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Davids JR ditropan 2.5mg generic gastritis nerviosa, Wenger DR ditropan 2.5 mg without prescription gastritis and back pain, Mubarak SJ (1993) Congenital muscular Funnel chest is relatively common, although epidemio- torticollis: Sequela of intrauterine or perinatal compartment syn- logical data are not available. Engin C, Yavuz S, Sahin F (1997) Congenital muscular torticollis: is heredity a possible factor in a family with five torticollis patients Clinical features, diagnosis in three generations? Fernandez Cornejo V, Martinez-Lage J, Piqueras C, Gelabert A, Funnel chest is diagnosed primarily on the basis of the Poza M (2003) Inflammatory atlanto-axial subluxation (Grisel’s clinical features. In the majority of cases, the diagnosis can be made even during the first year of life. A simple parameter for monitoring the progress of funnel chest is the depression below thoracic level in cen- timeters. The condition can be better assessed by stating the relationship between thoracic breadth, thoracic depth and indentation. An objective picture can be obtained by raster stereography ( Chapter 3. Cardiac and pulmonary function are of crucial im- portance in assessing severe forms of funnel chest and will need to be investigated if the condition is very pro- nounced. An ECG, exercise ECG, echocardiography must be recorded and the vital capacity measured in such cases. However, a reduction in the performance of the heart and lung is detected in only the rarest of cases, i. Psychological distress is much more frequently en- countered in funnel chest than the functional restriction, although very few adolescents will openly admit that they feel uneasy about their condition. They are embarrassed by their funnel chest and tend unconsciously to conceal it by pulling the shoulders forward. This kyphoses the spine and involves the risk of developing Scheuermann’s disease. In fact, we very frequently observe radiological and clinical signs of Scheuermann’s disease in connection with funnel chest. In my experience, over half of patients with funnel chest also suffer from thoracic, and occasion- ally also thoracolumbar or lumbar, Scheuermann disease (⊡ Fig. Funnel chest is also relatively frequently associated with a scoliosis (15%–20% [5, 8]). Radiographic findings A lateral x-ray of the rib cage will clearly show the depres- sion of the sternum (⊡ Fig. The depth of the depres- sion can also be correlated with the depth of the thorax. Additional imaging procedures (CT) are only required preparatory to surgery. Recently we have been evaluating a treatment with a kind of suction bell applied to the chest daily for 30–60 min. If cardiovascular function is not diminished, the ourselves have operated on 30 patients to date and have psychological distress can constitute a relative indication not experienced any serious complications. Now that a satisfactory surgical technique is available in the form of the Nuss technique (see below), 3. It is impor- tant, however, that the corresponding decision is taken Definition not by the parents or the doctor, but solely by the patient, Deformity of the thorax with keel-shaped protrusion of and only after, or towards the end of, puberty. Etiology, pathogenesis Previously employed surgical techniques involving Keeled chest, like funnel chest, occurs as a result of a correction performed directly on the deformity itself predisposition and is not an actual hereditary condition. Silicone implantation was also associated with certain Secondary forms occur in complications (e. In this thoracoscopic technique, two Occurrence small lateral incisions are made to allow insertion of a Keeled chest is rarer than funnel chest, although precise curved bar that exerts outward pressure on the sternum. The bar is left in situ for 2–3 years, after which time it can Clinical features then be removed. We perform this operation jointly with Keeled chest involves a symmetrical or asymmetrical pediatric (thoracic) surgeons because of the possible risk protrusion of the sternum (⊡ Fig. Three patients required revision sur- asymmetrical, causing the whole sternum to be slightly gery, in one case because of a pneumothorax, and in the tilted.

