Immobility Health Dictionary

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  2. Immobility

Immobility: From 1 Different Sources

Reduced physical activity, for example, through disease, injury, or following major surgery. Immobility is particularly harmful in the elderly because it causes muscle wasting and progressive loss of function.

Total immobility can produce complications including bedsores, pneumonia, or contractures. A common complication of partial immobility is oedema (fluid retention), which causes swelling of the legs. Rarely, sluggish blood flow encourages formation of a thrombus (abnormal blood clot) in a leg vein. Regular physiotherapy and adequate nursing care are important for any person who is totally immobile.

Health Source: BMA Medical Dictionary
Author: The British Medical Association

Constipation

A condition in which a person infrequently passes hard FAECES (stools). Patients sometimes complain of straining, a feeling of incomplete evacuation of faeces, and abdominal or perianal discomfort. A healthy individual usually opens his or her bowels once daily but the frequency may vary, perhaps twice daily or once only every two or three days. Constipation is generally de?ned as fewer than three bowel openings a week. Healthy people may have occasional bouts of constipation, usually re?ecting a temporary change in diet or the result of taking drugs – for example, CODEINE – or any serious condition resulting in immobility, especially in elderly people.

Constipation is a chronic condition and must be distinguished from the potentially serious disorder, acute obstruction, which may have several causes (see under INTESTINE, DISEASES OF). There are several possible causes of constipation; those due to gastrointestinal disorders include:

Dietary: lack of ?bre; low ?uid consumption.

Structural: benign strictures (narrowing of gut); carcinoma of the COLON; DIVERTICULAR DISEASE.

Motility: poor bowel training when young; slow transit due to reduced muscle activity in the colon, occurring usually in women; IRRITABLE BOWEL SYNDROME (IBS); HIRSCHSPRUNG’S DISEASE.

•Defaecation: anorectal disease such as ?ssures, HAEMORRHOIDS and CROHN’S DISEASE; impaction of faeces. Non-gastrointestinal disorders causing constipation include:

Drugs: opiates (preparations of OPIUM), iron supplements, ANTACIDS containing aluminium, ANTICHOLINERGIC drugs.

Metabolic and endocrine: DIABETES MELLITUS, pregnancy (see PREGNANCY AND LABOUR), hypothyroidism (see under THYROID GLAND, DISEASES OF).

Neurological: cerebrovascular accidents (STROKE), MULTIPLE SCLEROSIS (MS), PARKINSONISM, lesions in the SPINAL CORD. Persistent constipation for which there is no

obvious cause merits thorough investigation, and people who experience a change in bowel habits – for example, alternating constipation and diarrhoea – should also seek expert advice.

Treatment Most people with constipation will respond to a dietary supplement of ?bre, coupled, when appropriate, with an increase in ?uid intake. If this fails to work, judicious use of LAXATIVES for, say, a month is justi?ed. Should constipation persist, investigations on the advice of a general practitioner will probably be needed; any further treatment will depend on the outcome of the investigations in which a specialist will usually be involved. Successful treatment of the cause should then return the patient’s bowel habits to normal.... constipation

Akinesia

Loss or impairment of voluntary movement, or immobility. It is characteristically seen in PARKINSONISM.... akinesia

Alzheimer’s Disease

Alzheimer’s disease is a progressive degenerating process of neural tissue affecting mainly the frontal and temporal lobes of the BRAIN in middle and late life. There is probably a genetic component to Alzheimer’s disease, but early-onset Alzheimer’s is linked to certain mutations, or changes, in three particular GENES. Examination of affected brains shows ‘senile plaques’ containing an amyloid-like material distributed throughout an atrophied cortex (see AMYLOID PLAQUES). Many remaining neurons, or nerve cells, show changes in their NEUROFIBRILS which thicken and twist into ‘neuro?brillary tangles’. First symptoms are psychological with insidious impairment of recent memory and disorientation in time and space. This becomes increasingly associated with diffculties in judgement, comprehension and abstract reasoning. After very few years, progressive neurological deterioration produces poor gait, immobility and death. When assessment has found no other organic cause for an affected individual’s symptoms, treatment is primarily palliative. The essential part of treatment is the provision of appropriate nursing and social care, with strong support being given to the relatives or other carers for whom looking after sufferers is a prolonged and onerous burden. Proper diet and exercise are helpful, as is keeping the individual occupied. If possible, sufferers should stay in familiar surroundings with day-care and short-stay institutional facilities a useful way of maintaining them at home for as long as possible.

