By J. Dimitar. Loma Linda University.
Do not use an Repair this as soon as possible in the labour ward order zyvox 600mg line, unless enema: rough use may destroy your handiwork! If they do not purchase zyvox online now, you have not done a deep perineal wound gets sitz baths at least bd purchase generic zyvox from india. This may mean considerable difficult purchase zyvox 600mg with visa, intricate dissection, and it will mean a good understanding of the normal anatomy. Operate if your means The uterus can rupture before or during delivery, especially for effective referral are very limited. If there is a minor tear (1) in multipara, in the levator ani the patient may only have mild (2),after previous Caesarean Section, especially with a incontinence with loose stools: do not make a tolerable vertical incision, and situation worse! Consider that this region is always (3) when oxytocin is used, or primarily infected. Apply tissue forceps, and use scissors to separate the vaginal If a woman, particularly a multipara, arrives late in wall from the rectum gently (21-15C). While you exert obstructed labour, or you do not make this diagnosis, gentle tension on the vaginal wall, dissect laterally and free the uterus is likely to rupture. If primary care is really poor in your district, 50% Apply clamps to the cut edges of the vaginal skin, and hold of the women referred to you may need an operative them downwards. Extend the dissection upwards in the delivery, and of these 5% may end up with a uterine rupture. She is often sufficiently Incise the vaginal wall in the midline (21-15F), to expose the clear-headed to be able to tell you that she had strong rectum (21-15G). Hold the upper edge of the torn rectum in tissue forceps, and invert its mucosa If the membranes have ruptured some time before with a row of fine atraumatic long-acting absorbable sutures delivery, the contents of the uterus will become infected, (21-15J). Continue these until you reach the muco-cutaneous and the uterine muscle bruised and in poor condition for margin of the anal opening, so as to refashion a normal anus. Search for the retracted ends of the sphincter ani muscles, (2) Remove the baby and the placenta. This is essential, because if you only freshen up (4) Repair or remove the uterus on the indications given the margins, you will not achieve continence. Unless the rupture is extensive, and the tissues are Use hooks (21-15L), or baby Babcock forceps. Bring the particularly bruised and oedematous, repairing the uterus is hooks together to see if you have secured the sphincter likely to be easier than removing it, because distortion of the (21-15M,N) and approximate them with at least anatomy makes hysterectomy difficult. Excise any excess tissue on the Hysterectomy takes longer than repair, and causes more flaps of the vagina (21-15Q), taking care not to remove too bleeding. Bring the raw edges of the vaginal wall together with part of the lower segment, is easier than a total interrupted absorbable sutures (21-15R,S). If a previous Caesarean Section has left scar touch, even between contractions, which increase in strength D, suspect strongly that it was the midline classical type. Review of 70 cases of ruptured uterus in (3);The patient becomes anxious and restless with a Cameroun. Be aware of impending rupture when labour is obstructed, (2);Shock and pallor without immediate response to blood especially in multipara, and try to prevent it by rapid transfusion (especially if the placenta is retained). If the presenting part is jammed in the pelvis, If the presenting part is not easy to dislodge, try pushing no blood can escape from the vagina. If this fails, stop for fear of damaging ultrasound to see if the patient has a haemoperitoneum, the urethra. Pass your fingers anterior to the presenting part, or aspirate at the sides of the uterus. If there is one, (4);A tender uterus to palpation (it may feel soft, or be you will feel the inner surface of the abdominal wall. Later, the entire If you are convinced there is no rupture, proceed to vaginal abdomen may be tender. Sometimes, If the patient is sufficiently conscious to understand, the shape of the uterus changes, and you may be able to feel explain that you would like to tie the tubes. If she is not fit the foetus outside it (usually the limbs are close under the enough to understand, speak to the relatives. As a general rule, (6);The foetal head which was previously low in the pelvis, no woman who has had a ruptured uterus should ever has now risen higher and may now no longer be palpable become pregnant again. You may find a lot of bleeding, and uncommon but death within a very short time is not. The cervix may still be If the foetus is lying free in the peritoneal cavity, uterine closed in rupture of a vertical Caesarean scar, or a corneal rupture is complete. Deliver the