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CEREBRAL PALSY

Thu, 15 Sep 2011 19:45:57 +0100

INTRODUCTION

The term cerebral palsy (CP) was originally coined more than a century ago and loosely translates as "brain paralysis." However, a precise definition has remained elusive because cerebral palsy is not a single diagnosis but an "umbrella" term describing non-progressive brain lesions involving motor or postural abnormalities that are noted during early development, Mutch (2011). This has led to many definitions fro different authors but pointing to the same facts. For instance, Bax (2005) defined Cerebral palsy as "A group of disorders of the development of movement and posture causing activity limitations that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, cognition, communication, perception, and/or behavior and/or a seizure disorder." While it has also been defined as an umbrella term encompassing a group of a non-progressive and non contagious motor conditions that cause physical disability in human development, chiefly in the various areas of body movement, NCBDDD, (2002)

Since it leads to a non progressive injury to the brain it impact on the functioning of the body is vast. Cerebral palsy has many types which are dependant on the area of the brain that has been injured and the final presentation of the condition.

As any other condition, management of Cerebral palsy involves a multi-displinary approach of the health care team. The prognosis is also dependant on the individual.

ANATOMY OF THE BRAIN

The human brain is the center of the human nervous system. Enclosed in the cranium, the human brain has the same general structure as that of other mammals, but is over three times larger than the brain of a typical mammal with an equivalent body size.

Most of the spatial expansion comes from the cerebral cortex, a convoluted layer of neural tissue which covers the surface of the forebrain. Especially expanded are the frontal lobes, which are associated with executive functions. The brain controls the other organ systems of the body, either by activating muscles or by causing secretion of chemicals such as hormones and neurotransmitters. This centralized control allows rapid and coordinated responses to changes in the environment. Some basic types of responsiveness are possible without a brain.

The brain consists of six main regions: the telencephalon (cerebral hemispheres), diencephalon (thalamus and hypothalamus), mesencephalon (midbrain), cerebellum, pons, and medulla oblongata.Each of these areas in turn has a complex internal structure.

The cerebral hemispheres are two i.e the right and the left. For most of the activities of the body, there is contra lateral innervation as opposed to ipsilateral innervations except for the cerebellum. This simply means that the left side of the body is controlled by the right side of the telencempalon and vice vesa.

The diecephalon consists of the thalamus and hypothalamus. The hypothalamus performs numerous vital functions, most of which relate directly or indirectly to the regulation of visceral activities by way of other brain regions and the autonomic nervous system. The thalamus has multiple functions. Most nerve fibers going to the cerebrum pass through the thalamus.

The cerebellum also called little brain is a region of the brain that plays an important role in motor control. It is also involved in some cognitive functions such as attention and language, and probably in some emotional functions such as regulating fear and pleasure responses. Its movement-related functions are the most clearly understood, however. The cerebellum does not initiate movement, but it contributes to coordination, precision, and accurate timing. It receives input from sensory systems and from other parts of the brain and spinal cord, and integrates these inputs to fine tune motor activity. Because of this fine-tuning function, damage to the cerebellum does not cause paralysis, but instead produces disorders in fine movement, equilibrium, posture, and motor learning.

The mesencephalon is considered part of the brainstem. Its substantia nigra is closely associated with motor system pathways of the basal ganglia.

Dopamine produced in the substantia nigra plays a role in motivation and habituation of species from humans to the most elementary animals such as insects.

The pons measures about 2.5 cm in length. Most of it appears as a broad anterior bulge rostral to the medulla. Posteriorly, it consists mainly of two pairs of thick stalks called cerebellar peduncles. The pons contains nuclei that relay signals from the forebrain to the cerebellum, along with nuclei that deal primarily with sleep, respiration, swallowing, bladder control, hearing, equilibrium, taste, eye movement, facial expressions, facial sensation, and posture. Within the pons is the pneumotaxic center, a nucleus in the pons that regulates the change from inspiration to expiration. The pons also contains the sleep paralysis center of the brain as well as generating the dreams of REM sleep.

The medulla oblongata is the lower half of the brainstem. It controls autonomic functions, and relays nerve signals between the brain and spinal cord. It is also responsible for controlling several major points and autonomic functions of the body like, respiration by chemoreceptors, cardiac center for sympathetic and parasympathetic system, vasomotor center by baroreceptors and reflex centers of vomiting, coughing, sneezing, and swallowing.

Out of all the parts of the brain the cerebral cortex is very much involved in motor functions. The cerebral cortex is a sheet of neural tissue that is outermost to the cerebrum of the mammalian brain. It plays a key role in memory, attention, perceptual awareness, thought, language, and consciousness. It is constituted of up to six horizontal layers, each of which has a different composition in terms of neurons and connectivity. The human cerebral cortex is 2–4 mm (0.08–0.16 inches) thick. Further it is the part of the brain that contains the lobes.

