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These supplements are defined as products that are intended to enhance or supplement the diet gastritis jelovnik generic 40 mg esomeprazole free shipping. The labeling of these products is required to state that the product is not intended to diagnose, treat, cure, or prevent any disease, but the labels can still make other claims. For example, it is legal for manufacturers to state that their supplements promote healthy immune systems, reduce anxiety and stress, help maintain cardiovascular function, and reduce pain and inflammation. The labels may say that the product contains certain substances, but this claim may or may not be correct, and the included amounts of ingredients may or may not be factual. It is important to remember that just because a supplement is described as "natural," this is no guarantee of its safety. The Dietary Supplement and Nonprescription Drug Consumer Protection Act took effect in 2007. It required that manufacturers must include contact information on product labels for consumers so that they can report adverse effects of the products. Patient medical histories should always include complete listings of herbal supplements so that their effects and/or interactions can be tracked over time. Also, these products have a potential for causing allergic reactions because of ingredients that may be either not listed on the labels or not noticed by the consumer. Patients taking medications such as insulin, warfarin, or digoxin should be educated about never taking supplements without first discussing them with their physicians because these drugs have great potential for interactions. ChApter thirteen Dietary Supplements and Alternative Therapies 191 Al Dodge/Pearson Education, Inc. These include herbs such as aloe, black cohosh, chamomile, feverfew, ginkgo, milk thistle, rose hips, St. Why was the Dietary Supplement and Nonprescription Drug Consumer Protection Act passed Nonherbal Supplements Nonherbal supplements are specialty supplements that may be obtained from a variety of different animal or plant sources. They are usually more specific in their actions than herbal products and should be used only for very specific conditions. Substances such as chondroitin and glucosamine are natural body substances necessary for healthy cartilage and may be taken in supplement form. Chondroitin is a protein that helps cartilage to remain elastic, and glucosamine has been shown to aid in cartilage formation and repair. Vitamins, minerals, amino acids, flaxseed, and fish oils with omega fatty acids are other examples of specialty supplements. Examples of these supplements that have been linked to potentially serious adverse effects are many. The nonherbal supplement 5-hydroxytrytophan, along with the similar agent tryptophan, may contain contaminants linked to eosinophilia-myalgia syndrome. Alternative Therapies Complementary and alternative medicine therapies are those that are "outside" of mainstream health care. Advantages and limitations of these therapies should be explained to patients so that they can make accurate choices about their health care treatments. Often, alternative therapies can work together with pharmacotherapy to achieve the proper treatment and healing of patients. In many cultures, home remedies and folk remedies are used alongside pharmacotherapy. Even today, various groups in the United States have become more open to specific dietary changes, acupuncture, massage, and yoga as alternative therapies. Healers in African and Latin American countries use herbs, oils, and roots, along with religious rituals and implements. In Latin American countries, certain foods are heated or cooled to specific temperatures, at which they are believed to have healing properties. Asian medical practitioners believe in keeping the yin and yang (balance) of the body constant in order to maintain good health. They use herbs, specific diets, acupuncture, meditation, exercise, and spiritualists in this practice. Table 13-4 lists a variety of alternative therapies classified as home remedies or folk remedies. It is used for osteoporosis, leg pain and cramps, nausea, sore throat, weight loss, hypertension, sinus congestion, arthritis, hypercholesterolemia, detoxification, improving cognition, fighting infection, treating skin conditions, reducing pain of sunburn and shingles, vaginal infections, and for diabetes mellitus. She was regularly taking warfarin and captopril because of hypertension, atrial fibrillation, coronary artery disease, and a stroke that occurred 3 years previously. During the check-up, she complained of fatigue, swollen ankles, redness of the face, and headaches. She admitted to having added herbal supplements to her daily regimen of medications. If the physician instructed this patient to immediately stop taking the herbal supplements, what would be the likely outcome in relation to her prescribed medications and their effects For example, a 9-month-old baby who had severe eczema was treated with homeopathic substances by her parents because they feared traditional medicine. She died three days later of sepsis, which caused bleeding in her lungs and airways. However, they can Aldegonde/Shutterstock Courtesy of the author ChApter thirteen Dietary Supplements and Alternative Therapies 197 interact with a variety of other commonly used substances. Consumers who use them often state that they believe they contain more concentrated healing agents than are found in synthetically created medications. About 80% of the population of the world uses herbal remedies as their primary form of health care. Objective 2: explain why the dietary Supplement health and education Act was established. This act attempted to regulate herbal supplements as part of its overall description of dietary supplements. Manufacturers do not have to demonstrate the effectiveness of these products before they can be sold. Though labeling must state that these products are not intended to diagnose, treat, cure, or prevent any disease, their labels can still make other claims. Manufacturers can state that supplements may promote healthy immune systems, reduce anxiety and stress, help maintain cardiovascular function, and reduce pain and inflammation. Labels may say that products contain certain substances, but this claim may or may not be correct, and included amounts of ingredients may or may not be factual. Just because a supplement is described as "natural," this is no guarantee of its safety. An herbal supplement is any mixture of ingredients based on plant sources that is designed for the improvement of health or treatment of certain conditions. Herbal supplements are available in many different forms, including capsules, liquids, and powders. They may contain a variety of active ingredients, in widely varying quantities and strengths. Nonherbal supplements are specialty supplements that may be obtained from a variety of different animal or plant sources. Other examples of specialty supplements include vitamins, minerals, amino acids, flaxseed, and fish oils with omega fatty acids. Objective 6: List over-the-counter supplements and how they may interact with prescription medications. Most modern drugs contain only one active ingredient that is standardized and measured with accuracy, whereas many supplements contain a variety of active ingredients. It is quite possible that the large amounts of active chemicals may not work well together for a controlled effect. They focus on treating each person individually, considering the health of the whole person. Objective 8: explain how certain cultures have differing views on the use of supplements and alternative therapies. In the United States, the majority of cultural groups use their own preferred home or folk remedies.
