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By Z. Julio. University of South Alabama. 2018.

When the poliovirus affects the abolished in the United States and other brain stem order viagra soft 100 mg online erectile dysfunction treatment in the philippines, the muscles that control countries in which an immunization pro- breathing and swallowing are also affect- gram is widely available 100 mg viagra soft fast delivery erectile dysfunction premature ejaculation. When res- poliomyelitis has been nearly eradicated piration is affected purchase 100mg viagra soft erectile dysfunction las vegas, individuals require in the industrialized world, the residuals mechanical respiratory support such as of the condition experienced by those the “iron lung. In addition, polio depend on the nerves affected and small outbreaks continue to occur in the degree of damage. Individuals with developing countries, and a few cases con- affected lower extremities have difficulty tinue to appear in the industrialized world with ambulation and may require a as well. When upper extremities are involved, self-care skills Manifestations of Poliomyelitis may also be affected. If the trunk muscles are affected, a muscle imbalance may Individuals in the initial stages of polio result, lead to scoliosis (lateral curvature are acutely ill. Initial symptoms are usu- of the spine), which can interfere with ally nonspecific, such as gastrointestinal breathing as well as the functioning of or upper respiratory symptoms accompa- internal organs. Symptoms later progress to After the initial acute episode of polio- headache, stiff neck, and muscle pains. The degree of residual disability group of muscles are affected; in others, is dependent on the extent of the perma- paralysis is widespread and may include nent damage to nerves that has occurred. Extremity involvement is often asymmetrical, so that one extremi- Manifestations of Post-Polio Syndrome ty may have major paralysis while the opposite limb has only slight weakness or Poliomyelitis itself is not a progressive may not be affected at all. Consequently, many individu- cles are paralyzed, functions of sensation, als who contracted the disease 30 or more bowel and bladder control, and sexual years ago adapted to residual paralysis, response are left intact. Despite in- myelitis began to seek medical advice creasing decline, however, individuals will because of new symptoms that ranged not return to the level of disability they from mildly to severely debilitating. At experienced when polio was in its acute first they were not taken seriously. With appropriate exercise, strength were classified as having “emotional dis- and function can be improved and dete- turbances,” or symptoms were merely rioration slowed, if not halted. Spinal tap or fecal sample can ety of symptoms in individuals who had be used to confirm the diagnosis. The recovered from poliomyelitis many years diagnosis of post-polio syndrome is, at earlier. Symptoms of post-polio generalized fatigue syndrome may be difficult to distinguish • new muscle weakness in muscles not from other degenerative disorders of mus- previously affected cles and joints, such as osteoarthritis or • muscle pain (myalgia) and/or joint osteoporosis. General medical evaluation, pain routine laboratory tests, electromyographic • respiratory difficulty studies (graphic record of the contraction The cause of post-polio syndrome is un- of a muscle as the result of electrical stim- known (Burk & Agre, 2000). It appears ulation), and nerve conduction studies may that most of the motor neurons original- help to identify and exclude other dis- ly damaged in the initial bout of polio are eases. Magnetic resonance imaging may be involved in post-polio syndrome and used to exclude other conditions of the that most individuals who had polio are spine that could cause similar symptoms at risk to develop the syndrome. Those No specific treatment is available to who had been able to walk without assis- alter the course of post-polio syndrome. Those who had used muscle weakness, fatigue, and pain should Conditions Affecting the Spinal Cord 93 first have a thorough physical exam- reduction may be recommended to ination by a physician to rule out other reduce fatigue and stress on muscles and potential causes of symptoms. For those whose respiratory mus- is largely directed toward managing cles were also affected by the initial infec- symptoms and helping individuals main- tion, weight control can also help to tain functional status and independence prevent respiratory difficulty. Good health practices, including proper nutrition and adequate Psychosocial Issues in rest, are important. Post-Polio Syndrome Generalized fatigue is treated with lifestyle changes consisting of energy Since poliomyelitis