1. Shoulder injuries are common in sports and can be acute or chronic. They range from mild sprains to traumatic dislocations and are often painful and mobility-restricting.
2. MRI and CT scans are important imaging modalities to diagnose shoulder injuries and assess soft tissue damage, bone defects, and other pathology like tumors or fractures. MR arthrography provides high accuracy for labral tears.
3. Common acute injuries include dislocations, rotator cuff tears, and injuries to the biceps tendon. Chronic overload can also cause tendinopathy and impingement. The size and chronicity of rotator cuff tears affects prognosis.
i present this lovely topic at Notional Guard Hospital in Al-Ahsa in the Orthopedic department.
hope you enjoy
Fahad Al Hulaibi
Orthopedic Resident
NGH-A
i present this lovely topic at Notional Guard Hospital in Al-Ahsa in the Orthopedic department.
hope you enjoy
Fahad Al Hulaibi
Orthopedic Resident
NGH-A
Posterolateral corner injuries of knee joint Samir Dwidmuthe
Missed posterolateral corner injuries of knee joint is a common cause for failure of ACL and PCL reconstruction only next to malpositioned tunnels.
Isolated PLC injuries are uncommon, making up <2% of all acute knee ligamentous injuries. Covey JBJS 2001
Incidence of PLC injuries associated with concomitant ACL and PCL disruptions are much more common (43% to 80%). Ranawat JAAOS 2008
A recent (MRI) analysis of surgical tibialplateau fractures demonstrated an incidence of PLC injuries in 68% of cases. Gardner JOT 2005
Take home message
PLC injuries to be ruled out in every case of ACL& PCL rupture.
Neurovascular integrity to be checked in every case.
Grade I & II can be managed conservatively.
Grade III Acute- Repair.
Grade III Chronic- Anatomic PLC recon.
Beware of varus knee alignment.
Acromioclavicular (AC) joint injury is a term used to describe an injury to the top of the shoulder, where the front of the shoulder blade (acromion) attaches to the collarbone (clavicle).
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different soft tissue injuries are the part of curriculum for the undergraduate students at KUSMS.
Posterolateral corner injuries of knee joint Samir Dwidmuthe
Missed posterolateral corner injuries of knee joint is a common cause for failure of ACL and PCL reconstruction only next to malpositioned tunnels.
Isolated PLC injuries are uncommon, making up <2% of all acute knee ligamentous injuries. Covey JBJS 2001
Incidence of PLC injuries associated with concomitant ACL and PCL disruptions are much more common (43% to 80%). Ranawat JAAOS 2008
A recent (MRI) analysis of surgical tibialplateau fractures demonstrated an incidence of PLC injuries in 68% of cases. Gardner JOT 2005
Take home message
PLC injuries to be ruled out in every case of ACL& PCL rupture.
Neurovascular integrity to be checked in every case.
Grade I & II can be managed conservatively.
Grade III Acute- Repair.
Grade III Chronic- Anatomic PLC recon.
Beware of varus knee alignment.
Acromioclavicular (AC) joint injury is a term used to describe an injury to the top of the shoulder, where the front of the shoulder blade (acromion) attaches to the collarbone (clavicle).
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different soft tissue injuries are the part of curriculum for the undergraduate students at KUSMS.
Approach to acute knee injuries (knee injury)mahadev deuja
approach to acute knee injuries include detail history, focused knee exam and imaging/invasive procedure,Diagnosis is made at history most of the times.History should include mechanism of Injury,location of pain, mechanical symptoms like swelling/ effusion...
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
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Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Anti ulcer drugs and their Advance pharmacology ||
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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Shoulder sports related injuries
1. Shoulder Sports-Related Injuries
What the clinician needs to know
Manos Antonogiannakis
Orthopaedic Surgeon
Director of 3rd Orthopaedic Department
Centre for Arthroscopy & Shoulder Surgery
Hygeia General Hospital
Athens Sports Imaging Course
19 May 2017
3. Every sport can lead to acute injuries and pain of the
shoulder joint or chronic injuries due to overuse
Contact Sports, sports with a ball, mountain biking,
snowboarding, windsurfing, climbing, horse riding
fall
shoulder injury
4. By throwing a ball, the shoulder joint is subject to high
loads and accelerations . Due to the repetitive throwing
movement, chronic overload and microtrauma occurs.