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All these agents have important safety limitations and can aggravate or promote arrhythmias xyrem gastritis order cheap esomeprazole on line. Antidysrhythmic drug actions based on cellular electrophysiologic effects have been classified into four groups. This classification is recognized internationally and provides a general logic for grouping drugs. These drugs reduce the maximal rate of contraction of the myocardium and slow conduction. Quinidine is related to quinine and has been used in cardiac conditions since the 1920s. Fever, reduced platelets and megakaryocyte fragments (important in the clotting of blood), and liver function abnormalities can occur. Quinidine syncope, which is sudden ventricular fibrillation in patients taking quinidine, is potentially dangerous and can be life-threatening. Quinidine depresses the myocardium and the conduction system, decreasing the contractile force of the heart and slowing the heart rate. Quinidine is contraindicated in pregnancy, lactation, bacterial endocarditis, and myasthenia gravis. Advise patients to take quinidine with food to avoid gastric upset, although this may delay absorption of the drug. A diet high in citrus fruits, vegetables, and milk may delay excretion of the drug, so advise patients not to increase their intake of these foods beyond their normal diet. Tell patients to immediately report any chest pain or change in heart rhythm to their health care provider. Adverse effects are dry mouth, constipation, visual disturbances, and urine retention. Its mechanism of action appears to be the blocking of activated and inactivated sodium channels, with a great effect on depolarized or ischemic tissues. Adverse effects are neurologic, such as tremor and convulsions, rather than cardiac. Drowsiness, delirium, and paresthesias (abnormal burning, pricking, tickling, or tingling) may occur with too-rapid administration. The common adverse effects are gingival hyperplasia (an increase in the number of cells in the gums of the mouth, causing them to have a swollen appearance), blurred vision, vertigo (sensation of revolving, either of the patients themselves or of their environment), and nystagmus (constant, involuntary movement of the eyes). Phenytoin has noted drug interactions with cimetidine, disulfiram, dopamine, and fluconazole. It is used for the treatment of patients with life-threatening ventricular dysrhythmias. Adverse effects include dizziness, headache, fatigue, chest pain, and blurred vision. Flecainide may also produce nausea, constipation, and a change in taste perception. It is used for the treatment and management of patients with ventricular dysrhythmias. Adverse effects include blurred vision, dizziness, fatigue, somnolence, vertigo, and headache. It may also cause hypotension, nausea and vomiting, abdominal discomfort, constipation, dry mouth, and taste alterations. Relatively few dysrhythmias are caused primarily by sympathetic overactivity; most are regulated by autonomic tone, which is the firmness of muscles as controlled by the autonomic nervous system. In general, beta-blockers are well tolerated, but they may depress left-ventricular function, particularly in antiarrhythmic doses. Since then, several other beta-blockers have been approved to treat dysrhythmias, but propranolol is still the mainstay of treatment. Patients with other cardiac disorders, such as heart failure, must be carefully monitored because propranolol can slow the heart rate. Propranolol affects both types of beta receptors; because of this, it is considered a nonselective betablocker. In addition to its beta-blocking effect, it also causes a quinidine-like depression of the myocardium. Propranolol is contraindicated in bronchial asthma or bronchospasm, severe chronic obstructive airway disease, allergic rhinitis during pollen season, and pregnancy. This prolongs the potential contraction duration of the Purkinje fibers and the muscle fibers of the ventricles. Amiodarone has few cardiovascular adverse effects, perhaps because of its modest vasodilator action, which produces little or no left-ventricular depression. Pulmonary fibrosis can occur in some patients treated with the drug for more than 5 years and could be fatal. Other significant potential adverse effects include changes in thyroid function-hypothyroidism or hyperthyroidism-and visual disturbances as a result of optic neuritis or corneal microdeposits. Common adverse effects that may be self-limiting include dizziness, nausea and vomiting, anorexia, bitter taste, weight loss, and numbness of the fingers and toes. Tell patients to notify their health-care providers immediately if shortness of breath, cough, or a change in heart rate and rhythm occurs. Also, instruct patients to immediately report any vision changes to their healthcare providers. Advise patients, especially elderly patients, to protect their skin and eyes from the sun. Sotalol is used for the treatment of documented ventricular arrhythmias that, in the judgment of the physician, are life-threatening. The most common adverse effects of dofetilide are headache, dizziness, insomnia, nausea, diarrhea, and abdominal pain. It achieves its effect by activating a slow, inward sodium current rather than by blocking outward potassium currents. Injecting ibutilide can acutely terminate atrial fibrillation and atrial flutter, particularly in patients with recent onset of dysrhythmia. It may cause marked hypotension and is indicated only for the management of potentially lethal refractory ventricular tachyarrhythmias. The term refractory means the period during repolarization when cells cannot respond normally to a second stimulus. Focus on Geriatrics Heart Failure and Surgery The chance of having heart failure increases as we age. One in 15 elderly patients between the ages of 75 and 84 years is diagnosed with some type of heart failure. Therefore, it causes the depression of myocardial contractibility and dilation of coronary arteries. These effects lead to decreased cardiac work and cardiac energy consumption in patients with vasospastic angina. They should contact their health care provider if their blood pressure is below 90/60 mm Hg. Advise patients to notify their health care provider if they experience any breathing difficulty or change in heart rhythm. Also, advise patients to take verapamil with food to avoid an upset stomach and to increase their intake of fiber to avoid constipation. The adverse effects are dizziness, vertigo, emotional depression, sleepiness, headache, peripheral edema, hypotension, nausea, and constipation. It is used for essential hypertension, angina pectoris caused by coronary artery spasm and such dysrhythmias as atrial fibrillation, atrial flutter, and supraventricular tachycardia. Adverse effects include headache, fatigue, dizziness, nervousness, insomnia, and confusion. It may also cause edema, flushing, hypotension, nausea and vomiting, and impaired taste. What classes of antidysrhythmics are the least toxic and most powerful drugs available The inability to pump blood may be caused by various abnormalities in the myocardium. This condition results in gradual congestion of both the cardiopulmonary and vascular systems.