is not a progressive conservation measures. Physical activities disease, many individuals believed their should be paced to prevent excessive recovery to be permanent and adapted fatigue. Individuals may require frequent and adjusted to the functional limitations rest periods throughout the day. Using and residual effects associated with the additional assistive devices, such as a condition, going on to lead full and pro- wheelchair rather than crutches, may ductive lives. Exercises unexpected symptoms associated with that are tolerable and that do not con- post-polio syndrome threaten their func- tribute to more weakness and fatigue may tion and independence and can be psy- be prescribed. Individuals frustrating for the individual, who again are instructed to exercise for short inter- must adjust and adapt to continuing func- vals, to rest between bouts of exercise, and tional limitations, the potential use of to exercise only every other day to pre- new assistive devices, and an alteration in vent excessive muscle fatigue. After regaining function previ- Individuals with respiratory difficulty ously through much physical and emo- may require noninvasive positive-pressure tional effort, being forced to deal again ventilation at night. Because individuals with disability symptoms that are much with post-polio syndrome are more sus- like the initial symptoms can be discour- ceptible to infectious diseases, pneumonia aging. Individuals may reject new assis- and influenza vaccines are usually recom- tive devices because they symbolize the mended. Changes in Vocational Issues in Post-Polio Syndrome orthotics or in the mode of ambulation may be required. Moving from braces or Many individuals with poliomyelitis have crutches to a wheelchair can also reduce achieved gainful employment and lived stress on joints. Although its cause re- number of alterations necessary in the mains unknown, evidence suggests that work setting. In some instances, depending both genetic and environmental factors on performance requirements, the individ- may play a role (Janson, Leone, & Freese, ual may be unable to perform all of the 2002; Nussbaum & Ellis, 2003). Thus altering job duties or retrain- son’s disease involves extensive degener- ing for other job duties may be necessary. Most of the ability to lift, reach, walk, or climb may disabling symptoms associated with be altered. Parkinson’s disease are due predominant- The symptoms of post-polio syndrome, ly to drastic reductions of dopamine lev- whether pain, weakness, or fatigue, may els in the brain. Individuals who once increased the number of diagnosed cases used crutches or braces may require a of Parkinson’s disease among younger wheelchair for ambulation. If, because of increased describe a parkinsonian syndrome in symptoms and disability, the individuals’ which individuals experience Parkinson- current mode of transportation is no like symptoms that are due to other caus- longer accessible, transportation to and es. In addition, ciated with the ingestion of certain drugs because of increased disability, individu- (prescription or illicit) or exposure to tox- als may require additional time to get ic substances, such as carbon monoxide or ready for work. Secondary parkinsonism In some instances the onset of new gained attention in the early 1980s when symptoms and increasing limitations may the “designer drug” MPTP, which mim- result in depression, which can interfere icked the action of heroin, entered the with the individual’s ability to work effec- street market. Supportive counseling may be nec- after taking the drug, suddenly developed essary to enable the individual to cope permanent signs and symptoms of severe with increasing disability. Some medications used to treat mental illness may also pro- NEUROMUSCULAR CONDITIONS duce Parkinsonlike side effects if not closely monitored. Parkinson’s Disease A variety of other conditions mimic Parkinson’s disease, causing similar symp- Parkinson’s disease is a slowly progres- toms. These symptoms are collectively sive disorder of the central nervous sys- called parkinsonism and should be distin- tem, leading to progressive impairment of guished from Parkinson’s disease. Neuromuscular Conditions 95 Manifestations of Parkinson’s Disease more deliberate as the condition progress- es. As food collects in the mouth and the The four most common symptoms of back of the throat, individuals may be Parkinson’s disease include: prone to coughing and choking episodes. Motor changes related to Parkinson’s dis- • tremor ease may cause speech changes related to • muscle rigidity incoordination and reduced movement of • akinesia (complete or partial absence the muscles that control breathing, voice, of movement, or difficulty with vol- pronunciation, and rate of speaking.

