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구루병 등 대사성 골질환 정리

Metabolic, Endocrine and Hematologic DiseasesVitamin D metabolismCa, P and Vit. DRickets Definition An osteomalacic syndrome Failure of mineralization of chondroid and osteoid Lack of ionized calcium and/or phosphate Less mineralized bone per unit volume of bone Bowing deformities Stress fractures with resultant deformitiesBiochemical consequences of vitamin D deficiency rickets Vitamin D deficiency Reduced Ca absorption Depressed extracellular Ca Secondary hyperparathyroidism Depressed extracellular P Defective minerlization of the bone in formation Increased bone resorption Demineralization of the existing boneSevere osteomalacia: Marked increased in osteoid bordering trabecular and endosteal bone Almost all (~100%) bone surfaces are covered by osteoid (surface osteiod is 20% in normal bone)Rickets Types Vitamin D resistant Familial hypophosphatemia End organ insensitivity 1,25 (OH) 2 vitamin D production failure Deficiency, Gastrointestinal diseases, Renal osteodystrophy Endocrine, upping of the metaphyseal regionsRickets Clinical presentation Extremities Growth disturbances Enlargement of wrist, ankles, elbow Bowing deformities of long bones Fractures commonRickets Radiographic presentation Osteopenia Wide physes Cupping Thin lines of provisional zone of Ca missing Harris growth arrest lines Looser ’ s lines, bowingRickets Deformity Femur “ Slow bow ” typical, with gradual deformity throughout Apex, anterolateral rotation variable Distal femur metaphysis sometimes in valgus Deformity accelerates in pubertyRickets Deformity Tibia Varus most pronounced Internal rotation Apex, proximal metaphysis Minimal sagittal plane deformity Deformity accelerates in puberty “ cystic appearance ” in medial tibia physisRickets Medical treatment Phosphate 1,25 (OH) 2 Vitamin D Standard Phosphate, Calcitriol Vit. D 1500-5000 IU/day for 6-10 wks Within 2-4 wks, detectable healing evidence Newer options Human growth hormone, newer Vitamin D analogs Clinical course Girls is better forery Recurrence with metaphyseal osteotomies done before maturityStapling Reversible (forgiving) method of RX May be repeated P.R.N May obviate the need for osteotomy Fulcrum Extraperiosteal Extraphyseal Timing Trigonometric Femur/tibia: 0.9/0.6cm 1 /mm growthRickets Surgical treatment Femur Double level osteotomies Locked IM nail External fixation, an option Staged or bilateral Tibia Bilateral proximal metaphyseal osteotomies Oblique, with two plane correction Pins, screws, plating Cast or external fixation for immobilization Occasional other deformities Severe ankle varus Double level osteotomies with pins/E.F. Diaphyseal deformities IM fixation as many osteotomies requiredRickets Surgical treatment Ilizarov and uniplane fixators Length and deformity correction Allow anatomic axis realignment Can be used successfully Require longer for regenerate Higher rate of pin site looseningRickets Surgical treatment Avoid (or prevent recurrence) Osteotomies of diaphysis without IM nail Early-agunderstood) and osteoporosis Significant resorption of metaphyseal bone ex. SCFE Patterns of bone absorption of are variable ex. Rugger jersey spineRenal Osteodystrophy Clinical manifestations Younger children at the age of physiologic bowing usually do not develop renal osteodystrophy Much more common in older children who have already developed physiologic genu valgum Some improvement in alignment when successful medial treatment or transplantationBrown tumorHypoparathyroidism Increased density of long bones, skull Soft tissue calcifications Low calcium, high phosphate Treatment: Vitamin D Usually no orthopaedic Tx. requiredHypothyroidism Cretinism Older children Growth delay, lethargy Sluggish reflexes Bone age is an important factor in diagnosis Sometimes, epiphysis can be fragmented and appear similar to osteonecrosisHypervitaminosis D Hypophosphatasia Most commonly as side effect of other treatment Problem is hypercalcemia Occasionally see with immobilization after surgery Disconophilia Medical management Raise to at least 50% for hemorrhage Raise to 100% for surgery One unit of factor VIII concentrate 2% increase in the serum activity level per B.W(kg) with dosing every 8 to 12 hrs One unit of factor IX concentrate 1% increase in the serum activity level per B.W(kg) with dosing every 18 to 24 hrsHemophilia Acute phase Acute hemarthrosis: knee elbow ankle Less acute compartment syndrome, carpal tunnel syndrome, femoral neuropraxia Treatment Rapid and aggressive medical treatment Joint aspiration and decompression following replacement therapy Splinting for 24-48 hrs and rehabilitation starts Replacement continued through the next 5-7 days for re-bleedingHemophilia Chronic phase Begins with synovial hypertrophy and recurrent small bleeds Treatment Prophylactic concentrate regimen for 4-6 months, and then synovectomy Physiotherapy and NSAIDs for relentless arthropathy as Factor VIII inhibitors develop in 30% of patientsLeukemia Largest group of childhood maligna