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If 10 is the worse pain you have ever had and 0 is no pain gastritis ka desi ilaj discount esomeprazole 20 mg otc, what number is the pain I received birth control from a free clinic that does not require pelvic examinations for prescription refills. Painful lesions rule out syphilis, genital warts, and molluscum contagiosum as a source of the infection. Additional counseling included taking showers, avoiding tub baths, avoiding douching, personal hygiene approaches when toileting, and wearing loose-fitting clothing with cotton underwear. A follow-up appointment is recommended in 2 weeks if the lesions persist or worsen. Bowel obstruction: Sudden onset of crampy pain usually in umbilical area of epigastrium. Vomiting occurs early with small intestinal obstruction and late with large bowel obstruction. Ileus: Abdominal distention, vomiting, obstipation, and cramping due to a decreased peristalsis. Acute pancreatitis: Usually presents with a history of cholelithiasis or alcohol abuse. Pain is steady and boring and is unrelieved by change in position, located in the left upper quadrant and radiates to back; nausea, vomiting, and diaphoresis. Acute cholelithiasis or cholecystitis: Appears in adults more than children, females more than males, colicky pain progressing to constant pain; located in right upper quadrant that may radiate to right scapular area; pain of cholelithiasis is constant, progressively rising to plateau and falling gradually; nausea, vomiting, and history of dark urine and/or light stools. Renal calculi: Sudden-onset, excruciating colicky pain that may progress to constant pain. Pain in lower abdomen and flank and radiates to groin; nausea, vomiting, abdominal distention, chills and fever, and increased frequency of urination. Salmonella food poisoning: Acute onset 12 to 24 hours after exposure; lasts 2 to 5 days; moderate to large amounts of nonbloody diarrhea, abdominal cramping, and vomiting. Entamoeba histolytica: Acute onset 8 to 18 hours after ingestion of contaminated food or water, large amounts of bloody diarrhea, abdominal cramping, and vomiting. Diabetic enteropathy: Nocturnal diarrhea, postprandial vomiting, fatty stools from malabsorption caused by poorly controlled diabetes. Diabetic ketoacidosis: Excessive thirst, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity scented breath, and confusion. Variation in presentation is common, especially in infants, children, and older adults. Because of this the advanced practice provider discusses the possibility of pregnancy after the examination and the patient beings to cry and admits to having a boyfriend with whom she has had intercourse. There is no evidence to support an infection, food poisoning, obstruction, metabolic disorder, appendicitis, cholecystitis, or pancreatitis. The patient agrees to discuss the pregnancy with her mother with the advanced practice provider present. They are referred to a local obstetrics and gynecology clinic for further evaluation. I am a little short of breath, but I thought it was because I walked into the office from the parking lot. I get short of breath in the shower, but I bought a shower chair so I can sit down while I wash. Lipid panel showed slightly elevated triglycerides, which could indicate the need to adjust statin medication dose. Based on these findings, deep vein thrombosis and hypothyroidism as a cause for the weight gain can be ruled out. Since the weight gain was sudden, it is unlikely to be caused by increased food intake. Reviewed the importance of measuring weight daily and reporting a weight gain of 3 to 5 lb. Counseled on the need to reduce sodium in the diet and provided a list of highsodium foods, which the patient has stated he eats on a regular basis (ham), to avoid eating. Appointment made with the cardiology clinic in 3 days at which time the results of the echocardiogram and chest x-ray will be available. This is an immunoassay test method that detects specific proteins in blood or tissue. It combines an electrophoresis step with a step that transfers (blots) the separated proteins onto a membrane. Western blot is often used as a follow-up test to confirm the presence of an antibody and to help diagnose a condition. There are two types of thyroid hormones easily measurable in the blood, thyroxine (T4) and triiodothyronine (T3). For technical reasons, it is easier and less expensive to measure the T4 level, so T3 is usually not measured on screening tests. Additionally, most diseases impact both T4 and T3 similarly, so T4 is typically measured first. In particular, the "total T3," "free T3," and "T3 uptake tests" are very confusing, and are not the same test. High levels may be due to hyperthyroidism; however, technical artifact occurs when the bound/inactive T4 is increased. High levels suggest hyperthyroidism, and low levels are found in hypothyroidism and chronic illness. First, this is not a thyroid test, but a test on the proteins that carry thyroid around in your bloodstream. The results tell us how much thyroid hormone is free in the bloodstream to work on the body. While this test is less commonly ordered, it is still of use in special situations such as pregnancy. This test can vary by time of day, so a single abnormal measurement does not always mean there is a problem. Also, levels tend to be higher in older people, so it is not uncommon to see mild elevations in people in their 70s or 80s, which do not necessarily indicate a medical problem. Low white blood cell counts can be a sign of bone marrow diseases or an enlarged spleen. High Hgb can occur due to lung disease, living at high altitude, or excessive bone marrow production of blood cells. Low values suggest iron deficiency, high values suggest either deficiencies of B12 or folate, ineffective production in the bone marrow, or recent blood loss with replacement by newer (and larger) cells from the bone marrow. High values can occur with bleeding, cigarette smoking, or excess production by the bone marrow. Low platelets also can occur from clumping of the platelets in a lavender-colored tube. It can also be used to monitor hospitalized patients and people with certain known conditions, such as hypertension and hypokalemia. The patient was counseled on the infection, modes of transmission, and method of treatment. Encouraged patient to make an appointment as soon as possible, so antiretroviral therapy can begin. Encouraged patient to have spouse tested as soon as possible and reviewed approaches for safe intercourse. The patient was encouraged to maintain all scheduled health care appointments going forward and to return to the clinic at any time with questions or issues with other health problems. This can be secondary to many items such as edema, increased secretion, and smooth muscle contraction. While wheezing can occur anywhere in the airway and is mostly upon expiration, stridor is much louder and concentrated in the tracheal and laryngeal regions. The causes of stridor in adults are much different than those that cause wheezing, which include vocal cord paralysis, foreign body aspiration, and upper airway infection. Neck supple, no tonsillar enlargement, Mallampati airway score 2, soft pallet low lying Respiratory Chest expansion even, no cyanosis or pallor, lung sounds clear throughout, no crackles, rhonchi, or rales. Helpful in the diagnosis of pneumonia, effusions, malignancies, heart failure, edema, among other disorders.