In the field of intervention research there is some evidence of bias when excluding non-English publications trusted viagra soft 100 mg erectile dysfunction drugs at gnc. Methodological quality The methodological quality of each selected paper should be assessed independently by at least two reviewers cheap 50 mg viagra soft fast delivery impotence exercises for men. Chance-adjusted agreement should be reported cheap viagra soft 100mg mastercard erectile dysfunction evaluation, and disagreements solved by consensus or arbitration. To improve agreement, reviewers should pilot their quality assessment tools in a subset of included studies or studies evaluating a different diagnostic test. Validity criteria for diagnostic research have been published by the Cochrane Methods Group on Screening and Diagnostic Tests32 (http://www. The internal validity criteria refer to study characteristics that safeguard against the intrusion of systematic error or bias. External validity criteria provide insight into the generalisability of the study and judge whether the test under evaluation was performed according to accepted standards. Internal and external validity criteria, describing participants, diagnostic test and target disease of interest, and study methods may be used in meta-analysis to assess the overall “level of evidence” and in sensitivity and subgroup analyses (see Data extraction and Data analysis sections). It is important to remember that studies may appear to be of poor methodological quality because they were either poorly conducted or poorly reported. Methodological appraisal of the primary studies is frequently hindered by lack of information. In these instances reviewers may choose to contact the studies’ authors, or to score items as “don’t know” or “unclear”. Example A urine dipstick is usually read before the material is cultured. So, it can be interpreted that the dipstick was read without awareness of the results of the culture. However, the culture (reference test) may be interpreted with full awareness of the results of the dipstick. If blinding is not explicitly mentioned, reviewers may choose to score this item as “don’t know” or “diagnostic test blinded for reference test” (implicitly scoring the reference test as not blinded). A survey of the diagnostic literature from 1990 to 1993 in a number of peer-reviewed journals showed that only a minority of the studies satisfied methodological standards. Positive score Criteria of internal validity (IV) 1 Valid reference standard (Semi-)quantitative (2 points) to dipslide culture (1 point) 2 Definition of cut-off point for Definition of urinary tract infection/ reference standard bacteriuria by colony forming units per ml (1 point) 3 Blind measurement of index test and In both directions (2 points) or only reference test index or reference test 4 Avoidance of verification bias Assessment by reference standard independent from index test results (1 point) 5 Index test interpreted independently Explicitly mentioned in the publication, of all clinical information or urine samples from mixed outpatient populations examined in a general laboratory (1 point) 6 Design Prospective (consecutive series) (1 point) or retrospective collection of data (0 points) Criteria of external validity (EV) 1 Spectrum of disease In- and/or exclusion criteria mentioned (1 point) 2 Setting Enough information to identify setting (1 point)(community through tertiary care) 3 Previous tests/referral filter Details given about clinical and other diagnostic information as to which index test is being evaluated (symptomatic or asymptomatic patients (1 point) 4 Duration of illness before diagnosis Duration mentioned (1 point) 5 Comorbid conditions Details given (type of population) (1 point) 6 Demographic information Age (1 point) and/or gender (1 point) data provided 7 Execution of index test Information about standard procedure directly or indirectly available, urine collection procedure, first voided urine, distribution of microorganisms, procedure of contaminated urine samples, time of transportation of urine sample, way of reading index test, persons reading index test (1 point each) 8 Explanation of cut-off point of index test Trace, 2 or more (1 point if applicable) 9 Percentage missing If appropriate: missings mentioned (1 point) 10 Reproducibility of index test Reproducibility studied or reference mentioned (1 point) Blinding (IV3): When information about blinding of measurements was not given and the dipstick was performed in setting other than the culture, we assumed blind assessment of the index test versus the reference test, but not vice versa. Explanation of the cut-off point (EV8) was only necessary for the leukocyte esterase measurement. Comments Ideally, all participants should be submitted to the same reference test. Sometimes different groups of patients are submitted to different reference tests, but details are not given. In this case it is important to assess whether the different reference tests are recognised by experts as being adequate. Verification or