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Modified from Diamond and Forrester New Engl J Med 1979 b Only one of the three characteristics of angina pectoris is present (either retrosternal localization of pain order super cialis 80mg free shipping impotence urologist, pain precipitated by exercise or decreased at rest discount super cialis uk impotence pump medicare, or on nitrate medication) c Only two of the three characteristics of angina pectoris are present d All of the three characteristics of angina pectoris are present Please note that 1. Modified from Diamond and Forrester New Engl J Med 1979 b Only one of the three characteristics of angina pectoris is present (either retrosternal localization of pain, pain precipitated by exercise or decreased at rest, or on nitrate medication) c Only two of the three characteristics of angina pectoris are present d All of the three characteristics of angina pectoris are present Please note that 1. In only rare cases there is a clinical indication for cardiac function analysis alone. Tus, the technical approach may higher overall radiation exposure, downstream utiliza- better individually focus on two of the vascular beds tion, and invasive testing. However, the available evi- for follow-up of coronary aneurysms; however, in young dence (Chaps. Also, involve radiation exposure, and there is no need for con- because such stents represent 70–80 % of all implanted trast agent administration. Terefore, because of the importance of global should be made individually on the basis of the stent as well as regional cardiac function for the patient’s prog- material and diameter; however, selected patients with nosis and further management (Chap. It also helps standardize and positive results of noninvasive tests (high pretest likeli- facilitate communication with referring physicians. J Am Coll Cardiol 48:1896–1910 Cardiology and Cardiovascular Disease in the Young. N Engl racic echocardiography: comparison with magnetic resonance J Med 366:1393–1403 imaging. J statement of the North American Society of Cardiac Imaging and the Am Coll Cardiol 49:946–950 European Society of Cardiac Radiology. Circulation diagnostic accuracy of dual-source computed tomography coro- 114:645–653 nary angiography. On the other hand, should be used to make every patient understand the the patient must also be given explicit information about nature of the procedure. Such efective doses are lower than necessary federal legal regulations) should discuss the entire pro- for nuclear myocardial perfusion imaging (about 8–12 cedure with the patient and obtain written informed mSv) and conventional coronary angiography (about 8 consent. This questionnaire elicits information about the patient’s entire cardiovascular medical history and is very valuable for diagnostic procedures in the outpatient setting 54 Chapter 6 ● Patient Preparation Patients should know that lower heart rates (<60 beats examination be performed at a later time, for example per min) are associated with longer cardiac rest periods afer medical or electrical cardioversion. Informing about general contraindications to contrast agents (List them about the entire procedure prevents inadvertent 6. It is gener- be informed that they should hold their breath afer ally desirable to administer nitroglycerin because of the submaximal inspiration (ca. The submaximum depth of inspiration is important, because maximal inspiration may increase intrathoracic pressure List 6. Contraindications to iodinated contrast (Valsalva maneuver) and reduce infow of the contrast agents medium. Breath-hold train- nephropathy can be taken) ing on the scanner table is therefore also important 2. Intake of metformin-containing medications to determine whether a patient is able to hold his or (metformin needs to be discontinued for 48 h her breath for the required duration, or whether oxy- after contrast injection)a gen administration is needed to improve compliance. Using wide-volume scanning (320-rows) imaging in those patients) or fast prospective spiral acquisitions with second- 4. Intake of phosphodiesterase inhibitors (such as examiner should make sure that the patient is in sinus sildenafil, tadalafil, and vardenafil) rhythm. Arterial hypotension (systolic blood pressure feeling the radial pulse when meeting the patient. In the below 100 mmHg) case of patients with atrial fbrillation or frequent extra- 3. Hypertrophic obstructive cardiomyopathy ning period), the per-patient diagnostic accuracy is still 5. Second or third degree atrioventricular block C, Hamm B, Dewey M (2012) Indications, imaging technique, and 5. Radiology 244:48–63 Schönenberger E, Schnapauf D, Teige F, Laule M, Hamm B, Dewey M Achenbach S (2006) Computed tomography coronary angiography. J Am (2007) Patient acceptance of noninvasive and invasive