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ABSTRACT: Braces and splints can be useful for acute injuries, chronic conditions, and the prevention of injury. There is good evidence to support the use of some braces and splints; others are used because of subjective reports from patients, relatively low cost, and few adverse effects, despite limited data on their effectiveness. The unloader (valgus) knee brace is recommended for pain reduction in patients with osteoarthritis of the medial compartment of the knee. Use of the patellar brace for patellofemoral pain syndrome is neither recommended nor discouraged because good evidence for its effectiveness is lacking. A knee immobilizer may be used for a limited number of acute traumatic knee injuries. Functional ankle braces are recommended rather than immobilization for the treatment of acute ankle sprains, and semirigid ankle braces decrease the risk of future ankle sprains in patients with a history of ankle sprain. A neutral wrist splint worn full-time improves symptoms of carpal tunnel syndrome. Close follow-up after bracing or splinting is essential to ensure proper fit and use.
Joint and Soft Tissue Injection - Article
ABSTRACT: Injection techniques are helpful for diagnosis and therapy in a wide variety of musculoskeletal conditions. Diagnostic indications include the aspiration of fluid for analysis and the assessment of pain relief and increased range of motion as a diagnostic tool. Therapeutic indications include the delivery of local anesthetics for pain relief and the delivery of corticosteroids for suppression of inflammation. Side effects are few, but may include tendon rupture, infection, steroid flare, hypopigmentation, and soft tissue atrophy. Injection technique requires knowledge of anatomy of the targeted area and a thorough understanding of the agents used. In this overview, the indications, contraindications, potential side effects, timing, proper technique, necessary materials, pharmaceuticals used and their actions, and post-procedure care of patients are presented.
ABSTRACT: The prevalence of nutritional iron deficiency anemia in infants and toddlers has declined dramatically since 1960. However, satisfaction with this achievement must be tempered because iron deficiency anemia in infants and toddlers is associated with long-lasting diminished mental, motor, and behavioral functioning. Additionally, the prevalence of iron deficiency anemia in one- to three-year-old children seems to be increasing. The exact relationship between iron deficiency anemia and the developmental effects is not well understood, but these effects do not occur until iron deficiency becomes severe and chronic enough to produce anemia. At that point, treatment with iron can reverse the anemia and restore iron sufficiency, yet the poorer developmental functioning appears to persist. Therefore, intervention should focus on the primary prevention of iron deficiency. In the first year of life, measures to prevent iron deficiency include completely avoiding cow's milk, starting iron supplementation at four to six months of age in breastfed infants, and using iron-fortified formula when not breastfeeding. Low-iron formula should not be used. In the second year of life, iron deficiency can be prevented by use of a diversified diet that is rich in sources of iron and vitamin C, limiting cow's milk consumption to less than 24 oz per day, and providing a daily iron-fortified vitamin. All infants and toddlers who did not receive primary prevention should be screened for iron deficiency. Screening is performed at nine to 12 months, six months later, and at 24 months of age. The hemoglobin/hematocrit level alone detects only patients with enough iron deficiency to be anemic. Screening by erythrocyte protoporphyrin or red-cell distribution width identifies earlier stages of iron deficiency. A positive screening test is an indication for a therapeutic trial of iron, which remains the definitive method of establishing a diagnosis of iron deficiency.
Chronic Illness and Sexual Functioning - Article
ABSTRACT: Chronic illness and its treatments can have a negative impact on sexual functioning. The mechanism of interference may be neurologic, vascular, endocrinologic, musculoskeletal, or psychologic. Patients may mistakenly perceive a medical prohibition to the resumption of sexual activity, or they may need advice on changes in sexual activity to allow satisfactory sexual functioning. Family physicians must be proactive in diagnosing and managing the alterations in sexual functioning that can occur with chronic illness. Patient education and reassurance are essential. Before sexual activity is resumed, patients with cardiovascular disease should be stratified according to risk. Patients with musculoskeletal disease should be educated about positional changes that may improve comfort during sexual activity. Psychosocial concerns should be addressed in patients with human immunodeficiency virus infection or acquired immunodeficiency syndrome. In patients with cancer, it is important to discuss sexual problems that may arise because of negative body image and the effects of chemotherapy. Patients who have disabilities can benefit from the use of muscle relaxants, technical adaptations, and expansion of their sexual repertoire.
Diagnosing the Cause of Chest Pain - Article
ABSTRACT: Chest pain presents a diagnostic challenge in outpatient family medicine. Noncardiac causes are common, but it is important not to overlook serious conditions such as an acute coronary syndrome, pulmonary embolism, or pneumonia. In addition to a thorough history and physical examination, most patients should have a chest radiograph and an electrocardiogram. Patients with chest pain that is predictably exertional, with electrocardiogram abnormalities, or with cardiac risk factors should be evaluated further with measurement of troponin levels and cardiac stress testing. Risk of pulmonary embolism can be determined with a simple prediction rule, and a D-dimer assay can help determine whether further evaluation with helical computed tomography or venous ultrasound is needed. Fever, egophony, and dullness to percussion suggest pneumonia, which can be confirmed with chest radiograph. Although some patients with chest pain have heart failure, this is unlikely in the absence of dyspnea; a brain natriuretic peptide level measurement can clarify the diagnosis. Pain reproducible by palpation is more likely to be musculoskeletal than ischemic. Chest pain also may be associated with panic disorder, for which patients can be screened with a two-item questionnaire. Clinical prediction rules can help clarify many of these diagnoses.