A shoulder joint with a very good mobility has a major
advantage for a good throw due to the better acceleration
moments, the better throwing force and the higher ball
speed.
This -high speed- movement of the arm must be every
time stabilized from the joint capsule, the ligaments and
the surroundings tendons.
5. 5-8% of all acute injuries affect the shoulder joint
Sport injuries more commonly affect male active persons
from puberty up to the age of 45.
6. Correct diagnosis ist important
A well-established network of orthopedics, radiologists,
physiotherapists and trainers is a major requirement for a
efficient medical care.
The early and correct diagnosis will lead to the early
and correct therapy of the injury.
8. As clinical doctors we know the history
and examine the patient
We need information from imagining and
the radiologist :
In order to arrive to a diagnosis
In decision making about the type of treatment
9. The four major clinical entities of the shoulder
Instability
Stiffness
Loss of congruity
Loss of power
10. Most common acute shoulder injuries
i. Shoulder traumatic dislocation
ii. AC-Joint dislocation
Tear of the rotaror cuff
i. Rupture of the long head of the biceps tendon
ii. SLAP Lesion
iii. Fracture of the clavicle, scapula, humerus head
Usually caused by direct force or contact with other players
11. Chronic overload damage
i. Rotator cuff tendinopathy
ii. Long biceps tendinopathy
iii. Impingement syndrome/Bursitis subacromialis
iv. GIRD Syndrome
v. SLAP Lesion
vi. AC Joint Arthritis
12. X-rays serve to:
Confirm the diagnosis:
–Dislocated
–Reduced with notch (Hill Sachs).
Eliminate an associated fracture.
–Great tubercle
–Hill Sachs
–Glenoid bone
loss
13. Field strength : High field strength 1, 1.5, 3 Tesla
Low field strength 0.5 Tesla
Low field strength : longer time to generate images
High signal to noise ratio
Surface coils (transmitter and receiver of radiofrequency pulses) that generate
Pulse sequences
T1-weighted sequence (fat bright,- water , muscle intermediate – fibrous, calcioum
dark)
T2-weighted sequence(water ,fat bright-muscle intermediete-fibrous, calcioum dark
Proton density
Gradient echo
Fat saturation techniques (supress the signal from fat so that pathology to be more
obvious)
MRI nomenclature
The patient is placed into a magnetic field created by a strong
magnet
14. Benign tumors around the shoulder
Primary and metastatic malignant tumors
Subtle fractures of the upper part of the humerous or
the scapula
Sinovial diseases ( osteochondromatosis , PVS)
Neuropathies of the peripheral nerves that innervate
the muscles of the scapula and the shoulder
MRI for other diagnosis
Be especially suspicious when the clinical presentation is not
familiar
17. Shoulder traumatic dislocation
Greatest Range of Motion in the body
Motion in all 3 planes of movement
Prone to instability
Sacrifices stability for mobility
20. History:
degree of violence
level of athletic participation
number of dislocations
age of the patient
Clinical examination:
generalized joint laxity
direction of apprehension
21. Biomechanical Dysfunction
Failure of static and dynamic stabilizers
Ranges from mild subluxation to traumatic dislocation
What is Instability?
22. A patient with some degree of laxity dislocates his
shoulder after a minor or major accident
The most common presentation
24. Conventional MRI provides a good
overview of shoulder lesions and anatomy
MR arthrography modality of choice to
evaluate the labrum. It has the highest
sensitivity and specificity
But it is invasive and inconvenient for the
patient
32. Conventional MRI provides a good overview
of shoulder lesions and anatomy,
particularly the soft-tissue structures.
However, it is less accurate than MR
arthrography for depiction of small
labroligamentous lesions associated with
shoulder dislocation.
MR arthrography is the imaging modality of
choice to evaluate the labrum. It has the
highest sensitivity and specificity of all
available modalities.
But it is invasive and inconvenient for the
patient
33. Glenoid Shape
The inferior 2/3 of the glenoid is nearly a
perfect circle with avg diameter 24mm
Huysman et al. JSES 2006
35. Although a bony bankart and glenoid and
humeral bone defects are being depicted on
MRI at present CT-scans are better for the
quantification of the defects
37. What is the critical limit of Glenoid Bone
loss?
