Biceps Tendon Rupture With Post-operative Complications

Biceps Tendon Rupture With Post-operative Complications Locomotor PBL Experiment Writeup Introduction In this PBL, we observe a case of biceps tendon rupture with post-operative complication of heterotopic ossification. We will first go through the anatomy of the upper limb followed by a discussion of the ruptured biceps tendon, heterotopic ossification and finally mode of action of indomethacin. Learning Objectives 1. Osteology of the upper limb with emphasis on the elbow and wrist 2. The neurovascular supply to the upper limb 3. Movements possible at joints of upper limb and the range of movements possible with regards to the elbow and wrist and the muscles that bring about these actions. 4. Rupture of distal biceps tendon 5. Heterotopic ossification 6. Mode of action of Indomethacin 1. Osteology of the upper limb with emphasis on the elbow and wrist Arm The humerus is the largest and longest bone of the arm region connecting the shoulder to the forearm. Proximally, the head of the humerus articulates with the glenoid cavity of the scapula forming the glenohumeral joint. Distally the humerus articulates with the two bones of the forearm, the ulna and radius. The humerus is shown in more detail in figure 1 below. Figure 1 Humerus (1) For Anil’s case we will focus several prominent features on the distal region of the humerus which forms part of the elbow. There are two projections on either side of the distal end of the humerus which are the medial and lateral epicondyle. The medial epicondyle protects the ulnar nerve which passes just posteriorly and also serves as the attachment site for the forearm superficial flexor muscles. The lateral epicondyle conversely is the attachment site for the forearm extensor muscles. Anteriorly in between these two epicondyles are two articular surfaces: the round surfaced lateral capitulum which articulates with the radius and the spool shaped medial trochlea which articulates with the ulna. Also anteriorly, the radial fossa directly above the capitulum accommodates the head of the radius during flexion of the elbow whereas the coronoid fossa directly above the trochlea accommodates the coronoid process of the ulna during flexion of the elbow. Both the radial and coronoi d fossa limit flexion of the elbow. Posteriorly, the olecranon fossa accommodates the olecranon process of the ulna during extension of the elbow. The olecranon fossa prevents hyperextension of the elbow. Forearm The forearm is made up of two bones: ulna and radius. Proximally both of these bones articulate with the humerus whereas distally only the radius directly articulates with the carpals of the wrist thus connecting the arm to the wrist. The ulna and radius are shown in figure 2 below. Figure 2 Radius and Ulna (1) The ulna The ulna is the stabilizing bone of the forearm and is medial and longer of the two bones. There is a projection anteriorly at the proximal end called the coronoid process which fits into the coronoid fossa during elbow extension. Posteriorly on the proximal end of the ulna is the olecranon process (which forms the prominence of the elbow) which fits into the olecranon fossa during elbow extension. The articular surface between the olecranon and the coronoid articulates with the trochlear of the humerus and gives the movements of elbow extension and flexion. The radius The radius is the lateral and shorter of the two bones. The head of the radius is a flat button shaped process that articulates with the capitulum of the humerus. The neck of the radius is a constriction just distal to the head which Anil has fractured. Due to the fact that no neurovascular problems were found, it is safe to conclude that the deep branch of the radial nerve was not damaged in this case. The radial tuberosity is distal to the neck on the anterior site which is the attachment point for the tendon of biceps. Wrist The ulna does not directly articulate with the carpal bones of the wrist distally. There is an articular disc between the smaller distal head of the ulna and the carpal bones. The radius directly articulates with the scaphoid and lunate carpal bones on its larger distal end. This is shown in figure 3 below. Figure 3 Wrist joint (1) 2 The neurovascular supply of the upper limb Arterial supply The upper limb is supplied by the subclavian artery which branches off from the brachiocephalic trunk on the right and aortic arch on the left. The subclavian artery extends from its origin to the lateral border of the first rib. It then changes its name to the axillary artery which extends to the lateral border of teres major after which it becomes the brachial artery. The brachial artery extends to the cubital fossa of the elbow where it bifurcates into the radial and ulnar artery which run down the lateral and medial side of the forearm respectively. These two arteries anastomose in the palm of the hand forming the superficial (mainly supplied by ulnar artery) and deep (mainly supplied by radial artery) palmar arches. The fingers are supplied by the digital arteries branching from the palmar