TRANQUILLISERS can help control di?cult behaviour and sleeplessness but should be used with care. Recently drugs such as DONEPEZIL and RIVASTIGMINE, which retard the breakdown of ACETYLCHOLINE, may check

– but not cure – this distressing condition. About 40 per cent of those with DEMENTIA improve.

Research is in progress to transplant healthy nerve cells (developed from stem cells) into the brain tissue of patients with Alzheimer’s disease with the aim of improving brain function.

The rising proportion of elderly people in the population is resulting in a rising incidence of Alzheimer’s, which is rare before the age of 60 but increases steadily thereafter so that 30 per cent of people over the age of 84 are affected.... alzheimer’s disease

Bone, Disorders Of

Bone is not an inert sca?olding for the human body. It is a living, dynamic organ, being continuously remodelled in response to external mechanical and chemical in?uences and acting as a large reservoir for calcium and phosphate. It is as susceptible to disease as any other organ, but responds in a way rather di?erent from the rest of the body.

Bone fractures These occur when there is a break in the continuity of the bone. This happens either as a result of violence or because the bone is unhealthy and unable to withstand normal stresses.

SIMPLE FRACTURES Fractures where the skin remains intact or merely grazed. COMPOUND FRACTURES have at least one wound which is in communication with the fracture, meaning that bacteria can enter the fracture site and cause infection. A compound fracture is also more serious than a simple fracture because there is greater potential for blood loss. Compound fractures usually need hospital admission, antibiotics and careful reduction of the fracture. Debridement (cleaning and excising dead tissue) in a sterile theatre may also be necessary.

The type of fracture depends on the force which has caused it. Direct violence occurs when an object hits the bone, often causing a transverse break – which means the break runs horizontally across the bone. Indirect violence occurs when a twisting injury to the ankle, for example, breaks the calf-bone (the tibia) higher up. The break may be more oblique. A fall on the outstretched hand may cause a break at the wrist, in the humerus or at the collar-bone depending on the force of impact and age of the person. FATIGUE FRACTURES These occur after the bone has been under recurrent stress. A typical example is the march fracture of the second toe, from which army recruits suffer after long marches. PATHOLOGICAL FRACTURES These occur in bone which is already diseased – for example, by osteoporosis (see below) in post-menopausal women. Such fractures are typically crush fractures of the vertebrae, fractures of the neck of the femur, and COLLES’ FRACTURE (of the wrist). Pathological fractures also occur in bone which has secondary-tumour deposits. GREENSTICK FRACTURES These occur in young children whose bones are soft and bend, rather than break, in response to stress. The bone tends to buckle on the side opposite to the force. Greenstick fractures heal quickly but still need any deformity corrected and plaster of Paris to maintain the correction. COMPLICATED FRACTURES These involve damage to important soft tissue such as nerves, blood vessels or internal organs. In these cases the soft-tissue damage needs as much attention as the fracture site. COMMINUTED FRACTURES A fracture with more than two fragments. It usually means that the injury was more violent and that there is more risk of damage to vessels and nerves. These fractures are unstable and take longer to unite. Rehabilitation tends to be protracted. DEPRESSED FRACTURES Most commonly found in skull fractures. A fragment of bone is forced inwards so that it lies lower than the level of the bone surrounding it. It may damage the brain beneath it.

HAIR-LINE FRACTURES These occur when the bone is broken but the force has not been severe enough to cause visible displacement. These fractures may be easily missed. Symptoms and signs The fracture site is usually painful, swollen and deformed. There is asymmetry of contour between limbs. The limb is held uselessly. If the fracture is in the upper

limb, the arm is usually supported by the patient; if it is in the lower limb then the patient is not able to bear weight on it. The limb may appear short because of muscle spasm.

Examination may reveal crepitus – a bony grating – at the fracture site. The diagnosis is con?rmed by radiography.

Treatment Healing of fractures (union) begins with the bruise around the fracture being resorbed and new bone-producing cells and blood vessels migrating into the area. Within a couple of days they form a bridge of primitive bone across the fracture. This is called callus.

The callus is replaced by woven bone which gradually matures as the new bone remodels itself. Treatment of fractures is designed to ensure that this process occurs with minimal residual deformity to the bone involved.

