis etiology 3. Neurologic symptoms Pain, numbness, tingling Spine etiology, sacroiliac etiology 7. When weight is on Rectal examination for sphincter function and perianal affected side, normal sensation. Gross blood indicates pelvic fracture hip drops, indicat communicating with colon. Two divisions: anterior Iliohypogastric nerve (innervates exors), posterior (exten L2 Ilioinguinal nerve sors). Genitofemoral nerve rami of Lateral femoral L3 spinal Anterior Division cutaneous nerve nerves Subcostal (T12): Inferior to 12th rib Gray rami communicantes Sensory: Subxyphoid region L4 Motor: None Muscular branches to psoas and iliacus Iliohypogastric (L1): Under psoas, muscles pierces abdominal muscles L5 Femoral nerve Sensory: Above pubis Accessory obturator Posterolateral buttocks nerve (often absent) Lumbosacral trunk Motor: Transversus abdominis Obturator nerve Internal oblique Ilioinguinal (L1): Under psoas, pierces abdominal muscles Obturator (L2-4): Exits via obturator canal, splits into ant. Anterior Division Nerve to quadratus femoris (L4-S1): Exits greater Pudendal (S2-4): Exits greater then re-enters pelvis through sciatic foramen lesser sciatic foramen Sensory: None Sensory: Perineum: Motor: Quadratus femoris via perineal nerve (scrotal/labial br. Anatomic vari Nerve to Piriformis (S2): Directly innervates muscle ants include exiting through or above piriformis. Motor: Piriformis Sensory: None (in pelvis; see Chapters 8-10) Motor: None (in pelvis; see Chapters 8-10) Other Nerves (Nonplexus) Superior Cluneal (L1-3): Branches of dorsal rami. Medial Cluneal (S1-3): Branches of dorsal rami Sensory: Superior 23 of buttocks Sensory: Sacral and medial buttocks • Piriformis muscle is the landmark in gluteal region. Between iliopsoas/femoral nerve • Lateral femoral cuta of abdominal muscles & ilia anterior col & external iliac artery (pelvic neous nerve cus muscle for exposure umn of ace brim, lateral superior pubic • Inferior epigastric • Use rubber drains around ilio tabulum ramus) artery psoas/femoral n. Iliotibial tract (band) Can snap over greater trochanter of femur, creating “snapping hip” syndrome. Patient supine on table, under Dislocated femoral head lies posterior shows posterior dislocation anesthesia or sedation. Femur distal traction at flexed knee to pull head into adducted and internally rotated; hip acetabulum; slight rotary motion may also flexed. Assistant fixes pelvis by pressing on anterior superior iliac spines Anterior Dislocation Characteristic position Anterior view. Hip foramen of pelvis; hip flexed and femur flexed, thigh abducted widely abducted and externally rotated and externally rotated. Careful pulse B: Unicondylar Extraarticular: plate or nail for normal knee function evaluation (Doppler subtypes 1, 2, 3 Intraarticular: anatomic re • Many associated injuries exam if needed) C. Insert 20-gauge (3in) spinal needle upward/slightly medial direction at that point. Lateral: Insert a 20-gauge (3in) spinal needle superior and medial to greater trochanter until it hits the bone (the needle should be within the capsule, which extends down the femoral neck).

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  • https://www.asahq.org/-/media/sites/asahq/files/public/about-asa/governance-and-committees/caesar-covid/socca-residents-guide-2017.pdf?la=en&hash=E68064D7628D94CBEF659BF3AD35E28F7BC9937D
  • https://www.cardioteca.com/images/contenidos/Advanced-heart-failure-a-position-statement.pdf
  • http://meak.org/science/Kelly-C-Rogers/order-careprost-online-in-usa/