>25 – 30% bone loss
6.5 – 8.6mm AP width
Inverted pear appearance
Bone block procedures
Piasecki et al. AAOS J17 (8): 482. (2009)
38. Taverna et al. Pico Method 2D CT – measurement of
glenoid surface Critical Limit 25% loss of glenoid surface
Quantification of Glenoid Bone loss
39. Our practice
The percentage of the glenoid defect was evaluated on the en face reconstructed
view with the humeral head eliminated
Quantification of Glenoid Bone loss
42. OP Goal
Restoration of the anatomical structure and
biomechanical function of the joint to ensure:
• stability
• normal function, painlessness, normal range of
movement
• prevention of development of osteoarthritis
44. Pain over the AC Joint
Painfully limited mobility of the
shoulder
Clavicle higher in X-Rays than
Acromion
CAVE: Fracture of Proc. coracoideus
45. SC-Joint dislocation
Rare
High energie trauma with potential
other life-threatening injuries
Anterior > posterior dislocation
Posterior dislocation: danger for
compression of the trachea, major
vessels or mediastinum
CT with contrast is recommended
46. Tear of the rotaror cuff
• Dynamic stabilizer of the shoulder
• Contributes strength to the arm (50% of the abduction
strength is generated by supraspinatus)
• Couple forces stabilize and regulate the motion of the
shoulder
• Internal and external rotation of the shoulder
47. Natural History of a Tear
• Tears DO NOT HEAL
• Some but NOT ALL of them will progress
• Rot cuff arthropathy is the end stage (4-20%)
• 50% of newly symptomatic tears will progress in size
• 20% of asymptomatic tears will progress
• No Tear decrease in size
• 80% of partial tears progress in size or become full thickness in 2 years
[Yamaguchi K., 2006, Nice Shoulder Course]
48. Philosophy of treatment
Restore the equilibrium between
functional demands and capacity of the rotator cuff
Lower the functional demands of the patient.
Increase the functional capacity of the remaining intact cuff
Repair the cuff
Restore the anatomy even partially in an
atraumatic way
49. Prognosis
Dimensions and extent of tear
Condition of the involved tendon (retraction – elasticity)
Tear morphology
Chronicity of tear
Evidence of muscle atrophy, fatty degeneration
51. Partial Tears
Partial tears are better imaged by MR direct
arthrography
High(fluid) signal intensity due to Gadolinioum through a portion of the tendon
Common in young athletes in combination with SLAP tears
52. Steps in measuring the size of RCT
Measure L (medial to lateral length) Measure W (anterior to posterior length)
53. Complete Tears
Small 1cm
Medium 2-3cm
Large 3-5 cm
Massive >5cm
90-95% excellent in small and medium size tears
at 4 to 10 years follow-up
Good to excellent results in massive tears with
less than 75% fatty infiltration of the
Infraspinatus even at 10 years follow-up
54. Classification
Type Description Preoperative MRI Findings Treatment Prognosis
1 Crescent Short and wide tear
End-to-bone
repair
Good to excellent
2
Longitudinal
(L or U)
Long and narrow tear
Margin
convergence
Good to excellent
3
Massive
contracted
Long and wide
> (2 x 2 cm)
Interval slides
or partial repair
Fair to good
4
Cuff tear
arthropathy
Cuff tear arthropathy Arthroplasty Fair to good.
55. Preoperative estimation of fatty infiltration of
infraspinatus and supraspinatus muscle bellies
affects the prognosis
56. Fatty Infiltration
According to Goutallier et al.