Treatment is initially to relieve pain and may involve temporary splinting of the fracture site. Reducing the fracture means restoring the bones to their normal position; this is particularly important at the site of joints where any small displacement may limit movement considerably.

with plaster of Paris. If closed traction does not work, then open reduction of the fracture may

be needed. This may involve ?xing the fracture with internal-?xation methods, using metal plates, wires or screws to hold the fracture site in a rigid position with the two ends closely opposed. This allows early mobilisation after fractures and speeds return to normal use.

External ?xators are usually metal devices applied to the outside of the limb to support the fracture site. They are useful in compound fractures where internal ?xators are at risk of becoming infected.

Consolidation of a fracture means that repair is complete. The time taken for this depends on the age of the patient, the bone and the type of fracture. A wrist fracture may take six weeks, a femoral fracture three to six months in an adult.

Complications of fractures are fairly common. In non-union, the fracture does not unite

– usually because there has been too much mobility around the fracture site. Treatment may involve internal ?xation (see above). Malunion means that the bone has healed with a persistent deformity and the adjacent joint may then develop early osteoarthritis.

Myositis ossi?cans may occur at the elbow after a fracture. A big mass of calci?ed material develops around the fracture site which restricts elbow movements. Late surgical removal (after 6–12 months) is recommended.

Fractured neck of FEMUR typically affects elderly women after a trivial injury. The bone is usually osteoporotic. The leg appears short and is rotated outwards. Usually the patient is unable to put any weight on the affected leg and is in extreme pain. The fractures are classi?ed according to where they occur:

subcapital where the neck joins the head of the femur.

intertrochanteric through the trochanter.

subtrochanteric transversely through the upper end of the femur (rare). Most of these fractures of the neck of femur

need ?xing by metal plates or hip replacements, as immobility in this age group has a mortality of nearly 100 per cent. Fractures of the femur shaft are usually the result of severe trauma such as a road accident. Treatment may be conservative or operative.

In fractures of the SPINAL COLUMN, mere damage to the bone – as in the case of the so-called compression fracture, in which there is no damage to the spinal cord – is not necessarily serious. If, however, the spinal cord is damaged, as in the so-called fracture dislocation, the accident may be a very serious one, the usual result being paralysis of the parts of the body below the level of the injury. Therefore the higher up the spine is fractured, the more serious the consequences. The injured person should not be moved until skilled assistance is at hand; or, if he or she must be removed, this should be done on a rigid shutter or door, not on a canvas stretcher or rug, and there should be no lifting which necessitates bending of the back. In such an injury an operation designed to remove a displaced piece of bone and free the spinal cord from pressure is often necessary and successful in relieving the paralysis. DISLOCATIONS or SUBLUXATION of the spine are not uncommon in certain sports, particularly rugby. Anyone who has had such an injury in the cervical spine (i.e. in the neck) should be strongly advised not to return to any form of body-contact or vehicular sport.

Simple ?ssured fractures and depressed fractures of the skull often follow blows or falls on the head, and may not be serious, though there is always a risk of damage which is potentially serious to the brain at the same time.

Compound fractures may result in infection within the skull, and if the skull is extensively broken and depressed, surgery is usually required to check any intercranial bleeding or to relieve pressure on the brain.

The lower jaw is often fractured by a blow on the face. There is generally bleeding from the mouth, the gum being torn. Also there are pain and grating sensations on chewing, and unevenness in the line of the teeth. The treatment is simple, the line of teeth in the upper jaw forming a splint against which the lower jaw is bound, with the mouth closed.

Congenital diseases These are rare but may produce certain types of dwar?sm or a susceptibility to fractures (osteogenesis imperfecta).

Infection of bone (osteomyelitis) may occur after an open fracture, or in newborn babies with SEPTICAEMIA. Once established it is very di?cult to eradicate. The bacteria appear capable of lying dormant in the bone and are not easily destroyed with antibiotics so that prolonged treatment is required, as might be surgical drainage, exploration or removal of dead bone. The infection may become chronic or recur.

Osteomalacia (rickets) is the loss of mineralisation of the bone rather than simple loss of bone mass. It is caused by vitamin D de?ciency and is probably the most important bone disease in the developing world. In sunlight the skin can synthesise vitamin D (see APPENDIX 5: VITAMINS), but normally rickets is caused by a poor diet, or by a failure to absorb food normally (malabsorbtion). In rare cases vitamin D cannot be converted to its active state due to the congenital lack of the speci?c enzymes and the rickets will fail to respond to treatment with vitamin D. Malfunction of the parathyroid gland or of the kidneys can disturb the dynamic equilibrium of calcium and phosphate in the body and severely deplete the bone of its stores of both calcium and phosphate.