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Massage application is concentrated at fascial anchoring points where multidirectional fascial connections converge granulomatous gastritis symptoms buy cheap esomeprazole 20 mg. Symptoms related to dysfunction of the lymphatic system and superficial vein system involve superficial fascia. Massage would be adapted to target this tissue layer by using a light pressure with drag and holding at resistance barrier. The deep fascial layers require massage application that generates enough pressure to reach the muscle compartments and layers (Stecco et al. However, when the ground substance becomes stiff and sticky, there is a change in the quality of hyaluronan (Stecco et al. Factors related to the changes are overuse and lack of use; systemic inflammation; stress related to sympathetic autonomic nervous system overactivation; and physical factors, such as cold (Robert et al. Fascia allows continuity of nerves, blood and lymph vessels between the sliding tissues. Modified massage could help restore the pliability and slip of the ground substance. In general, variable pressure is applied at differing angles with consistent drag on the tissues, producing shear, tension and torsion stress. There is a space (fluid gap) between fascial layers that is filled with ground substance and is slippery because tissue layers are meant to slide over each other (Stecco et al. When the mechanical force is applied, it causes the fluid gap to increase because the fluid pressure of hyaluronan increases as fascia is deformed. As the jelly-like ground substance is pushed, it creates a little mound in front of the contact point that separates the layers and increases the slipperiness. Fibrosis is the formation of excess fibrous tissue or scar tissue, usually because of injury or long-term inflammation. Fibrosis can also occur with overuse syndromes, such as tendonitis, which then becomes tendonosis. Massage can create mild inflammation in the fibrotic tissue and trigger an active acute, but controlled and productive, healing process. There is usually ground substance densification in areas of fibrosis; therefore, increasing pliability and sliding is typically included as a massage outcome. Assessment the general application of massage is the assessment process involving observation, palpation and joint movement. The underlying principles for fascial dysfunction are assessment of ease and bind, and massage therapy is an excellent platform for soft-tissue and movement assessment. This aspect of massage is not treatment but looks and feels like a massage that is pleasurable and achieves the outcome of general relaxation. In a general full body massage, soft-tissue and joint mobility is assessed for motion restriction by palpation and/or joint movement. During joint movement assessment it is important to identify the physiological barrier where the client experiences appropriate stiffness, and the pulling sensation into the area being stretched acts as a protective mechanism, preventing movement to the anatomical limits and potential injury. It may take multiple sessions supported by client self-stretching to see sustained results. During general massage the therapist identifies areas of tightness/bind where the normal sliding of fascia does not occur. The quality of the fascia can generally be assessed by noting the pliability of the skin and subcutaneous layers. Thickened, adhered fascia is less mobile, and the skin will glide only a short distance before feeling tight (bind). If the client has requested that alterations in fascia are addressed, and has sufficient adaptive capacity to respond positively to the interventions, and there are no contraindications for treatment, then massage application is modified to create change in the dysfunctional fascia. Those with a variety of connective tissue hypermobility disorders often experience chronic joint, limb and/or back pain and easy bruising. Increasing tissue pliability and supporting flexibility with stretching methods to increase mobility is a concern in hypermobility conditions. Massage application would instead support managing the sensations of stiffness and discomfort by gently mobilizing soft tissue between the joints and stimulation of pleasurable sensations. Scleroderma is a term for a group of disorders that causes thick, tight skin, build-up of scar tissue and organ damage. These disorders fall into two general categories: localized scleroderma and systemic sclerosis. Localized scleroderma is confined to the skin and, sometimes, the muscle beneath it. These conditions are typically autoimmune related and involve a maladaptive inflammatory response. Creating additional inflammation, such as may occur with frictioning methods, should be avoided. Cautions: yellow and red flags Before applying massage as an intervention, it is necessary to understand the contraindications. If hypermobility is identified during assessment it is important to determine the underlying reasons. Generalized hypermobility is a common feature in many hereditary connective tissue disorders and many features overlap. Benign joint hypermobility syndrome is a condition where joints easily move beyond the normal range expected for a particular joint. Most commonly, hypermobile joints appear without any underlying health conditions. Contributing factors can include bone shape or the depth of the joint sockets, muscle tone or strength, a poor sense of proprioception, which is the ability to sense how far the area is stretching, and a family history of hypermobility. Some people with hypermobile joints also develop stiffness or pain in their joints in an attempt to increase joint stability. Benign joint hypermobility syndrome needs to be distinguished from other disorders that share many common fea- Treatment during massage Focused tension (stretching/elongation) of the tissues appears to be an effective mechanical force for influencing the fascia. These methods, rather than engaging and attempting (by whatever means) to overcome resistance (bind), do the exact opposite. The massage practitioner simply maintains the joint or tissue in this ease position (see Chs 10 and 15, in particular). Breathing can enhance the ease position and is incorporated by having the client inhale and exhale, typically holding the breath for a few seconds in the direction that further contributes to the ease of tissue tension. Because indirect functional techniques are non-invasive methods, they should be the first approach attempted to normalize tissue and joint movement. These methods begin at the restriction barrier (bind) and move into the resistance. Because these methods produce changes by increasing the intensity of the mechanical force application to move tissue beyond the point of bind, the potential for adverse effects is increased. Stretching is considered a direct technique because it engages bind and moves through it. A modification that incorporates indirect methods and more aggressive direct stretching, involves moving back and forth between the ease position and the bind position. Then the restrictive barrier of a joint or tissue is engaged in each plane of motion and is held taut at the barrier until softening occurs. The corrective activating force allows movement slightly through the restrictive barrier, and this position is held for up to a maximum of 120 seconds, Treatment interventions Direct and indirect connective tissue methods Both direct and indirect connective tissue methods have been shown to reverse the inflammatory effects in cells that have been strained repetitively. A direct technique moves the restricted tissue into the barrier caused by binding. An indirect technique moves the tissue away from the restrictive barrier to a point of ease. Changing the strain pattern in cells (indirect, away from the bind, or direct, toward the bind) may result in improvement in symptoms. It is effective to alternate two or three times between direct and indirect application (Bordoni & Zanier 2015). Paul Standley, PhD (University of Arizona, College of Medicine) researched the effects of the magnitude of elongation on bioengineered tendons. The optimal result in terms of wound closure was achieved with 6% of load for 3 minutes. How does this information translate into effective application of elongation methods during massage According to the study, brief (1 minute), light (3%) tension stress had no effect on wound healing, and strong (12%), long (5 minutes) tension stress aggravated and interfered with wound healing.