in CT scan
0 Normal
1
Some fatty
streaks
2 More muscle
3 Muscle = Fat
4 More fat
58. Ruptur of the long head of the biceps tendon
Long biceps tendon
• length: 10cm
• diameter: 5-6 mm
• intraarticular fraction
• extraarticular fraction
intratubercular fraction
extratubercular fraction
Sliding 2cm in and out of the joint
59. Anterior pain at the sulcus bicipitalis
Distalisation of the muscle belly
Loss of force
5%-20% elbow flexion
10-20% forearm supination
60. Tenotomy vs Tenodesis
• Damage/Quality of the tendon
• Age of the patient
• Activity level
• Cosmetic issues
• Wish of the patient
Young, slim patient with high
activity level and cosmetic issues
Bad quality of tendon, old patient
Tenodesis
Tenotomy
Decision for tenotomy or tenodesis:
68. Fracture of the clavicle
Most common cause: fall on the extended hand
Clavicle fractures: 3% of all fractures
Clavicular fractures:
i) of the middle third: 70%
ii) lateral clavicle fractures: 25%
iii) medial clavicle fractures: 5%
69. Conservative therapy
i) no additional nerve-, vascular- or major soft tissue
injuries
ii) Length shortening <15-20 mm
iii) Angle of the fracture <20-25 °
Clavicle 8-Brace
•so tight that the patient tolerates it
•no neurological or venous problems
70. OP Indication
• Vascular or nerve injuries
• Open fracture
• Tranverse intermediate fragment (poor healing)
• Fragment pressure to the skin or danger of skin perforation
• ´Floating shoulder´ (ipsilateral clavicle fracture and fracture
of the neck of glenoid)
• Pathological fractures
• Pseudoarthrosis
71. Fracture of the scapula
nearly 1% of all fractures
High energie trauma, fall from greater
height, shoulder dislocation
often associated with other severe injuries
such as thorax injuries or clavicle
fractures
72. Fracture of the humerus head
5% of all fractures
70% of all patient with humerus head fracture are older
than 60 years old
Danger for posttraumatic osteonecrosis due to the
reduced vascularisation
73. Conservative therapy
Dislocation of fracture < 1cm
Rotation of the humerus head < 45°
OP Indication
Tuberculum dislocation >5mm (<65 years old)
>10mm (<65 years old)
Axis Deviation > 45°
Intraarticular formation of a gap >2mm
77. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
78. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
Group Glenoid Defect Hill-Sachs Lesion Recommended Treatment
1 <25% On track Arthroscopic Bankart repair
2 <25% Off track Arthroscopic Bankart repair plus remplissage
3 >25% On track Latarjet procedure
4 >25% Off track Latarjet procedure with or without humeral
sided procedure (humeral bone graft or remplissage),
depending on engagement of Hill-Sachs lesion
after Latarjet procedure
79. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
A.Three-dimensional CT scan with en face view of a normal glenoid, with subtraction of the humeral head
The width of the glenoid track without a glenoid defect is 83% of the glenoid width.
B. Relation of glenohumeral joint in abduction and external rotation.
The distance from the medial margin of the contact area (M) to the medial margin of the cuff footprint (F) is 83%±14%
of the glenoid width: F - M = 83% of glenoid width = glenoid track.
80. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
A. 3D CT scan with en face view of a glenoid with bone loss of width d.
In such a case with glenoid bone loss, the glenoid track will be 83% of the normal glenoid width minus d.
B. Relation of glenohumeral joint in abduction and external rotation.
One should note the loss of contact of the intact humeral articular surface with the articular surface of the glenoid.
In this case the large Hill-Sachs interval (i.e., distance from posterior rotator cuff attachments to medial margin of Hill-
Sachs lesion) is wider than the glenoid track, whose width has been reduced because of the glenoid bone loss.
81. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
How to Determine Whether Hill-Sachs Lesion Is “On
Track” or “Off Track”
1. Measure the diameter (D) of the inferior glenoid, either by arthroscopy or from 3D CT scan
2. Determine the width of the anterior glenoid bone loss (d).
3. Calculate the width of the glenoid track (GT) by the following formula: GT = 0.83 D - d.
4. Calculate the width of the HSI, which is the width of the Hill-Sachs lesion (HS) plus the width
of the bone bridge (BB) between the rotator cuff attachments and the lateral aspect of the
Hill-Sachs lesion: HSI=HS + BB.
5. If HSI > GT, the HS is off track, or engaging. If HSI < GT, the HS is on track, or non-engaging.
82. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
83. Evolving Concept of Bipolar Bone Loss and the Hill-Sachs Lesion:
From “Engaging/Non-Engaging” Lesion to “On-Track/Off-Track” Lesion
Giovanni Di Giacomo, Eiji Itoi, Stephen S. Burkhart
84. ●From engaging Hill Sachs to On-
track & Off-track lesions
No Bone Loss Arthroscopic Bankart Repair
Glenoid Bone Loss
> 25%
Arthroscopic Bankart Repair + Bone grafting procedure
What
happens in
between?
It is the combination of the existing lesions
Large Hill-Sachs lesion + No glenoid bone loss
=
Small Hill-Sachs lesion + 15% -20% glenoid bone loss