work-up bias may be present if not all participants who received the index test are referred to the reference test(s). Verification bias is present if the participants are referred according to the index test results. This is usually the case in screening studies where only subjects with positive index test results receive the reference test, so that only a positive predictive value can be calculated. Estimation of accuracy will not be possible in these studies unless complete follow up registries are available. This is the case if, for example, cancer screening registries and cancer diagnosis registries are coupled. Data extraction Two reviewers should independently extract the required information from the primary studies. Detailed information must be extracted about the participants included in the study and about the testing procedures. The cut-off point used in dichotomous testing, and the reasons and the number of participants excluded because of indeterminate results or infeasibility, are always required. Example Detailed information extracted in the case of the dipstick meta- analysis: mean age, male/female ratio, different cut-off points for leukocyte esterase (trace, 2 ,3 ), time needed for transportation, whether indeterminate results were excluded, included as negative, or repeated. As the information extracted may be used in subgroup analyses and statistical pooling of the validity, possible sources of heterogeneity should be defined based on existing evidence or hypotheses. Example In the dipstick meta-analysis we hypothesised that the following factors may explain heterogeneity if present: procedures of collection of test material (method of urine collection, delay between urine collection and culture), who was executing the test and how (manually or automatic), and different brands of commercial products. For the meta-analysis of dichotomous tests (see below) it is necessary to construct the diagnostic 152 GUIDELINES FOR SYSTEMATIC REVIEWS 2 2 table: absolute numbers in the four cells are needed. Totals of “diseased” and “non-diseased” participants are needed to calculate prior probability (pretest probability), and to reconstruct the 2 2 table from sensitivity, specificity, likelihood ratios, predictive values or receiver operator characteristic (ROC) curves. If possible, the 2 2 table should be generated for all relevant subgroups. Further information to extract includes year of publication, language of publication, and country or region of the world where the study was performed. Comments A standardised data extraction form may be used simultaneously with but separately from the quality assessment form. This approach facilitates data extraction and comparison between reviewers. The form has to be piloted to ensure that all reviewers interpret data in the same way. As in other steps of the review where judgements are made, disagreements should be recorded and resolved by consensus or arbitration. Lack of details about test results or cut-off points, inconsequential rounding off of percentages, and data errors require common sense and careful data handling when reconstructing 2 2 tables. If predictive values are presented with sensitivity and specificity in “diseased” and “non-diseased” individuals, the calculation of the four cells from sensitivity and specificity can be confirmed by using the predictive values. Details can be requested from the authors of the studies, but these attempts are often unsuccessful, as the raw data may no longer be available. Example In a review of the accuracy of the CAGE questionnaire for the diagnosis of alcohol abuse, sufficient data were made available in only nine of the 22 studies selected, although the authors of the review tried to contact the original authors by all means. Because diagnostic accuracy studies are often heterogeneous and present limited information it is typically difficult to complete a meta-analysis. If heterogeneity is identified, important information is obtained from attempts to explain it. For instance, the effect that each validity criterion has on the estimates of diagnostic accuracy and the influence of previously defined study characteristics should be explored as potential explanations of the observed study to study variation. Describing the results of individual studies Reporting the main results of all included studies is an essential part of each review. It provides the reader with the outcome measures and gives an insight into their heterogeneity. Each study is presented with some background information (year of publication, geographical region, number of diseased and non-diseased patients, selection of the patients, methodological characteristics) and a summary of the results. In view of the asymmetrical nature of most diagnostic tests (some tests are good to exclude a disease, others to confirm it), it is important to report pairs of complementary outcome measures, that is, both sensitivity and specificity, positive and negative predictive value, likelihood ratio of a positive and of a negative test, or a combination of these.