의/약학| 2011.05.07| 47페이지| 1,500원| 조회(235)

골다공증, 구루병, 신성 이영양증

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Gait analysis

Gait AnalysisGait analysis offers maximal challenge to patient care Surgery: focus on the primary dysfunction, not the compensatory motion Surgery in neuromuscular disease is a guessing game prior to clinical gait analysisMethods Observational gait analysis We know well that our sight, by rapid observation, discovers from one vantage point, an infinity of forms; nevertheless, it only understands one thing at a time Leonardo da VinciMethods Modern gait analysis 1) video system 2) motion measurement system 3) force plates 3D kinematic and kinetic analysis 4) dynamic electromyography 5) energy consumption detectorKinematics The study of the joint motions observed CCD camera markers 3 planes (sagittal, frontal transverse) Joint angles , angular velocities angular accelerationKinetics The study of the forces by the joints during gait Joint forces Moments PowerGait analysis Normal gait Provides a basis of understanding locomotion Defines normal ranges Pathological gait Identifies deviations iesGait cycle 1)0-100%(foot strike-ipsilateral foot strike) 2) Phases Stance phase (60%, foot strike - toe off) Swing phase (40%, toe off - foot strike)Events Foot strike: 0% Opposite toe-off: 10% Opposite foot strike: 50% Toe-off: 60%Stance phase(FS-TO) 1. Initial double limb support 2. Single limb support 3. Second double limb supportSwing phase(TO-FS) 4. Initial swing 5. Mid swing 6.Terminal swingBipedal locomotion Right foot Left foot Initial double limb support: Second double limb support Single limb support: Swing Second double limb support: Initial double limb support Swing: Single limb supportGait data 1) step length( 보장 ): FS-OFS 2) stride length( 활보장 ): FS-2nd FS 3) step width( 보폭 ) 4) cycle time (sec) 5) cadence( 분속수 ): steps/min 6) walking velocity (cm/sec)Development of gait 1) adult pattern: 3.5Y↑ 2) cadence↓, step length↑, walking speed→ 3) by the development and maturation of the nervous and musculoskeletal systemsSagittal plane motion curves 1) pelvic tilt 2) hip flexioscillate like body center of mass B) most horizontal at end of double limb supportHip flexion/extension a) 0 º -40 º single sinusoidal curve b) maximum extension in OFS c) maximum flexion in terminal swingKnee flexion/extension a) 5 º -60 º , double wave b) flexion wave of early stance (shock absorber) c) flexion wave of early swing (foot clearance)Ankle plantar flexion/dorsiflexion a) DF10 ° to PF 20 º b) PF in early stance c) DF in single limb support d) Rapid PF in late stance e) Rapid DF in early swingRockers (1)First rocker (heel rocker): loading response, eccentric dorsiflexor (2) Second rocker (ankle rocker): midstance, eccentric Achilles (3) Third rocker (forefoot rocker): terminal stance, concentric AchillesCoronal plane motion curves 1) pelvic obliquity contralateral pelvis: normally drop in early stance phase (cf. Trendelenburg gait)Coronal plane motion curves 2) hip abduction/adduction a) similar to pelvic obliquity b) adduction in OTO c) abduction in TOTransverse plane morotation Peak IR at OFS IR begins in late swingTransverse plane motion curves Tibial rotation Similar to femur rotation Peak E/R at toe-off Foot rotation Mainly E/R Small I/R during second double supportKinematic data( Joint angles) Stiff Knee gait in CP Coronal Sagittal TransverseKinetics Supplement to EMG and movement measurement Ground reaction force (the law of action reaction) : Vertical , Medial-lateral, Anterior-posteriorKinetic values from kinematic dataJoint moment force(F) x distance(D) Ankle joint moment after heel contact: dorsiflexors moment plantar flexors momentJoint power = joint moment x angular velocity a) Concentric muscle contraction = power generation b) Eccentric muscle contraction = power absorptionKinetic dataDynamic electromyography To identify muscles with abnormal timing Surface electrodes Fine-wire electrodes Non-invasive Invasive Easy to apply License Muscle groups Deep, small musclesQuestion What is the phase of the most high stress of patellofemoral jointKnee extensors flexors Ankle dorsiflexors Hip extensorsMuscle actions 2) Loading response (heel rocker) Goal: accept weight Knee extensors Ankle dorsiflexors Hip abductors Hip extensorsMuscle actions 3) Midstance (ankle rocker) Goal: stabilize knee Ankle plantar flexorsMuscle actions 4 ) Terminal stance (forefoot rocker) Goal: accelerate mass Ankle plantar flexors (concentric)5) Preswing Goal: prepare for swing Hip flexors (concentric) Muscle actions6) Initial swing Goal: clear foot Ankle dorsiflexors Hip flexors 7) Midswing Goal: clear foot Ankle dorsiflexors Muscle actions8) Terminal swing Goal: decelerate shank Knee flexors extensors Hip extensors Ankle dorsiflexors Muscle actionsClinical Application of Gait Analysis 1) Descriptive study: normal/patient 2) Comparative study: preop/postopObservational analysis a) Clinical evaluation (Pre-gait) strength, passive mobility, spasticity, motor control and sensation b) Data collection videotaping in sagittal frontal planes c) Data reductio