arches. The arterial supply is illustrated in figure 4 below. Figure 4 Arterial supply of upper limb (2) Venous supply There are two main types of veins in the upper limb. Firstly, superficial veins which can be seen subcutaneously. There are three main superficial veins which are the cephalic (laterally), basilic (medially) and median cubital (connection between cephalic and basilica at the cubital fossa) veins. The superficial veins are shown in figure 5 below. Figure 5 Venous supply to upper limb (3) Secondly, there are deep veins which usually accompanies the arteries in pairs and have the same name as the arteries. Perforating veins connect the superficial and deep veins to allow blood to always find a way back to the heart. All the veins eventually drains into the axillary vein, then to the subclavian vein, then brachiocephalic vein and finally into the heart via superior vena cava. Nervous supply The brachial plexus serves as the nerve supply for the upper limb arising from spinal nerve roots from C5, 6, 7, 8 and T1. There are 5 terminal branches of the brachial plexus in the arm. Table 1 below shows the five terminal nerves with their corresponding roots, motor supply, sensory supply and clinical test. Table 1 Nerves, corresponding roots, motor supply, sensory supply and clinical test (4) 3 Movements possible at joints of upper limb and the range of movements possible with regards to the elbow and wrist and the muscles that bring about these actions. The elbow consists of three joints: the humeroulnar joint from the trochlear notch of the ulnar to trochlear of humerus, the humeroradial joint from the head of the radius to the capitulum of humerus and the superior radioulnar joint from the head of the radius to the radial notch of the ulna. The humeroulnar and humeroradial joints allow for flexion and extension of the elbow whereas the superior radioulnar joint allows for pronation and supination. This happens when the head of the radius which is enclosed in annular ligament crosses over the fixed ulna bone. The muscles that move the elbow are shown in table 2 below: Table 2 Main muscles of elbow (5) Movements and ranges for the elbow and wrist are shown in table 3 below: Table 3 Movements and ranges for elbow and wrist (6) 4 Rupture of distal biceps tendon Symptoms Symptoms include swelling in the front of the elbow, severe pain at the elbow and a bulge in the upper arm because of the shortened biceps brachii muscle. Since Anil shows no biceps tendon reflex upon assessment, this is likely to be a complete rupture of the tendon. Cause In this case, Anil is diagnosed to have ruptured his distal biceps tendon which attaches to the radial tuberosity. Distal biceps tendon rupture tends to be caused by a single traumatic event involving flexion of the elbow at a right angle against resistance. For Anil, the snapping of the rope caused his elbow to straighten suddenly. His biceps contracted extra hard to prevent this from happening but the extreme tension in his biceps and tendon led to the rupture of the distal biceps tendon. Treatment Since Anil is still relatively young at 38 years old and still needs full use of his upper limb, the surgical treatment option is most preferred. Sometimes the tendon is attached by stitching through holes made in the bone. However the surgery for Anil was done by attaching the tendon to the bone using a small metal plate and screws into the radius to secure the plate usually called the endobutton technique (7, 8) which has a very good prognosis of regaining full mobility in the elbow. Complications Complications after the surgery include nerve damage and heterotopic ossification. After eight weeks Anil returned with stiffness, difficulty in turning his hand over and wrist pain which the doctor diagnosed as heterotopic ossification after palpation of a firm mass along the biceps tendon. Direct intervention was not taken as the biceps tendon needed time to fully heal. 5 Heterotopic ossification Heterotopic ossification is the growth of bone in abnormal places such as soft tissue. Heterotopic ossification is a notable complication of distal biceps tendon repair. The current proposed pathogenesis of how heterotopic ossification arises is the transformation of pluripotential mesenchymal cells which are recruited to the fracture healing site into osteoblasts that results in ectopic bone formation. (9) Bone, tendons and ligaments which are all connective tissue all share the same mesenchymal stem cell origin (shown in figure 6) and thus mesenchymal stem cells recruited to promote tendon repair can differentiate into osteoblasts. Osteoblasts can also be pulled out of the bone when the tendon ruptures and therefore can lead to bone deposition. Hence great attention has been given to cleaning and irrigating the surgical zone. (10) Figure 6 Mesenchymal stem cells differentiation (11) The heterotopic ossification at the biceps tendon led to Anil having reduced supination to just 20Â ° due to the biceps being the main supinator muscle. After twenty weeks, the heterotopic ossification was surgically removed. Radiation therapy