coronary Coll Cardiol 48:1919–1928 angiography. Reconstruction performed on a 1602 matrix cardiac cycle with a temporal resolution of 250 ms. However, a serious limitation of the technique devel- oped by Harell was that they could only reconstruct images of a single plane of the heart. Noncalcified fibrotic plaque +80 (+30 to +130 Noncalcified lipid plaque +10 (−40 to +40) 7. In addition, image noise should be low enough and the contrast-to-noise ratio high enough for visual- Water 0 ization of the coronary arteries. However, for accurate visualization of very small and are given in Hounsfeld units, see Table 7. In axial scans, the table translation bound to merge together in the reconstructed image. This is referred to as a multisegment reduce the tube current during helical acquisitions. Axial scans have the advantage of reducing patient dose, but the required stitching of 7. Of course, prospectively acquired axial scans noise may be decreased by raising the tube current (step-and-shoot) do not allow assessment of cardiac 61 7 7. All helical acquisitions depicted in (Panels A–C )allow assessment of cardiac function. Different axial scans are separated by at least one heartbeat to allow for translation of the patient. Such novel “single heartbeat” techniques within a single heartbeat are prone to artifacts caused by carry the promise of further dose reduction. The appear- arrhythmia, since it is not possible to predict if the sub- ance of helical and axial scans on flm that is exposed on sequent heartbeat will be stable or irregular. There is significant overscanning visible on the films exposed using these approaches. Thus, for this scanner, we used a very sensitive film (GafChromic) that was circularly placed around a body phantom and gave the results shown in (Panel E). In this example, 16 cm were covered in the Z-axis and the resulting effective dose was below 1 mSv; however, one should note that 25 cm were radiated along the Z-axis because the adaptive dose shield is currently not fast enough to completely avoid over- ranging in high-pitch spiral scans (We are thankful to R. Example of a 66-year-old woman who had a premature atrial contraction during the heartbeat intended for volumetric scanning (asterisk in (Panel A). Scanning was immediately stopped when the arrhythmia occurred and was continued during the subsequent beat with a safety window (Panel A). Only the second, nonarrhythmic beat was used for reconstruction of images (Panel B). Physicists provide the basis for radiation dosimetry with the defnition of the funda- Bone marrow 0.

She was on antiretrovirals prenatally with an undetectable viral load and is doing well order super cialis erectile dysfunction treatments herbal. Based on the results of this clinical trial and the guidelines that have been set out since its publication (htp:// aidsinfo super cialis 80 mg on line erectile dysfunction herbal supplements. Suggested Answer: Afer birth the infant should begin receiving oral zidovudine within 6–12 hours. Typically a follow-up visit purely to check medication compliance is done at 2–4 weeks of age, and also to screen for zidovudine-associated anemia. Maternal viral load, zidovudine treatment, and the risk of trans- mission of human immunodefciency virus type 1 from mother to infant. Follow- Up: Children were followed until 30 days afer the last scheduled injection (total of 150 days), with assessments at each injection visit and daily if hospitalized. T is may explain why a wide variation was seen in hospitalization reductions: 56% reduction in the united States versus 64% reduction in the united Kingdom versus 40% reduction in Canada. In addition, the pos- sibility of co-infections with other viruses or bacteria is not clearly addressed. Finally, patients with renal, hepatic, or signifcant cardiac comorbidities were excluded, as were those with seizure disorders or immunodefciencies, and thus the results may not apply to these high-risk populations. Suggested Answer: In addition to discussing strategies to avoid infection (hand washing, avoiding known sick exposures) with the family, it is important to ofer palivizumab pro- phylaxis for this infant. Palivizumab, a humanized respiratory syncytial virus monoclonal antibody, reduces hospitalization from respiratory syncytial virus infection in high-risk infants. Prophylactic administration of respi- ratory syncytial virus immune globulin to high-risk infants and young children. Reduction of respiratory syncytial virus hospital- ization among premature infants and infants with bronchopulmonary dyspla- sia using respiratory syncytial virus immune globulin prophylaxis. Efectiveness of palivizumab: evaluation of outcomes from the 1998 to 1999 respiratory virus season. Lower tract disease was cate- gorized as croup-laryngitis, tracheobronchitis, bronchiolitis, or