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Studies performed in the context of more severe acute clinical pain ditropan 2.5mg without prescription gastritis ginger ale, on the other hand buy generic ditropan 2.5 mg on-line gastritis diet 8 plus, are more negative. In a study of general surgery patients, efficacy of information pro- vision, relaxation, and no intervention was compared as a function of Moni- toring and Blunting coping styles (Scott & Clum, 1984). Blunters reported less pain and used less analgesics when provided with no intervention, which appear at least not inconsistent with the matching hypothesis. How- ever, contrary to the matching hypothesis, Monitors appeared to do best with breathing relaxation as opposed to information provision (Scott & Clum, 1984). Work by Wilson (1981) also in general surgery patients found that Blunters did not experience exacerbated pain following an information provision intervention, again failing to support the matching hypothesis. More recent work in surgical patients also indicated that efficacy of a relax- ation intervention did not differ depending on the degree to which patients preferred a Monitoring coping style (Miro & Raich, 1999). Differences in the measures used to assess coping style, types of interventions employed, and other procedural details make comparisons across studies more difficult. However, clinical support for a coping style by intervention type matching hypothesis is at best weak. Moreover, the absence of validated clinical pro- cedures for determining preferred coping style for purposes of selection of intervention type (e. Other Potential Moderators As noted previously, there is evidence from several studies that interven- tions including sensory focus, breathing relaxation, and use of control- enhancing statements reduce the discomfort of dental procedures only among those with a high desire for control and a low level of perceived con- trol prior to intervention (Baron et al. Given the importance of perceived control in determining satisfaction with acute pain management (Pellino & Ward, 1998), these findings suggest that if resources for providing psychological acute pain interventions are lim- ited, it may be most appropriate to focus these resources on individuals who express a desire for greater control over the acute pain experience. Laboratory acute pain research has indicated that imagery, analgesia suggestions, and distraction were effec- tive for reducing acute pain only among individuals high in hypnotizability (Farthing et al. This might not be considered surprising given that individuals high in hypnotizability may be more capable of developing vivid mental imagery (Farthing et al. As with coping style, validated clini- cal criteria for making treatment decisions based on assessment of hypno- tizability are not available. Therefore, the practical clinical utility of this moderator variable is questionable. BARRIERS TO EFFECTIVE CLINICAL USE OF PSYCHOLOGICAL INTERVENTIONS FOR ACUTE PAIN If psychological interventions for acute pain can be clinically useful in some circumstances, as appears to be the case, what are the barriers to their use? A study by Jiang and colleagues (Jiang, Lagasse, Ciccone, Jakubowski, & Kitain, 2001) of hospital acute pain management practices indicated wide- spread underutilization of nonpharmacological techniques. A primary fac- tor contributing to this underutilization was resource availability (Jiang et al. With the current focus on reduction of health care costs nation- wide, cost containment becomes a major barrier to providing the trained personnel and staff time to implement many psychological pain manage- ment strategies in situations in which they have proven effective. Clearly, as described earlier, there are potential risks associated with inadequate control of acute post-surgical pain (e. Provision of psychologically based interventions in the context of an overall program for management of postsurgical pain may therefore be cost-effective in the long term. However, the short-term nature of the dis- tress and pain associated with brief but painful medical and dental proce- dures may simply not be viewed as justifying the time and personnel costs needed to implement many psychological interventions for acute pain (Lud- wick-Rosenthal & Neufeld, 1988). Moreover, the absence of a psychiatric di- agnosis to justify provision of a psychological intervention, which is typi- cally a requirement for purposes of insurance reimbursement, may be a practical barrier to having psychological acute pain interventions be ad- ministered by psychologically trained staff. Brief and simple techniques that can be implemented quickly either through automated procedures (e. PSYCHOLOGICAL INTERVENTIONS FOR ACUTE PAIN 263 a memory-based positive emotion induction requiring less than 5 minutes of time has been shown to diminish acute pain sensitivity and pain-related physiological arousal, and could be carried out by nursing staff with limited training (Bruehl et al. Distraction techniques also require little effort to implement, and therefore may be more widely useful. Our clinical experience indicates that unless significant skills acquisition and practice time are available prior to exposure to the acute pain situa- tion, the benefits of using more elaborate interventions (e. Ideally, there would be sufficient contact time with the patient on a separate day prior to exposure to the pain stimulus for mutual selection of an acceptable intervention, for the intervention to be taught, and for patients to practice the skills on their own prior to the pain (using taped intervention instructions if appropriate). If less time is available, it is im- portant to select interventions that are reasonable for the patient to learn and practice adequately in the time that is available. Information provision and distraction interventions are most amenable to limited practice time, followed in (approximate) ascending order of difficulty by coping self- statement interventions, breathing relaxation, imagery techniques, hypno- sis, progressive muscle relaxation, and combined approaches. Patient acceptance and adherence may be another barrier to effective use of psychological interventions.

