Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
The ionized fraction determines the activity of calcium in cellular and membrane function purchase vaseretic online. The concentration of total calcium can vary without changing the ionized fraction by changing the protein concentration generic 10mg vaseretic with visa. It is also possible to vaseretic 10 mg on line vary the ionized fraction without changing the total calcium by changing serum pH. About 50% of the filtered calcium is reabsorbed in the proximal tubule, and most of the remainder ($40% of the total) is reabsorbed in the loop of Henle, primarily the ascending limb of the loop of Henle. A small amount of calcium is reabsorbed in the distal convoluted tubule and an even smaller amount in the collecting tubule. Although hypoalbuminemia results in reduction of total serum calcium, ionized calcium remains unchanged (physiologically more important fraction). Low serum calcium concentration stimulates 1-hydroxylation of 25-hydroxyvitamin D by the kidney to form 1,25-dihydroxyvitamin D (the active form of vitamin D). This hormone inhibits bone reabsorption and 1-hydroxylation of 25-hydroxyvitamin D and thereby ameliorates hypercalcemia. With some exceptions, renal calcium handling varies directly with renal Naþ handling. Therefore, renal calcium excretion is increased by saline diuresis, loop diuretics, and volume expansion. In contrast, renal calcium excretion is decreased in volume depletion and other states associated with renal salt retention. One notable exception to this general rule is that the natriuresis associated with thiazide diuretics is accompanied by decreased, rather than increased, urinary calcium excretion. Abnormalities in the concentration of serum proteins are a common cause of these disorders. Hypoalbuminemia causes a decrease in the total serum calcium level without a change in the level of ionized calcium. The symptoms depend on the magnitude of the decrease in serum calcium, the rate of the drop, and its duration. The symptoms of hypocalcemia are due to the resultant decrease in the excitation threshold of neural tissue, which causes an increase in excitability, repetitive responses to a single stimulus, reduced accommodation, or even continuous activity of neural tissue. Primary hyperparathyroidism ($50% of cases), malignancy, use of thiazide diuretics, vitamin D excess, hyper and hypothyroidism, granulomatous disorders, immobilization, and milk-alkali syndrome. Rapid onset is more likely to be symptomatic than a slowly progressive level, regardless of the ultimate level at presentation. Acute, symptomatic hypercalcemia should be treated aggressively, first with saline infusion to expedite calcium excretion. Most patients with hypercalcemia are significantly volume-depleted as a result of the osmotic diuresis related to the hypercalciuria. Care must be taken to keep input equal to or greater than output to avoid making the patient hypovolemic again. Calcitonin is useful for decreasing serum calcium and has the added advantage of rapid onset of action. It may be given in the presence of renal insufficiency or thrombocytopenia or when mithramycin is contraindicated. Its disadvantage is that rapid resistance often develops, probably related to the development of antibodies. This resistance can sometimes be delayed by concomitant administration of prednisone. Bisphosphonates inhibit osteoclast activity and are effective with those cancers in which this mechanism is present. What other agents are useful for treatment of less significant levels of hypercalcemia? Serum phosphate is lowered by insulin, glucose (by stimulating insulin secretion), and alkalosis, which cause transcellular translocation of phosphate from plasma. Phosphate is resorbed predominantly in the proximal tubule, with small amounts being absorbed in the distal tubule. Patients with progressive renal disease develop hyperphosphatemia, hypocalcemia, and secondary hyperparathyroidism. What are the main disturbances thought to be responsible for the abnormalities of calcium and phosphate metabolism in progressive renal disease? Decreased gut resorption of calcium exacerbates the hypocalcemia and reduces available calcium for bone mineralization. Reduced levels of 1,25-dihydroxyvitamin D result in defective bone mineralization (osteomalacia in adults, rickets in children). This leads to functional hypoparathyroidism and the resultant effects on the serum level and urinary excretion of calcium and phosphate. The patient usually presents with nausea, vomiting, anorexia, weakness, polydipsia, and polyuria. If it continues, metastatic calcification can occur, leading to mental status changes, nephrocalcinosis, band keratopathy, pruritus, and myalgias. The hyperkalemia may be due to many possible causes, including hyporenin-hypoaldosteronism, adrenal insufficiency, drugs such as pentamidine and trimethoprim-sulfamethoxazole, and even isolated hypoaldosteronism. Other electrolyte abnormalities include hypocalcemia, hypomagnesemia, and hypouricemia. Hypercalcemia is seen in association with lymphomas and cytomegalovirus infection. The common predisposing factors are respiratory alkalosis, decreased dietary intake, transcellular shifts due to glucose administration, and rarely, associated proximal tubular injury leading to phosphate wasting. Chronic alcoholism is the most common cause of hypomagnesemia in the United States. It is seen in alcoholics who are withdrawing and more commonly in those who had withdrawal seizures.