Osteoporosis A metabolic bone disease resulting from low bone mass (osteopenia) due to excessive bone resorption. Su?erers are prone to bone fractures from relatively minor trauma. With bone densitometry it is now possible to determine individuals’ risk of osteoporosis and monitor their response to treatment.

By the age of 90 one in two women and one in six men are likely to sustain an osteoporosis-related fracture. The incidence of fractures is increasing more than would be expected from the ageing of the population, which may re?ect changing patterns of exercise or diet.

Osteoporosis may be classi?ed as primary or secondary. Primary consists of type 1 osteoporosis, due to accelerated trabecular bone loss, probably as a result of OESTROGENS de?ciency. This typically leads to crush fractures of vertebral bodies and fractures of the distal forearm in women in their 60s and 70s. Type 2 osteoporosis, by contrast, results from the slower age-related cortical and travecular bone loss that occurs in both sexes. It typically leads to fractures of the proximal femur in elderly people.

Secondary osteoporosis accounts for about 20 per cent of cases in women and 40 per cent of cases in men. Subgroups include endocrine (thyrotoxicosis – see under THYROID GLAND, DISEASES OF, primary HYPERPARATHYROIDISM, CUSHING’S SYNDROME and HYPOGONADISM); gastrointestinal (malabsorption syndrome, e.g. COELIAC DISEASE, or liver disease, e.g. primary biliary CIRRHOSIS); rheumatological (RHEUMATOID ARTHRITIS or ANKYLOSING SPONDYLITIS); malignancy (multiple MYELOMA or metastatic CARCINOMA); and drugs (CORTICOSTEROIDS, HEPARIN). Additional risk factors for osteoporosis include smoking, high alcohol intake, physical inactivity, thin body-type and heredity.

Individuals at risk of osteopenia, or with an osteoporosis-related fracture, need investigation with spinal radiography and bone densitometry. A small fall in bone density results in a large increase in the risk of fracture, which has important implications for preventing and treating osteoporosis.

Treatment Antiresorptive drugs: hormone replacement therapy – also valuable in treating menopausal symptoms; treatment for at least ?ve years is necessary, and prolonged use may increase risk of breast cancer. Cyclical oral administration of disodium etidronate – one of the bisphosphonate group of drugs – with calcium carbonate is also used (poor absorption means the etidronate must be taken on an empty stomach). Calcitonin – currently available as a subcutaneous injection; a nasal preparation with better tolerance is being developed. Calcium (1,000 mg daily) seems useful in older patients, although probably ine?ective in perimenopausal women, and it is a safe preparation. Vitamin D and calcium – recent evidence suggests value for elderly patients. Anabolic steroids, though androgenic side-effects (masculinisation) make these unacceptable for most women.

With established osteoporosis, the aim of treatment is to relieve pain (with analgesics and physical measures, e.g. lumbar support) and reduce the risk of further fractures: improvement of bone mass, the prevention of falls, and general physiotherapy, encouraging a healthier lifestyle with more daily exercise.

Further information is available from the National Osteoporosis Society.

Paget’s disease (see also separate entry) is a common disease of bone in the elderly, caused by overactivity of the osteoclasts (cells concerned with removal of old bone, before new bone is laid down by osteoblasts). The bone affected thickens and bows and may become painful. Treatment with calcitonin and bisphosphonates may slow down the osteoclasts, and so hinder the course of the disease, but there is no cure.

If bone loses its blood supply (avascular necrosis) it eventually fractures or collapses. If the blood supply does not return, bone’s normal capacity for healing is severely impaired.

For the following diseases see separate articles: RICKETS; ACROMEGALY; OSTEOMALACIA; OSTEOGENESIS IMPERFECTA.

Tumours of bone These can be benign (non-cancerous) or malignant (cancerous). Primary bone tumours are rare, but secondaries from carcinoma of the breast, prostate and kidneys are relatively common. They may form cavities in a bone, weakening it until it breaks under normal load (a pathological fracture). The bone eroded away by the tumour may also cause problems by causing high levels of calcium in the plasma.