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Elevated Intracranial Pressure (ICP) – ↑ ICP ↓perfusion ⇒ ischemic brain damage D ditropan 5mg cheap gastritis milk. Production of free-radical molecules Other secondary causes of brain injury include: Hypotension Hyperemia Electrolyte imbalances Hyponatremia Anemia Infection Hyperthermia Carotid dissection Hyperglycemia Epilepsy/seizures Hypercarbia Vasospasm/ischemia Hypoglycemia Primary Head Injury Contusion—bruising of cerebral (cortical) tissue Occurs on the undersurface of the frontal lobe (inferior frontal or orbitofrontal area) and anterior temporal lobe discount 5mg ditropan free shipping gastritis medicine cvs, regardless of the site of impact (Figure 2–1) May produce focal, cognitive, and sensory-motor deficits Is not directly responsible for loss FIGURE 2–1. Location of Contusions of consciousness following trauma May occur from relatively low velocity impact, such as blows and falls Diffuse axonal injury (DAI): DAI is seen exclusively in TBI Damage seen most often in the corpus callosum and other midline structures involving the parasag- ittal white matter, the interventric- ular septum, the walls of the third ventricle and the brain stem (mid- brain and pons) (Figure 2–2) FIGURE 2–2. Locations of Diffuse Axonal Injury 50 TRAUMATIC BRAIN INJURY Responsible for the initial loss of consciousness seen in acute TBI Results from acceleration-deceleration and rotational forces associated with high-velocity impact (MVAs) The axonal injury seen in severe TBI is thought to be secondary to damage to the axo- plasmic transport in axons (with ↑ Ca++ influx) leading to axonal swelling and detachment Secondary Head Injury Brain Swelling Occurs after acute head injury within 24 hours. Vasogenic edema: – Due to outpouring of protein rich fluid through damaged vessels – Extracellular edema – Related to cerebral contusion 2. Cytogenic edema: – Found in relation to hypoxic and ischemic brain damage – Due to failing of the cells’ energy supply system ↑cell-wall pumping system ⇒ intracellular edema in the dying cells PENETRATING HEAD INJURIES Missile/Fragments Deficits are focal corresponding to location of lesions caused by bullet/fragment If the brain is penetrated at the lower levels of the brain stem, death is instantaneous from respiratory and cardiac arrest. Risk of long-term posttraumatic epilepsy is higher in penetrating head injuries compared to nonpenetrating injuries RECOVERY MECHANISMS Plasticity Brain plasticity is when the damaged brain has the capabilities to repair itself by means of morphologic and physiologic responses Plasticity is influenced by the environment, complexity of stimulation, repetition of tasks, and motivation It occurs via 2 mechanisms: 1) Neuronal regeneration/neuronal (collateral) sprouting 2) Unmasking neural reorganization TRAUMATIC BRAIN INJURY 51 Neuronal Regeneration Intact axons establish synaptic connections through dendritic and axonal sprouting in areas where damage has occurred May enhance recovery of function, may contribute to unwanted symptoms, or may be neutral (with no increase or decrease of function) Thought to occur weeks to months post-injury Functional Reorganization/Unmasking Healthy neural structures not formerly used for a given purpose are developed (or reas- signed) to do functions formerly subserved by the lesioned area. Brain plasticity—remember “PUN” Plasticity = Unmasking + Neuronal sprouting OTHER RELATED PHENOMENA ASSOCIATED WITH HEAD INJURY RECOVERY Synaptic Alterations Includes diaschisis and increased sensitivity to neurotransmitter levels Diaschisis: Mechanism to explain spontaneous return of function (Figure 2–3) 1. Lesions/damage to one central nervous system (CNS) region can produce altered function in other areas of the brain (at a distance from the original site of injury) that were not severed if there is Injury (Site A) connection between the two sites Altered function also occurs here (Site B) (through fiber tracts). There is some initial loss of func- was not severed by the initial injury and is distant from tion secondary to depression of the original site of injury (site A). Recovery of functions areas of the brain connected to controlled by site B will parallel recovery of site A the primary injury site, and reso- lution of this functional deaffere- nation parallels recovery of the focal lesion (Feeney, 1991). Functional Substitution/Behavioral Substitution Techniques/new strategies learned to compensate for deficits and achieve a particular task Other Theories of Recovery Include Redundancy: Recovery of function based on activity of uninjured brain areas (latent areas) that normally would contribute to that function (and are capable of subserving that function) Vicariation: Functions taken over by brain areas not originally managing that function. Lesions that interrupt the metabolic or structural integrity of the RAS or enough of the cortical neurons receiving RAS projections can cause coma. DISORDERS OF CONSCIOUSNESS Coma It is a state of unconsciousness from which the patient cannot be aroused; there is no evi- dence of self- or environmental-awareness