This lower pressure is important in preventing progression of renal disease and other end-organ damage purchase online vaseretic. Their adverse metabolic consequences include renal potassium loss leading to cheap vaseretic 10 mg overnight delivery hypokalemia 10 mg vaseretic, hyperuricemia from uric acid retention, carbohydrate intolerance, and hyperlipidemia. Treatment of isolated systolic hypertension with low-dose thiazides results in lower stroke rates and death. Questions 1 and 2: For each patient with a skin lesion, select the most likely diagnosis. The lesions appear as sharply marginated erythematous papules with silvery-white scales. They are palpable, firm, and appear violaceous with some nodules appearing purple brownish. Questions 3 through 5: For each patient, select the associated skin and clinical findings. A 22-year-old man is diagnosed with psoriasis, and has never received any treatment. A 43-year-old woman develops a rash on her arms and hands after starting a new job in a factory. The lesions have well-demarcated erythema and edema with superimposed closely spaced vesicles and papules. A 19-year-old woman with asthma has a chronic rash with distribution on her hands, neck, and elbow creases. A 85-year-old woman has large blistering lesions on the abdomen and thighs that come and go 8. A 85-year-old woman has large blistering lesions on the abdomen and thighs that come and go without therapy (See Figure 2–2. She has noticed 10 lb weight loss over the past 3 months with heartburn and early satiety. A 22-year-old woman develops an acute contact dermatitis to a household-cleaning agent. Which of the following treatments is most appropriate during the bullous, oozing stage? Which of the following is a characteristic of ringworm of the scalp as compared with other dermatophytoses? On examination, there are large tense, serous-filled bullae on the affected areas. A 27-year-old woman has a 1-year history of loosely formed bowel movements associated with some blood and abdominal pain. A 58-year-old man complains of an enlarged, pitted nose, and a facial rash that “flushes” in response to drinking hot liquids or alcohol. The rash is on both cheeks, and it is red and flushed in appearance, with some telangiectatica and small papules. A 70-year-old man develops multiple pruritic skin lesions and bullae mostly in the axillae and around the medial aspects of his groin and thighs. There are some lesions on his forearms and on his lower legs (first appeared in this location), and moderately painful oral lesions. Questions 22 and 23: For each patient with a skin lesion, select the most common associated features. The lesions appear light brown with sharp margination and are of variable size from small tiny “freckle”-like macules to larger patches. Examination shows increased pigmentation, with accentuated skin lines and the skin appears “dirty. Questions 24 through 28: Match the following descriptions with the correct diagnosis. On examination, she has multiple inflammatory papules on her face, with some even larger nodules and cysts. A 70-year-old man comes to the emergency department because of a skin rash and severe itching. He appears ill; there is a generalized skin rash that is scaly, erythematous, and thickened. A 32-year-old woman comes to the emergency department because of a generalized erythematous skin rash. She was recently started on trimethoprim-sulfamethoxazole (Septra) for a urinary tract infection. Examination shows the diffuse rash involving her whole body including the palms and soles. Which of the following is the most appropriate interpretation of the generalized lymphadenopathy finding? A 62-year-old man develops scaling and nonscaling patches, and plaques over his chest and back. Examinations of the blood film and skin biopsy histology, both, reveal unusually large monocytoid cells. Which of the following statements about the prognosis of cutaneous T-cell lymphoma is true? Which of the following treatments is used for most patients with cutaneous T-cell 35.