The human brain contains four (4) anatomical lobes on both sides of the brain. The Frontal lobe is concerned with conscious thought; damage can result in mood changes. Parietal lobe plays an important role in integrating sensory information from various senses, and in the manipulation of objects; portions of the parietal lobe are involved with visuospatial processing. The Occipital lobe has the sense of sight; lesions can produce hallucinations and the Temporal lobe has the sense of smell and sound, as well as processing of complex stimuli like faces and scenes.

The brain ends inferiorly by a tail like structure, the spinal cord. This runs through the vertebral bones where it is protected from mechanical injury.

CEREBRAL PALSY

The term cerebral palsy refers to any one of a number of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination but don’t worsen over time. Even though cerebral palsy affects muscle movement, it is not caused by problems in the muscles or nerves. It is caused by abnormalities in parts of the brain that control muscle movements. The majority of children with cerebral palsy are born with it, although it may not be detected until months or years later. The term cerebral palsy (CP) was originally coined more than a century ago and loosely translates as "brain paralysis." However, a precise definition has remained elusive because cerebral palsy is not a single diagnosis but a collection of conditions that develops during pregnancy, childbirth, and early childhood up to about age three.

Cerebral palsy (CP) is divided into four major classifications to describe different movement impairments. These classifications also reflect the areas of the brain that are damaged. Paneth, (2007) the four major classifications are: Spastic, Ataxic, Athetoid/dyskinetic and Hypotonic.

SPASTIC CEREBRAL PALS

The most common type of overall cerebral palsy, occurring in 70% to 80% of all cases. People with this type of CP are hypertonic. It is characterized by spasticity (velocity-dependent increase in tone), hyperreflexia, clonus, and an up going Babinski reflex. Pathologically, it results when there is an insult to the cortex or pyramidal tract.

ATAXIC

Ataxia type symptoms can be caused by damage to the cerebellum. The forms of ataxia are less common types of cerebral palsy, occurring in at most 10% of all cases. Some of these individuals have hypotonia and tremors.

Motor skills such as writing, typing, or using scissors might be affected, as well as balance, especially while walking. It is common for individuals to have difficulty with visual and/or auditory processing.

ATHETOID CEREBRAL PALSY

Athetoid or dyskinetic cerebral palsy is mixed muscle tone, thus both hypertonia and hypotonia. People with athetoid CP have trouble holding themselves in an upright, steady position for sitting or walking, and often show involuntary motions. It takes a lot of work and concentration to get their hand to a certain spot. Because of their mixed tone and trouble keeping a position, they may not be able to hold onto objects, especially small ones requiring fine motor control. About one-quarter of all people with CP have athetoid CP i.e it occurs in 10% to 20% of all cases.The damage occurs to the extrapyramidal motor system and/or pyramidal tract and to the basal ganglia. High bilirubin levels in the blood of infants, if left untreated, can lead to brain damage in certain areas (kernicterus), which can lead to athetoid cerebral palsy.

HYPOTONIC CEREBRAL PALSY

Hypotonia is the opposite of hypertonia. People with hypotonic CP have musculature that is limp, and can move only a little or not at all.

CAUSES OF CEREBRAL PALSY

Causes of cerebral palsy can be grouped in three. These are pre- natal, peri – natal and post –natal causes.

Pre – natal causes - The majority of children with cerebral palsy are born with it, although it may not be detected until months or years later. This is called congenital cerebral palsy. This can be due to the mother having malaria leading to reduced red blood cells in the blood. Other causes may be HIV status of the mother and the social aspect of the mother i.e if the mother drinks alcohol or smokes. Trauma and poisoning of mother can also result in cerebral palsy.

Peri – natal - This is among the acquired causes of cerebral palsy (CP). It describes the acquisition of cerebral palsy due to the activities that take place at the time of birth of the child. Surgical operation or any other trauma due to the use of forceps, breech presentation, prolonged labor and birth asphyxia are the most peri – natal causes of CP.

Post – natal - This is attributed to the causes of CP from the time the baby is born to about three years of age. Infection of the baby by malaria, TB, meningitis, and sexually transmitted infections are the common causes.

RISK FACTORS

Just as there are particular types of brain damage that cause cerebral palsy, there are also certain medical conditions or events that can happen during pregnancy and delivery that will increase a baby’s risk of being born with cerebral palsy. These are:

Ø Low birth weight and premature birth: Weigh less than pounds at birth or are born less than 37 weeks into pregnancy.

Ø Multiple births: Twins, triplets, and other multiple births even those born at term increase the risks. The death of a baby’s twin or triplet further increases the risk.

Ø Infections during pregnancy: Diseases caused by viruses, such as toxoplasmosis, rubella (German measles), cytomegalovirus, and herpes, can infect the womb and placenta.

Ø Blood type incompatibility: Rh incompatibility is a condition that develops when a mother’s Rh blood type (either positive or negative) is different from the blood type of her baby. Because blood cells from the baby and mother mix during pregnancy, if a mother is negative and her baby positive, for example, the mother’s system won’t tolerate the presence of Rh-positive red blood cells. Her body will begin to make antibodies that will attack and kill her baby’s blood cells.

Ø Exposure to toxic substances: Mothers who have been exposed to toxic substances during pregnancy, such as methyl mercury, are at a heightened risk of having a baby with cerebral palsy.

