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Bolsters cheap maxolon 10 mg otc, or tie-over dressings, are often necessary in selected anatomical locations where shearing forces and tridimensional configuration challenge the skin graft’s stabilization. Staples or resolvable suture may be used to fix the skin graft on the wound. The bolster stitches must hold together the skin graft and the surrounding normal skin and the knot should be tighten in the ordinary fashion. Petrolatum-based fine-mesh gauze is applied on the skin graft overlapping 3–4 cm and a cotton bolster embedded in normal saline and liquid paraffin is secured with the bolster stitches. The bolster is then removed in 5 days (7 days for full-thickness grafts) unless purulent discharges are detected before the planned day of removal (Fig. Other techniques that have been used for graft fixation include fibrin glue, resolvable staples, and tape. Perfect positioning of graft site is essential for proper healing in a good functional position. The intervention of rehabilitation services is a key issue to The Small Burn 215 A B FIGURE14 Donor sites are extensive in minor and medium-sized burns, therefore wounds should be always covered with sheet autografts. Good preoperative planning should include postoperative posi- tioning and splinting. Grafts that extend over joints and other anatomical locations (hands, feet, and neck) need proper splinting. A comprehensive plan should be made before surgery, and preliminary splints should be tailored for postoperative positioning. Experts in physiotherapy and occupational therapy are invited to assist and intervene at the end of the operation. After a light protective dressing has been applied, the splints are then molded again to adapt to the anatomical configuration. After completion, they are hold in place with a second external dressing. Splints are revised during the first and consecutive dressing changes and tailored to the specific patient’s needs.

When harvesting is complete discount maxolon 10 mg fast delivery, the angle of the dermatome is diminished to let the blade cut through the skin graft. This will leave the final portion of the skin graft thinner than the rest. If a uniform skin graft is desired, the surgeon can either discard the final part or stop the dermatome while maintaining its angle. The thickness of the drum is then opened to maximum aperture and the dermatome is gently withdrawn, exposing the final part of the skin graft. Epinephrine-soaked (1:10,000) Telfa dress- ings are then applied to the surface of the donor site to allow good hemostasis. Specific Donor Sites Patients with minor burns present with many donor sites. Choice of donor site depends on graft requirements, anatomical location, extent of burn, patient’s char- acteristics, and patient’s preference. The most commonly used donor sites for small- and medium-sized burns are: Scalp Thigh Back The Small Burn 201 A B FIGURE6 Donor sites are infiltrated with normal saline with epinephrine 1/200,000 to promote hemostasis, provide enough tension to immobilize the skin, and produce an even surface. Powered dermatomes should be used to harvest the skin, which provide the best quality of skin by a reproducible means. Donor sites are infil- trated before harvest, which provide good blood loss control. Donor sites are then dressed with epinephrine-soaked Telfa dressings for 10 min. The Small Burn 203 The scalp provides the surgeon with the best quality of skin for burn surgery. The harvesting is practically painless and the donor site remains concealed pro- vided the hairline is not crossed.

In this test the iac joint purchase maxolon 10mg mastercard, along with an arthrogram for confirmation, patient has pain with flexion, adduction, and internal is extremely useful in confirming the diagnosis of rotation of the hip joint while supine. A hip stress fracture or osteonecrosis of the femoral head2,10–12 may not be apparent on plain films Intra-articular causes of hip pain include osteoarthritis, and further advanced imaging such as MRI should be inflammatory arthritis, septic arthritis, osteonecrosis,3 obtained if clinical suspicion is high. Lateral hip pain implies greater bursa injection, an intra-articular hip joint injection, trochanteric bursitis, whereas groin pain is typically an iliopsoas bursa injection, a sacroiliac joint injec- seen with iliopsoas bursitis/tendonitis or intra-articu- tion, and lumbar spine injections such as facet joint lar causes, particularly arthritis. It is not uncommon for groin pain from intra- KNEE PAIN articular causes, particularly arthritis, to radiate down into the thigh and medial knee. A history regarding overuse syndromes or amenorrhea in a young woman may lead to the diag- Extra-articular causes 5 Referred pain from the lumbar spine or sacroiliac joint nosis of a femoral neck stress fracture or musculo- Greater trochanter bursitis tendinous strain. A history of audible snapping or Iliopsoas tendonitis clicking implies the presence of etiologies such as Coxa saltans (snapping hip) coxa saltans (snapping hip),8 iliopsoas bursitis, and Muscle strains and contusions 6 Intra-articular causes labral pathology. Patients with hip arthritis usually Labral pathology give a history of mechanical symptoms such as lock- Loose bodies ing, clicking, and catching. Osteonecrosis of the femoral head Osteoarthritis, inflammatory arthritis, septic arthritis Typical physical examination findings in patients Femoral neck stress fractures with arthritis include limited hip range of motion, -- 130 VI REGIONAL PAIN tears, tendon tears, spontaneous osteonecrosis of the TABLE 24–2 Differential Diagnosis of Knee Pain knee (SONK), an inflamed plica, and patellofemoral Extra-articular causes pain syndrome. Also in the differential Intra-articular causes diagnosis, particularly in a patient with a recent injury Meniscal tear or surgical procedure to the knee, is reflex sympa- Chondral injuries Osteonecrosis thetic dystrophy. Ligament injury It is useful to ask the patient to describe the exact Tendon injury location of the pain and even to point to where the Symptomatic plica pain is located. Anterior knee pain is suggestive of Patellofemoral pain syndrome Osteoarthritis, inflammatory arthritis, septic arthritis patellar or quadriceps tendonitis or patellofemoral pathology. Lateral knee pain may represent iliotibial band tendonitis, a lateral meniscus tear, or lateral compartment arthritis. Medial knee pain may repre- imaging such as MRI can be extremely helpful for sent pes anserine tendonitis, a medial meniscus tear, suspected meniscal, chondral, and ligament injuries and medial compartment arthritis. Questions with respect to associated injuries or surgery, along with a history of tempera- LEG (CALF) PAIN ture and skin color changes, may lead to a diagnosis of reflex sympathetic dystrophy. A thorough exam should also It is important to determine where knee pain is include range of motion of the knee, a ligament sta- located, originates, or radiates toward.