has been an established supplement in treatment of heterotopic ossification. (10, 12, 13) The mechanism of how radiation therapy works is still unclear but is thought to inhibit pluripotential mesenchymal stem cells from differentiating. (14) However, even though radiation therapy is effective, there has been concerns about malignancy from the radiation. Low doses ( 6 Mode of action of Indomethacin Non-steroidal anti-inflammatory drugs (NSAID) such as Indomethacin are also commonly used to supplement surgical excision of heterotopic ossifications. (10, 13) Indomethacin non-selectively inhibits cyclooxygenase (COX1 and COX 2) which are involved in the production of prostaglandins from arachidonic acid. During the healing of a fracture, mesenchymal stem cells differentiate into chondrocytes which is independent of COX-2. COX-2 then produces prostaglandins which cause the chondrocytes to hypertrophy. These hypertrophic cells secrete growth factors which cause angiogenesis, osteoclast recruitment, osteogenesis and fracture bridging which leads to bone deposition shown in figure 7 below. However NSAIDs have to be carefully prescribed especially with patients who have reflux diseases as NSAIDs can lead to ulcer formation. (19) Figure 7 Formation of bone via COX-2 and prostaglandins (20) In conclusion, more research has to be done into the pathophysiology of heterotopic ossification as well as selective drugs that only inhibit COX-2 so that NSAIDs can be safely prescribed even for patients who have reflux diseases. Bibliography 1.N. Marieb E, Hoehn K. Human Anatomy and Physiology. 9th ed: Pearson Education Inc; 2013. 2.Quizlet. BIO 1600 Chapter 13 2015 [cited 2015 16 February]. Available from: http://quizlet.com/16204351/bio-1600-chapter-13-flash-cards/. 3.TeachMeAnatomy. Venous Drainage of the Upper Limb 2015 [cited 2015 16 February]. Available from: http://teachmeanatomy.info/upper-limb/vasculature/veins/. 4.Wong You Jing J. Nerves, corresponding roots, motor supply, sensory supply and clinical test2015. 5.Wong You Jing J. Main muscles of elbow. 2015. 6.Wong You Jing J. Movements and ranges for the elbow and wrist2015. 7.Bain GI, Prem H, Heptinstall RJ, Verhellen R, Paix D. Repair of distal biceps tendon rupture: a new technique using the Endobutton. J Shoulder Elbow Surg. 2000;9(2):120-6. 8.Greenberg JA, Fernandez JJ, Wang T, Turner C. EndoButton-assisted repair of distal biceps tendon ruptures. J Shoulder Elbow Surg. 2003;12(5):484-90. 9.H. Hastings II, Grahamn TJ. The classification and treatment of heterotopic ossification about the elbow and forearm. Hand Clinics. 1994;10(3):417-37. 10.Ellerin BE, Helfet D, Parikh S, Hotchkiss RN, Levin N, Nisce L, et al. Current therapy in the management of heterotopic ossification of the elbow: a review with case studies. Am J Phys Med Rehabil. 1999;78(3):259-71. 11.Serotec A. Mesenchymal Stem Cell 2015 [cited 2015 16 February]. Available from: http://www.abdserotec.com/mesencyhmal-stem-cell-antibodies.html. 12.McAuliffe JA, Wolfson AH. Early excision of heterotopic ossification about the elbow followed by radiation therapy. J Bone Joint Surg Am. 1997;79(5):749-55. 13.Viola RW, Hastings H, 2nd. Treatment of ectopic ossification about the elbow. Clin Orthop Relat Res. 2000(370):65-86. 14.Ayers DC, Pellegrini VD, Jr., Evarts CM. Prevention of heterotopic ossification in high-risk patients by radiation therapy. Clin Orthop Relat Res. 1991(263):87-93. 15.Brady LW. Radiation-induced sarcomas of bone. Skeletal Radiol. 1979;4(2):72-8. 16.Kim JH, Chu FC, Woodard HQ, Melamed MR, Huvos A, Cantin J. Radiation-induced soft-tissue and bone sarcoma. Radiology. 1978;129(2):501-8. 17.Heyd R, Strassmann G, Schopohl B, Zamboglou N. Radiation therapy for the prevention of heterotopic ossification at the elbow. J Bone Joint Surg Br. 2001;83(3):332-4. 18.Poggi MM, Thomas BE, Johnstone PA. Excision and radiotherapy for heterotopic ossification of the elbow. Orthopedics. 1999;22(11):1059-61. 19.Wallace JL. Prostaglandins, NSAIDs, and gastric mucosal protection: why doesnt the stomach digest itself? Physiol Rev. 2008;88(4):1547-65. 20.Robson L. Bone formation from Mesenchymal stem cells. 2015. 1

Netflix case study Essay

Netflix offers online video streaming and DVD rental services for a flat fee to all subscribers. After Reed Hastings, the CEO of Netflix had announced the company’s new strategy of separating its online service and DVD rental services into two accounts for its subscribers, the company’s stock fell to $63 per share from $300 per share and lost 805,000 subscribers in three month. Although facing so many challenges, Reed Hastings choose to continue his new strategies, but with a sincerely apologize for the change and a detailed explanation of why they made this decision and what’s in it for current subscribers. Stock price of Netflix close on yesterday was 312.40. Problems and challenges Although it seems that Netflix has recovered from the separation strategy, but there still are some problems and challenges are waiting for the company. First of all, Netflix online streaming branch is facing fierce competition from companies