Ø Thyroid abnormalities, mental retardation, and seizures

Ø Breech presentation: Babies with cerebral palsy are more likely to be in a breech position (feet first) instead of head first at the beginning of labor.

Ø Complicated labor and delivery: A baby who has vascular or respiratory problems during labor and delivery may already have suffered brain damage or abnormalities.

Ø Small for gestational age: Babies born smaller than normal for their gestational age are at risk for cerebral palsy because of factors that kept them from growing naturally in the womb.

Ø Low Apgar score: checks a baby's heart rate, breathing, muscle tone, reflexes, and skin color during the first minutes after birth.

Ø Jaundice: Bilirubin, a substance normally found in bile, builds up faster than the baby’s Liver can break it down and pass it from the body. This produces a condition called kernicterus, which kills brain cells and can cause deafness and cerebral palsy.

Ø Seizures: An infant who has seizures faces a higher risk of being diagnosed later in childhood with cerebral palsy. (National Institute of Neurological Disorders and Stroke, 2011)

DIAGNOSIS

The diagnosis of cerebral palsy has historically rested on the patient's history and physical examination. Once diagnosed with cerebral palsy, further diagnostic tests are optional. CT or MRI is warranted when the etiology of a patient's cerebral palsy has not been established - an MRI is preferred over CT due to diagnostic yield and safety. When abnormal, the neuroimaging study can suggest the timing of the initial damage. The CT or MRI is also capable of revealing treatable conditions, such as hydrocephalus, porencephaly, arteriovenous malformation, subdural hematomas and hygromas, and a vermian tumor. Furthermore, an abnormal neuroimaging study indicates a high likelihood of associated conditions, such as epilepsy and mental retardation. Ashwal et al. (2004)

SIGNS AND SYMPTOMS

The signs of cerebral palsy usually appear in the early months of life, although specific diagnosis is usually delayed until later. Parents are often the first to suspect that their baby’s motor skills aren’t developing normally. Infants with cerebral palsy frequently have developmental delay, in which they are slow to reach developmental milestones such as learning to roll over, sit, crawl, smile, or walk. Some infants with cerebral palsy have abnormal muscle tone as infants. Decreased muscle tone (hypotonia) can make them appear relaxed, even floppy. Increased muscle tone (hypertonia) can make them seem stiff or rigid. In some cases, an early period of hypotonia will progress to hypertonia after the first 2 to 3 months of life. Children with cerebral palsy may also have unusual posture or favor one side of the body when they move.

PROGNOSIS

Cerebral palsy doesn’t always cause profound disabilities. While one child with severe cerebral palsy might be unable to walk and need extensive, lifelong care, another with mild cerebral palsy might be only slightly awkward and require no special assistance. Supportive treatments, medications, and surgery can help many individuals improve their motor skills and ability to communicate with the world.

MANAGEMENT

Cerebral palsy can’t be cured, but treatment will often improve a child's capabilities. Many children go on to enjoy near-normal adult lives if their disabilities are properly managed. In general, the earlier treatment begins the better chance children have of overcoming developmental disabilities or learning new ways to accomplish the tasks that challenge them. There is no standard therapy that works for every individual with cerebral palsy. A comprehensive management plan will pull in a combination of health professionals with expert knowledge. Management of CP involves medical and surgical intervention and physiotherapy management.

MEDICAL INTERVENTION

Oral medications such as diazepam, baclofen, dantrolene sodium, and tizanidine are usually used as the first line of treatment to relax stiff, contracted, or overactive muscles.

Injections of alcohol into muscles to reduce spasticity. The benefits last from a few months to 2 years or more, but the adverse effects include a significant risk of pain or numbness, and the procedure requires a high degree of skill to target the nerve.

Botulinum toxin (BT-A), injected locally, has become a standard treatment for overactive muscles in children with spastic movement disorders such as cerebral palsy. BT-A relaxes contracted muscles by keeping nerve cells from over-activating muscle. A number of studies have shown that it reduces spasticity and increases the range of motion of the muscles it targets.

The relaxing effect of a BT-A injection lasts approximately 3 months. Undesirable side effects are mild and short-lived, consisting of pain upon injection and occasionally mild flu-like symptoms. BT-A injections are most effective when followed by a stretching program including physical therapy and splinting. BT-A injections work best for children who have some control over their motor movements and have a limited number of muscles to treat, none of which is fixed or rigid.

Intrathecal baclofen therapy uses an implantable pump to deliver baclofen, a muscle relaxant, into the fluid surrounding the spinal cord. Baclofen works by decreasing the excitability of nerve cells in the spinal cord, which then reduces muscle spasticity throughout the body. Because it is delivered directly into the nervous system, the intrathecal dose of baclofen can be as low as one one-hundredth of the oral dose. Studies have shown it reduces spasticity and pain and improves sleep.

SURGICAL INTERVENTION

Orthopedic surgery is often recommended when spasticity and stiffness are severe enough to make walking and moving about difficult or painful. For many people with cerebral palsy, improving the appearance of how they walk – their gait – is also important. A more upright gait with smoother transitions and foot placements is the primary goal for many children and young adults.

