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Orthoses for Spinal Pain

Key Points Causation of back pain is often multifactorial and may be unidentifiable. Although there is only limited evidence of benefit, the most consistent recommendation is that lumbar orthoses can be used in subacute back pain for a period of no more than 3 weeks to avoid paraspinal atrophy. When used specifically for the treatment of pain, cervical orthoses have demonstrated limited benefit and may lead…

Principles and Components of Spinal Orthoses

Key Points Spinal bracing serves three primary objectives: controlling pain by limiting motion and unloading discs, vertebrae, and other spinal structures; stabilizing weak or injured structures by immobilizing the spine; and providing a three-point force system to provide correction or prevent progression of a deformity. Custom devices are always necessary for patients with atypical dimensions or significant bony prominences. Intimacy of fit is best accommodated by…

Biomechanics of the Spine

Key Points The primary biomechanical functions of the spinal column are to support the substantial loads induced during activities of daily living and protect the spinal cord while allowing physiologic mobility. This chapter presents a framework for understanding these biomechanical functions of the spine by first discussing the stability of the osteoligamentous spinal column and the role played by the muscles. The chapter progresses to a…

Principles of Normal and Pathologic Gait

Key Points Human gait is a complex phenomenon that involves intricate interactions between the pelvis, hips, knees, and ankles. Understanding human gait requires a solid knowledge of underlying physiology and biomechanical principles. Observational gait analysis skills are essential in the evaluation of pathologic gait patterns. Comprehending the relationship between clinical examination findings, biomechanical influences, and gait pattern observations leads to optimal orthotic intervention. Normal Human Gait…

Principles of Fabrication

Key Points Fabrication can be classified into three subsets: (1) constructed from raw materials; (2) combined from raw materials and specially designed components; or (3) mass-produced, generic, completed devices that can be modified to fit the patient. Although meticulous fabrication remains essential for creating an optimal orthosis, the methods and materials currently used create much stronger, thinner, lighter, and more biomechanically sophisticated orthoses than previously possible.…

Materials Science

Key Points A thorough knowledge of the material science, its application, and other general principles summarized in this chapter is prerequisite to ensuring that the orthosis and assistive devices provided by practitioners will be durable, safe, and as unobtrusive as possible and will perform the required function for as long as necessary. Understanding these fundamentals enables the practitioner to assess designs; materials; and, more importantly, failures…

Genetic Influences on Anterior Cruciate Ligament Injury

Introduction There is no single factor that causes acute anterior cruciate ligament (ACL) injuries. ACL ruptures are therefore considered multifactorial conditions with evidence from both familial and case-control genetic association studies that DNA sequence variants play an important role in its etiology. A growing number of common variants within genes encoding proteins, such as collagens, fibrillins, and proteoglycans, involved in the structure and regulation of the…

Orthotic Prescription

Key Points A prescription for an orthosis communicates the type of device recommended to meet the biomechanical needs of the patient to improve function and promote participation in life activities. An appropriate orthotic prescription and treatment plan is generated based on knowledge of the patient's disease process along with information from a comprehensive history, physical examination, and integration of patient-related and environmental factors. Optimally, the prescription…

Anatomy and Biomechanics of the Anterior Cruciate Ligament

Acknowledgment We acknowledge James S. Starman, Mario Ferretti, Timo Järvelä, and Anthony Buoncristian, the authors of the previous edition, for their great contribution to this chapter. Introduction Anterior cruciate ligament (ACL) reconstruction is among the most common procedures performed in orthopaedics, with over 130,000 reconstructions performed annually in the United States alone. The ACL has therefore been extensively studied, and outcomes of ACL surgery have received…

Vascular anomalies

Introduction Vascular anomalies are a complex broad group of developmental abnormalities that present significant challenges in diagnosis and management. The rarity and diverse presentation of vascular anomalies often mean patients are seen by multiple specialists, before a correct diagnosis and treatment can be instigated. Accurate and timely diagnosis are crucial, and a multidisciplinary team approach is essential for their appropriate evaluation and management. The exact make-up…