의/약학| 2011.05.07| 47페이지| 1,500원| 조회(255)

보행, gait, 보행분석

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Embryology

EmbryologyHistory Hippocrates of Cos (B.C. 460~377) The first recorded embryological studies Aristotle of Stagira (B.C 384~322) Founder of Embryology JH van Arnheim A van Leewenhoek (1677) Miniature human being in sperm KE Von Baer (1827) Father of modern embryology RG Edwards P Steptoe (1978) Technique of in vitro fertilizationWhy study Embryology? Sheds light on the gross anatomy of the body Helps to explain the anatomy of congenital malformationEmbryogenesis Embryonic period Fertilization to 8 weeks of gestation Fetal period 9 weeks to gestation to birth Gradual transformation Develop into a recognizable human being with primordia of all major systems 56 days embryoBeginning of human development (first week) Fertilization zygote Zygote blastomeres A ball of 12 or more blastomeres (Morula) Morula Blastocyte Blastocyte is implanted in the endometrium : embryoblast, blastocytic cavity, trophoblast Embryonic period cleavage Cavity formationBeginning of human development (first week) Embweek) Embryoblast differentiate into a bilaminar embryonic disc (epiblast, hypoblast) Localized thickening of the hypoblast -- Prechordal plate Embryonic periodFormation of bilaminar embryonic disc Embryonic periodFormation of germ cell layers early tissue organ differentiation (3rd week) Gastrulation BMPs play an essential role Three germ cell layer axial orientation Embryonic ectoderm, endoderm, mesoderm Neurulation Formation of the neural plate neural fold closure of the fold to form the neural tube Formation of primitive streak, notochord, somite… Embryonic periodGastrulation Embryonic periodNeurulation Embryonic periodDevelopment of Somites From paraxial mesoderm First pair at the end of 3 rd week 42~44 pairs of somites by the end of 5 th week Somite separate into Sclerotome – forms vertebral body ribs Myotome – forms myoblasts Dermatome – contribute to dermis of the skin Notch pathway genes (Notch Signaling), Hox genes, other signaling factors Embryonic periodDevelopment of Somitms of the body form from three germ layers 4 th week -- eye, 4 chamber heart, limb bud 4 to 8 th week – major ext. internal structures 8 th week – human appearance Developmental disturbance during this period may give rise to major congenital anomalies of the embryo (rubella, drugs…) Embryonic periodEmbryonic periodEmbryonic period Derivatives of the three germ cell layersFetal Period Rapid body growth and differentiation of tissue organ system Relative slowing of head growth Changes are not so dramatic than embryonic period 3 RD Trimester Rapid physical growth Refinement of organ structure Continued neurologic developmentFetal PeriodDevelopment of Bone Cartilage Condensation of mesenchymal cells Regulators of skeletal development Bone Morphogenetic Protein (BMP 5 7) The Growth factor Gdf5 Members of the TGF-B superfamily Intramembranous ossification Endochondral ossificationIntramembranous ossification In mesenchyme that has formed a membranous sheath Condensed mesenchyme differentiatnceEndochondral ossification Condensed mesenchyme undergo chondrification to form cartilage bone model Ossification center by the end of embryonic period Appositional growthDevelopment of Joint during the 6 th week 3 Joint types Synovial joint Cartilaginous joint Fibrous jointDevelopment of Axial Skeleton Sclerotomes Paired condensation of mesenchymal cells around notochord Consists of loose cranial dense caudal cells Metameric shift Caritilaginous stage Bony stage of vertebral development4 weeks 5 weeksA: Mesenchymal vertebra (5 weeks) B: Chondrification center (6 weeks) C: 7 weeks E,F: At puberty D: At BirthPosition of Spinal Cord 1 ST trimester: entire length of embryo Birth: L 3 Skeletal maturity: L1-L2Spinal Malformation Spina bifida Most common, defect of neural arch fusion Defect of formation Wedged vertebra, hemivertebra… Defect of segmentation Unsegmented bars, Block vertebra… VACTER (vertebra, anal atresia, cardiac, tracheoesophageal, renal) Association Noxious influence durily stage) Hox genes regulate patterning in the developing limb Bone models in proximodistal sequence Upper limb bud(26 or 27 days) with lower limb bud 1 ~2 days later Mesenchymal bones (5 th wk) Hyaline cartilage bone model (6 th wk) AER (Apical Ectodermal Ridge) Inductive influence on the mesenchyme Apoptosis in the interdigital region (by BMP?)Early stage of Limb Development 28 days 33 days 6 weeksDevelopment of Limbs (Final stage) Primary ossification center (7 th ~12 th wk) The upper lower limb rotate in opposite direction Upper limb; rotate laterally Lower limb; rotate medially Secondary ossification center Bones at the knee (34~38 th wk), others after birthRotation of the limbsNeuromuscular Development One Nerve, One somite relation during migration of somite Upper Lower extremity innervation retains the original pattern of somite innervation Muscles 5 th week; Myoblasts  Myotubes Actin Myosin  Sarcomeres 8 th week; Movement of muscleDevelopment of dermatomal patterns of the li