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The movements of the temporomandibular joint include Four ligaments support the sternoclavicular joint and pro- depression and elevation of the mandible as a hinge joint 100mg viagra soft with visa erectile dysfunction with diabetes type 1, pro- vide flexibility cheap viagra soft 50 mg otc what age does erectile dysfunction usually start. An anterior sternoclavicular ligament covers traction and retraction of the mandible as a gliding joint order viagra soft 50mg on-line erectile dysfunction other names, and the anterior surface of the joint, and a posterior sternoclavicular lateral rotatory movements. The lateral motion is made possible ligament covers the posterior surface. An inter- clavicular ligament extends between the sternal ends of both The temporomandibular joint can be easily palpated by ap- clavicles, binding them together. The costoclavicular ligament plying firm pressure to the area in front of your ear and open- ing and closing your mouth. This joint is most vulnerable to extends from the costal cartilage of the first rib to the costal dislocation when the mandible is completely depressed, as in yawn- tuberosity of the clavicle. Relocating the jaw is usually a simple task, however, and is ac- complished by pressing down on the molars while pushing the jaw Of all the joints associated with the rib cage, the sternoclavicu- backward. Excessive force along the long axis of the clavicle may displace the clavicle forward and downward. Injury to the costal cartilages is painful and is caused Temporomandibular joint (TMJ) syndrome is a recently rec- most frequently by a forceful, direct blow to the costal cartilages. The apparent cause of TMJ syndrome is a malalign- ment of one or both temporomandibular joints. The symptoms of Glenohumeral (Shoulder) Joint the condition range from moderate and intermittent facial pain to intense and continuous pain in the head, neck, shoulders, or The shoulder joint is formed by the head of the humerus and the back. Clicking sounds in the jaw and limitation of jaw movement are common symptoms. Some vertigo (dizziness) and tinnitus glenoid cavity of the scapula (fig. Articulations © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 216 Unit 4 Support and Movement Joint Joint capsule cavity FIGURE 8. The joint capsule is rein- Although two ligaments and one retinaculum surround and forced with three ligamentous bands called the glenohumeral support the shoulder joint,most of the stability of this joint de- ligaments (not illustrated). The final support of the shoulder joint is the transverse humeral retinaculum, a thin band that extends from the greater tubercle to the lesser tubercle of the labrum: L. Articulations © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 Chapter 8 Articulations 217 Acromion (cut) Tendon of long head of biceps Joint capsule brachii m. An incision has been made into the joint capsule and the humerus has been retracted laterally and rotated posteriorly. The stability of the shoulder joint is provided mainly by the ten- Elbow Joint dons of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles, which together form the musculotendinous (rotator) The elbow joint is a hinge joint composed of two articulations— cuff. The cuff is fused to the underlying capsule, except in its inferior as- pect. Because of the lack of inferior stability, most dislocations (subluxa- the humeroulnar joint, formed by the trochlea of the humerus tions) occur in this direction. The shoulder is most vulnerable to trauma and the trochlear notch of the ulna, and the humeroradial when the arm is fully abducted and then receives a blow from above— joint, formed by the capitulum of the humerus and the head of as for example, when the outstretched arm is struck by heavy objects the radius (figs. Degenerative changes in the musculotendinous cuff produce an inflamed, painful condition known as pericapsulitis. On the posterior side of the elbow, there is a large olecranon bursa to lubricate the area. A Two major and two minor bursae are associated with the radial (lateral) collateral ligament reinforces the elbow joint on shoulder joint. The larger bursae are the subdeltoid bursa, located the lateral side and an ulnar (medial) collateral ligament between the deltoid muscle and the joint capsule, and the sub- strengthens the medial side. A third joint occurs in the elbow region—the proximal ra- The subcoracoid bursa, which lies between the coracoid process dioulnar joint—but it is not part of the hinge. At this joint, the and the joint capsule, is frequently considered an extension of the head of the radius fits into the radial notch of the ulna and is subacromial bursa. A small subscapular bursa is located between held in place by the annular ligament. Because so many muscles originate or insert near the The shoulder joint is vulnerable to dislocations from sudden elbow, it is a common site of localized