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If the pathologic process responsible for pain of carpometacarpal joints of the fingers is not adequately treated fluoxetine 20 mg sale, the patient’s functional disability may worsen and muscle wasting and ultimately a frozen carpometacarpal joints of the fingers joint may occur buy 20mg fluoxetine free shipping. Plain radiographs are indicated in all patients who present with pain of the carpometacarpal joints of the fingers (Figs 20 mg fluoxetine overnight delivery. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. A small linear high-frequency ultrasound transducer is placed in a longitudinal parallel axis over the base of the metacarpal to be injected and a survey scan is taken (Fig. The transducer is slowly moved proximally along the metacarpal until the hypoechoic cleft between the base of the metacarpal and the distal articular surface of the carpal is in the center of the image. After the joint is identified, it is evaluated for arthritis, effusion, synovitis, infection, ganglion cysts, tumor, and crystal arthropathy (Fig. The overlying tendons and surrounding soft tissue is then evaluated for abnormality (Figs. Correct patient position for ultrasound evaluation of the carpometacarpal joints of the fingers joint. Longitudinal ultrasound image demonstrating erosive changes of the second carpometacarpal joint in a patient with rheumatoid arthritis. Extended field of view image demonstrating a low echogenicity mass (arrows) adjacent to the flexor tendon. Longitudinal ultrasound image demonstrating a ganglion of the abductor pollicis longus. Care should be taken to correctly diagnose all pathology responsible for the patient’s pain and functional disability so a rational treatment plan can be designed and implemented. Degenerative and post-traumatic arthritis affecting the carpometacarpal joints of the fingers. The ligament and skeletal anatomy of the second through fifth carpometacarpal joints and adjacent structures. Technique for intra-articular injection of the carpometacarpal joint of the fingers. Anatomy and pathomechanics of ring and small finger carpometacarpal joint injuries. The most common site of pathology in trigger finger is in the flexor tendon and tendon sheath of the flexor digitorum superficialis and profundus muscles of the second to fifth fingers. Sesamoid bones, bone excrescences, and foreign bodies within the tendon sheath at the level of the metacarpal heads may also contribute to the development of trigger finger (Fig. The key landmark when performing ultrasound-guided injection for trigger finger is the A1 pulley at the level of the metacarpophalangeal joint. Sagittal sonogram shows the volar plate at the level of joint space (arrows), with the flexor tendon more superficial (T). Sonography of the finger flexor and extensor system at the hand and wrist level: findings in volunteers and anatomical correlation in cadavers. A nerve tract ran on the radial aspect of the tumor, causing compression (arrowhead). Locked metacarpophalangeal joint of the middle finger caused by a lipoma in the flexor tenosynovium: a case report. Other causes of trigger finger include direct trauma to the tendon sheaths, especially at the site of the A1 pulley, tendon sheath infection, nodules, foreign body, or compression by osteophytes of the heads of the metacarpal, sesamoid bones, or abnormal bone growth from other medical conditions such as acromegaly (Fig. Repeated irritation from repetitive motion as the tendons pass back and forth over boney prominences and through swollen and stenotic tendon sheaths can cause significant tendinopathy and edema of the tendon sheaths themselves (Fig. Over time, if the inflammation remains untreated, nodules may develop of the tendons which may lock as they pass beneath a retraining tendon pulley causing a triggering phenomenon as the nodule catches on the pulley. When this occurs, the patient experiences a catching or locking of the finger when the finger is in flexion or extension (Fig. Activities associated with the development of trigger finger included repetitive gripping activities involving the hand such as clenching a horse’s reins or steering wheel too tightly. Coexistent arthritis, sesamoiditis, gout, other crystal arthropathies, and synovitis of the metacarpal and interphalangeal joints may predispose the patient to the development of trigger finger. Axial T1-weighted (A) and fat-saturated T2- weighted (B) magnetic resonance images through the distal aspect of the left index finger reveal a heterogeneous lobulated mass situated along the radial aspect of the flexor tendon apparatus. The mass demonstrates areas of low to intermediate signal intensity on both T1- and T2-weighted images (arrows). C: Axial fat-saturated T1-weighted image obtained at the same level demonstrates heterogeneous enhancement of the mass. An ill-defined area of 532 relative hypo-enhancement (arrow) corresponds to a similar region of low signal intensity on T1- and T2-weighted sequences, presumably representing densely fibrous elements. Transverse ultrasound image near the head of the metacarpal demonstrating tenosynovitis of a flexor tendon. Note haloing of the tendon, fiber disorientation, and ulnar rotation of the superficial and deep flexor tendons. A trigger finger is caused by a painless nodule in a flexor tendon in the palm, near the head of the metacarpal. The nodule is too big to enter easily into the tendon sheath when the person tries to extend the fingers from a flexed position. With extra effort or assistance, the finger extends with a palpable and audible snap as the nodule pops into the tendon sheath. Gripping activities exacerbate not only the pain, but the incidence of the triggering phenomenon associated with trigger finger. Often, the patient will awaken to find his or her finger locked in a flexed position with significant morning stiffness, a common complaint. On physical examination, in addition to tenderness to palpation over the tendon nodules and along the affected tendon, the examiner may appreciate a creaking sensation with flexion and extension of the trigger finger. A triggering phenomenon may be noted, especially if the patient is examined shortly after awakening. An audible pop may be appreciated as the tendon nodule passes over area of tendon sheath stenosis. Plain radiographs of the wrist are indicated in all patients suspected of suffering from trigger finger to rule out occult bony pathology and to identify calcific tendinitis. Based on the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, uric acid, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging and ultrasound imaging of the hand is indicated to assess the status of the affected tendons and tendon sheath as well as to identify other occult pathology including arthritis, sesamoiditis, and synovitis (Fig. Sonogram longitudinal to the foreign body shows the echogenic wood splinter (arrows), which is made more conspicuous because of the surrounding hypoechoic halo (arrowhead).