Selective dorsal rhizotomy (SDR) is a surgical procedure recommended only for cases of severe spasticity when all of the more conservative treatments – physical therapy, oral medications, and intrathecal baclofen -- have failed to reduce spasticity or chronic pain. In the procedure, a surgeon locates and selectively severs over activated nerves at the base of the spinal column.

PHYSIOTHERAPY MANAGEMENT

Physical therapy, usually begin in the first few years of life or soon after the diagnosis is made. It is a cornerstone of cerebral palsy treatment. Physical therapy programs use specific sets of exercises and activities to work toward two important goals: preventing weakening or deterioration in the muscles that are not being used (disuse atrophy), and keeping muscles from becoming fixed in a rigid, abnormal position (contracture).

Resistive exercise programs (also called strength training) and other types of exercise are often used to increase muscle performance, especially in children and adolescents with mild cerebral palsy. Daily bouts of exercise keep muscles that are not normally used moving and active and less prone to wasting away. Exercise also reduces the risk of contractures, one of the most common and serious complications of cerebral palsy.

Normally growing children stretch their muscles and tendons as they run, walk, and move through their daily activities. This insures that their muscles grow at the same rate as their bones. But in children with cerebral palsy, spasticity prevents muscles from stretching. As a result, their muscles do not grow fast enough to keep up with their lengthening bones. The muscle contracture that results can set back the gains in function they have made. Physical therapy alone or in combination with special braces (called orthotic devices) helps prevent contracture by stretching spastic muscles.

The Bobath technique has had a widespread influence on the core physical therapies of cerebral palsy treatment

ALTENATIVE DEVICES

Occupational therapy. This kind of therapy focuses on optimizing upper body function, improving posture, and making the most of a child’s mobility. An occupational therapist helps a child master the basic activities of daily living, such as eating, dressing, and using the bathroom alone. Fostering this kind of independence boosts self-reliance and self-esteem, and also helps reduce demands on parents and caregivers.

Spinal cord stimulation was developed in the 1980s to treat spinal cord injury and other neurological conditions involving motor neurons. An implanted electrode selectively stimulates nerves at the base of the spinal cord to inhibit and decrease nerve activity. The effectiveness of spinal cord stimulation for the treatment of cerebral palsy has yet to be proven in clinical studies. It is considered a treatment alternative only when other conservative or surgical treatments have been unsuccessful at relaxing muscles or relieving pain.

Other alternative therapies are involved at different times in the management of CP. These may include speech therapy, Therapeutic (subthreshold) electrical stimulation, Threshold electrical stimulation, Hyperbaric oxygen therapy

TRAUMATIC BRAIN INJURY

Thu, 15 Sep 2011 19:40:50 +0100

INTRODUCTION

Head injury is an alteration in mental or physical functioning of the brain. Any injury to the head may cause traumatic brain injury (TBI). It can be defined also as any trauma that leads to injury of the scalp, skull, or brain. The injuries can range from a minor bump on the skull to serious brain injury. The Loss of consciousness does not necessarily need to occur though in many cases it is there. There are two major types of TBI:

Penetrating Injuries: In these injuries, a foreign object (e.g., a bullet) enters the brain and causes damage to specific brain parts. This focal, or localized, damage occurs along the route the object has traveled in the brain. Symptoms vary depending on the part of the brain that is damaged.

Closed Head Injuries: Closed head injuries result from a blow to the head as occurs, for example, in a car accident when the head strikes the windshield or dashboard. These injuries cause two types of brain damage:

Primary brain damage, which is damage that is complete at the time of impact, and may include a skull fracture, contusions or bruises, hematomas or blood clots, lacerations and nerve damage.

Secondary brain damage, which is damage that evolves over time after the trauma, may include:

brain swelling (edema)
increased pressure inside of the skull (intracranial pressure)
epilepsy
intracranial infection
fever
hematoma
low or high blood pressure
low sodium
anemia
too much or too little carbon dioxide
abnormal blood coagulation
cardiac changes
lung changes
nutritional changes

There are many more consequences that result from head injuries.

Physical problems may include hearing loss, ringing or buzzing in the ears, headaches, seizures, dizziness, nausea, vomiting, blurred vision, decreased smell or taste, and reduced strength and coordination in the body, arms, and legs.

Traumatic head injuries have costed so many nations a lot of money especially developed countries because of the increased number of vehicles, theft, conflicts etc.

The Glasgow Coma Scale (GCS) developed by Jennett and Teasdale is used to describe the general level of consciousness of patients with TBI and to define broad categories of head injury. It is often used to help define the severity of TBI. Mild head injuries are generally defined as those associated with a GCS score of 13-15, and moderate head injuries are those associated with a GCS score of 9-12. A GCS score of 8 or less defines a severe head injury.