empty uterus into the resuscitation is impossible if bleeding continues internally. Divide the round ligament (21-18) if this makes the fast, and the other for blood. The presenting part may have disengaged, (4) extend, rarely, transversely across the posterior wall of so that your hand passes through the rupture into the the uterus (21-17E). Try to get a tourniquet (a taut Foley catheter is the ligament, open its peritoneal roof, and ligate the most readily available) around the base of the uterus, bleeding vessels. Or, clamp the edges of the With one finger inside the broad ligament and another tear with several pairs of Green-Armytage forceps. Exert traction on the running tracking up from the torn vessels on one side towards the suture to expose the depths of the tear. Do not forget to perform a tubal ligation (unless you (2) A rupture with clean edges which are easy to see and are have repaired a lower segment rupture, and the patient not too oedematous. Hysterectomy may be surprisingly easy when the tear is (1) Extensive or multiple tears. In these circumstances, (2);Postpartum haemorrhage, which is not responding to a hysterectomy is preferable. Start by defining the position of the uterine pedicles, the ovarian pedicles, and the round ligaments (21-18). If the tear extends into the cervix or lower segment, Having delivered the uterus from the abdomen, maintain reflect the bladder as for a lower segment Caesarean traction on it with one hand, or insert a traction suture. Ask your assistant to pull the Start by identifying: (1) the uterus and round ligaments, uterus forwards and to the opposite side. Deflect the bladder, and trace the ureters over the whole If there is much, apply haemostats or transfixion sutures. Start at the apex of the rupture; if convenient hold it with a Lift the right tube and ovary with one hand, and push a stay suture. Suture it as for Caesarean Section, using 2 layers finger of your other hand from behind through the avascular of continuous long-acting absorbable in a large (#2 or #3) area in the broad ligament. Leave the ovary and tube in place on one or tear going down to the cervix from below upwards, but both sides. Traction on the On the side on which you will remove the ovary, clamp the suture will help to bring the lower end into view. Make the second layer an inverting continuous clamp and divide the tube and the ovarian ligament near the suture. If they are very thick and vascular, you may have to corners, or repair the vagina, usually anteriorly. Make sure the points of the forceps are close to the uterus or even a little in its wall. Use a double transfixion ligature because of its width, and then do the same thing on the other side. Excise the uterus through its lower segment, just above the level of the cut uterine vessels. Have artery forceps ready to pick up the cut edge of the lower segment, before it disappears in the depth of the pelvis. If the tear extends across the lower segment, it will probably serve as the line of demarcation to remove the uterus. Examine the edge and remove any very oedematous and bruised tissue, again first checking the position of the ureters. If there is a downward tear in the cervix, repair this now, after making sure that the bladder and ureters are well out of the way. Suture the anterior and posterior walls of the lower segment with figure-of-8 sutures, being sure to include the angles on each side, because these bleed. If there are signs of infection, leave the centre open so that you can insert a drain; otherwise close it. Using the clamps that you have already applied, pull the Start on the left at the pedicle of the infundibulo-pelvic uterus well up in the midline, and cut the peritoneum ligament, and suture the anterior edge of the peritoneum to between the uterus and the bladder.
Force training (three times a week for ten years) makes it possible to 40 maintain the maximum level of isometric force in elderly subjects aged at a level 41 corresponding to a sedentary young person purchase generic zyvox pills. Improvements in force production as 42 a result of training can be achieved even in subjects over the age of eighty buy 600 mg zyvox with visa. The 43 percentage of force gain is similar to that obtained by subjects aged around sixty 44 or by young adults (Le Page et al order zyvox with american express. Studies have been carried out on 03 models of diminished muscle activity such as prolonged bed-rest generic zyvox 600 mg online, immobilization or 04 microgravity. The results show that muscular atrophy is accompanied by reduction 05 in muscle fibre size, force production and muscular work capacity as well as 06 alterations in locomotor coordination (Bloomfield, 1997). The mechanisms that would allow us to explain 15 how muscles age, why we lose both mass and force are still not well understood. On the other