like Amazon instant video, YouTube, iTunes store, and Hulu. Second, On-demand TV offering are now hot area, many big-pay TV operator such as Verizon and Comcast Corp are trying to bring on-demand TV to cable users which will offer fresher content than online streaming companies like Netflix. Third of all, The DVD rental branch called Qwikster are now competing with companies like Amazon and Redbox DVD rental. From what we can see in the future, DVD service may finally run out of business and how to minimize the damage to Netflix is a big problem waiting for a solution. SWOT Strength Netflix is offering a flat fee policy, which is cheaper than Amazon and iTunes users and is easier to retain current users. A very distinctive strength Netflix have is that Netflix is also a producer. In this year’s Emmy Awards, Netflix Inc’s groundbreaking political thriller House of Cards took home an award for directing. As its name shows in Emmy, Netflix may win not only an award, but many potential users. Many people may position Netflix as a company provides high quality shows than other video distributors. Weakness Although the stock price has gone up this year and everyone now thinks Reed Hastings is the one sees the future, the remaining problem is how to survive with a $7.99 monthly flat fee for subscribers and at the same time spending more than $5 billion for the next five years to purchase TV shows and Movie License. Customers always wants more and pay less. Huge amount of spending force Netflix to attract new users in a rapid speed, but attract new users itself will be another big spending. Although the original drama â€Å"house of cards† generated a big buzz for Netflix, but the cost is considerable. Opportunities New technologies bring opportunities to online streaming video companies. Netflix has mobile app for both Android and ios system and it works well. People want to access to on-demand videos more convenient by using mobile phone and tablets. The trend of globalization gives Netflix the opportunity to grow itself. The fourth quarter of 2012, Netflix gained 3 million new global subscribers. Threat Competition from Amazon, iTunes, Hulu, Google TV, and cable networks may pose threat to the company. BRAD BEALE, Director of digital video content acquisition of Amazon is known for its ability of picking up successful shows and get the license earlier than other companies. Hulu also spend a lot on bringing new contents in. Although Netflix is cheaper, Amazon offers free instant vedio to prime membership and two-day free shipping for its customers. Also, Amazon, Apple and Google now all offer their own devices for video streaming, such as Apple TV, Kindle Fire. Questions Q.1. A strong consumer backlash emerged in response to major changes in Netflix’s business model. What are some of the arguments in favor of Hasting’ decision to split the company? What decisions and options are available to Hastings? Were they good decisions? 2- 3 paragraphs Many believe DVD rental business is fading because of new technologies. People no longer want to wait for the DVD to arrive. Instead they want on-demand video services. Slip the company bring price lower for stream only customers and it is fair for them to pay for cheaper price. Put in account information is easier and benefit is longer. Hastings can choose to change the company back to the old model by listening to customers and close the DVD service a couple years later when the DVD rental industry lost all the business. I think its good decisions because the financial information shows that Reed Hastings made the good decision and wins the game. The revenue grow almost half and subscribers grow even more this year. Works Cited Laporte, N. (2013, July 1). A TALE OF TWO NETFLIX. Fast Comapny , 177, pp. 31-32. Mint. (2013, September 23). ‘Breaking Bad,’ ‘Modern Family’ win top Emmy Awards. (H. M. Ltd., Producer) Retrieved Septemner 29, 2013, from Mint: http://search.proquest.com.rlib.pace.edu/docview/1434860801?accountid=13044 Peterson, T. (2013, September 23). 2013 MEDIA MAVENS: BRAD BEALE. Advertising Age , 84 (33), p. 1. Ramachadran, S. (2013, September 20). Cable Fights to Feed ‘Binge’ TV Viewers; Comcast, Verizon FiOS Vie With Netflix, Amazon for Rights to Show Complete Series. (Dow Jones & Company Inc) Retrieved September 30, 2013, from Wall Street Journal: http://search.proquest.com.rlib.pace.edu/docview/1434160601?accountid=13044 View as multi-pages

What Everyone Is Saying About Complet List of All Essay Topics and Direction Is Wrong and Why