ANATOMY OF THE HEAD

Skull: it’s the skeleton of the head that forms the cranium and facial skeleton. The cranium encloses the brain and its coverings, some parts of the cranial nerves and blood vesses. There are about 22 bones that are joined to form the skull. These are: 2 parietal,2 temporal, 1 frontal, 1 occipital, 1 ethmoid, 1 sphenoid, 2 maxilla, 2 zygomatic, 1 mandible,2 nasal, 2 palatine, 2 inferior nasal concha, 2 lacrimal and 1 vomer.

Cranial nerves: these are nerves that transmit impuses from sense organs. They are twelve in number and their naming correspond to their area of function. In order of increasing numbers these are: Olfactory, Optic, Oculomotor, Trochlea, Trigeminal, Abducens, Facial, Vestibulocochlea, Glossopharyngeal, vagus, Accesory and Hypoglossal cranial nerves.

CAUSES/ETIOLOGY OF HEAD INJURY

While various mechanisms may cause TBI, the most common causes include motor vehicle accidents (eg, collisions between vehicles, pedestrians struck by motor vehicles, bicycle accidents), falls, assaults, sports-related injuries, and penetrating trauma.

Motor vehicle accidents account for almost half of the TBIs in suburban/rural settings. In cities with populations greater than 100,000, assaults, falls, and penetrating trauma are more common etiologies of head injury. The male-to-female ratio for TBI is nearly 2:1, and TBI is much more common in persons younger than 35 years.

INCIDENCE/PREVALENCE

All cases of traumatic brain injury are supposed to be treated as an emergency. Different countries have different prevalence rates depending on the economical stability of the country. As many as 10% of these injuries are fatal, resulting in a lot of persons hospitalization.

Head injury data are difficult to compare internationally for multiple reasons, including inconsistencies and complexities of diagnostic coding and inclusion criteria, case definitions, ascertainment criteria (for example, hospital admissions versus door-to-door surveys), transfers to multiple care facilities (for example, patient admissions may be counted more than once), and adding to this complexity is the finding that some individuals with cognitive and emotional sequelae from mild head injury may not establish the casual connection between their injury and its consequences. Such patients may not seek treatment and may not be expressed in official demographic data.

DIAGNOSIS

As with most injuries and illnesses, finding out what happened to the patient is very important. The information may be provided by the patient, people who witnessed the event, emergency medical personnel, and if applicable, the police. The circumstances are very important since it is important to find out the severity and intensity of the trauma sustained by the head.

Physical examination begins with assessing the ABCs (airway, breathing, circulation) to make certain that the patient is stable and does not need emergent life-saving interventions. This is especially important in those patients who are unconscious and may not be able to maintain their own airway or breathe on their own.

If the patient is not fully awake, the examination will initially try to determine the level of coma using the Glosgol Coma Scale.

If no other injuries are found on examining the body, attention will be paid to the head and the neurologic exam. The neurologic exam may include evaluation of the cranial nerves, the short nerves that leave the brain and control the face muscles, eye movements, swallowing, hearing and sight, among other functions. Apart from the case history and the physical examination, diagnosis of TBI will also involve the following:

· CT scan

· MRI

· Radiography

SIGNS AND SYMPTOMS

The symptoms of a head injury can occur immediately or develop slowly over several hours or days. Even if the skull is not fractured, the brain can bang against the inside of the skull and be bruised. The head may look fine, but complications could result from bleeding or swelling inside the skull. The following symptoms suggest a more serious head injury signs and symptoms that may require emergency medical treatment:

Changes in, or unequal size of pupils
Convulsions
Distorted features of the face
Fluid draining from nose, mouth, or ears (may be clear or bloody)
Fracture in the skull or face, bruising of the face, swelling at the site of the injury, or scalp wound
Impaired hearing, smell, taste, or vision
Inability to move one or more limbs
Irritability (especially in children), personality changes, or unusual behavior
Loss of consciousness, confusion, or drowsiness
Low breathing rate or drop in blood pressure
Restlessness, clumsiness, or lack of coordination
Severe headache
Slurred speech or blurred vision
Stiff neck or vomiting
Symptoms improve, and then suddenly get worse (change in consciousness)

COMPLICATIONS

Severe head injuries can cause serious complications. This is mainly because a serious injury to the head can potentially damage the brain, sometimes permanently.

In particularly severe cases, a serious head injury can result in death. This is why a condition will be closely monitored just after admittion to hospital. This will allow any complications that arise to be dealt with promptly and effectively. The following are the complications:

Infection: If the skull is fractured during a head injury, the risk of developing an infection may be increased. Skull fractures can occasionally tear the membrane. If this happens, bacteria can enter the wound and cause an infection.

Coma: A coma is where you are unconscious and unresponsive for a long time. Some people who have a severe head injury may enter a coma. Most comas only last a few days or weeks, but sometimes they can last for years. Many people recover from comas. However, in some severe cases, the patient never regains consciousness or goes into a vegetative state. A vegetative state is a situation where a person may seem to be awake and may show some limited physical response, but they have no awareness of their surroundings.

Brain injury: This can lead to a variety of complications. Some types of brain injury are only temporary, whereas others result in permanent damage. The effect of any brain injury will depend on:

where on the head the injury occurs
the type of injury, for example if the skull is fractured
the severity of the injury, for example if it requires surgery

Physical effects: Difficulty moving or keeping your balance and loss of co-ordination. Headaches or increased tiredness can also be experienced.