pneumonia. Known allergic children were included if their wheezing occurred with other signs of respiratory tract infection. Who Was Excluded: Children seeking care for other purposes at the pediatric practice or those over 15 years of age; children whose parents refused consent. Study Overview: Consenting children (per parents) were examined and had clini- cal and epidemiologic data collected, as well as throat culture for viruses and myco- plasma sent. Criticisms and Limitations: is study was performed in a single center with a group of initially two pediatricians that grew to a total of four. T e inclusion of patients depended on the clinical categorization of their illness as lower respi- ratory tract, which was not corroborated with imaging or any other modality. Additionally, there are no descriptions of interobserver variability or reliability between diferent practitioners’ assessments. T roat swabs were used to determine etiologic agents of lower tract illness, but it is now known that the agents present in the oropharynx may not accurately describe lower respira- tory tract pathogens. Additionally, “croup-laryngitis” is discussed as a single entity, while currently these are man- aged as distinct clinical entities. Other Relevant Studies and Information: • is group also published studies analyzing respiratory infections utilizing data from their outpatient private practice and a local university daycare2; they also studied the epidemiology and etiology of croup3 and tracheobronchitis. His parents are concerned because he was hospitalized overnight at 4 months of age for bronchiolitis. Descriptive epidemiological features of bronchiolitis in a population- based cohort. Viral etiologies of infant bronchiolitis, croup, and upper respiratory illness during four consecutive years. Subjects had either premature labor prior to 37 weeks gestation, or pro- longed rupture of membranes >12 hours, since those are sepsis risk factors. A total of 20 women and their 21 infants were later excluded due to intrapartum fever, randomization errors, or incomplete data. Follow Up: Patients were followed until the results of postpartum cultures were known, and the women’s postpartum clinical courses were followed. Endpoints: Infants were tested for colonization of “surface” sites (external audi- tory canal, throat, gastric contents, umbilicus, and rectum), and bacteremia. T e women were tested for postpartum vaginal group B streptococcal colonization and postpartum illness (temperature > 37. Criticisms and Limitations: e exclusion of 20 women, including 13 with intrapartum fever, may have introduced atrition bias. T ese women and their babies may have been most likely to be infected, and they were not included in the analysis. No participants in the study, including outcome assessors, were blinded, which may have introduced detection bias. T e study excluded women with full-term babies whose membranes were rup- tured fewer than 12 hours, so the results might not be generalizable to those patients. She wonders if the benefts outweigh the risks, noting a friend who has a penicillin allergy. Infection in babies is much less likely when mothers receive antibiotics in labor. T is beneft appears to come without the risk of antibiotic resistance or more infections with other bacteria. With regard to her question about allergic reactions, you might tell her that anaphylaxis with intrapartum antibiotics is extremely rare, especially in a person without pre- vious penicillin allergy, and her doctors will be closely monitoring her for any reaction. Prevention of early-onset neonatal group B strepto- coccal disease with selective intrapartum chemoprophylaxis. Who Was Excluded: Infants who did not have scoring performed, or for whom the charts were unavailable. Components of the Apgar Score Apgar score 0 1 2 Heart rate None <100 100– 140 Respiratory efort Apneic Irregular or Breathing or crying shallow Refex irritability None Reduced grimace, sneeze, or cough Muscle tone Flaccid Decreased good tone, spontaneously fexed arms and legs Color Cyanosis Acrocyanosis entirely pink Dr. Apgar then looked for factors such as mode of delivery and type of anes- thesia that might be associated with lower scores. T e author states that most of the deliveries for which the chart was missing were low-risk deliveries. Additional Information: • Most institutions added 5-minute scores afer they were shown to correlate more closely with mortality. In one cohort of 49,000 infants followed for 7 years, 73% of those who developed cerebral palsy had 5-minute Apgar scores ≥7. Apgar’s name5: • Appearance (color) • Pulse (heart rate) • Grimace (refex irritability) • Activity (muscle tone) • Respiratory efort • Apgar scores are not used to dictate resuscitation since resuscitative eforts must be initiated before 1 minute of life.