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For practical dried and presented as a white powder in vials for purposes best 20 mg fluoxetine, a conversion ratio of 1:1 between Xeomin reconstitution with sterile saline before use (Fig order genuine fluoxetine on-line. Bocouture® is Xeomin’s sister toxin buy generic fluoxetine pills, presented in ideally used within 48 h following reconstitution, 50 U vials and licensed for aesthetic use. Inactive 10 Botulinum Toxins 105 ingredients also differ between products; Botox/ cleaves the vesicle-associated membrane protein Botox Cosmetic contains sodium chloride. Dysport/Azzalure contains lactose, and Xeomin/ both type A and type B toxins ultimately block the Bocouture contains sucrose. Other products release of acetylcholine leading to temporary paralysis include Neuronox® (M edy-Tox, Seoul, South of striated muscle. Korea) and Prosigne® (Lanzhou Institute of Clinically, the effects of botulinum toxin injections Biological Products, China). Although these prod- begin 2–3 days following treatment and are maximal at ucts are presented as 100 U vials of lyophilized 10–14 days. After approximately 1 month, new unmy- botulinum toxin type A complex and reportedly elinated nerve “sprouts” begin to grow from the nerve have 1:1 conversion rates to Botox®, effcacy and endings to re-establish functional connections within safety studies and trials are lacking compared to the motor units. Following repeated injec- tions over several years of treatment, disuse atrophy of denervated muscle may prolong the effects of subse- 10. Botulinum toxin causes a faccid paralysis of striated the release of sweat from eccrine sweat glands is muscle by blocking the release of the neurotransmitter also mediated by acetylcholine. This application has led to the treatment of at the synaptic cleft, releasing acetylcholine to act on axillary, palmar, and plantar hyperhidrosis with cholinergic receptors in striated muscle. Any inter- ference with one or more of these proteins prevents W hen botulinum toxin is injected subcutaneously or formation of the so-called synaptic fusion complex and intramuscularly, it exhibits effects at the injection site blocks release of acetylcholine [15]. The spread of toxin in the tissues is termed neurotoxin surrounded by a protective protein com- the “action halo. The complex is resistant to acidic environments the size of the action halo: manipulation or manual and protects the toxin from the harsh environment of spreading following injection, volume of solution the digestive tract. After injection, determines the position of the tissues they act upon the neurotoxin is probably released in less than a min- (Fig. Unopposed cholinergic nerve cell membrane, leading to endocyto- activity of the elevators will therefore elevate the brow sis of the toxin into the intracellular compartment. Similarly, the light chain (L) from the vesicle into the cytosol of unopposed action of the depressors will drop the brow the nerve. For this reason, treating frontalis alone 25 protein at the neuromuscular junction and blocks without the depressors will result in a heavy ptotic brow the neuroexocytosis of acetylcholine into the synaptic and should never be performed. Botulinum toxin type B (M yobloc®) denervating depressor anguli oris results in reduced 106 P. Imprecise injections will at best lead to suboptimal the lateral part increases the activity of lateral frontalis results and at worst to complications such as brow or and creates a lateral brow lift. An understanding of the lid ptosis, mouth asymmetries, or even visual distur- dynamics and behavior of the mimetic muscles and bance. The muscles of facial expression are thin, fat their response to chemodenervation allows them to be muscles that act either as sphincters of facial orifces, manipulated to achieve a variety of aesthetic results. M any of these mus- cles are intimately