EWING’S TUMOUR is a malignant growth affecting long bones, particularly the tibia (calfbone). The presenting symptoms are a throbbing pain in the limb and a high temperature. Treatment is combined surgery, radiotherapy and chemotherapy.

MYELOMA is a generalised malignant disease of blood cells which produces tumours in bones which have red bone marrow, such as the skull and trunk bones. These tumours can cause pathological fractures.

OSTEOID OSTEOMA is a harmless small growth which can occur in any bone. Its pain is typically removed by aspirin.

OSTEOSARCOMA is a malignant tumour of bone with a peak incidence between the ages of ten and 20. It typically involves the knees, causing a warm tender swelling. Removal of the growth with bone conservation techniques can often replace amputation as the de?nitive treatment. Chemotherapy can improve long-term survival.... bone, disorders of

Disuse Atrophy

The wasting of muscles after prolonged immobility. This can be seen after lengthy immobilisation in a plaster cast, and is particularly severe following paralysis of a limb through nerve injury. (See ATROPHY.)... disuse atrophy

Leg Ulcer

An open sore on the leg that fails to heal, usually resulting from poor blood circulation to or from the area.

There are various types of ulcer.

Venous ulcers (also referred to as varicose or stasis ulcers) occur mainly on the ankles and lower legs and are caused by valve failure in veins; they usually appear in conjunction with varicose veins.

Bedsores (decubitus ulcers) develop on pressure spots on the legs due to a combination of poor circulation, pressure, and immobility over a long period.

Leg ulcers can also be due to peripheral vascular disease and diabetes mellitus.

In the tropics, some infections can cause tropical ulcers.... leg ulcer

Trench Foot

This is due to prolonged exposure of the feet to water – particularly cold water. Trench warfare is a common precipitating factor, and the condition was rampant during World War I. Cases also occurred during World War II and during the Falklands campaign. (The less common form, due to warm-water immersion, occurred with some frequency in the Vietnam war.) It is characterised by painful swelling of the feet accompanied in due course by blistering and ulceration which, in severe, untreated cases, may progress to GANGRENE. In mild cases recovery may be complete in a month, but severe cases may drag on for a year. (See also IMMERSION FOOT.)

Treatment Drying of the feet overnight, where practicable, is the best method of prevention, accompanied by avoidance of constrictive clothing and tight boots, and of prolonged immobility. Frequent rest periods and daily changing of socks also help. The application of silicone grease once a day is another useful preventive measure. In the early stages, treatment consists of rest in bed and warmth; in more severe cases treatment is as for infected tissues and ulceration. ANALGESICS are usually necessary to ease the pain. Technically, smoking should be forbidden, but the adverse psychological effects of this in troops on active service may outweigh its advantages.... trench foot

Veins, Diseases Of

Veins are the blood vessels that convey blood back from the tissues towards the heart. Two common conditions that affect them are THROMBOSIS and varicosities (see below).

Varicose veins are dilated tortuous veins occurring in about 15 per cent of adults – women more than men. They most commonly occur in the legs but may also occur in the anal canal (HAEMORRHOIDS) and in the oesophagus (due to liver disease).

Normally blood ?ows from the subcutaneous tissues to the super?cial veins which drain via perforating veins into the deep veins of the leg. This ?ow, back towards the heart, is aided by valves within the veins. When these valves fail, increased pressure is exerted on the blood vessels leading to dilatations known as varicose veins.

Treatment is needed to prevent complications such as ulceration and bleeding, or for

cosmetic purposes. Treatment alternatives include injection with sclerosing agents to obliterate the lumen of the veins (sclerotherapy), or surgery; in the elderly or un?t, an elastic stocking may su?ce. One operation is the Trendelenburg operation in which the saphenous vein is disconnected from the femoral vein and individual varicose veins are avulsed. (See also VASCULITIS.)

Thrombosis Thrombosis occurs when blood, which is normally a liquid, clots within the vein to form a semisolid thrombus (clot). This occurs through a combination of reduced blood ?ow and hypercoagulability (a reduced threshold for clotting). The most common site for this to occur is in the deep veins of the leg, where it is known as a deep-vein thrombosis (DVT).

Predisposing factors include immobility (leading to reduced blood ?ow), such as during long journeys (e.g. plane ?ights) where there is little opportunity to stretch one’s legs; surgery (leading to temporary post-operative immobility and hypercoagulability of blood); oestrogen administration (low-dose oestrogen oral contraceptives carry a very low relative risk); and several medical illnesses such as heart failure, stroke and malignancy.