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Panel A shows a curved multiplanar reformation of the left anterior descending coronary artery with a 90 % stenosis (arrow) and corresponding anterior ischemia (arrows) on stress myocardial perfusion with monochromatic imaging before stent implantation (Panel B) cheap super cialis 80mg otc erectile dysfunction unani medicine. Panels C and D show the results after stent implantation with improved blood flow (arrowheads) (Image courtesy of G generic 80 mg super cialis free shipping erectile dysfunction doctors in lafayette la. Various automatic phase selection sofware tools are now available for use in Abstract clinical practice. If the phases reconstructed using any of these methods are not sufcient for making a reliable diag- In this chapter, we describe how to read and report nosis, further reconstructions (e. Typical artifacts and how to avoid them is also reviewed, a coronary artery segment may occasionally discussed in this chapter. Note the excellent visualization of the distal vessel segment with automatic phase selection (asterisk in Panel A ). There are multiple motion artifacts in the other reconstruction intervals (marked with asterisks), rendering these phases nondiagnostic (artifacts were identified using the axial source images). In many cases, the right coronary artery is best seen at end-systole (especially at higher heart rates) If a stenosis is seen in any phase, this fnding should potential motion in the image (e. If no stenoses are seen and image quality is good, frmation can be accomplished in two ways: (1) by cor- it is not necessary to go through all the reconstructed relating the results with those for the same coronary coronary artery phases. As in all radiological examinations, a systematic reduction) stenoses in distal segments or minor side approach is pivotal to a comprehensive evaluation of branches without a more proximal stenosis (Fig. Easy evaluation of Tus, major branches and side branches as well as bifur- the coronary arteries is now possible by reading (semi) cations are frst places to look when searching for signif- automatic curved multiplanar reformations, which are cant stenoses. However, the fndings is an interesting indirect indicator of a signifcant steno- should always be confrmed on the original slices in sis located distally, and its recognition is critical. Reading Furthermore, aneurysms of the coronary arteries are is improved when curved multiplanar reconstructions, present in 5 % of patients with atherosclerotic coronary double-oblique reconstructions, and source images artery disease but can also be present in patients without signifcant stenoses (Fig. Obtain a quick overview of the gross anatomy, ventricular contraction, extrasystoles, or atrial fbrilla- e. Assess the individual coronary arteries and major phases selected for image reconstruction. Evaluate the cardiac extracoronary structures d triggering and reconstructing image data without scan- 4. The axial source images represent the basic reconstructions that contain all c This includes the cardiac valves, the myocardium, the atrial, information available in the three-dimensional dataset. Scrolling This includes assessment of all organs other than the heart and has to be performed on large fields of view. Evaluate the through the slices back and forth on a workstation is the large vessels (e. Additional informa- the pulmonary arteries for presence of emboli), mediastinum, tion can be obtained from thin-slab maximum-intensity hila, lungs, chest wall and breasts, abdominal organs, and bones in organ-adapted window-level settings. The left main coronary artery (segment 5) is also of great relevance and in about 3 % of cases obstructive stenoses are found here; they are mainly treated with bypass grafting (about two-thirds of cases) and less commonly with percutaneous coronary intervention. It is important to note that it is very rare to detect an isolated distal obstructive (>50 %) stenosis without a significant proximal lesion in a patient. Nevertheless, also side branches and distal segments (as small as 2 mm in diameter) need to be searched for significant stenoses that might be amenable to treatment. Bifurcations are other important sites to look for stenoses when ruling out coronary artery disease. The left anterior descending coronary artery consists of segments 6–10, with the two diagonal branches being segments 9 and 10. The left circumflex coronary artery consists of segments 11–15, with the two (obtuse) marginal branches