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Young patients often underestimate an injury and assume it is a "sprain" that will settle quickly diet gastritis erosif discount 20mg esomeprazole amex. These clinical signs are "inadequate indicators" of scaphoid fractures when used alone and should be combined to achieve a more accurate clinical diagnosis. When all three signs are positive at the initial examination, the specificity improves to 74%, so three out of four patients will have a fracture. It consists of six stages: preventing, diagnosing, preparing, intervening, recovering/rehabilitating, and finally monitoring/ managing. Each stage consists of the following: patient involvement (what patients need to be educated about), measures needed to be collected, patient care activities taking place, and finally delivery of care (what activities of care occur). When assessing the imaging for a scaphoid injury, the following questions must be answered by the clinician. Is it a ligamentous injury or is it associated with another bony injury, and, fourth, if so, is it associated with subluxation or dislocation The answers to the four questions on imaging confirm the presence or absence of a scaphoid fracture. In patients who do not have a fracture, the decision is then to either discharge, image further, or review again (if a scaphoid fracture is clinically suspected, defined as a patient with (1) an appropriate injury, (2) pain on the radial side of the wrist, (3) tenderness or pain on the tests mentioned earlier, and (4) no obvious fracture seen on at least four good-quality radiographic views). Strong clinical suspicion of a scaphoid fracture should include more than one of the signs mentioned earlier. Smoking cessation should be re-emphasized due to higher risk of nonunion in all fractures. With the thumb immobilized, the additional restriction of movement of the scaphoid is very small, so not much is gained, but patient disability is increased. A functional position is when the thumb is kept in a position of opposition to allow pulp pinch and tripod pinch. This position does not allow prehension and the patient has very limited capacity to perform even activities of daily living. There are two groups of patients who may require restricting the function of the thumb: patients in whom compliance is uncertain and those with marked ligamentous laxity in whom even light pinch may cause scaphoid movement. That is why there is no place for an above-elbow cast as this disables the patient. A discussion regarding cast care/hygiene and possible problems should take place and written instructions provided. In particular, we ask patients to return if the cast softens enough to allow wrist movement and explain that this may permit wrist and scaphoid movement and could result in a breakdown of the healing process. After an interval of around a couple of weeks, a thorough examination and repeat scaphoid radiographs should be taken after removing the plaster to identify those with persistent symptoms and signs. In the absence of a fracture, either the patient can be treated as a soft-tissue injury of the wrist and be discharged with wrist exercises or a follow-up appointment can be arranged in 6 weeks to ensure a significant soft-tissue injury is not missed. We usually discharge patients with advice if there is no clinical indication of a ligament injury. Patient information leaflets should be provided for further education of the possibility of a fracture and what to look out for in the first few weeks with the patient provided with direct access back to the treating team if symptoms persist. Immobilization in a cast for 6 weeks will result in union of 80 to 85% of displaced fractures of the scaphoid. The procedure must be explained and the patient should understand the benefits and risks of surgery and clearly know the alternative to surgery. The benefits are that the fracture is stabilized usually sufficiently to avoid external immobilization. Many patients assume that fixing the fracture means that they can resume activity, regardless of its demands on the wrist, as if the fracture has "healed" and do not appreciate that 25. Restricting wrist movement, particularly radioulnar deviation, restricts scaphoid movement. This is more restrictive but permits some function as pulp pinch and tripod pinch are preserved. The risks of surgery include infection (1%19), the need for additional surgery (7. Chondrolysis and implant-related problems can also occur especially if the hold was poor or the implant was long protruding into a joint. Patients being treated surgically are reviewed on the ward on the day of the procedure. By this point, the surgeon will have determined the approach and method of treatment. The procedure of percutaneous reduction and techniques for reduction have been well described and are now commonly employed. The patient is discharged from hospital after being given appropriate analgesia and provided with a discharge summary with clear instructions regarding wound care and postoperative instructions. Activity is restricted to not lifting greater than 1 kg (around a bag of sugar) and the patient is advised to avoid repetitive movement of the wrist. Utilizing the hand for activities of daily living, personal hygiene,22 and immediate return to light work activity are usually allowed and encouraged. As discussed in the previous section, depending on the fracture displacement this can vary between 4 weeks in undisplaced or minimally displaced fractures and 6 weeks, which is acceptable in most cases. Once the cast is removed, the stepdown process may involve using a wrist splint or allowing the wrist to be fully free, depending on the presence of partial union, which is discussed in the following section. Hand therapy is only needed if there is persistent, unexpected stiffness without any obvious structural cause. Should the patient develop a postoperative complication such as infection, he or she should be taken back to the theater to address the problem immediately, but this is rarely needed. Any malposition or incorrect length of the screw fixation must be immediately corrected. This aspect is important and needs a clear decision as cartilage is damaged irreversibly if a long implant is not immediately revised. Return to activity should be individualized to the personality of the fracture, the quality of stabilization, and the patient. The patient is usually advised against contact sports for 2 to 3 months and counseled about the risk of refracture. Note the radiolunate joint cartilage and that between the proximal part of the scaphoid and the radius is maintained. The answer is "no," if it is minimally displaced (with a step or gap of 1 mm), "yes, possibly" if the step or gap is 1 mm, and "yes, probably" if the step or gap is 2 mm. The fracture may be stabilized with a cast, a screw, or very rarely it may need bone graft to restore structure and stability. Should the fracture be minimally displaced (1 mm), the surgeon may still offer the alternative of percutaneous screw fixation. The problem faced in scaphoid fractures is poor compliance, where patients think that this is a minor injury with little consequence. Most patients with a scaphoid fracture are young, active, and are expected to have had normal hand function prior to the injury. In addition, the surgeon should establish whether the patient uses their hands regularly for dexterous tasks and especially tasks needing wrist movement. The anesthetist may review the patient for a formal discussion and decision on the use of regional anesthetic block or general anesthesia. The consent process ensures that the patient understands the procedure, the aftercare, the impact on their activities, and the possible complications. The surgeon should use plain language and incorporate the use of drawings or models to help the patient understand the procedure. It is important that the postoperative recovery and rehabilitation process is also discussed. In all cases, the clinician should stress the importance of smoking cessation, given that it significantly increases the risk of nonunion of fractures overall31 and its association with failure of operative treatment in established nonunion. Union Patients who have been treated in a cast for the past 6 weeks should have their cast removed and be examined for tenderness. Radiographic views of the scaphoid should be taken to confirm the absence of adverse radiological features such as a gap at the fracture site, displacement, and, very rarely, if an implant has been used, lucency or implant movement will suggest failure of union. Radiographs taken 12 weeks after a scaphoid fracture do not provide reliable and reproducible evidence of healing.