Coma is essentially universal in severe TBI Up to 50% of patients in coma > 6 hours die without ever regaining consciousness. Survivors who remain unresponsive for > 2–4 weeks evolve into vegetative state Eyes remain continuously closed No sleep-wake cycles on electroencephalogram (EEG) There is no spontaneous purposeful movement (e. Persistent VS VS present ≥ 1 month after TBI or Nontraumatic brain injury Permanent VS VS present > 3 months after Nontraumatic brain injury or VS present > 12 months after TBI, in both children and adults American Congress of Rehabilitation Medicine (1995)—advocates to simply use the term vegetative state (VS) followed by the length of time it persists instead of the terms persis- tent and permanent. The Aspen Neurobehavioral Conference (1996), supported the ACRM recommendations to use the term VS + specify cause of injury + specify length of time since onset. Addition of agents to enhance specific cognitive and physical functions – In patients emerging out of coma or VS, the recovery process may be (theoretically) hastened through the use of pharmacotherapy – Agents frequently used include: Methylphenidate Dextroamphetamine Dopamine agonists (levocarbidopa and carbidopa) Amantadine Bromocriptine Antidepressants—tricyclic antidepressants (TCA’s) & selective serotonin reuptake inhibitors (SSRIs) – The efficacy of pharmacologic therapy to enhance cognitive function has not been proven Sensory stimulation—widely used despite little evidence of efficacy as previously mentioned. A Decerebrate Posture: There is extension of the upper and lower extremities. B Decorticate Posture: There is flexion of the upper extremities and extension of the lower limbs. PREDICTORS OF OUTCOME AFTER TBI WIDELY USED INDICATORS OF SEVERITY IN ACUTE TBI The best Glasgow Coma Scale (GCS) score within 24 hours of injury Length of coma Duration of posttraumatic amnesia (PTA) – Note: The initial GCS and the worst GCS (within the first 24 hours) have also been pro- posed as acute indicators of severity in TBI 56 TRAUMATIC BRAIN INJURY Glasgow Coma Scale TABLE 2–1 Glasgow Coma Scale: (Teasdate and Jennett, 1974) Best Motor Response Best Verbal Response Eye Opening Score 6 5 4 1 None None None 2 Decerebrate posturing Mutters unintelligible Opens eyes to pain (extension) to pain sounds 3 Decorticate posturing Says inappropriate Opens eyes to loud (flexion) to pain words voice (verbal commands) 4 Withdraws limb from Able to converse— Opens eyes painful stimulus confused spontaneously 5 Localizes pain/pushes Able to converse—alert away noxious stimulus and oriented (examiner) 6 Obeys verbal commands Total GCS score is obtained from adding the scores of all three categories. Katz and Alexander (1994)—PTA correlates with Glasgow Outcome Scale (GOS) score at 6 and 12 months— predictor of outcome PTA correlates strongly with length of coma (and with GOS—see below) in patients with DAI but poorly in patients with primarily focal brain injuries (contusions) Galveston Orientation and Amnesia Test (GOAT)—developed by Harvey Levin and colleagues, is a standard technique for assessing PTA. It is a brief, structured interview that quantifies the patient’s orientation and recall of recent events – The GOAT includes assessment of orientation to person, place, and time, recall of the cir- cumstances of the hospitalization, and the last preinjury and first postinjury memories – The GOAT score can range from 0 to 100, with a score of 75 or better defined as normal – The end of PTA can be defined as the date when the patient scores 75 or higher in the GOAT for two consecutive days. The period of PTA is defined as the number of days beginning at the end of the coma to the time the patient attains the first of two succes- sive GOAT scores ≥ 75 (Ellenberg, 1996) Categories of PTA: Duration of PTA is often used to categorize severity of injury according to the following criteria: TABLE 2–2. Posttraumatic Amnesia Duration of PTA Severity of Injury Category Less than 5 minutes Very mild 5–60 minutes Mild 1–24 hours Moderate 1–7 days Severe 1–4 weeks Very severe Greater than 4 weeks Extremely severe TABLE 2–3. Classification of Posttraumatic Amnesia Length of PTA Likely Outcome 1 day or less Expect quick and full recovery with appropriate management (a few may show persisting disability) More than 1 day, Recovery period more prolonged—now a matter of weeks or months. Many patients are left with residual problems even after the recovery process has ended, but one can be reason- ably optimistic about functional recovery with good management. There must be increasing pessimism about functional recovery when PTA reaches these lengths. More than 4 weeks Permanent deficits, indeed significant disability, now certain. It is not just a matter of recovery but of long-term retraining and management. From Brooks DN and McKinlay WW, Evidence and Quantification in Head Injury: Seminar notes. In this study, the sign of responsiveness used was evidence of the patient following commands Other Indicators of Outcome after TBI Include: Age – Children and young adults tend to have a generally more positive prognosis than older adults.