Nerve surgery may be helpful in cases of abscess formation purchase 10 mg vaseretic with amex, or nerve pain related to buy cheapest vaseretic and vaseretic compression from the enlarged nerve in confined 224 spaces purchase vaseretic 10 mg with amex, such as the carpal tunnel. Persistent ulceration from anaesthesia is treated by transferring sensate flaps to these areas. In conclusion, the main clinical and diagnostic features of uncommon miscellane ous neuropathies that may present to the hand surgeon before a diagnosis is made are highlighted. Hopefully, awareness of these conditions will allow earlier diagnosis and intervention limiting debilitating functional loss. Evaluation and management of upper extremity neuropathies in Charcot-Marie-Tooth disease. Hereditary neuropathy with liability to pressure palsies: electrophysiological and genetic study of a fa mily with carpal tunnel syndrome as only clinical manifestation. Hand-arm vibration syndro me: a common occupational hazard in industrialized countries. Hereditary neuropathy with liability to pressure palsies is not a major cause of idiopa thic carpal tunnel syndrome. In the most recent literature, especially Tin the North American, there are even arguments against the surgical treatment, due to the lack of safe and consistent clinical tests. These different opinions argue partially to the fact that different specialists, such as vascular surgeons, thoracic surgeons, orthopaedic surgeons, and neurosurgeo ns, treat this syndrome. Confusion is also increased by the different ways it is called, such as cervical rib syndrome, scalenus anticus syndrome, costoclavicular syndrome, hyperabduction syndrome, pectoralis minor syndrome, brachiocephalic syndrome, no cturnal paresthetic brachialgia, fractured clavicle-rib syndrome, effort vein thrombosis (Paget-Schroetter syndrome), superior outlet syndrome, Naffziger syndrome, subcora coid pectoralis minor syndrome, first thoracic rib syndrome, costoclavicular compressi on syndrome, cervical rib and band syndrome. Willshire (1860) did the first description of a cervical rib anomaly, while the first description of the role played by the anterior scalenus muscle in the nerve compression by a cervical rib was done by Murphy (1906). The term “thoracic outlet syndrome” was originally coined in 1956 by Peet1 to indicate compression of the neurovascular structures in the interscalene triangle corresponding to the possible aetiology of the symptoms. There are different physiological and anthropomorphic factors that might reduce these spaces. Furthermore, structural anomalies, related to the skele ton or to the soft tissues around, can play a main role. The regions in which the neurovascular bundles (brachial plexus and subclavian vessels) can be narrowed are mainly three: the prescalene area, the interscalene triang le and the costoclavicular space. Furthermore, there are two more distal regions, such as the clavipectoral region and the subarachnoidal space, in which, even if much less frequently, compression may occur. Poitevin2, during his extremely precise anatomical dissections, bring again the attention to the prescalene space: the latter has already been described by Sebileau,3 who talked about a series of fibrotic structures connected to the pleural cupola, and created the term “suspension pleural system”. Three are the struc tures that form it: 227 1) the transverse septo-costal ligament (from the C7 transverse apophysis it inserts close to the anterior scalene muscle insertion). The interscalene space is a triangle formed by the posterior margin of the anterior scalene muscle, the anterior margin of the middle scalene and the first rib. This space has a variable geometry considering the changes that occur during shoulder movements. The most involved structures considering their position are the inferior primary trunk and the subclavian artery; the T1 root, after exiting its intervertebral foramen, proceeds from the bottom to the top, to reach C8 root and create the primary inferior trunk. Considering this anatomical path together with anatomical anomalies, it is easy to un derstand how T1 and C8 are the most involved roots in the compression. The third area of conflict is the costoclavicular space that has a wide range of dimen sions considering the movements the shoulder is related to. Even if more rarely, proce eding from proximal to distal, another possible compression site is the subarachnoidal space; in our experience only one case on 300 treated patients. Not only anatomical reasons can lead to a compression but also physiological and anthropomorphic ones due to an unbalance between the content and the container. Among these the progressive drop of the acromioclavicular region plays a main role joint in female due to the increase in load of the mammary gland with the age. Another condition is related to those asthe nic patients with long neck and hypotrophic muscles of the scapular girdle that favour the closure of the anatomical