의/약학| 2011.05.07| 33페이지| 1,500원| 조회(140)

발생, 발생학, embryo, embryology

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TLICS

Thoracolumbar Injury Classification and Severity Scale (TLICS) and Load sharing classificationLoad sharing classification McCormak, 1994 Follow-up of 28 patients who had three-column spinal fractures surgically stabilized by short-segment instrumentation screws and plates and autograft fusion . revealed 10 patients with broken screws Retrospective examination screw fractures all occurred in patients with a greater amount of injury to the vertebral body Proposed with a primarily therapeutic utility as a predictor of posterior short-segment fixation Load sharing classificationLoad sharing classification Three components (point system) the amount of damaged vertebral body, the spread of the fragments in the fracture site, the amount of corrected traumatic kyphosis Load sharing classificationThree components the amount of damaged vertebral body Comminution at CT sagital plane Less than 30% : 1 point 30~60 % : 2 points More than 60 % : 3 points Load sharing classificationThree components the spread of the fragments in the fracture site CT axial plane No displacement or less than 1mm : 1 point displacement less than 2mm Less than 50% comminution : 2 points displacement more than 2mm more than 50% comminution : 3 points Load sharing classificationLoad sharing classification Three components The amount of corrected traumatic kyphosis 0~30’ : 1 point 40~90 ’ : 2 points More than 90’ : 3 pointsTotal points of 3 components More than 7 points failure of posterior instrumention or nonunion Can be used preoperatively predict screw breakage when short segment, posteriorly placed pedicle screw implants are being used describe any spinal injury select spinal fractures for anterior reconstruction, in addition to transpedicular fixatioin Load sharing classificationTLICS Conceptualized based on a survey given to the Spine Trauma Study Group in 2002 to identify treatment algorithms for common TL injuries characteristics of injury that played a key role in the decision-making process Three major categories The morphology of the injury The integrity of the posterior ligamentous complex The neurologic status of the patientThe morphology of the injury initial step is to scrutinize available imaging studies Compression injuries Translational/rotational injuries Distraction injuries TLICSCompression injury Most common form of thoracolumbar fracture Results from an axial load to the spine Compression fracture 1 point load is transferred to ant. vertebral body deforms into a wedge, causing kyphosis posterior vertebral body remains intact Bursting fracture 2 points load is trasferred to ant. post. ant. post. cortex is disrupted retropulsion into the spinal canal. TLICS - morphologyTranslational/ rotational injury 3 points significant injury from violent torsional, shear forces, or both usually cause significant ligamentous or osseous damage that resuls in unstable spine TLICS - morphologyDistraction injury 4 points tensile disruption of the spinal column cause osseous, ligamentous, or combined injuries of the spine and usually results in a circumferential instability TLICS - morphologyFive categories of neurologic injury Intact 0 points Nerve root injury 2 points Cord injury Incomplete 3 points Complete 2 points Cauda equina syndrome 3 points TLICS – neurologic injuryPosterior ligamentous complex (PLC) Components : supraspinous ligament, interspinous ligament, ligamentum flavum , and facet joint capsules An intact PLC is determined by absence of a palpable gap between spinous processes, absence of interspinous widening on plain films or CT images, absence posterior ligamentous hyperintensity on MRI imges Intact 0 point Injury suspected /indeterminate 2 points Injured 3 points TLICS - PLCTotal points Determinined by adding the assigned points in all the major categories help surgeons and nonsurgeons assess the severity of the injury and to guide the decision of treatment 3 points or less Nonoperative 4 points Nonoperative or operative 5 points or more operative TLICS – Total pointsTLICS - summary CTLICS - summary CThank you for your attention{nameOfApplication=Show}