related to or mingle with fbers of the muscles around them. Inadvertent injection or spread of botulinum toxin into the “wrong” muscle can lead to complications. Frontalis, corrugator supercilii, depressor supercilii, procerus, and orbicularis oculi represent the periorbital facial muscles. The perioral muscles include the leva- tor muscles, zygomaticus major and minor, risorius, orbicularis oris, depressor anguli oris, depressor labii, and mentalis. In the neck, the platysma muscle lies superfcially and extends into the lower face (Fig. Frontalis represents the anterior belly of the occip- itofrontalis muscle and is the main elevator of the brows. It arises from the epicranial aponeurosis and passes forwards over the forehead to insert into fbers of orbicularis oculi, corrugators, and dermis over the brows. Contraction raises the eyebrows and creates horizontal furrows across the forehead. Its fbers pass in con- Brow depressors Procerus centric loops around the orbit, well beyond the confnes Corrugator supercilii of the orbital rim. Preseptal orbicularis oculi arises from the Lower lid elevator Orbicularis oculi (pretarsal medial canthal tendon, passes over the fbrous orbital part) septum of the orbital rim, and inserts into the lateral M outh and lip elevators Levator labii palpebral raphe. The pretarsal portion, involved in Levator anguli oris blinking, overlies the tarsal plate of the eyelid and has Levator labii superioris alaeque nasi similar origins and insertions to its preseptal counter- Zygomaticus major and minor part. In some individuals, contraction of the pretarsal M entalis (lower lip) part results in fne lines under the eye or bulging of the M outh and lip depressors Depressor labii lid itself. Corrugator supercilii arises from the supero- Depressor anguli oris medial aspect of the orbital rim and passes upwards and Platysma outwards to insert into the dermis of the middle of the Nose Compressor naris brow. From its origin deep to frontalis, two slips of Dilator naris muscle, one vertical and one transverse, pass through Depressor septi fbers of frontalis to reach the dermis. Corrugator super- Neck Platysma cilii depresses the brow and pulls it medially, as in frowning. Depressor supercilii is a thin slip of muscle Frontalis (m edial) Frontalis (lateral) Depressor supercilli Procerus Levator labii superioris alaeque nasi Corrugator Orbicularis oculi: Pretarsal part Preseptal part Orbital part Zygom atici Com pressor naris Dilator naris Orbicularis oris Depressor septi Depressor anguli oris M entalis Depressor labii Platysm a Fig. Procerus arises from the slip of muscle arising from the maxilla above the central nasal bone, passes superiorly, and inserts into the der- incisor, deep to the mucous membrane of the upper lip. It depresses the inserts into the cartilaginous nasal septum and pulls the lower forehead skin in the midline to create a horizontal nose tip inferiorly. Fibers insert into the border pass downward to insert into the corner of the mouth of the mandible, perioral muscles, modiolus, and dermis and lateral aspect of the upper lip, respectively. As part of aging, its fbers attenuate or Superior fbers of these muscles lie beneath the orbital thicken to create platysmal bands. Functionally, platysma part of orbicularis oculi where they are prone to dener- depresses the mandible during deep inspiration but is vation with injudicious injections of botulinum toxin probably more important as a mimetic muscle to express below the lateral canthus. Orbicularis oris acts as a sphincter around the mouth the skin of the face is adherent to the underlying mimetic and its fbers interlace with all of the other facial mus- muscles through the superfcial musculoaponeurotic sys- cles that act on the mouth. Contraction of these oris has various actions including pursing, dilation, facial muscles creates hyperdynamic lines, particularly and closure of the lips.