spaces. Finally, we would like to remember those dynamic conditions, such as certain kind of jobs or sports that facilitate hyperabduction or weight lifting: this leads to a compensatory hypertrophy of the scalene muscles and to a decrease of the interscalene space. In such a complex anatomical and physiological condition, the structural anomalies that cause a further tightening of these spaces have to be considered as well. Usually, the presence of a cervical rib leads to a compression at the level of the tho racic outlet. Cervical ribs are classified according to Gruber5 scale in four types: type I: a rib that appears as a short bar of bone that not exceed more than 2. The transverse mega-apophysis of C7 may play a pathological role, especially if its lateral end has a pointed shape. The presence of an anomaly of the scalene muscle could be the cause of 228 the compression. In our experience, muscular anomalies are the most frequent cause of compressi on. Among them, a hypertrophic anterior scalene muscle, the presence of an accessory scalene muscle, or hypertrophy of the middle scalene muscle is presented. The anterior scalene muscle is for sure the most involved structure in the compression of the subcla vian artery, but there is a wide agreement that this is just part of the problem. Sometimes this muscle has a sharp anterior margin that interferes with the inferior primary trunk of the brachial plexus. Especially in the presence of a transverse C7 mega-apophysis, the insertion of the middle scalene muscle is projected anteriorly; this causes the primary inferior trunk to create an angle sometimes larger than 30 degrees. Another cause of compression is related to the presence of anomalous fibrous bands: these structures are often seen during the surgical dissection of the outlet, especially at the level of the inferior primary trunk.
Splenic artery rupture can be fatal to best purchase for vaseretic both mother and fetus and require resection cheap 10 mg vaseretic overnight delivery. Subclavian artery aneurysms are not true aneurysms but post-stenotic arterial dilatation generated by disturbed blood flow order genuine vaseretic on-line. A cramping pain or discomfort associated with activity that is relieved by rest, yet returns with resumption of activity. The location of claudication discomfort suggests the level of the arterial obstruction. For example, calf claudication is associated with thigh level arterial obstruction. Calf discomfort with activity that is both reproducible and relieved by rest and occurs in a patient with normal arterial circulation but with lumbar spine stenosis. To make the discomfort dissipate, the patient must relieve pressure on the spine by either sitting or lying down. Imaging evaluation of the lumbar spine shows lumbar spinal stenosis, often from protrusion of an intravertebral disc. Dietary modification to lower fat intake in combination with exercise improves this ratio. In addition, statins seem to have a protective effect unrelated to cholesterol control. Finally, pentoxifylline and cilostazal are medications used to increase pain-free walking distance in patients with claudication. Unfortunately, pentoxifylline does not work any better than placebo, but recent studies suggest that cilostazal may improve walking distance up to 200%. Antiplatelet therapy with aspirin is also helpful, particularly for the secondary prevention of cardiac and cerebrovascular disease, which are frequently concurrent (and sometimes without symptoms) in these patients. Sobel M, Verhaeghe R: Antithrombotic therapy for peripheral artery occlusive disease, Chest 133:1–38, 2008. Anticoagulation is indicated for the initial treatment of acute arterial emboli or thrombosis. This technique works well for short, focal lesions, but longer segments of disease are prone to early recurrent stenoses produced by development of both scar tissue and recurrent atherosclerotic plaque. Bypass is accomplished using a new conduit to redirect blood around an area of extensive arterial disease. This is best done using the patient’s saphenous vein for the smaller arteries of the leg, whereas artificial conduits can be used for the larger arteries of the abdomen/pelvis. To ensure success of these techniques, one must originate the bypass in an area free of disease. The distal target artery needs to also be free of obstruction and have good runoff into the distal circulation. These newer percutaneous techniques focus on recanalizing the arterial lumen using balloon dilatation to fracture the atherosclerotic plaque away from the arterial wall followed by insertion of a stent to reexpand the arterial lumen. This technique was initially only utilized to treat short focal stenoses or occlusion (<5–10 cm in length). As stenting technology has evolved, longer and more complex segments of disease are being treated. Appropriate patient selection and preoperative preparation produce perioperative mortality rates < 2% for inflow procedures such