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Therefore gastritis diet best buy esomeprazole, manipulation of urinary pH results in decreased passive reabsorption and increased excretion. Other routes of drug elimination include: Glomerular filtration Occurs at the glomerulus of the kidney tubule. However, blood cells and large molecules such as proteins cannot undergo this process due to their size; therefore, drugs bound to albumin remain in the blood. Passive tubular reabsorption Since lipid-soluble drug concentrations in the blood are lower than those in the tubule, this concentration gradient moves drugs out of the tubule and back into the blood. Conversion of lipid-soluble drugs into more polar forms reduces passive reabsorption and speeds up excretion of these drugs. One type of pump is used for Lungs-important for the elimination of alcohol and anesthetic gases Breast milk-important for the elimination of aspi- rin, barbiturates, and other drugs Sweat, tears, urine, and feces-elimination that may be alarming if the patient is not expecting the orange-red discoloration caused by phenazopyridine or rifampicin 32 Unit one General Principles Bile-leading to the recirculation of compounds, such as chloramphenicol (its inactive metabolites are reactivated by hydrolysis in the gut), morphine, rifampicin, tetracycline, and digitoxin Saliva-sometimes used in monitoring drug concentrations in body fluids To aid in the proper excretion of drugs, the patient should follow these guidelines: Take medications as ordered. Cough and breathe deeply after general anesthesia to help eliminate anesthetics more quickly. Chew gum or suck on hard candy to decrease the unpleasant effects of drugs that are eliminated through saliva. Increase intake of fluids because this will increase the filtration of urine and increase blood volume, thereby assisting in proper excretion. Maintain proper diet and amount of physical activity because both of these speed drug excretion. Keep skin clean to help avoid irritation from drugs that are eliminated through the sweat glands. The clearance of a drug is calculated by dividing its rate of elimination by its plasma concentration, usually in mL per minute. Most drugs experience clearance at a relatively constant rate over a large range of plasma concentrations. For different drugs, the amounts of clearance range from small percentages of blood flow to a maximum of total blood flow to the organs of elimination. Therefore, in every patient, drug clearance is based on the drug administered, blood flow, and the healthiness of the organs of elimination. Clearance is, therefore, equivalent to the extraction capability multiplied by the rate that the drug is delivered to these organs. Total clearance of a drug is directly affected by the amount of blood flow to the organs of elimination. The rate of drug clearance can also be significantly affected by cardiac disease, as well as drugs that alter blood flow. The half-life is the major determinant of the duration of drug action, and the half-life of each drug may be different. A drug with a short half-life of 2 or 3 hours must be administered more often than one with a longer half-life of 12 hours. No matter how much drug was administered, the half-life still means how long it takes for 50% to leave the Drug Clearance Drug clearance is the pharmacokinetic measurement of plasma volume that is completely cleared of a drug per unit of time. Consequently, some drugs, such as diazepam, may cause coma in patients with severe liver damage when given in ordinary doses. However, the more the drug is present in the body, the larger the amount that is lost during one half-life. It is important to remember that drug responses are related to concentrations at the sites of action. There is a direct correlation between therapeutic and toxic responses compared to how much drug is present in the plasma. Therefore, plasma concentrations are able to predict therapeutic as well as toxic responses. The minimum effective concentration is the plasma drug level below which therapeutic effects do not occur. A beneficial drug must have concentrations that meet or exceed the minimum effective concentration. The toxic concentration is the plasma level at which toxic effects begin to occur. The peak concentration is the highest level at which a drug is present in the body, whereas the trough concentration is the lowest level at which a drug is present in the body. The goal of drug dosing is to keep plasma drug levels within the therapeutic range. An example of a drug with a narrow therapeutic range is lithium; an example of a drug with a large therapeutic range is acetaminophen. Which drugs are more dangerous to use in regard to their type of therapeutic range and why Give an example of a drug with a narrow therapeutic range and one with a large therapeutic range. Drug levels rise during absorption, but then decline while metabolism and excretion occur. Responses to the drug do not occur until plasma drug levels have reached the minimum effective concentration. A maintenance dose keeps the plasma concentration of the drug continuously in the therapeutic range. However, the more a drug is taken, the more chance that drug accumulation will occur. Repeated drug dosages cause the drug to build up until a steady plateau level is reached. Total body stores of the drug are higher after a follow-up dose than they were after an initial dose. At some point, with repeated dosing, the amount of drug that is eliminated between doses will equal the amount that is administered. This means that average drug levels remain constant, and plateau has been reached. This is true because the actual amount of drug that is lost between doses increases each day. Although 50% of the total amount of the drug in the body is still lost every day, the amount in grams or milligrams gets continually larger as total body stores increase day after day. If a drug is taken repeatedly in the same dose, plateau is reached in about four half-lives. When the dosage stays the same, the time needed to reach plateau does not depend on dosage size. This may occur when the body cannot eliminate the drug sufficiently, or when it is taken in multiple doses at intervals shorter than recommended. When drug accumulation occurs, toxic levels can be reached, and adverse effects are prevalent. It is important to understand that one drug may increase or reduce the therapeutic as well as adverse effects of another drug. Also, the combination of two drugs may result in unique responses that differ widely from the effects of either drug used individually. Drug interactions may occur due to direct chemical or physical interactions; alterations in absorption, distribution, metabolism, or renal excretion; and interactions involving P-glycoprotein. Other interactions between drugs occur due to those using the same receptor, interactions from actions at separate sites, and because of combined toxicity. In general, a person in good general health experiences better therapeutic drug responses. In a person who is clinically considered to be in starvation, protein binding of drugs is reduced, and responses are intensified. Common examples are when a patient forgets to take a medication per the correct schedule or when a hospitalized patient is the victim of a medication administration error. Also, medication errors occur, which involve patients, physicians, nurses, pharmacists, and pharmacy technicians. The patient was also taking the anticoagulant warfarin (Coumadin) that had been prescribed by his cardiologist. Warfarin is a drug that is metabolized more rapidly when given with phenobarbital. This patient was later brought into the emergency room with a possible hemorrhagic stroke. Thinkstock/Stockbyte/Getty Images 36 Unit one General Principles Chapter Capsule this section repeats the objectives from the beginning of the chapter and then provides a summary of the most important concepts for that objective. Absorption-the process of drug movement into the systemic circulation Distribution-the passage of a drug or agent through blood or lymph to various body sites Metabolism (biotransformation)-the utilization of a drug by the body via (mostly) liver enzymes Excretion-the removal of a drug from the body, via (mostly) the kidneys objective 2: explain the primary ways that drugs cross cell membranes.