Deep-vein thrombosis presents as a tender, warm, red swelling of the calf. Diagnosis may be con?rmed by venogram (an X-ray taken following injection of contrast medium into the foot veins) or by ultrasound scanning looking for ?ow within the veins.

Prevention is important. This is why patients are mobilised and/or given leg exercises very soon after an operation, even major surgery. People should avoid sitting for long periods, particularly if the edge of the seat is hard, thus impeding venous return from the legs. Car drivers should stop regularly on a long journey and walk around; airline travellers should, where possible, walk round the aisle(s) and also exercise and massage their leg muscles, as well as drinking ample non-alcoholic ?uids.

Diagnosis and treatment are important because there is a risk that the clotted blood within the vein becomes dislodged and travels up the venous system to become lodged in the pulmonary arteries. This is known as PULMONARY EMBOLISM.

Treatment is directed at thinning the blood with ANTICOAGULANTS, initially with heparin and subsequently with WARFARIN for a period of time while the clot resolves.

Blocked super?cial veins are described as super?cial thrombophlebitis, which produces in?ammation over the vein. It responds to antiin?ammatory analgesics. Occasionally heparin and ANTIBIOTICS are required to treat associated thrombosis and infection.... veins, diseases of

Cerebral Palsy

A disorder of posture and movement resulting from damage to a child’s developing brain before, during, or immediately after birth, or in early childhood. Cerebral palsy is nonprogressive and varies in degree from slight clumsiness of hand movement and gait to complete immobility.

A child with cerebral palsy may have spastic paralysis (abnormal stiffness of muscles), athetosis (involuntary writhing movements), or ataxia (loss of coordination and balance). Other nervous system disorders, such as hearing defects or epileptic seizures, may be present. About 70 per cent of affected children have mental impairment, but the remainder are of normal or high intelligence.

In most cases, damage occurs before or at birth, most commonly as a result of an inadequate supply of oxygen to the brain. More rarely, the cause is a maternal infection spreading to the baby in the uterus. In rare cases, cerebral palsy is due to kernicterus. Possible causes after birth include encephalitis, meningitis, head injury, or intracerebral haemorrhage. Cerebral palsy may not be recognized until well into the baby’s 1st year. Initially, the infant may have hypotonic (floppy) muscles, be difficult to feed, and show delay in sitting without support.

Although there is no cure for cerebral palsy, much can be done to help affected children using specialized physiotherapy, speech therapy, and techniques and devices for nonverbal communication.... cerebral palsy

Femur, Fracture Of

The symptoms, treatment, and possible complications of a fracture of the femur (thigh-bone) depend on whether the bone has broken across its neck (the short section between the top of the shaft and the hip joint) or across the shaft.Fracture of the neck of the femur, often called a broken hip, is very common in elderly people, especially in women with osteoporosis, and is usually associated with a fall. In a fracture of the neck of the femur, the broken bone ends are often considerably displaced; in such cases there is usually severe pain in the hip and groin, making standing impossible. Occasionally, the broken ends become impacted. In this case, there is less pain and walking may be possible. Diagnosis is confirmed by X-ray. If the bone ends are displaced, an operation under general anaesthesia is necessary, either to realign the bone ends and to fasten them together, or to replace the entire head and neck of the femur with an artificial substitute (see hip replacement). If the bone ends are impacted the fracture may heal naturally, but surgery may still be recommended to avoid the need for bed rest.

Complications include damage to the blood supply to the head of the femur, causing it to disintegrate. Osteoarthritis may develop in the hip joint after fracture of the femur neck itself. However, immobility and the need for surgery in the elderly may result in complications, such as pneumonia, that are not directly related to the fracture site.

Fracture of the bone shaft usually occurs when the femur is subjected to extreme force, such as that which occurs in a traffic accident. In most cases, the bone ends are considerably displaced, causing severe pain, tenderness, and swelling.

Diagnosis is confirmed by X-ray. With a fractured femoral shaft there is often substantial blood loss from the bone. In most cases, the fracture is repaired by surgery in which the ends of the bone are realigned and fastened together with a metal pin. Sometimes the bone ends can be realigned by manipulation, and surgery is not necessary. After realignment, the leg is supported with a splint and put in traction to hold the bone together while it heals.