being segments 12 and 14. In case of right-coronary dominance, at least one right posterolateral branch (segment 4b) is present and supplies the inferolateral myocardial segments. If the left coronary artery is dominant, the distal left circumflex ends as the posterior descending coronary artery (segment 4a). In case of codominance, segment 4a is part of the right coronary, and the distal left circumflex ends as a posterolateral branch (4b) after giving off two marginal branches. Volume-rendered image (Panel A) and multiplanar reconstructions (Panels B and C) of the left anterior descending coronary artery in a 47-year-old male with atypical chest pain. The patient had no coronary artery stenoses but did have dilating coronary artery disease. There is some focal myocardial bridging, and the right and left circumflex coronary arteries were also dilated (not shown) 155 10 10. Excluding the arrhythmic peaks and using only the typical R-wave peaks for editing (arrowheadsinPanel F) greatly improves the images of both the right (Panel B) and the left (Panel D) coronary artery system. The right-hand cornerinsetsin (Panels E and F) show the unedited and edited heart rate courses over time that were used for image reconstruction. Axial, coronal, and sagittal images are the pri- of the percent diameter stenosis (based on reference and mary source of information stenosis diameters, Fig. Curved multiplanar reformations are convenient Continuously improving automatic vessel detection for identifying stenoses and segmentation tools are available for the creation 3. Tese automatic overview of vessels and lesions but may obscure sofware tools are currently available on all commercial stenoses and overestimate calcified lesions workstations and allow diagnostic accuracy to be main- 4. Angiographic emulations and three- dimensional tained while relevantly reducing analysis time. When renderings may be used for elegant display and using one of the currently available reconstruction tools, presentation of findings however, the user must be aware of two limitations of automatic segmentation that can lead to false-positive or false-negative lesions: First, the automatic vessel prob- Compared with the source images, all other recon- ing tools do not always entirely follow the course of the structions such as curved reformations, maximum- coronary vessels (especially if these are very tortuous). This wide view can be benefcial in detecting rienced readers, curved multiplanar reformations alone abnormalities such as short coronary stenoses or wall are not recommended but should be supplemented by irregularities (Fig. Also, reconstructed images can interactive double-oblique reformations along the ves- be useful for demonstrating results during multidisci- sels. Printouts showing the recon- detection is that the most proximal segment of the coro- structed coronary arteries can be sent to the referring nary artery may not be completely probed. Signifcant physicians as summaries of image fndings and images proximal stenosis can thus be missed if one looks only stored in the picture archiving and communication sys- at the automatically probed vessel segments. However, tem can be used for demonstration in interdisciplinary this limitation is also easily overcome by manually conferences. Tese are currently being validated for Curved multiplanar reformations are generated using a clinical use and may have the potential to be used as a centerline along the coronary vessel path and show large second reader to increase sensitivity, especially when a parts of the coronary vessel lumen in a single image less experienced reader is interpreting the scan. Depending on the workstation In addition to motion artifacts resulting from a rapid used, the curved multiplanar reformations may be or irregular heartbeat, heavily calcifed coronary seg- rotated around their centerlines, thereby rotating the ments pose the greatest challenge because they obscure coronary artery lumen around its longitudinal axis and the coronary artery lumen (Fig. In contrast, this 75 % diameter stenosis (as measured on quantitative coronary angiography) is easily detected on a curved multiplanar reformation (arrow on Panel J ), demon- strating the advantage of such reconstructions along the vessel course. Curved multiplanar reformations allow estimation of the percent diameter stenosis from two perpendicular directions along the long axis or from orthogonal cross-sections and also the detection of coronary artery plaques, with evaluation of their composition.