Hormonal effects: Damage to the pituitary gland may lead to the low production of hormones and as a result temper with homiostalsis.

Sensory effects: Senses may be affected by a head injury. The sense of taste or smell may be lost. One would not be able to appreciate temperature changes in the environment or inside the body. Further facial palsy is due to injury to the facial cranial nerve.

Cognitive effects: Following a head injury, the ability to think, process information and solve problems may be affected. Memory problems are experienced, particularly with short-term memory, and have difficulty with speech and communication skills.

Emotional or behavioural effects: After a severe head injury, some patients experience feelings of irritation, anger or selfishness You may also laugh or cry more than before the injury.

PREVENTION

There are many ways that Traumatic Head Injury can be prevented. Most of the measures are dependant on the individual to follow the guidelines.

Always use safety equipment during activities that could result in head injury. These include seat belts, bicycle or motorcycle helmets, and hard hats.
Obey traffic signals when riding a bicycle. Be predictable so that other drivers will be able to determine your course.
Be visible. Do not ride a bicycle at night unless you wear bright, reflective clothing and have proper headlamps and flashers.
Use age-appropriate car seats or boosters for babies and young children.
Make sure that children have a safe area in which to play.
Supervise children of any age.
Do not drink and drive, and do not allow yourself to be driven by someone whom you know or suspect has been drinking alcohol or is otherwise impaired.

MANAGEMENT

Treatment varies widely depending on the type and severity of injuries.

Minor head injuries are often treated at home as long as someone is available to watch the person.

Bed rest, fluids, and a mild pain reliever, may be prescribed. Ice may be applied to the scalp for pain relief and to decrease swelling.
Cuts will be numbed with a medication usually given by injection. They will then be cleansed. Hidden injuries and foreign matter are looked for. The wound usually is closed with skin staples, stitches (sutures), or skin glue. Tetanus immunization will be updated if needed.

· People with serious closed head injuries are almost always admitted to the hospital for observation and repeated studies to assure that the condition does not worsen.

Occasionally a head injury may cause elevated pressure within the skull. An intracranial pressure (ICP) monitor probe may be surgically inserted into the brain through the skull to measure the pressure. If the pressure rises too high, it may be necessary to do surgery to decompress the brain. Death is possible.

Intravenous medications may be used to control intracranial pressure as a temporizing measure until the crisis resolves or surgery is performed.

o Medication to prevent seizures may be given to prevent or treat seizures that occur from the head injury. Seizures after head injury often do not require treatment because they may not reoccur.

o Antibiotics are usually not required in closed head injuries. Some doctors use antibiotics in all cases of basilar skull fracture. Other doctors do not feel this is useful.

When there is a closed head injury with bleeding inside the skull, the doctor must consider a number of factors to determine the correct treatment. Some of these include the location of the bleeding, severity of the symptoms, the presence of any other injuries, and progression of symptoms. Surgery may be needed. Other options include pressure monitors, medication to prevent seizures, and antibiotics to prevent infection. People with this type of injury may need a breathing tube inserted (intubation) to help prevent further brain injury. Angiography may be performed. Penetrating head injuries often require some sort of surgery, usually to remove foreign material or to stop bleeding. Other options include pressure monitors, medication to prevent seizures, and antibiotics to prevent infection. People with this type of injury may need a breathing tube inserted. Angiography may be performed.

FRACTURES

Thu, 15 Sep 2011 19:34:57 +0100

INTERTROCHANTERIC FRACTURES

Hip fractures can be divided into two groups: intra-capsular femoral neck fractures (further localized as subcapital, transcervical or bicervical) and extra-capsular peri-trochanteric fractures, namely the intertrochanteric and subtrochanteric fractures. An intertrochanteric hip fracture occurs between the greater trochanter, where the gluteus medius and minimus muscles (hip extensors and abductors) attach, and the lesser trochanter, where the iliopsoas muscle (hip flexor) attaches.

ANATOMY OF THE FERMUR

The femur is the largest bone in the body. It is 45 cm in length. The femoral head faces upwards, medially and forwards. The neck is about 5cm long and is set at an angle of 125° to the shaft. The junction between the neck and the shaft is marked anteriorly by the trochanteric line, laterally by the greater trochanter, medially and somewhat posteriorly by the lesser trochanter and posteriorly by the prominent trochanteric crest, which unites the two trochanters.

The femur connects to the pelvis by way of a ball and socket joint to form the hip joint. This allows it to have a variety of movement. The movements possible in the hip are: flexion, extension, abduxion, adduction, internal and external rotation and circumduction. The muscles involved in the excursion of these movements are:

· Flexors= iliacus and psoas major assisted by rectus femoris, Sartorius, pectineus;◊◊

· Extensors=gluteus maximus, the hamstrings;

· Adductors = adductor longus, brevis and magnus assisted by gracilis and pectineus;

· Abductors=gluteus medius and minimus, tensor fasciae latae;

· Lateral rotators= gluteus maximus assisted by the obturators, gemelli and quadratus femoris;

· Medial rotators — tensor fasciae latae and anterior fibres of gluteus medius and minimus.