Complications include failure of the bone ends to unite or fusion of the broken ends at the wrong angle, infection of the bone, or damage to a nerve or artery.

A fracture of the lower shaft can cause permanent stiffness of the knee.... femur, fracture of

Osteoporosis

Loss of bone tissue, causing the bone to become brittle and fracture easily. Bone thinning is a natural part of aging. However, women are especially vulnerable to loss of bone density after menopause, because their ovaries no longer produce oestrogen hormones, which help maintain bone mass.

Other causes of osteoporosis include removal of the ovaries; a diet that is deficient in calcium; certain hormonal disorders; prolonged treatment with corticosteroid drugs; and prolonged immobility. Osteoporosis is most common in heavy smokers and drinkers, and in excessively thin people.

The first sign of osteoporosis is often a fracture, typically just above the wrist or at the top of the femur. One or several vertebrae may fracture spontaneously and cause the bones to crumble, leading to progressive height loss or pain due to compression of a spinal nerve.

Osteoporosis is confirmed using bone X-rays and densitometry.

Bone loss can be minimized by adequate dietary calcium, and regular, sustained exercise to build bones and maintain their strength.

Long-term hormone replacement therapy after the menopause can prevent osteoporosis in women.

Bisphosphonate drugs may be given to prevent bone loss.... osteoporosis

Pulmonary Embolism

Obstruction of the pulmonary artery or one of its branches in the lung by an embolus, usually after a deep vein thrombosis (see thrombosis, deep vein). If the embolus is large enough to block the main pulmonary artery, or if there are many clots, the condition is life-threatening. Pulmonary embolism is more likely after recent surgery, pregnancy, and immobility. A massive embolus can cause sudden death. Smaller emboli may cause severe shortness of breath, rapid pulse, dizziness, chest pain made worse by breathing, and coughing up of blood. Tiny emboli may produce no symptoms, but, if recurrent, may eventually lead to pulmonary hypertension.

A diagnosis may be made by a chest X-ray, radionuclide scanning, and pulmonary angiography.

An ECG and venography may also be performed.

Treatment depends on the size and severity of the embolus.

A small one gradually dissolves and thrombolytic drugs may be given to hasten this process.

Anticoagulant drugs are given to reduce the chance of more clots.

Surgery may be needed to remove larger clots.... pulmonary embolism

Thrombosis

The formation of a thrombus (blood clot) in an undamaged blood vessel. A thrombus that forms within an artery supplying the heart muscle (coronary thrombosis) is the usual cause of myocardial infarction. A thrombus in an artery of the brain (cerebral thrombosis) is a common cause of stroke. Thrombi sometimes form in veins, either just below the skin or in deeper veins (see thrombosis, deep vein).In arteries, thrombus formation may be encouraged by atherosclerosis, smoking, hypertension, and damage to blood vessel walls from arteritis and phlebitis.

An increased clotting tendency may occur in pregnancy, when using oral contraceptives, or through prolonged immobility.

An arterial thrombosis may cause no symptoms until blood flow is impaired.

Then, there is reduced tissue or organ function and sometimes severe pain.

Venous thrombosis may also cause pain and swelling.

Diagnosis is made by doppler ultrasound.

In some cases, angiography or venography may also be used.

Treatment may include anticoagulant drugs or thrombolytic drugs, nonsteroidal anti-inflammatory drugs, and antibiotic drugs.

In life-threatening cases, thrombectomy may be needed.... thrombosis

Phlebothrombosis

n. obstruction of a vein by a blood clot, without preceding inflammation of its wall. It is most common within the deep veins of the calf of the leg – deep vein thrombosis (DVT) – in contrast to *thrombophlebitis, which affects superficial leg veins. Prolonged immobility, heart failure, pregnancy, injury, and surgery predispose to thrombosis by encouraging sluggish blood flow. Many of these conditions are associated with changes in the clotting factors in the blood that increase the tendency to thrombosis; these changes also occur in some women taking oral contraceptives.

The affected leg may become swollen and tender. The main danger is that the clot may become detached and give rise to *pulmonary embolism. Regular leg exercises help to prevent deep vein thrombosis, and anticoagulant drugs (such as heparin and warfarin) are used in prevention and treatment. Large clots may be removed surgically in the operation of thrombectomy to relieve leg swelling.... phlebothrombosis


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