Although the so-called upper-outer claim of autoimmune disease associated with breast quadrant will contain the most breast cancers discount 80mg super cialis fast delivery erectile dysfunction protocol ebook free download, so is that implants generic super cialis 80mg with amex erectile dysfunction drugs nz, there was never, either at the time or since, even location the quadrant that contains the most breast tissue; purported incidence or prevalence attached to that alleged hence, residency in the superolateral quadrant in of itself association; there were only patients (deluded or self- is not a particular danger sign in a nodule. Lack of an serving) and eager lawyers driving the claims through aspirant retrieval by tapping does not signal breast cancer, courts and too often succeeding, which gave birth to that but appearance of fluid aspirant in that situation rules wave of economic waste. Capsule contraction and scarring occur in 15% to hardness; 20 durometers is comparable to a soft to 25% of cases of silicone implants; implant rupture occurs medium grape and 60 durometers approaches the hard- in 5%. Perhaps, the most important is that the doctor should explain both the strengths and the weaknesses of any test 12. This is the foremost proce- women in the United States occur in women older than dure so that the patient is provided with the best data 65 years of age. About one-quarter occur in the age group through which the patient’s health care is in accord with of 50 to 65 years, leaving about one-quarter for the under the doctors, but avoiding placing the physician in a defen- 50 age group. It follows that patient and doctor must avail them- ing report on the subject was freshly published as that selves of other reasonable means of screening for breast manuscript was being processed. Mammography choice for the 26-year-old woman with a cyclically tender itself has been estimated to be only 70% sensitive. All other choices given in the vignette have ably, the cancers missed are most likely to be the smallest relevance at certain times and under certain circum- nodules by both methods. However, the clinical picture is that of fibrocystic tionable, breast self-examination appears to confer addi- disease. If the nodule disappears as fluid is yielded in the tional advantages only if performed monthly or more procedure in the given setting, cancer can virtually be often, even by an initially insecure and unpracticed woman. Disappearance is Specificity of all three methods is obviously imperfect, and defined as nonrecurrence of the cystic nodule after a negative breast biopsies will necessarily occur. Effect of age, breast density, and family history on the sensitivity of first screening mammography. She has (E) Reflex sympathetic dystrophy worked with her hands and wrists handling small part and feeding them into an automated machine 2 A 25-year-old woman fell onto her outstretched hand 100 times per hour, with 30 minutes for lunch break and incurred a fracture of the distal radius that and two 15-minute rest periods. There is no tenderness ven- following would be appropriate for treating this frac- trally over the radius or between the extensor tendons ture during the acute phase in the family doctor’s of the thumb. You consider tal palmar crease conservative management consisting of wrist splint- (E) Sugar-tong splint from the elbow to the distal ing in the neutral position, to prevent repetitive palmar crease gripping and wrist flexion, glucocorticoid injection into the carpal tunnel space, or both. What are the 3 A 45-year-old man works repetitively lifting 30- to chances of alleviation for an indefinite or perma- 40-pound boxes of steel auto parts overhead to place nent period? Yesterday during one such (A) Excellent move, he tripped and fell forward to catch himself (B) Good with his full weight on his arms and shoulders while (C) Not good still holding the box. This resulted in an acute severe (D) Poor sharp pain in the left shoulder accompanied by an (E) Nil audible pop. Among other tests the family doctor stands behind the patient with the patient’s left arm 6 A 28-year-old male patient slips and falls onto his at his side and elbow flexed 90 degrees. He right hand on the left shoulder with modest down- is complaining of wrist pain, and you examine him. There is an audible pop and the feel- longitudinal or torque