tenderness, inflam- jerks of the arm, especially in children before strong shoulder mation, and pain. Because of the weakness of this joint in tendinous soreness in this area. The structures most generally children, parents should be careful not to force a child to follow strained are the tendons attached to the lateral epicondyle of the by yanking on the arm. The strain is caused by repeated extension of the wrist painful and may cause permanent damage or perhaps muscle atro- against some force, as occurs during the backhand stroke in phy as a result of disuse. Articulations © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 218 Unit 4 Support and Movement Joint capsule joint capsule Joint capsule (b) Joint (a) capsule (c) Joint capsule Joint capsule Joint capsule (d) (e) FIGURE 8. Metacarpophalangeal Each joint also has two collateral ligaments, one on the lateral side and one on the medial side, to further reinforce the joint and Interphalangeal Joints capsule. The metacarpophalangeal joints are condyloid joints, and the Athletes frequently jam a finger. It occurs when a ball forcefully interphalangeal joints are hinge joints. The articulating bones of strikes a distal phalanx as the fingers are extended, causing a the former are the metacarpal bones and the proximal phalanges; sharp flexion at the joint between the middle and distal phalanges. Each joint ligaments support the joint on the posterior side, but there is a tendon from the digital extensor muscles of the forearm. Treatment involves splinting each joint on the palmar, or anterior, side of the joint capsule. If splinting is not effective, surgery is generally performed to avoid a permanent crook in the finger. Articulations © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 Chapter 8 Articulations 219 Humerus Joint capsule (cut) Coronoid fossa Radial fossa Radial collateral ligament Articular cartilage Articular cartilage of capitulum of trochlea Ulnar collateral ligament Annular ligament Coronoid process Radius Ulna FIGURE 8. A portion of the joint capsule has been removed to show the articular surface of the humerus. Articulations © The McGraw−Hill Anatomy, Sixth Edition Companies, 2001 220 Unit 4 Support and Movement Joint capsule Ligamentum capitis femoris FIGURE 8. The acetabular labrum, a fibrocartilaginous rim and the acetabulum of the os coxae (fig. It bears the weight that rings the head of the femur as it articulates with the acetab- of the body and is therefore much stronger and more stable than ulum, is attached to the margin of the acetabulum. The hip joint is secured by a strong fibrous joint capsule,several ligaments,and a number of powerful muscles. The liga- largest, most complex, and probably the most vulnerable joint mentum capitis femoris is located within the articular capsule in the body.

Fractures of this type may be extremely painful because of pinched spinal nerves viagra soft 100 mg mastercard erectile dysfunction grand rapids mi. It also has cupped superior articular surfaces that articulate with the oval oc- cipital condyles of the skull buy discount viagra soft 50mg erectile dysfunction liver. This atlanto-occipital joint supports the Thoracic Vertebrae skull and permits the nodding of the head in a “yes” movement viagra soft 100 mg without prescription impotence yoga postures. It has a peg- Twelve thoracic vertebrae articulate with the ribs to form the like dens (odontoid process) for rotation with the atlas in turning posterior anchor of the rib cage. Thoracic vertebrae are larger the head from side to side, as in a “no” movement. Each thoracic vertebra has a long spinous process, Whiplash is a common term for any injury to the neck. Muscle, which slopes obliquely downward, and facets (fovea) for articula- bone, or ligament injury in this portion of the spinal column is tion with the ribs (fig. Joint dislocation occurs commonly between the fourth and fifth or fifth and sixth cervical vertebrae, where neck move- Lumbar Vertebrae ment is greatest. Bilateral dislocations are particularly dangerous be- cause of the probability of spinal cord injury. Compression fractures The five lumbar vertebrae are easily identified by their heavy bodies and thick, blunt spinous processes (fig. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton 162 Unit 4 Support and Movement L3 Transverse process Spinous L4 process Superior L5 articular process Intervertebral disc Sacrum Coccyx (a) FIGURE 6. Their articular processes are also distinc- sacrum that is continuous with the vertebral canal. Paired supe- tive in that the facets of the superior pair are directed medially rior articular processes, which articulate with the fifth lumbar instead of posteriorly and the facets of the inferior pair are di- vertebra, arise from the roughened sacral tuberosity along the rected laterally instead of anteriorly. The smooth anterior surface of the sacrum forms the poste- Sacrum rior surface of the pelvic cavity. It has four transverse lines de- noting the fusion of the vertebral bodies. At the ends of these The wedge-shaped sacrum provides a strong foundation for the lines are the paired pelvic foramina (anterior sacral foramina). A median sacral crest is formed along the posterior surface by the fusion of the spinous processes. Posterior sacral foramina Coccyx on either side of the crest allow for the passage of nerves from The triangular coccyx (“tailbone”) is composed of three to five fused the spinal cord. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton Chapter 6 Skeletal System: Introduction and the Axial Skeleton 163 FIGURE 6. Elderly individuals may suffer a further loss of height because of osteoporosis (see Clinical Considerations at the Region Bones Diagnostic Features end of this chapter). Cervical 7 Transverse foramina; superior The regions of the vertebral column are summarized in facets of atlas articulate table 6. An abrupt fall on the coccyx, however, sixth vertebrae are generally may cause a painful subperiosteal bruising, fracture, or fracture- bifid dislocation of the sacrococcygeal joint. An especially difficult child- Thoracic 12 Long spinous processes that birth can even injure the coccyx of the mother. Coccygeal trauma is slope obliquely downward; painful and may require months to heal. Which are the primary curves of the vertebral column and thick spinous processes which are the secondary curves? Describe the characteristic Sacrum 4 or 5 fused Extensive auricular surface; curves of each region. What is the function of the transverse foramina of the cer- sacral promontory; sacral vical vertebrae? Describe the diagnostic differences between a thoracic and Coccyx 3 to 5 fused Small and triangular; coccygeal vertebrae cornua a lumbar vertebra. Which structures are similar and could therefore be characteristic of a typical vertebra? Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton 164 Unit 4 Support and Movement Costal cartilages FIGURE 6. Objective 14 Identify the parts of the rib cage and compare A jugular notch is formed at the superior end of the manubrium, and contrast the various types of ribs. The manubrium articu- lates with the costal cartilages of the first and second ribs. The The sternum (“breastbone”), ribs, costal cartilages, and the previ- body of the sternum attaches to the costal cartilages of the sec- ously described thoracic vertebrae form the rib cage (fig. The rib cage is anteroposteriorly compressed and more narrow superiorly than inferiorly. It supports the pectoral girdle and upper extremities, protects and supports the thoracic and upper sternum: Gk. Skeletal System: © The McGraw−Hill Anatomy, Sixth Edition Introduction and the Axial Companies, 2001 Skeleton Chapter 6 Skeletal System: Introduction and the Axial Skeleton 165 Articular surfaces Head of head of rib Neck Tubercle Articular surface Angle of tubercle Superior surface Body Costochondral joint Costal groove Internal surface Inferior surface Costal cartilage FIGURE 6. The xiphoid process does not attach projects posteriorly and articulates with the body of a thoracic to ribs but is an attachment for abdominal muscles. The tubercle is a knoblike process, just lat- cartilages of the eighth, ninth, and tenth ribs fuse to form the eral to the head. It articulates with the facet on the transverse costal margin of the rib cage. The neck is the constricted area two costal margins come together at the xiphoid process. The body is the curved main sternal angle (angle of Louis) may be palpated as an elevation part of the rib. Along the inner surface of the body is a depressed between the manubrium and body of the sternum at the level of canal called the costal groove that protects the costal vessels and the second rib (fig. Spaces between the ribs are called intercostal spaces and sternal angle are important surface landmarks of the thorax and are occupied by the intercostal muscles. Fractures of the ribs are relatively common, and most fre- quently occur between ribs 3 and 10. The first two pairs of ribs are protected by the clavicles; the last two pairs move freely and will Ribs give with an impact. Little can be done to assist the healing of broken ribs other than binding them tightly to limit movement. Embedded in the muscles of the body wall are 12 pairs of ribs, each pair attached posteriorly to a thoracic vertebra. Anteriorly, Knowledge Check the first seven pairs are anchored to the sternum by individual costal cartilages; these ribs are called true ribs. What deter- five pairs (ribs 8, 9, 10, 11, and 12) are termed false ribs. Although the ribs vary structurally, each of the first 10 pairs has a head and a tubercle for articulation with a vertebra. In addition, each of CLINICAL CONSIDERATIONS the 12 pairs has a neck, angle, and body (fig. The head Each bone is a dynamic living organ that is influenced by hor- mones, diet, aging, and disease.

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