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Because the subcutaneous region is less vascular than the muscle tissues gastritis symptoms bad breath cheap esomeprazole, subcutaneous injections are absorbed less rapidly. Transdermal injections (tuberculin test), transdermal patches, and otic or ophthalmic administration are other routes. Transdermal nitroglycerin (Nitrostat) is absorbed rapidly and provides sustained blood levels after application to the skin in the form of either an ointment or a transdermal patch. Some drugs, such as fentanyl patches (Duragesic), also provide certain systemic effects, such as pain relief. Drugs administered in low concentrations tend to be less rapidly absorbed than those administered in high concentrations. Lipid solubility Generally, drugs with high lipid solubility are absorbed more quickly than those with low lipid solubility. Those with high lipid solubility also readily cross membranes separating them from the blood. This is because the blood that contains the newly absorbed drug is replaced quickly by blood that is drug-free. A large gradient between drug concentrations outside the blood and in the blood exists. Surface area the rate of absorption is mostly determined by the amount of surface area available. This is why orally administered drugs are more commonly absorbed from the small intestine, which has a larger surface area, than from the stomach. Which routes of administration protect drugs from chemical decomposition that may occur in the stomach or liver Drug Distribution the movement of pharmacologic drugs throughout the body after they are absorbed is known as distribution. Drugs may interact with components in the blood, and can be chemically or physically altered prior to reaching their targets. Many drugs are bound to circulating proteins, usually albumin, and lipoproteins or glycoproteins. Only the fraction of drugs that is not bound to protein can bind to cellular receptors, pass across tissue membranes, and gain access to cellular enzymes, thus being distributed to body tissue. Changes in protein binding can therefore sometimes cause changes in drug distribution. The initial rate of distribution of a drug depends heavily on the blood flow to various organs. There are three major influencing factors related to drug distribution: blood flow to the body tissues, how drugs are able to exit the vascular system, and how drugs are able to enter body cells. After administration, a drug is carried in the blood to body tissues and organs, with the flow rate influencing the speed at which the drug is delivered. Low regional blood flow affects drug therapy in two specific conditions: tumors and abscesses. Therefore, antibiotics cannot reach the bacteria they contain and, instead, surgical drainage is required initially. This step is required for the drug to reach its target cells, and so the drug can be metabolized and excreted. Another factor is P-glycoprotein, which is the transporter that pumps many drugs out of cells. During pregnancy, the placenta is able to transfer drugs from the mother to the fetus. The substances most likely to pass through the placenta are those that are lipid soluble and nonionized. These agents are linked to birth defects, drug dependency, and respiratory depression. Albumin remains in the bloodstream because of its size and lack of a transport system. Drugs that are highly bound to albumin cannot leave the bloodstream, meaning they cannot reach their sites of action, metabolism, or excretion. Protein binding is also a source of drug interactions, since one drug can displace another for a protein such as albumin. Nearly all drugs must enter cells in order to be metabolized and excreted, and some drugs must enter cells in order to reach their sites of action. Lipid solubility and the existence of a transport system also influence this situation. Many drugs bind with receptors on cell membrane surfaces in order to become effective, and do not need to cross cell membranes. Drug Metabolism Most drug metabolism, also referred to as biotransformation, occurs in the liver through the same biochemical pathways and reactions that affect nutrients, vitamins, and minerals. The majority of metabolism in the liver occurs through the hepatic microsomal enzyme system or P450 system. Its key component is cytochrome P450, which is actually a group of 12 enzyme families. Until the liver is mature, extreme care must be taken to prevent injury caused by drug administration. Certain drugs cause the liver to increase rates of metabolism, often by synthesizing drug-metabolizing enzymes, which is called enzyme induction. In this situation, the drug can increase the rate of its own metabolism, requiring increased dosages. Induction of drug-metabolizing enzymes can also speed up metabolism of concurrent drugs, requiring increased dosages as well. The first-pass effect is an important mechanism that influences drug action and metabolism. Metabolism accomplishes the conversion of molecules as well as biodegration of foreign substances. If the liver has a high metabolic capacity, the drug is totally inactivated on its first pass, and no therapeutic effects occur. The liver is temporarily bypassed, and the drug reaches therapeutic levels in the systemic blood. An example is nitroglycerin, which may avoid the first-pass effect via sublingual administration, since this method allows it to be absorbed directly into the systemic circulation. Enzymes act on most drugs in the body and convert drugs to end-products called metabolites during metabolism. Hydrolysis-the cleaving of a compound into simpler compounds with the uptake of the hydrogen and hydroxide parts of a water molecule 4. Toxic drug action can be influenced by drug metabolism, interactions, activation, toxicity, and adverse effects. Side effects are usually less serious than adverse effects, are predictable, and may occur even at therapeutic doses. Another important factor to consider is enterohepatic recirculation, in which a drug is moved from the liver, through the bile duct, to the duodenum. The process of enterohepatic recirculation means that susceptible drugs can stay in the body for a much longer time than other drugs. Fortunately, not all glucuronidated drugs experience this recycling, and are excreted intact in the feces. The calculation of correct dosage of drugs based on body weight is discussed in Chapter 10. Examples of differences between males and females in relation to drug response include the increased effects of certain opioid analgesics in women and increased mortality in women when treated with digoxin or quinidine. Today, more drug trials focusing on females are being conducted in order to better understand these many differences in drug response. Another important factor is that women must be questioned about the possibility of pregnancy since the use of drugs in pregnant women is generally not recommended unless benefits outweigh risks to the fetus. An example of an agent that has proven effectiveness in African Americans is the combination of the vasodilators called isosorbide dinitrate and hydralazine. This combination drug has reduced 1-year mortality among African Americans, yet has not yet been tested with significant results in any other racial group.