as aortic bypass, renal artery endarterectomy, and mesenteric artery bypasses, whereas outflow procedures to improve blood flow into the lower leg and foot have 30-day mortality rates of 4–5%. Are percutaneous endovascular procedures less risky than open surgical procedures? The endovascular procedure is performed with a light sedation and requires only local anesthetic at the skin puncture site. Major risks consist of allergic reactions to the iodine contrast used to visualize arteries, potential renal failure created by the toxic effects of the iodine contrast in the renal tubules, and local arterial trauma secondary to the initial puncture and wire insertion where a dissection plane is created that leads to arterial thrombosis and embolization of the atherosclerotic plaque downstream during the balloon and stenting portion of the procedure. How do results of open surgical procedures compare with percutaneous endovascular interventions? Short-term results in appropriately selected patients are excellent for both procedures. With endarterectomy or bypass, the 30-day patency rates > 95%, whereas 30-day patency rates for the majority of endovascular recanalization procedures > 80%; however, these endovascular results vary depending on the location, length, and severity of the disease treated. Shorter, more focal disease responds much better than longer, more diffuse disease. Five-year patency rates for both techniques > 90%; therefore, balloon angioplasty and stenting have become the standard of care for this disease. Unfortunately, even with the use of stenting, many arterial segments treated with endovascular repair develop recurrent disease within 6–12 months. Some reports suggest > 50% recurrence rates, but this topic is still under close study. In summary, the surgical bypass works better long-term but carries higher upfront risk whereas endovascular recanalization procedures are less risky but, at the present time, do not produce equivalent long-term results. Smoking cessation dramatically improves maintenance of patency of both procedures. The use of statin drugs has been shown to improve patency of surgical bypass grafting and is being evaluated with endovascular recanalization procedures. At present, patient who have stents placed are started on clopidogrel, an antiplatelet adhesion medication. This decreases the incidence of stent thrombosis until the struts of the stent are covered. In addition, the use of aspirin or warfarin or both has been shown to improve long-term patency of leg bypass grafts, especially in patients requiring a second or third redo procedure; however, this advantage must be weighed against the risk of bleeding in an elderly population.
Rapidly spreading inflammation may be Fournier’s gangrene purchase vaseretic with visa, requiring immediate evacuation cheap vaseretic 10 mg online. Evacuation/Consultation Criteria: Evacuate as above for Fournier’s gangrene buy vaseretic 10mg overnight delivery, phimosis/paraphimosis. Dorsal Slit Procedure Essential: If the patient has severe phimosis where the foreskin has scarred down to a small hole and the patient is having significant pain and discharge from the penis, the foreskin needs to be incised (dorsal slit). Similarly, if paraphimosis is severe, excessive circumferential swelling may compromise blood flow in the penis, which can be relieved with a dorsal slit. Attempt non-surgical reduction with anti-inflammatory medications, ice water and lubricants. Assemble equipment: 1% lidocaine (w/o Epi), needle and syringe, clamp, forceps, scalpel or surgical scissors, needle driver, 4-0 suture, prep solution, alcohol. Prep the penis as with any surgical procedure (sterile scrub, Betadine, drape), and attempt to clean between the head and the foreskin, especially on the dorsal side. Use 1% lidocaine and a small needle (25-26 gauge) infiltrate the skin about mid-shaft and extend the wheal at least halfway around the shaft of the penis. Use a straight clamp to crush the skin from the phimotic area back to the glans (head). The glans will still have sensation and the patient should be able to tell you if the meatus is being cannulated. Leave the clamp on for 5 minutes to compromise blood flow in the area to be incised. Remove the clamp and use a scissors to cut the crushed skin where the clamp had been. Clean the penis with sterile prep solution between the head and foreskin, then wipe prep solution away with alcohol. Monitor the patient, as this maneuver is only temporary and the slit can contract. However, the cancer can grow rapidly so early detection and referral is necessary to avoid treatment delays. Objective: Signs Using Basic Tools: Tender testis; palpable mass in testis, spermatic cord or epididymis; mass may appear smooth and spherical, be located on the surface or deep in the testis, enlarge with standing, transilluminate with a bright flashlight. Using Advanced Tools: Lab: Urinalysis: Nitrite and leukoesterase positive urine suggest infection. Assessment: Differential Diagnosis Solid, non-transilluminating mass that is >4 millimeter size, located below the testicular surface and inseparable from the testis must be considered to be cancer until proven otherwise. Transilluminating smooth spherical masses are benign and are hydrocele (around the testis), spermatocele or loculated hydrocele (above the testis). Other masses in the scrotum, either on the cord, in the scrotal skin or in the midline area near the penis are almost always benign. Painful area behind the testis is usually an indication of epididymitis (see Epididymitis section). If the pain in the scrotum is severe, refer to sections on epididymitis and torsion. If epididymitis is suspected or cannot be eliminated, add doxycycline 100 mg po bid x 14 days. Follow-up Actions Return evaluation: Check patient in 2-4 weeks for change in mass. Evacuation/Consultation Criteria: Urgently evacuate patients with suspected cancer. Any mass that prevents examination of the entire testis, that is increasing in size, or appears to be inseparable from the testis should be referred for further evaluation. Prostatitis is commonly due to an infection, so an empiric trial of antibiotics is useful. Subjective: Symptoms Difficulty urinating: Obstructive symptoms include slow start, low flow and dribbling; irritative symptoms include frequency (> q 2 hours) and/or urgency; pain in the head of the penis or under the scrotum; low back pain; fever. Objective: Signs Using Basic Tools: Tender prostate with/without tender pelvic floor or coccyx (palpate 360° on rectal exam); distended bladder Using Advanced Tools: Lab: Urinalysis: heme and leukoesterase positive urine (infection). Assessment: Differential Diagnosis Irritative voiding symptoms with or without fever urinary tract infection until proven otherwise, distal ureteral stone, urethral stricture, bladder neck dysfunction, bladder or prostate cancer, foreign body in bladder, overflow incontinence. Obstructive voiding enlarged prostate, urethral stricture, and neurologic disease of the spine or peripheral nerves. Painful prostate urinary tract infection, bladder neck dysfunction/prostatodynia/pelvic floor dysfunction, musculoskeletal pain, coccydynia, seminal vesiculitis Plan: Treatment: Infection Primary: 1. Treat any male suspected of having an infection for 30 days regardless of the location of symptoms (kidney, prostate or scrotum). Infected urine can easily reflux into prostatic ducts, therefore assume the prostate is infected. If symptoms persist and urinalysis continues to be abnormal without improvement after 3-5 days, suspect bacterial resistance and change antibiotics. If a bladder is palpated, attempt to pass a Foley catheter (Procedure: Bladder Catherization). If patient’s symptoms worsen, consider suprapubic aspiration (see Procedure: Suprapublic Bladder Aspiration). Doxycycline or Vibramycin are not as effective since they are bacterio-static, and should only be used (100 mg po bid) if there is no other alternative.
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Nonoperative treatment—Nonoperative treat the inferior screw adjacent to buy vaseretic with paypal the inferior ment is generally limited to generic 10 mg vaseretic overnight delivery elderly nonam neck and the posterior superior screw adja bulators who are considered too high risk for cent to buy 10mg vaseretic amex the posterior femoral neck. The goal for these patients should be recommended open capsulotomy for non early bed to chair mobilization in attempt to displaced femoral neck fractures, with limit the complications of prolonged recum the theory that capsulotomy relieves bence: atelectasis, thromboembolic disease, pressure from the intracapsular hema urinary tract infection, and decubitus ulcers. Timing of surgery—Patients should undergo capsulotomy actually lowers the rate of surgery as soon as they are deemed medi osteonecrosis; however, it does have its cally stable. Recent stud sume a flexed, abducted, and externally ies have shown some benefit to the model of rotated position has also been shown orthopaedic and geriatric medicine cocare in to decrease intracapsular pressure. In young patients, dis of displaced femoral neck fractures largely placed femoral neck fractures are treated depends on the patient’s age and activity kat. In younger patients, closed or open prosthesis has a theoretic advantage reduction is performed followed by internal over the unipolar, as the second articu fixation (Fig. The goal is anatomic re lation in the bipolar has been suggested duction and it may be necessary to perform to decrease acetabular wear. In practice, either a Smith-Petersen or a Watson-Jones ap however, it has been shown that the sec proach to ensure proper reduction. In older, ond articulation in a bipolar often ceases less active patients, most authors recom to function and it essentially becomes a mend prosthetic replacement of the femoral unipolar construct. For most low-demand elderly patients, (a) Internal