hand, changes in certain extrinsic factors, 18 such as the secretion of certain hormones and neuromuscular inactivity, appear to 19 be involved in this process. However we do not know if the oxidative 22 stress liberated by exercise could be damaging to the muscle especially in elderly 23 individuals in the lack of a certain adaptation to regular exercise. It should be noted 24 that during aging there is a gradual increase in the proinflammatory state which 25 could increase the incidence of muscle injury following exercise (Fulle et al. It is not always easy to formulate an adequate 31 standard exercise protocol for each individual. It is not necessarily the role of the 32 doctor to determine how much exercise a healthy individual should undertake in 33 order to stay healthy. This falls into the domain of preventive medecine to maintain 34 a good quality of life for our aging population. One could imagine however, that 35 the doctor could prescribe a series of regular exercises which are adapted to the 36 health status of the patient, then this would be followed by a specialist in physical 37 education. Nevertheless we could ask the question is this really his role and could 38 not these roles be inverted. It is surprising in our modern day culture that the majority of the population 43 prefers to participate in sport by proxy from their arm chair rather than carrying 44 out some sort of physical exercise themselves. In addition, exercise training in cardiovascular disease 13 limits the incidence of coronary events (Abete et al. Recent studies have shown that improving physical fitness leads to better 18 performances in tasks assessing a diversity of cognitive domains (Renaud and 19 Bherer, 2005). In 23 order to preserve independence during aging, it would be advisable to encourage 24 our contemporaries to indulge in regular exercise and physical activity. It is estimated that approximately 45% of all women will suffer at least one osteoporotic fracture during 20 their lifetime. Genetic, environmental, nutritional, biomechanical and hormonal factors 21 determine the integrity of the skeleton and age-related bone loss and thus the risk for devel- 22 oping osteoporosis. Several pharmacological agents that are capable for decreasing the risk 23 of fractures are currently available and have proven their efficacy in randomized clinical 24 studies. Also, evidence suggests that individ- 27 ualized advice on lifestyle modification, e. Such fractures often have considerable consequences 05 for the patient due to increased morbidity and pain, loss of independence, reduced 06 life expectancy (following hip and vertebral fractures), and reduced health related 07 quality of life. It also imposes enormous costs on the society in terms of hospital 08 treatment, rehabilitation, and nursing home care. The annual costs of osteoporotic 09 fractures and their sequels are estimated to exceed $14. The number of osteoporotic fractures is expected to rise due to demographic 11 changes of increasing the number of elderly persons. Thus, it is projected that the 12 number of hip fractures will increase 45 folds during the next 4050 years as 13 a consequence of the increasing population aged 65 years or above. Even more 14 importantly, this increase will be most pronounced in the developing countries. Bone loss starts shortly thereafter at some skeletal 34 sites (lumbar spine and proximal femur) and a decade later at other skeletal sites 35 (Matkovic et al. A continuous, slow, age-related bone loss is observed in both men and 37 women and results in an overall bone loss of 2025% of both cortical (the outer 38 dense envelop of most bones) and trabecular bone (located internal to the cortical 39 bone at the end of long bones and in the vertebrae and other short or irregular bones). A decade after the menopause, the rapid phase of bone loss terminates and 43 merges with the slow but progressive aged-related bone loss. Schematic representation of changes in bone mass over life in cancellous (broken line) and 19 cortical (solid line) bone in women (left panel) and men (right panel) from age 50 onward. In men only one phase of continuous bone loss is observed but in women two phase are recognized: a perimenopausal 20 accelerated phase of bone loss and a late slow phase. Note also that the accelerated phase, but not the 21 slow phase, involves disproportionate loss of cancellous bone (Riggs et al. In addition, to age-related decrease in bone mass, 26 significant changes do also occur in what is known as bone quality that includes 27 several parameters e. Age-related 29 changes in these factors contribute to the deterioration of the mechanical strength of 30 the skeleton (Mosekilde et al. Currently, no-invasive 31 methods that measure the bone quality factors are being developed for clinical or 32 epidemiological studies. However, the increase