의/약학| 2011.05.07| 18페이지| 1,500원| 조회(169)

TLICS, Thoracolumbar Injury, thoracolumbar

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scoliosis

Classification of i diopathic adolescent scoliosisKing – Moe classification King - Moe method is determined from Cobb angles measured on curve segments in the Anterior/ Posterior radiographs (1983).King – Moe classification (Type I) The King Moe type I spine is a double curve through the lumbar and thoracic spinal regions Both curves pass through CSVL (True double curve) The lumbar curve tends to be larger in Cobb angle as well as more rigid than the thoracic curve. * CSVL: Center sacral vertical lineKing – Moe classification (Type II) The King Moe type II spine is also a double curve through the lumbar and thoracic spine, although the lumbar curve is less prominent than in type I. Both curves pass through CSVL (False double curve) The lumbar curve is much more flexible and the thoracic curve is the primary structural curve.King – Moe classification (Type III) The King Moe type III spine is a single primary thoracic curve. The lumbar curve, while present, does not cross CSVL , and is significantly less curved than the thoracic curve.King – Moe classification (Type IV) The King Moe type IV spine is a very long thoracic curve. tend to exhibit a marked C-shape where the distal inflection point is near the L4 . The proximal inflection point is in the proximal thoracic or cervical region. The L4 vertebra is significantly rotated away from the neutral.King – Moe classification (Type V) The King Moe type V spine is a double thoracic curve tend to extend into the cervical spine and also may have a third compensatory curve in the lumbar region. rotation away from the neutral position near the top endplate of the T1 . ( positive T1 tilt ; T1 tilt to convex side of upper curve )King – Moe classification Old fashioned - Harrington rod implant Only consider thoracic curve Not include thoracolumbar, lumbar, triple curve Low interobserver and intraobserver reliability Difficult to classify between king type II and IIILenke classification Lenke developed a more sophisticated procedure for classifying spinal deformities(2001). The technique was developed as it was found that the King Moe classification showed poor reliability and reproducibility. Lenke suggested that : 1. Be comprehensive- Include all types of curves 2. Emphasize consideration of sagittal alignment 3. Help define treatment that could be standardized 4. Be based on objective criteria from each curve type 5. Allow for good-to-excellent interobserver and intraobserver reliability 6. Be easily understood practical valueLenke classificationLenke classification Structural curves may also include smaller curves (minor curves) that have little or no flexibility in the bending image. In order for one of the curve patterns to be classified as structural , it must meet one of the following criteria: Proximal Thoracic curve pattern must have: Side-bending Cobb 25 º T2 - T5 Kyphosis 20 º Main Thoracic curve pattern must have: Side-bending Cobb 25 º Thoracolumbar/Lumbar curve pattern must have: Side-bending Cobb 25 º T10 – L2 Kyphosis 20 ºLenke classification Location of Apex (SRS definition) Curve Apex Thoracic T2-T11-12 Disc Thoracolumbar T12-L1 Lumbar L1-2 Disc-L4Lenke classificationLenke classificationLenke classificationLenke classificationCase I 1 6 / F King type II 4 3 38 1 0 L2 T8 Main thoracic curve Side-bending Cobb : T 43 º L38 º Lumbar spine modifier B Thoracic Sagittal profile 10 º  N Type I, B, N CSVLCase II Double Major curve Side-bending Cobb : T 45 º L42 º Lumbar spine modifier C Thoracic Sagittal profile 19 º  N Type III, C, N 1 1 / F King type II T8 L1 4 5 42 1 9 CSVLThank You for Your Attention{nameOfApplication=Show}

의/약학| 2011.05.07| 19페이지| 1,500원| 조회(202)

측만증, SCOLIOSIS, lenke

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