fixation—When internal fixation the unipolar replacement is the recom is chosen, anatomic reduction is essential mended prosthesis (Fig. If attempts pre-existing degenerative disease of the at closed reduction do not clearly result hip. For basi-cervical fractures, fixa suggested improved outcomes regarding tion with a sliding hip screw is another pain and function for total hip arthro alternative. Nonunion—The nonunion rate for femoral neck paralysis from a prior cerebrovascular fractures is determined largely by fracture dis accident are also at increased risk of dis placement. Nondisplaced or impacted femoral location and generally should be treated neck fractures have a nonunion rate of approxi with a hemiarthroplasty. Biomechanical studies have shown nonanatomic reduction and metabolic condi that even when a person attempts to be non tions such as dialysis dependent renal failure. For young patients attempt is usu cannot comply with restricted weight bear ally made to preserve the femoral head with a ing. For these reasons, it is recommended valgus intertrochanteric osteotomy with plate that elderly patients be allowed to weight fixation. In older patients nonunion is treated bear as tolerated to assist with mobilization with hemiarthroplasty of the hip. For younger patients restriction blood supply, the femoral head is prone to os of weight bearing may be considered if frac teonecrosis after femoral neck fracture. Nondisplaced or impacted fractures have ther option requires care to maintain anatomic an osteonecrosis rate of 8% or less, while Gar reduction of the femoral neck. Magnetic resonance imaging is more sen fail due to aseptic loosening, infection, or acetab sitive than plain radiographs at demonstrating ular wear. Acetabular wear toms include groin or thigh pain and about 33% can occur with either a unipolar or a bipolar of patients require further surgical procedures. Studies have shown many bi In younger patients, attempts to revascular polar implants function essentially as a unipolar ize the femoral head such as drilling and bone within the first year. In older patients after a hemiarthroplasty typically results in groin with advanced osteonecrosis, the treatment is pain and treatment generally consists of conver typically prosthetic replacement. Mortality—For elderly patients, in hospital mor loosening can often be seen radiographically be tality from hip fracture is approximately 3% to fore symptoms such as thigh pain develop. Femoral neck stress fractures—In patients with matched controls and ranges between 20% and osteopenic bone, femoral neck stress fractures 40%. Risk factors for increased mortality include can occur with repetitive loading from normal pre-existing cardiac or pulmonary disease, cog daily activities. Thromboembolic disease—Even with prophy heavy and repetitive load such as seen in mili laxis, the rate of thromboembolic disease after tary recruits or long distance runners. Stress hip fracture is substantial, with some reports fractures result in new onset groin pain. Ipsilateral femoral neck and femoral shaft frac din), aspirin as well as pneumatic compression tures—Ipsilateral femoral neck fractures oc boots. Fixation failure—Risk factors for implant fail ation of the femoral neck fracture, followed ure include osteopenia, fracture comminution, by reamed retrograde nailing of the femoral and nonanatomic reduction. Neurologic impairment—In patients with severe options are generally performed on younger neurologic impairment such as advanced patients, while prosthetic replacement is gener Parkinson’s disease, paralysis from previous ally the preferred options for elderly patients. Subtrochanteric femur fracture—Subtrochan proach to the hip should be considered when teric femur fracture can result from multi performing hemiarthroplasty. This helps pre ple unfilled drill holes in the lateral femur, vent both wound contamination as well as hip or starting holes for fracture fixation that dislocation from noncompliance. Treat have a significant adductor contracture and ment options for the fracture include revision should undergo adductor release at the time of to a sliding hip screw with a long side plate, or arthroplasty. Nonoperative treatment—Nonoperative treat ing them poor candidates for internal fixation. In ment should only be considered in nonam these patients, even nondisplaced fractures may bulators who are deemed too high-risk for best be treated with femoral head replacement. If nonoperative treat are prone to proximal femoral deformity and ex ment is elected, it is an option to mobilize the cessive bleeding at surgery. If the acetabulum is patient with early bed to chair activity, with involved, treatment should consist of total hip the goal of preventing the sequelae of pro arthroplasty. Patients occurs, a reconstructive procedure may be in should be evaluated for metastases before sur dicated later on if the patient’s medical condi gery, including full pelvis and femur films.