Arterial supply to these muscles is the femoral artery which is the chief artery to the lower limb. The femoral artery is a continuation from the external iliac artery which enters the femoral triangle deep to the mid point of the inguinal ligaments. As it descends downwards it gives arterial tributaries like deep femoral artery (profunda femoris)-the chief artery to the thigh, circumflex femoral artery and the obturator artery.

The hip receives nervous supply from the femoral, sciatic and obturator nerves. These nerves also supply the knee joint.

CAUSES AND PRESENTENTION

Different people have different fracture presentations, Intertrochanteric fractures are often seen in frail older people after low energy falls (i.e., from a standing height). Although the kinetic energy of such a fall is far more than is needed to break the bone, most falls do not lead to fracture. It should be understood that the elderly have reduced activity and their stability is already compromised. This makes them easy victims to falling.

The health of an individual also matters. In his article said, Elderly patients frequently have other significant coexisting or preexisting pathologic conditions that result in decreased resistance to the stresses of anesthesia, trauma, and surgery and an increased need for extensive postoperative rehabilitation. Coexisting or preexisting conditions that were present but unknown, undiagnosed, or simply tolerable before the fracture include pulmonary insufficiency, cardiac insufficiency, mitral valve insufficiency, aortic valve insufficiency, cardiovascular insufficiency, hypertension, dehydration, malnutrition, and any of a number of metabolic diseases or endocrine diseases, including diabetes and hypothyroidism.

In young persons, hip fractures generally result from trauma associated with significant force. For example, 75% of all femoral head fractures, more common among young patients, occur as a result of motor vehicle collisions.

In older persons, more than 90% of hip fractures result from trauma or torsion associated with a minor fall or, occasionally, in the absence of any obvious traumatic event.ostioporosis is the leading cause of hip fracture.

Other risk factors for hip fracture include the following:

Neurological impairment
Caucasian race
Cigarette smoking
Institutional living
Maternal history of hip fracture
Previous hip fracture
Physical inactivity
Tall stature
Alcohol abuse
Previous Coles or vertebral fracture attributed to osteoporosis
Low body weight
Impaired vision
Prolonged corticosteroid use
Use of medications that decrease bone mass, including furosemide, thyroid hormone, Phenobarbital, and phenytoin.
In patients with intertrochanteric fractures there is significant swelling, with tenderness to palpation in the proximal thigh region. The leg may lie in internal or external rotation. The patient cannot flex the hip or abduct the leg. Hemorrhage into the injured thigh may also be substantial.

INCIDENCE, PREVALENCE AND EPIDEMYOLOGY

Intertrochanteric fractures are very common in children who have high energy of running up and down. They are also common in young athletes like dancers, runners, high jumpers etc. The elderly are among the people who suffer the effect of intertrochanteric fractures due to frequent falls. This is because as one grows old they happen to loose balance.

Hip fracture occurs in approximately 80 per 100,000 persons or approximately 250,000 persons each year. The rate of hip fracture increases with age, doubling each decade after age 50 years. Nearly half of all hip fractures occur in adults older than 80 years. Hip fracture at a young age is rare and is usually the result of a high-velocity injury or, rarely, secondary to bone pathology.

The US frequency of hip fracture, when age and sex are adjusted, ranks the highest in the world. Western Europe and New Zealand also have reported high rates, with the lowest rates occurring in the South African Bantu people and in East Asian countries, where the incidence of osteoporosis is low.

ETIOLOGY

The etiology of intertrochanteric fractures is the combination of increased bone fragility of the intertrochanteric area of the femur associated with decreased agility and decreased muscle tone of the muscles in the area secondary to the aging process. The increasing bone fragility results from osteoporosis and osteomalacia secondary to a lack of adequate ambulation or antigravity activities, as well as decreased hormone levels, increased levels of demineralizing hormones, decreased intake of calcium and/or vitamin D, and other aging processes.

PROGNOSIS

Hip fractures are very dangerous episodes especially for elderly and frail patients. The risk of dying from the stress of the surgery and the injury in the first few days is about 10%. If the condition is untreated the pain and immobility imposed on the patient increase that risk. Problems such as pressure sores and chest infections are all increased by immobility. The prognosis of untreated hip fractures is very poor.

DIAGNOSIS

Diagnosis of intertrochanteric fractures is done in the same as that of other fractures of the hip. Care must be taken to rule out the more benign isolated fracture of the greater trochanter; an MRI or CT may be needed for that purpose. An isolated fracture of the greater trochanter may occur as an avulsion by the gluteus medius, and needs only symptomatic (palliative) treatment . Other radiographic materials like x-rays also help in the diagnosis of these fractures. Physically, there may be abnormal painful movement at the hip especially if there is a complete fracture. Hemorrhage is usually indicated by swelling of the thigh and an increase in girth of the proximal thigh when compared to the normal leg.