stress to the distal radius. An ing of the head of the humerus riding over an appar- x-ray is negative for fracture of the distal radius or ent brief obstruction. However, 3 days later the patient (A) Impingement syndrome is still complaining of wrist pain. On re-examination (B) Biceps tendonitis you note tenderness near the base of the left thumb (C) Supraspinatus strain/sprain metacarpal between the extensor tendons. The (D) Clavicle fracture patient complains that the persistent pain is made (E) Torn superior labrum worse by clenching his fist. Since (C) Soft tissue sprain of the wrist experiencing prolonged use of a handheld posthole (D) Carpal navicular fracture digging tool a year ago, he has found that the numb- (E) Rupture of the flexor carpi radialis tendon ness has persisted even by day and involves the thumb and part of the ring finger. He complains also of mid- 7 An 18-year-old male high school student got into a ventral forearm pain and shoulder pain on the right. He the dorsal aspects of any of the fingers of the right has swelling of the hand seen prominently on the hand. Which of the following is the most sal aspect of the hand in the shape of a tooth mark. The fifth digit deviates in an ulnar direction when the (A) Median nerve compression fist is closed. Which of the following is the most com- (B) Cervical disc herniation involving C5, C6, and C7 plete diagnosis: (C) Scalene anticus syndrome (A) Contusion of the right hand (D) Herpes zoster (B) Closed fracture of the fifth proximal phalanx (E) Ulnar nerve compression (C) Open fracture of the fifth metacarpal (D) Closed fracture of the fifth metacarpal 5 Regarding the patient in Question 1, you perform (E) Infected open fracture of the fifth metacarpal and find positive the Phalen and Tinel tests. You find the following maneuver would be useful in determining finger to be swollen to about half above its normal whether this man has the impingement syndrome? There is pain with passive extension of the finger, and (A) Testing the proximal biceps insertion for ten- the hand otherwise presents no remarkable change. There has been holding his right arm with his left; the arm is held in no trauma to the elbow. Imme- tion diately he is in pain, holding his right arm with his (E) Cold applications to the elbow left hand. The right acromion 13 A 35-year-old woman has an accident in the kitchen manifests prominence that is reduced by downward with a paring knife. What is the most likely treatment of the (C) Buddy tape the finger to the adjacent middle patient? DeQuervain syndrome, also called gravity alone, sometimes called the “empty bucket test. The maneuver that produces Clavicle fracture is shown by obvious deformity (caused the pain with ulnar deviation while “making a fist” is by a direct blow or by falling laterally against the shoulder. Treatment is conservative with physical therapy modalities in the vast majority of 4. Carpal tunnel syndrome exhibits the typical median carpal tunnel syndrome, compression of the median nerve distribution of numbness and weakness of thumb nerve, secondary to relative contraction of the flexor reti- to finger opposition. Scaphoid fracture seldom if ever naculum of the wrist that contains the tendons, blood occurs without a clear cut history of fall onto the out- supply, and median nerve. It occurs commonly and is stretched hand and manifests tenderness in the anatomic aggravated by repetitive hand gripping. More important, of the distal radius is a non-entity but in traumatic frac- however, is that this patient does not exhibit dermatomal ture this injury too results from falling onto the out- distribution of the sensory symptoms, because the dorsa stretched hand. Reflex sympathetic dystrophy presents of the thumb, index, middle, and (half) of the ring fin- with marked palor, rubor, pain, and regional sweating. A short arm cast as described proxi- syndrome wherein the scalene anticus muscle in the tho- mal and distal to the fracture. A Volar splint extending racic outlet contracts and causes compression of the from the mid forearm to the distal palmar crease is too peripheral roots of C7, C8, or both, thus involving a dis- short and allows too much movement at the fracture, that tribution that approximates the ulnar nerve (sensation to is, forearm pronation and supination.

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