ABSTRACT: Persons with mental retardation are living longer and integrating into their communities. Primary medical care of persons with mental retardation should involve continuity of care, maintenance of comprehensive treatment documentation, routine periodic health screening, and an understanding of the unique medical and behavioral disorders common to this population. Office visits can be successful if physicians familiarize patients with the office and staff, plan for difficult behaviors, and administer mild sedation when appropriate. Some syndromes that cause mental retardation have specific medical and behavioral features. Health issues in these patients include respiratory problems, gastrointestinal disorders, challenging behaviors, and neurologic conditions. Some commonly overlooked health concerns are sexuality, sexually transmitted diseases, and end-of-life decisions.
ABSTRACT: Musculoskeletal pain can be difficult for children to characterize. Primary care physicians must determine whether the pain may be caused by a systemic disease. Change in activity, constitutional symptoms such as fevers and fatigue, or abnormal examination findings without obvious etiology should raise suspicion for rheumatic disease. A complete physical examination should be performed to look for extra-articular signs of rheumatic disease, focusing on but not limited to the affected areas. A logical and consistent approach to diagnosis is recommended, with judicious use of laboratory and radiologic testing. Complete blood count and erythrocyte sedimentation rate measurement are useful if rheumatic disease is suspected. Other rheumatologic tests (e.g., antinuclear antibody) have a low pretest probability in the primary care setting and must be interpreted cautiously. Plain radiography can exclude fractures or malignancy; computed tomography and magnetic resonance imaging are more sensitive in detecting joint inflammation. Family physicians should refer children to a subspecialist when the diagnosis is in question or subspecialty treatment is required. Part II of this series discusses rheumatic diseases that present primarily with musculoskeletal pain in children, including juvenile arthritis, the spondyloarthropathies, acute rheumatic fever, Henoch-SchÃ¶nlein purpura, and systemic lupus erythematosus.
ABSTRACT: Deviations from a normal age-appropriate gait pattern can be caused by a wide variety of conditions. In most children, limping is caused by a mild, self-limiting event, such as a contusion, strain, or sprain. In some cases, however, a limp can be a sign of a serious or even life-threatening condition. Delays in diagnosis and treatment can result in significant morbidity and mortality. Examination of a limping child should begin with a thorough history, focusing on the presence of pain, any history of trauma, and any associated systemic symptoms. The presence of fever, night sweats, weight loss, and anorexia suggests the possibility of infection, inflammation, or malignancy. Physical examination should focus on identifying the type of limp and localizing the site of pathology by direct palpation and by examining the range of motion of individual joints. Localized tenderness may indicate contusions, fractures, osteomyelitis, or malignancy. A palpable mass raises the concern of malignancy. The child should be carefully examined because non-musculoskeletal conditions can cause limping. Based on the most probable diagnoses suggested by the history and physical examination, the appropriate use of laboratory tests and imaging studies can help confirm the diagnosis.
ABSTRACT: Injections are valuable procedures for managing musculoskeletal conditions commonly encountered by family physicians. Corticosteroid injections into articular, periarticular, or soft tissue structures relieve pain, reduce inflammation, and improve mobility. Injections can provide diagnostic information and are commonly used for postoperative pain control. Local anesthetics may be injected with corticosteroids to provide additional, rapid pain relief. Steroid injection is the preferred and definitive treatment for de Quervain tenosynovitis and trochanteric bursitis. Steroid injections can also be helpful in controlling pain during physical rehabilitation from rotator cuff syndrome and lateral epicondylitis. Intra-articular steroid injection provides pain relief in rheumatoid arthritis and osteoarthritis. There is little systematic evidence to guide medication selection for therapeutic injections. The medication used and the frequency of injection should be guided by the goal of the injection (i.e., diagnostic or therapeutic), the underlying musculoskeletal diagnosis, and clinical experience. Complications from steroid injections are rare, but physicians should understand the potential risks and counsel patients appropriately. Patients with diabetes who receive periarticular or soft tissue steroid injections should closely monitor their blood glucose for two weeks following injection.
ABSTRACT: Management of a wide variety of musculoskeletal conditions requires the use of a cast or splint. Splints are noncircumferential immobilizers that accommodate swelling. This quality makes splints ideal for the management of a variety of acute musculoskeletal conditions in which swelling is anticipated, such as acute fractures or sprains, or for initial stabilization of reduced, displaced, or unstable fractures before orthopedic intervention. Casts are circumferential immobilizers. Because of this, casts provide superior immobilization but are less forgiving, have higher complication rates, and are generally reserved for complex and/or definitive fracture management. To maximize benefits while minimizing complications, the use of casts and splints is generally limited to the short term. Excessive immobilization from continuous use of a cast or splint can lead to chronic pain, joint stiffness, muscle atrophy, or more severe complications (e.g., complex regional pain syndrome). All patients who are placed in a splint or cast require careful monitoring to ensure proper recovery. Selection of a specific cast or splint varies based on the area of the body being treated, and on the acuity and stability of the injury. Indications and accurate application techniques vary for each type of splint and cast commonly encountered in a primary care setting. This article highlights the different types of splints and casts that are used in various circumstances and how each is applied.