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Lumbar spine: Make an initial mark over spinous During palpation discount 2.5mg ditropan with visa gastritis symptoms deutsch, the skin moisture purchase ditropan 5 mg free shipping gastritis histology, temperature and process S1 and a second mark 10 cm above this. The distance between elasticity of the skin are assessed and any dermographic these skin marks increases as the patient bends forward, reaching a urticaria noted. Thoracic spine: A mark is made over spinous process C7, and a second mark is made 30 cm below this. As the patient ▬ Heel-drop test bends forward the distance between the two increases by 2–3 cm The patient is asked to stand on tiptoe and the exam- iner rests his hands on the patient’s shoulders. The patient is now asked to drop onto his heels while the examiner simultaneously presses down on the shoul- ders. This maneuver will elicit any vibration-related pain in the spine caused by inflammation, tumors or herniated disks. Mennell sign: In disorders of this joint, pain is elicited if the hip on the same side is overextended. A very rough (and quick) indication of a motor disorder can be obtained by checking the patient’s ability to walk on tiptoes or on heels. Reclination of the trunk: The maximum reclination of the pects of the neurological examination from the orthopae- spine is measured as the angle between the upper body’s vertical axis dic standpoint are described in chapter 2. Examination protocol for the back Examination position Examination Questions I. The following standard spinal x-rays are recorded: Functional x-rays of the cervical spine from the side ▬ Cervical spine, AP and lateral: during maximum inclination and reclination: The patient can either stand or lie down for the AP If instability or a ligamentous injury is suspected, the x-ray of the cervical spine. The central x-ray beam is cervical spine is x-rayed (on the awake patient) from targeted on the 4th cervical vertebra (at the level of the the side, while the patient is sitting up and during Adam’s apple) and is inclined towards the head at an maximum inclination and reclination (⊡ Fig. For the lateral x-ray, Thoracic spine, AP and lateral: the patient can either stand, sit or lie down, and hold The AP and lateral x-rays of the thoracic spine should, his head up straight in a neutral position. For the lateral x-ray of the tho- For the specialist dens x-ray the patient is placed on racic spine, the patient is asked to raise his arms. With central beam is targeted horizontally at the level of the the patient’s mouth opened as wide as possible, the 6th thoracic vertebra and tilted towards the head at central beam is vertically aligned with the center of an angle of about 10°. While the x-ray is re- vertebral bodies and the intervertebral disks viewed corded, the patient is asked to say »ah«, causing the from the side (⊡ Fig. The dens, axis, lateral masses likewise be recorded while the patient is standing. They are also effective for targeted on L3 at the patient’s waist level (⊡ Fig. In adolescents, wide cassettes should be used so that Myelo-CT : the iliac crest is included in the x-ray (so that the re- Myelo-CT has largely superseded the conventional maining growth potential can be assessed). Angiograms can be recorded conventionally, as MR ▬ Oblique x-rays of the lumbosacral junction: angiograms or, using a more recent technique, as CT For the oblique x-rays of the lumbar spine, the patient angiograms, which produce the best view of the blood lies on his side on the examination table and then vessels. Such images are required in certain tumors turns 45° to the right so that the small vertebral joints or for depicting the artery of Adamkiewicz prior to on the right are viewed (similarly, raising the left side vertebrectomies. MRI of the spine: The central beam is targeted vertically onto the center The MRI scan is used for cases of inflammation and of L3 (⊡ Fig. If deformities are The technetium scan is useful for revealing small tu- present, this overview is more useful for evaluating mors that are not clearly depicted with conventional the statics of the spine than individual images of the imaging techniques (e. For full-grown patients the spine must be Ultrasound scans are recorded in cases of a suspected x-rayed using combined films in special cassettes. Since the distance from the x-ray tube is considerable, this not only has an adverse effect on image quality, Reference but also involves a high dose of radioactivity. Positioning of the patient and targeting of the central beam in oblique x-rays of the lumbosacral junction (after) 66 3. But there are also others who are so thick-skinned that they can live without a backbone. If their will is broken we say that it is »bent« to the will of an- other.