in fracture risk takes place approximately 36 10 years later in males compared with females. Hip fractures often occur in elderly people during falls on the side when 40 standing or walking slowly (Cummings and Nevitt 1989). Based 18 on patients admitted to Danish Hospitals (Danish Hospital Central Register). Bone matrix is built 28 up of type I collagen (90%) and the remaining 10% is composed of a large 29 number of non-collagenous proteins (e. Non-collagenous proteins participate in the process 31 of matrix maturation, mineralization and may regulate the functional activity of 32 bone cells. Bone remodeling is a bone regenerative process taking 37 place in the adult skeleton aiming at maintaining the integrity of the skeleton 38 by removing old bone of high mineral density and high prevalence of fatigue 39 microfractures and replacing it with young bone of low mineral density and better 40 mechanical properties. This process is important for the biomechanical compe- 41 tence of the skeleton and it also supports the role of the skeleton as an active 42 participant in the divalent ion homeostasis. These sites are determined by specific mechanical needs or mechanical 04 signals, the nature of which is not known. This is followed by activation to the 05 osteoclast precursor cells to fuse and form functional multinucleated osteoclasts. They recreate the amount of bone matrix removed by the 11 osteoclasts and secure a proper mineralization of the newly formed osteoid tissue. In the young adult, there is a balance 20 between the amount of bone removed by osteoclasts and the amount of bone 21 formed by osteoblast and bone mass is unchanged. On the other hand, age-related decreased 03 mean wall thickness and impaired osteoblast functions have been observed 04 in several histomorphometric studies in the elderly (Cohen-Solal et al. These changes are also caused by age-related 09 changes in bone remodeling dynamics. An age-related increase in the activation 10 frequency (turnover) or in resorption depth will by itself threaten the integrity of 11 the 3-dimensional trabecular network (Mosekilde, 1990). During bone resorption, 12 deep osteoclastic lacunae may hit thin trabecular structures leading to trabecular 13 perforations. Concomitant remodeling processes on the opposite sides of thicker 14 trabeculae may have the same consequence. The thinning of trabecular structures 15 with age due to the imbalance between bone resorption and bone formation may also 16 increase the risk of perforations. The consequence of this process is a progressive 17 loss of trabecular elements, deterioration of bones three-dimensional structure and a 18 loss of mechanical strength with age. Complex calculations from trabecular density 19 and intertrabecular distances suggest that age-related trabecular perforations and 20 structural changes contribute more to the age-related decrease in bone strength 21 compared with age-related decrease in bone mass. The available data 32 suggest that decreased cell proliferation capacity of osteogenic stem cells is the 33 rate limiting factor for bone formation with age (Stenderup et al. The aging 34 microenvironment may also contribute to the age-related decreased bone formation 35 since sera obtained from old persons (a surrogate for the aging microenvironment 36 of bone) exerted inhibitory effects on osteoblast differentiation of osteoprogenitor 37 cells compared to sera obtained from young persons (Kassem et al. Age-changes in the endocrine system and its contribution to the observed age-related bone 21 loss.
In fact discount zyvox online amex, ergot of rye substitutes the grain of rye with deep zyvox 600 mg free shipping, purplish sclerotium - a plant ailment caused by the fungus called Claviceps purpurea buy cheapest zyvox. In other words purchase zyvox discount, a sclerotium (ergot) is basically considered a fungus and when it is present in plants they ought not to be consumed in large amounts since it is toxic for humans as well as livestock. When secale cornutum is found in any crop, it becomes infected and when any person is infected with the toxin of this fungus, it is known as ergotism. Poisoning caused by the ergot of rye is denoted as ergotism and it can be distinguished by two types of symptoms. Convulsive ergotism wherein malfunctioning of the nervous system caus- ing the patient to endure spraining and distorting inpain, together with shuddering, trembling and a twisted neck. The other type known as gagrenous ergotism, a condition where the vic- tim may drop parts of their extremities, for instance lose fingers, toes and even ear lobes ow- ing to constraint of blood vessels passing through these extremities. Victims who endure such constriction of the blood vessels also experience a scorching pain - something common among the farm animals that are left to graze in open fields. Stasis