What Everyone Is Saying About Complet List of All Essay Topics and Direction Is Wrong and Why Every single one of their songs have become the most heavenly song you could possibly hear. Bear in mind you could make funny argumentative essays if you do a few things. There are a lot of things you wish to live, many things you feel, and you simply don't know if a number of the situations you do are ok or not. MP3 music needs to be free. Test essay questions will be dependent on the topic, naturally. Test scores demonstrate that the usa is educationally behind other developed nations in Europe and Asia. Your topic is so important because you've got to make sure it is related to the class that you're taking unless it is for English class. Research-based topics require students to assemble information till they write. The reader ought to be impressed by the manner in which you defend your ideas. It is essential to select a great topic so as to compose a wonderful paper. Every one of the ideas above will provide you with a chance to reveal your creative side and capacity to talk about your opinion. It is very important to get started with demonstrating the principal idea of the entire piece so you and your readers are going to be on the very same page. Permit the professional academic writers help to your informative paper! Inspiration to make your own advertising or media argumentative essay topics isn't tricky to discover. Writing prompts are among the best approaches to create confident writers who take pleasure in the practice. Life is far better than it was 50 decades ago. As an issue of fact, the content of your essay is dependent on what you're likely to write about. You should participate in far-reaching studying to cover all facets of this issue and all point of views by different folks. When you have the topic, answer the question and after that support your answer with three or more explanations for why you believe it. It's importan t to select debatable argumentative essay topics since you need opposing points you may counter to your own points. Think of what you could do in order to make your school more beautiful. The role of assigning an essay to middle school students is to make awareness and permit them to develop writing skills. Sometimes teachers give individual topics to every student, and at times they don't. Students ought to be permitted to pray in school. Argumentative essay is about arguing and debating on a subject, which is debatable. Researching the topic will enable you to find out more about what fascinates you, and should you pick something you truly like, writing the essay will be more enjoyable. Moral argumentative essay topics are a few of the simplest to get carried away with. Recent argumentative essay topics that are related to society is going to do. Deciding on your topic isn't that easy. It's needless to say that you should go for a subject that you regard as interesting. You must pick an overall topic and as soon as you have you can begin by doing some research on it. You will probably locate a different and terrific topic you will love to write about. What to Expect From Complet List of All Essay Topics and Direction? There are just a few things that define whether an essay you're working on is going to be a good one. 1 Direction's faces are only the icing in addition to the cake. You're now prepared to write your very first research paper and you can't decide what things to write it on. To begin with, local newspaper papers are sometimes an excellent place to discover interesting argumentative essay topics. Write an essay to convince your principal your idea is one which should be adopted. Another good idea is to receive some absolutely free essay examples of different kinds and on various subjects to find a general idea of the way in which a prosperous debatable paper looks. People in demand of case study research should rush to appreciate our assistance. It is also easy as you can conveniently find a lot of information on world history very easily on the web. When it can be difficult to inspire children to compose essays, the trick is to introduce subjects or issues they are interested in. For instance, students might write about the advantages of a vegan diet. Normally, it doesn't include references and quotes in it. After you choose a topic, you h ave to react to the query and substantiate your response with three or more motivations as to why you think like that. So be certain that you decide on a subject, which has values in it. It's possible for you to pick topics from assorted lists of ready themes.

Chronic Fatigue Syndrome Essay - 1924 Words

Chronic Fatigue Syndrome Thankfully, it is hard for most people to imagine a tiredness and weakness of body that would keep one confined to a bed. There are people today who have lived a very active lifestyle for years and have suddenly found themselves burdened by a feeling of bodily weariness they never knew was possible. It all happens so swiftly and surprisingly that many are terrified by these changes taking place. CFS, otherwise known as chronic fatigue syndrome, is this illness characterized by debilitating fatigue. At times, this disease is also referred to as chronic fatigue immune dysfunction syndrome (CFIDS), or chronic Epstein-Barr virus (CEBV). However, no matter what it is called, it remains a nightmare for those who†¦show more content†¦One can simply become tired, while others may be totally bedridden and disabled from fatigue. Sometimes the body is better, so the individual can lead an almost normal lifestyle, but then days or weeks later this strength may easily wane. 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