COMPLICATIONS

Patients with hip fractures are rested in bed to a point where there is proof of callus formation at the fracture. Complications of prolonged bed rest in elderly patients include bronchopneumonia, deep venous thrombosis and pulmonary thrombo-embolus, urinary retention, decubitus ulcers, joint contractures and mental confusion. Due to reduced movement there is reduced muscle tone and strength. Contractures are non-exceptional especially before commencement of physiotherapy. In case of the elderly, malunion is another complication because of other predisposing factors like osteoporosis and poor nutrition. Though fractures of the femoral neck will interrupt completely the blood

Supply from the diaphysis, fractures of the intertrochanter does not have an effect on the supply of blood to the head of femur.

PREVENTION

Prevention of intertrochanteric fracture involves prevention of frequency of falls in the children and the elderly as they are the most affected subjects. Young sports men should ergonomically be advised on how they should prevent traumatic injuries. The elderly who have balance problems can be provided with walking aids like a frame or crutches. Improving the social and economical status of the people in the community also helps improve the diet and hence prevention of osteoporosis.

MANAGEMENT

Most hip fractures are treated by orthopedic surgery, which involves implanting an orthosis. The surgery is a major stress on the patient, particularly in older people. Pain is significant, forcing the patient to remain immobilized. Since prolonged immobilization can be more of a health risk than the surgery itself, post-operative patients are encouraged to become mobile as soon as possible, often with the assistance of physical therapy (physiotherapy).

If operative treatment is refused or the risks of surgery are considered to be too high the main emphasis of treatment is on pain relief. Skeletal or skin traction may be considered in the elderly or children for long term treatment. Aggressive chest physiotherapy is needed to reduce the risk of pneumonia and skilled nursing to try to avoid pressure sores and DVT/pulmonary embolism most patients will be bedbound for several months. Non-operative treatment is no longer an alternative in developed countries with modern health care. This called the conservative approach to fracture treatment.

TREATMENT

Treatment of trochanteric fractures is in three stages i.e. medical, surgery and physiotherapy.

SURGICAL TREATMENT

In any patient who hopes to get out of bed, the treatment of intertrochanteric fractures is surgical followed by the postoperative rehabilitation phase. Surgery is currently the main approach that is used to reduce trochanteric fractures. This increases the rate at which healing takes place and, thus, the patient mobilizes early. Stabilize the patient's medical condition before surgical intervention. The traditional treatment in recent decades is the sliding hip screw. This device has a large screw in the femoral head and neck engages a plate fixed to the shaft, with sliding of the screw allowed if and when the fracture impacts.

Traction

Still safe and predictable but prolonged hospitalization is required. This is both expensive and exposes the wound to infection.

External Fixation

This is rarely indicated. It is used mainly in cases where ORIF is not feasible or if there is a severe open wound.

Plating

This is now seldom performed, but may be useful when IM nailing is not possible but may be suitable in children.

Intramedullary Nail

It is regarded as the best technique, allowing early mobilization, thus avoiding prolonged hospitalization and infection.

MEDICAL TREATMENT

Many of patients are unwell before breaking a hip; it is common for the break to have been caused by a fall due to some illness, especially in the elderly. Nevertheless, the stress of the injury, and a likely surgery, does increase the risk of medical illness including heart attack, stroke, and chest infection.

Patients are immobilized and in bed for many days; they are frequently catheterized though this causes Urinary tract infection (UTI) to occur. Blood clots may also result into Deep Venous Thrombosis (DVT) when blood in the leg veins clots and causes pain and swelling. Mental confusion is extremely common following a hip fracture.

Medical treatment of all of these medical conditions is mainly pharmacological.

In the case of treating UTIs and other chest infections, chemotherapeutic drugs like aminoglycosides beta-lactam compounds and sulfonamides and many more drugs depending on the individuals problem of the patient. NSAIDs are used to releave the pain that comes due to the fracture. Pressure mattresses advocated to avoid pressure sores.

PHYSIOTHERAPY MANAGEMENT

Many clinical practitioners have recommended that physiotherapy as a very useful approach to the treatment of fractures.

Effects of Physiotherapy

I. Muscle Balance Assessment and Exercise

Following immobilization muscles surrounding the fracture site lose bulk, length and strength. It is very important that a safe exercise program is prescribed and progressed under the supervision of a physiotherapist to restore muscle length and balance and prevent secondary complications occurring.

II. Joint Mobilization

Joint stiffness often occurs when a limb is not allowed to move for several weeks. Physiotherapists are trained in techniques which can improve and restore range of movement of the affected joints once the fracture has healed.

III. Massage:

The release of tight bands and trigger points that occur within

Muscles following splinting or casting has been shown to reduce pain

and restore muscle length.

IV. Heat and Electrotherapy:

It is very common for stiffness within soft tissues to occur following

Prolonged immobilization. Heat and Electrotherapy have been shown

To be useful adjuncts to manual treatment and exercise therapy in

Relieving pain and restoring muscle length.

V. Gait Education:

A fracture requires the use of gait aids such as crutches then the physiotherapist can advise with the most appropriate equipment and way of walking that promotes optimal healing and safety.