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Katz K purchase 2.5mg ditropan with visa gastritis dieta recomendada, David R order ditropan 5mg fast delivery gastritis green tea, Soudry M (1999) Below-knee plaster cast for the treatment of metatarsus adductus. Peterson HA (1986) Skewfoot (forefoot adduction with heel val- the naked foot is subject to cultural differences. J Pediatr Orthop 6: 24–30 ern countries (for obvious reasons), parents’ concern 6. J Bone Joint Surg (Br) 60: 530–2 about a normal foot shape is much greater than in North 7. Smith JT, Bleck EE, Gamble JG, Rinsky LA, Pena T (1991) Simple America or northern Europe, where the foot tends to method of documenting metatarsus adductus. Accordingly, inserts or even 11: 679–80 custom-made shoes are produced in substantial quanti- ties in Italy and Spain, and surgical procedures involving the foot are also much more common in these countries 3. The differing forms of flatfoot prompting a mother or father to take their children to a and valgus foot are listed in ⊡ Table 3. This chapter deals with physiological flat valgus foot, Like the back and the knee, the foot is also often its differentiation from flexible flatfoot and their differen- used in everyday linguistic usage in a symbolic sense. The other conditions involving a flattened Although certain figures of speech are emotionally col- medial arch are addressed in other chapters (see notes in ored, the actual shape of the foot is not used to represent ⊡ Table 3. When we are anxious about the outcome of a development we get cold feet. Someone who thinks on his feet is > Definition capable of making good decisions quickly. Someone who Increased valgus position of the heel and flattening of drags his feet is unnecessarily delaying a decision. To put the longitudinal arch in children, compared to adults, as one’s foot down is to exert one’s authority. The aesthetic qualities of the foot are also worth bear- Etiology ing in mind. Footwear is strongly influenced by fashion Children show more pronounced anteversion of the trends. The importance that we attach to the beauty of femoral neck compared to adults. Differential diagnosis: flattened longitudinal arch of the foot Etiology Clinical findings Investigation Treatment Congenital flatfoot Congenital Present at birth Clinical Operation during the 1st year Congenital flatfoot, con- Valgus position of the heel X-ray: vertical of life (talar reduction) genital convex pes valgus, Abduction and pronation of the talus Cast and orthotic treatment congenital vertical talus, forefoot for 2–3 years congenital rocker-bottom Missing longitudinal arch flatfoot (chap. To avoid tripping over their own had to wear shoe inserts during their own childhood and feet, the child unconsciously tries to correct its intoeing therefore consult the doctor in order to ensure that their gait by turning the feet outwards. This external rotation own child doesn’t miss out on any necessary treatment. Note that this arch is lacking in children themselves: Turning your upper body, and thus the lower under 3 years of age because of the fat pad and that the leg as well, internally over the weight-bearing foot will foot arch may not be properly delineated until the age of produce valgus rotation of the heel and, automatically, 6. With the child standing on tiptoe, we can also observe hyperpronation of the forefoot with flattening of the how the foot arch forms with the varization of the heel. Naturally the height of the longitudinal arch is subject to considerable variation. Some patients will show a relative- Diagnosis, measures ly deep arch even in adulthood, but this is not associated Because of the mechanism for correcting the intoeing gait, with any morbidity, i. Not infrequently, the mothers and fathers ally-supporting inserts will not influence the height of the 410 3. In a study conducted in our hospital, the results difficult from the outset. Only when the child reaches the for the group of patients fitted with inserts were worse age of around 6 years does the weight-bearing surface than those for those without inserts. It can be stated con- by the fact that the inserts make the muscles »lazy« and fidently, however, that flexible flatfoot is a rare condition the active development of the arch is less likely to occur (in this part of the world it probably affect fewer than 1 in than when inserts are not fitted. Even the wearing of shoes a thousand children) if one accepts as a criterion the fact has an adverse effect on the development of the foot arch that the medial arch is completely filled in on a footprint 3. The problem of flat valgus foot is accentuated by recorded in a school-age child. One interesting study in overweight, by an abnormal valgus axis of the lower leg India showed that the widening of the weight-bearing and by general ligament laxity. The transitions to flex- surface occurred 3 times more frequently in children who ible flatfoot are blurred.

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