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Burn and thermal injury are the major complications of diathermy use resulting from Incorrect application of the diathermy plate Patient in contact with earth metals Poor technique Direct coupling of instruments (see Figure 11 purchase fluoxetine 20 mg with visa. Capacitance coupling – Inductive coupling occurs when an electrode is inside an insulator with a further conduction outside (i buy fluoxetine. Patient touching earthed metal fluoxetine 10 mg overnight delivery, such as drip stands or the metal areas of the operating table. Accidental activation of foot pedal Not replacing electrode in quiver after use Accidental contact of active electrode with retractors, instruments, towel clips etc. Channelling effects occur because heat is produced where the current density is greatest. The patient plate electrode: Incorrect placement is the most common cause of accidental diathermy burns. It should be placed away from bony prominences and scar tissue (which have poor blood supply and therefore poor heat distribution). What precautions should the surgeon take to make sure diathermy is used safely in the operating theatre? Check insulation (but remember that even intact insulation may fail with high voltages due to the effects of capacitance coupling). Place the diathermy in a safe, insulated container (quiver) when it is not being used. Laser stands for Light Amplification by the Stimulated Emission of Radiation Laser emissions are Collimated – Parallel output beam results in little energy loss Coherent – Waves are all in phase resulting in little loss of energy Monochromic – All of the same wavelength the effects of a laser depend on photochemical, photomechanical and photothermal factors. Lasers are classified according to the amount of damage they can cause Class 1 – Generally safe Class 2 – Safe within the time of the blink reflex Class 3 – Cause blindness after short exposure from mirrored surfaces Class 4 – Unsafe even with reflection from non-mirrored surfaces All medical lasers belong to class 4, so both patients and operators are required to wear goggles. Patient risks: Excessive burning Scar formation Visceral perforation Airway fire Operator risks: Accidental skin exposure Corneal or retinal burns Cataracts Environmental risk: Fire risk What safety precautions should be taken when using lasers in the operating theatre? Designated laser controlled area, with warning signs, avoiding reflective surfaces with matt-black surfaces (see Figure 11. Cut-out devices and shrouded foot pedals to minimise the risk of unintended operation. Surgeon should warn the theatre staff before firing the laser (and when not being used the laser should be remain in ‘standby’ mode). Wet swabs may be used to decrease risk of inadvertent laser damage to adjacent tissues. Laparoscopy and creation of a pneumoperitoneum What are the advantages and disadvantages of minimal access surgery? Advantages: Decreased wound size Reduced wound infection, dehiscence, bleeding, herniation and nerve entrapment Decrease in wound pain Improved mobility Decreased wound trauma Decreased heat loss Improved vision Disadvantages: Reliance on remote vision and operating Loss of tactile feedback Dependence on hand-eye coordination Difficulty with haemostasis Reliance on new techniques Extraction of larger specimens What are the complications of laparoscopy? Complications of trocar insertion: Bleeding, damage to underlying viscera Complications of gas carbon dioxide insufflation. This can occur by having the core of the diathermy hook acting as one electrode and the metal laparoscopic port acting as another electrode with a layer of insulation in between. Current flowing through the active diathermy hook can induce current in the metal port, which can potentially damage adjacent tissues. Fortunately such incidents are rare and can be prevented by using non-conducting ports (Figure 11. Lignocaine 3 mg/kg (7 mg/kg with adrenaline) Bupivacaine 2 mg/kg Prilocaine 6 mg/kg (9 mg/kg with adrenaline) Ropivacaine 3–4 mg/kg Levobupivacaine 2 mg/kg What is the difference between lignocaine and bupivacaine? Lignocaine – Early onset of action (2–3 minutes), short acting (1–2 hours), good sensory block Bupivacaine – Slower onset of action (10–15 minutes), long lasting (4–6 hours), more cardiotoxic What are the benefits and risks of using adrenaline in local anaesthetics? Benefits: Less bleeding (vasoconstriction) Prolonged duration of action Higher doses can be used Reduced systemic absorption and decreased risk of toxicity Risks: Increased risk of ischaemic necrosis when operating on appendages supplied by end arteries (digits, penis etc. Reactive hyperaemia can occur in the post-operative period with increased risk of bleeding and haematoma. The drug of choice is prilocaine because it is the least cardiotoxic and has the largest therapeutic index. Local anaesthetic toxicity principally results in effects on the central nervous system and cardiovascular system. One of the earliest and reliable signs of systemic toxicity is perioral paraesthesia. These are followed by dizziness, which may progress to convulsions, cardiac arrhythmias, collapse and even death. Case Study You plan to excise a lipoma in an 85-year-old gentleman under local anaesthesia, since he is otherwise unfit for a general anaesthetic. If you use the maximum dose of lignocaine, can you still infiltrate the wound with bupivacaine at the end of the operation to achieve longer lasting analgesia? The important point here is that the effects are additive, so one cannot simply switch agents when the maximum safe dose is approaching. Similarly, mixing the two agents together (to provide both a rapid onset and long duration of action) does not allow an increased dose. In addition, a suture is a joint with minimal connective tissue located in the skull vault (e. Sutures are classified as follows: Absorbable or non-absorbable, natural or synthetic and monofilament or braided. It is absorbed between 56 and 70 days and provides adequate support for around 30 days. It causes an inflammatory tissue reaction and should be avoided in the placement of vascular prostheses or artificial heart valves. Shape: Straight Curved 1/4 circle 3/8 circle 1/2 circle 5/8 circle J shaped Compound curve Type: Round-bodied needles – They are designed to separate (not cut) tissue fibres. After the needle is passed, the tissue closes tightly around the suture material to form a leak-proof line. Intestinal Heavy Blunt taper point Blunt point Cutting needles – They are designed for tough or dense tissues. A needle with an eye carries a double strand, which creates a larger hole and disruption to the underlying tissue. This reduces handling, preparation time and causes less trauma to the underlying tissues. In a reverse cutting needle, the cutting edge is situated on the outside of the needle and is therefore less likely to cut through the tissues. In addition, by having the apex cutting edge on the outside of the needle curvature, this improves the strength of the needle and increases its resistance to bending.

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