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Metacarpal fractures account for 30% of hand fractures gastritis diet order esomeprazole overnight, and non-thumb fractures for 88%. The initial evaluation focuses on fracture stability to establish whether surgical or conservative treatment is required; the deformity that is less tolerated is malrotation because it causes overlapping finger. Our favorite technique is pinning and intramedullary fixation to obtain a good stability avoiding soft tissue damage during dissection. In case of long spiral fracture, an open reduction and an internal fixation by screws can be performed, only in case of transverse or oblique or multiple metacarpal fracture, we perform an open reduction and internal fixation using plate and screws. Metacarpal fractures have a good prognosis if treated conservatively or surgically, complications are generally related to nonunion, shortening, and malrotation in case of incorrect indication to the nonsurgical treatment; when surgery is performed, stiffness, tendon adhesion, loss of range of motion, and superficial infections are the most common complications. None of the available operative methods have proved superior in treating of metacarpal fractures. Keywords: metacarpal fractures, metacarpal fractures treatment, plate or screw fixation metacarpals, external fixation metacarpals 22. There are four major types of metacarpal fractures: transverse, oblique, spiral, and comminuted. Fractured metacarpal bones, from the first to the fifth, are characterized by edema and deformity; in oblique or spiral fractures, the finger may be malrotated and shortened. In the case of the thumb, the misalignment is more difficult to detect because it cannot be directly compared to a finger. On examination, the hand presents swelling and dorsal deformity; when the patient is asked to close the hand into a fist, the interosseous muscles depress the metacarpal head and the knuckle disappears (dropped knuckle). A rotation problem is easily identified by having the patient flex the fingers into a fist, which demonstrates overlapping fingers or malrotation of the nail apparatus. If the patient cannot flex the fingers, local anesthesia at the fracture site is required to assess them for malrotation. Shortening is detected by X-rays, it is more common in the little and index finger and in case of multiple fractures. The intermetacarpal ligaments prevent shortening by more than 3 to 4 mm in the central digits; shortening exceeding 5 mm reduces the efficiency of intrinsic muscle contraction and extension is impaired. The bone shaft is affected in injuries involving axial loading, torsion, direct falls, or crushing. Metacarpal fractures can be classified as transverse, oblique, spiral, and comminuted. If the trauma involves directly the hand, the fracture pattern is usually transverse or comminuted, whereas a fall on an outstretched arm mostly causes spiral or oblique fractures. The majority of metacarpal fractures are isolated, simple, and stable and can be managed without surgery. Semipronated oblique views allow evaluating the index and middle finger; semisupinated oblique views enable evaluation of the ring and little finger. Extensive soft tissue loss requires coverage with local tissue if possible or else with a free flap. A wound requires surgical exploration and examination (and repair as needed) of the extensor tendon. Kirschner (K)-wire or intramedullary fixation is preferred in open fractures where soft tissue healing is a cause for concern. In open fractures with bone loss and inpatients with multiple metacarpal fractures, we feel that locking plate fixation is more effective in preserving length and alignment, if the soft tissue envelope permits. In patients with bone loss and/or soft tissue damage, external fixation is to be preferred. Dorsal fasciotomy is required in crush injury if compartment syndrome is to be prevented. In severely comminuted fractures with bone loss, cement application to replace the bone loss followed by use of secondary bone chips (induced membrane technique) or by a bone graft has been reported. The ring finger is the only finger lacking tendon attachment and is therefore less prone to deformation forces in case of fracture. The metacarpal bones form a volar concave arc and provide a stable platform for the phalanges and neurovascular structures. The sagittal bands stabilize the extensor tendon over the head of the metacarpal and unite the collateral ligaments and the intermetacarpal ligaments of the volar plate. When using a dorsal surgical approach, the complexity of hand anatomy should always be kept in mind to prevent impairment/loss of extension or stiffness. The fibrocartilage volar plate and the intermetacarpal ligaments form a strong structure between the bones and prevent shortening in case of fracture of a single metacarpal bone. Transverse fractures show a dorsal angulation, due to the unequal traction of the interosseous muscles and the force exerted by the extrinsic extensor tendons on the distal fracture segment. According to the literature, the application of a functional cast to manage transverse metacarpal fractures significantly improves outcomes. Selection of the treatment option for metacarpal fractures requiring fixation is less straightforward, and there is no significant advantage in using any one fixation technique. The goals of treatment are to restore length, correct rotational deformity, and enable early mobilization to prevent stiffness. The interosseous muscles arise from the metacarpal bones and insert into the extensor 22. In spiral or oblique fractures, the rotational deformity is the most obvious problem and the one tolerated least: 1 mm causes 5 degrees of malrotation, which results in 1. The use of intramedullary fixation, external fixation, screws, and plates is determined by fracture type, the number of metacarpals involved, and the finger affected. Transverse fractures are managed with intramedullary techniques, either anterograde or retrograde (nails, K-wires, headless screws), which involve minimal dissection. Sometimes these fractures require open reduction and internal fixation because of the disruption of surrounding support structures, especially the intermetacarpal ligaments. In patients with shaft fracture of the fourth and fifth metacarpal, and sometimes also those with fracture of other metacarpal shafts, external fixation with K-wires, and/or external fixation (Joshi or others) is an optimal solution that avoids soft tissue damage and bone devascularization and provides stable reduction and early mobilization. In case of a long oblique fracture line, the use of interfragmentary compression screws is indicated if the fracture length is double in length of the bone diameter; this permits the positioning of at least two screws. Soft tissue dissection is required for anatomical reduction, and achieving compression is technically demanding. In short, oblique fractures or transverse fractures, plate and screws can provide stable fixation and ensure early mobilization. A variety of plates and screws are available; titanium and locking plates have been the most widely used in the past few years. Complication rates up to 35% have been reported in some series due to hardware failure, infection, and poor fracture healing. First metacarpal extra-articular fractures can generally be managed conservatively,6 although screw and plate fixation also enable early mobilization. The main concern with shaft fractures of the first metacarpal is the possible loss of the first web space due to adduction deformity determined by the flexor and extensor pollicis muscles, which reduces both pinch and grip strength of the hand. If misalignment or rotational deformity cannot be managed conservatively, we favor intermetacarpal pinning and intramedullary techniques to provide fracture stability without affecting the extensor tendons or other soft tissues during dissection. Long spiral fractures can be managed by open reduction and screw fixation; plate fixation is reserved for transverse/short oblique, comminuted fractures, or for multiple metacarpal fractures where other methods are not practicable. In patients with severe trauma and multiple fractures where fasciotomy is indicated, external or internal fixation is performed depending on tissue condition. Three-point molding-dorsal pressure at the fracture site and palmar pressure proximally and distally-is important in transverse fractures. The potential for secondary displacement is so high that X-rays should be taken weekly for at least 3 weeks. Any displacement should be treated with repeat reduction and cast or surgery if necessary. Such outcomes are probably due to the young age of the patient population typically affected by these fractures, where tissues are smooth and less prone to develop stiffness. Intramedullary Locking Nails A novel device enabling locking of the proximal part of the nail can be applied to enhance stability. It can also be used in unstable fractures and in patients with fracture of several metacarpal bones. The nail is then introduced under fluoroscopic guidance into the intramedullary canal, to fix the fracture site. At the end of the procedure, the locking system is introduced perpendicular to the nail at the base of the metacarpal and cut. The advantages of this technique are that it avoids stripping the periosteum, involving minimal devascularization and enabling very early motion.