and ptosis of viscera forces the patient to cross her legs in order to avoid prolapsus. Feels cold even in warm room Worse: forenoons and evenings; left side, cold air, before thunder-storm. Silizium provides the matrix of the earths crust and accordingly it is the foundation of plant life and to a large extend also for animal life. Lack of strength and bite gritboth mentally and physically is the guide towards silicea in homeopathy. If the absorption of a exsudate sero-albumine of a bursa cannot be achieved by Calcium phosporicum you could use silicea. It continues the good effects of Veratrum and Digitalis without any of the undesirable effects of either. Bee hives were wiped inside with this herb in order to keep the bee colony together. In Russia the root was used internally and externally against bites of rabid dogs. In herbal healing mainly the blossoms and dried plants were used which were collected during the flowering period. Staphisagria heals toothache if it gets worse by touch, even touch by the tongue, by food and drinks. May be used with advantage to tone the heart, and run off dropsical accumulations. In pneumonia and in severe prostration from hemorrhage after operations and acute diseases. If there was eczema in a patient in the past, Sulfur will play an important role (Caust) Skin diseases (Psora). Lymph glands enlarged Malaria workers in Sulfur mines seem to be immune against Malaria, even if the mines are located in endemic aereas (Cooper). Irregular distribution of blood (some parts appear hot, provoking flashes, others are cold). It follows Arnica after bruises, fllows Conium after bruises of glands, follows Ruta after bone bruise. Back pain Arinica/Symphytum Prickling pain Fractures D30 daily, bruises, periost pain, bone pain after injury. Swelling of lymphnodes, leukemia C200 divided dosage method (Ramakrishnan)* Eye injury. Some Na- tive Americans boiled the root hairs to make a wash for stopping external bleeding. One tribe inhaled the odor of the crushed leaves to cure headache or toothache (which may be a classic case of a cure worse than the disease). Root poulticed for wounds, underarm deodorant; leaf poulticed to reduce swelling, they ate the root to stop epileptic seizures. Case: 60 year old male with long lasting food allergic dysentery foul intestinal complaints. Should prove the most homeopathic drug for angina pectoris, with coronaritis and high tension (Cartier). Adapted to the most severe types of inflammation and pain, early and persistent prostration. Tumor specimen and laboratory assessments for compatibility are costly and time consuming. Therefore it is preferred to monitor the patient and treat or stop treatment accordingly. Tissue proliferation: nose polyp, polyp urethra, excrescence urethra after gonorrhea. Mental disease; all advanced myxedema show mental disorder with tendency towards dementia. Edema after scarlet fever (Apis, Helleborus nigra, Lachesis, Colchicum) It is important against pupura. Usneaderm ointment Weber, Corynebacterium minutissimum D (X) 200 1x5 every 2 weeks. Cheyne-Stokes; marked pain along arteria basilaris; large pigmented spots on forehead, substantial weakness (Bapt. Irritation in gastro-intestinal tract drives the patient out of the bed early in the morning. Womens health consists, instead, of knowledge and expertise of professionals in many disciplines who work together to improve womens health status. This broad foundation allows us to explore womens health from a biopsychosocial perspective, and to consider the many facets of womens health and the many factors that impact womens health status. This text is intended as a reference both for nonhealth professionals who wish to have a more in-depth understanding of various topics, and for health profes- sionals searching for an introduction to fields outside of their own. The first portion of the Encyclopedia serves as an introduction to the study of womens health. Each entry is followed by a list of suggested readings, as well as a listing of resources available on the Internet and elsewhere. We trust that you will find these pages both exciting and informative in their depth and coverage. Foundation Topics in Womens Health History of Womens Health in the United States 3 Siran M. Foundation Topics in Womens Health History of Womens Health in the United States water, and sanitation; education; decent housing; secure History of Womens Health in work; useful role in society; and political will and public support. These elements provide a framework to study the United States womens health in the United States in a temporal con- text, and to draw a trajectory of it through history. Koroukian have greatly contributed to health disparities observed in todays societies throughout the world, particularly in regard to education and to social, economic, and political empowerment. These