The acutely swollen leg

Introduction The acutely swollen leg is a common presenting complaint in the emergency room. It may represent a sudden presentation of an underlying chronic disease, or it may be the manifestation of a new acute problem, in particular deep vein thrombosis (DVT). A number of diseases can be associated with swelling of the lower extremity. It is important to identify the cause of the swelling, as…

Chronic leg swelling

There are various conditions that can cause chronic lower limb swelling ( Box 18.1 ). The three most common are chronic venous insufficiency (CVI), lymphoedema and dependent oedema, which may be associated with inactivity and obesity. This chapter explores these three conditions further. Box 18.1 Differential diagnosis of chronic leg swelling Venous disease Primary varicose veins Primary deep venous incompetence Post-thrombotic syndrome Arteriovenous malformations Lymphoedema Primary…

Varicose veins

Introduction Varicose veins are extremely common and part of a spectrum of chronic venous disorders. The management of venous disease is a major cause of healthcare expense in the UK National Health Service (NHS) and worldwide. , The enormous impact of venous disease, including varicose veins on patient quality of life is widely acknowledged. , As venous disease may present in many different ways, a variety…

Central venous and dialysis access

Introduction Access to the venous circulation is an almost universal requirement in hospitalised patients for intravenous fluid, medicine or blood products administration. This is most commonly achieved with an indwelling peripheral intravenous cannula, but central venous access may be required for central venous pressure monitoring, parenteral nutrition, haemodialysis (HD), haemofiltration, the administration of cytotoxic drugs or long-term antibiotics. For acute HD, central venous catheters (CVCs) are…

Renal and visceral arterial disease

PART 1 Disorders of The Renal and Mesenteric Circulation: Kirthi Bellamkonda, Ramesh Kaushal Tripathi Introduction Renal vascular disease Vascular involvement of the renal artery and vein encompasses multitude of conditions and aetiopathologies; the treatment options for these are equally broad and evolve constantly. We present here a brief review of the traditional understanding of these diseases and the current evidence available in the management of a…

Thoracic and thoraco-abdominal aortic disease

Introduction Diseases of the thoracic and thoraco-abdominal aorta are less common than infra-renal abdominal aortic aneurysms (AAAs) but their management should be familiar to vascular surgeons, as they often present acutely. This is partly because of the greater utilisation of cross-sectional imaging, which has in turn led to an apparent increase in the incidence of thoracic aortic conditions. Over the last two decades, endovascular repair has…

Peripheral and abdominal aortic aneurysms

Introduction The normal diameter of the aorta varies with age, sex and bodyweight. It decreases in size as it leaves the thorax and enters the abdomen, tapering to its iliac bifurcation. However, the infra-renal aorta enlarges progressively with age. An aortic aneurysm is a permanent localised dilatation of all three layers of the vessel wall of at least a 50% increase in diameter compared to the…

Primary and secondary vasospastic disorders (Raynaud’s phenomenon) and vasculitis

Introduction A range of vasospastic and inflammatory disorders can present with ischaemia and thus come to the attention of the vascular clinician. These include primary and secondary Raynaud’s phenomenon (RP), and conditions that cause vasculitis (the vasculitides). Diagnostic accuracy is important as management is directed by the underlying pathogenic process, be it vasospasm or inflammation. Diagnosis can be challenging, not least because presenting features of the…

Vascular disorders of the upper limb

Introduction Arterial diseases of the upper limb are relatively rare in comparison with those involving the lower extremity. The good collateral supply around the shoulder and elbow explains why chronic occlusive disease is commonly asymptomatic, but acute occlusion caused by embolism can result in limb-threatening ischaemia. In addition, thoracic outlet syndrome, subclavian–axillary vein thrombosis and occupational vascular problems need to be considered. In this chapter, we…

Extracranial cerebrovascular disease

Introduction Stroke is the third commonest cause of death and is a major cause of neurological disability. It is defined as an acute loss of focal cerebral function with symptoms exceeding 24 hours (or leading to death), with no apparent cause other than a vascular origin. A transient ischaemic attack (TIA) has the same definition but lasts <24 hours. In the UK, the annual incidence of…