inequalities have existed in the past and persist through contemporary times. This chapter provides a brief overview of the history of The dramatic improvements in womens health dur- womens health and the array of factors that have played ing the 20th century should be noted at the onset. First, it presents a background changes are described in detail in a document compiled describing gender-based disparities in health care. From 1900 to 1990, been perceived by society, their representation in the womens life expectancy increased by more than 30 health care workforce, and the development of the med- yearsfrom 48. These dramatic toward gaining equality with men in education, employ- changes occurred even before the introduction of antibi- ment, societal role, and political empowerment. Such patterns of atypical and/or nonspe- to advances in medicine and technology, many women cific symptomatology greatly contribute to an with disabling conditions are now able to survive and underestimation of the extent of the problem by the participate in various activities at a rate higher than ever. In fact, it has been found that women are ing with disabilities; 70% of those with nonsevere dis- referred for coronary artery bypass graft at a more abilities and 25% of those with severe disabilities were advanced stage of the disease than men. This is in part a result umented higher rates of such procedures in men than in of the failure to integrate womens health in general women. However, investigators have been unable to medical practice due to (1) a view of womens health as determine whether these findings indicated that these pro- encompassing only the reproductive system, consisting cedures were overused by men or underused in women. Because until recently medical research ing not only reproductive health, but general health as has almost exclusively included men, the symptoms, pro- well.
Free the biceps tendon from the radius discount 600 mg zyvox amex, and the brachialis Cut the anterior muscles 15cm distal to the site of section cheap 600mg zyvox overnight delivery. Find the radial nerve in the groove between brachialis and Cut the triceps 4cm distal to the site of section or free its brachioradialis buy zyvox 600 mg online, pull it buy zyvox 600mg with amex, and cut it proximally. Preserve the triceps fascia lateral side of the elbow, cut the extensor muscles 65cm and muscle as a long flap. Retract the periosteum 1-2cm to distal to the joint, and reflect their origin proximally. Reflect the triceps tendon anteriorly and suture it to the tendons of the brachialis and biceps. Suture the muscle mass to cover Saw the radius and ulna (35-12C) and smooth their cut the bony prominences and exposed tendons at the end of edges. Put sutures through the periosteum when Release the tourniquet, control bleeding and close the necessary. C, round off the radial & distal styloids, and preserve the distal radio-ulnar joint and the triangular ligament. Start the incision 15cm distal to the radial styloid, extend it distally towards the base of the first metacarpal. An elbow with even a short flap by joining the two ends of the palmar incision over the length of forearm is better than none. Bring the dorsal flap distally level muscles, peel off the periosteum 1-2cm off the radius and ulna, with the base of the middle metacarpal. If you cut the flaps with the arm prone, (If a neuroma forms here, it will be far from the scar. Try to preserve as much length Cut all tendons just proximal to the wrist and let them to as possible. Cut round the capsule of the wrist If there is enough good skin, make equal anterior and joint and remove the hand. Saw or nibble off the radial and posterior flaps (35-12A), as long as the diameter of the ulnar styloids. Do not injure the radio-ulnar joint or its triangular The radial and ulnar nerves run on the outside of their ligament. Damage to these will make rotation of the arteries, and the median nerve under flexor digitorum forearm difficult, and the joint will be painful. Reflect the flaps proximally to the site of bone section, and expose the soft tissues under them. Pull the finger flexor and extensor tendons distally, cut them, and allow them to retract into the forearm. Find the 4 wrist flexors and extensors (flexor & extensor carpi radialis & ulnaris), free their bony insertions and reflect them proximally to the site of bone section. Anchor the tendons of the wrist flexors and extensors to the remaining carpal bones in line with their normal insertions to preserve wrist function. If elaborate procedures are done to save it, not only is it likely to become stiff, but the neighbouring normal fingers are likely to become stiff too. However, leave as much length in the thumb as possible, because length here is more important than motion. The amputations on the left are easier, uglier, and stronger than those on the right. Amputating Most patients prefer a shorter finger covered with good through a joint is easier than cutting through a metacarpal. Textbook of operative surgery E&S Livingstone 1969 with kind permission Therefore, ask the patient if he uses his fingers for special skills. An amputation through the mcp joint that does not remove It is not easy to decide on the best. It is usually said though that this A flap from the volar surface of the finger is thus usually (preferably leaving also a stump of phalanx) makes a better than a graft. It is certainly an easier operation but a more too much length, a graft may be necessary. If possible, use elegant solution is a ray amputation through the shaft of a full thickness skin, although a split skin graft does metacarpal below its head (35-14). Retaining the stump of a phalanx (35-14A) further strengthens the hand by keeping the fingers apart and When amputating through the middle phalanx, try to retain preventing them from deviating towards one another the middle of the shaft, because the flexor digitorum (35-14B). If you are in doubt as to where to amputate, satisfactorily without his index finger (35-14 F), provided choose the more distal site. You can revise the amputation the head of the metacarpal has been removed obliquely later. Plan them carefully in relation to the ends of the bones, and close them without tension, even if the finger has to be shorter. A shorter amputation with loose flaps is better than a longer one with tight shiny ones. Make the palmar flap a little longer than the dorsal one, because this will preserve the maximum amount of pulp tissue, which is very sensitive. With all amputations: (1),If in doubt, make all flaps a bit longer than you think you will need. Neuromas are sure to develop, but if you do this they will be away from the scar and the finger tip. Flex the index finger and mark out the incision on its knuckle (35-15E,16A), so that the radial flap is larger and extends nearly half-way down the shaft of the proximal phalanx. Deepen the incision dorsally until you can see the extensor tendon, then cut it and turn it distally. F, proximal phalangeal amputation the scar by trimming away the ligaments around the of the middle finger. When you cut flaps through the webs, use a The disadvantage of removing the metacarpal head is that complete web on one side and no web on the other side. D, expose the metacarpal head and remove the distal part of Leave the base of the metacarpal, and suture the deep the finger. Use any convenient occupational therapy, such as rolling Preserve the subcutaneous tissue with the flap, and cut the bandages, to make sure using the fingers starts soon extensor tendons (35-17B). Shorten the flexor tendons as deep in the palm as If a little finger is stiff, and gets in the way, hindering you can. Cut the vessels & nerves distal to the branches of hand function by catching on objects, make a dorsal the palmar skin. Turn the palmar flap medially, and close racquet incision (35-15H); preserve the insertion of the skin without tension. Provided an above-knee amputation stump avoids the This is easier than amputating through the mcp joint. An amputee will also have to learn to balance with the hip Proceed as for the distal phalanx below, but amputate instead of the foot muscles. Join these 2 incisions to make a dorsal flap at the level of the joint, and a palmar flap 1cm distal to the flexor crease (35-15D). Dissect back the fibro-fatty tissue to find the digital vessels and nerves, the extensor expansion, and the flexor tendon in its sheath. If you cannot preserve tendon insertions, divide them and let them retract; never suture the extensor to the flexor tendon over the bone stump because of the quadriga effect where the flexed amputated finger reaches the palm before the other fingers, and so weakens the grip of the hand. Separate the nerves from the vessels, and divide the nerves proximal to the vessels. Preserve the articular cartilage, which provides a shock pad and close the wound. If < of the nail remains, a patient will be troubled later by the irregular hooked remnant, so excise the whole nail bed. If you have to remove some of the pulp, do not make a flap; place a non-stick dressing and allow the wound to heal on its own. If you can preserve the pulp, flex the terminal joint and make a transverse incision across its dorsal surface 6mm distal to the joint (35-15A). Continue the incision as far as the sides of the phalanx, and deepen it down to the bone. Cut the phalanx with bone avoids the condyles of the femur, the longer it is the better. Trim protruding condyles and the anterior part of the phalanx to make a less bulbous stump; then fold the flap and close the wound (35-15B). Rasp away and make (3),cuts little muscle and no bone, so it is quick, there is the end of the bone smooth.