Getting Powerful Shapely Glutes
Pelvic girdle and to the proximal thigh is often considered hip pain. True intra-articular hip pain will cause pain in the groin area with occasional radiation to the knee. Lateral thigh pain often is secondary to trochanteric bursitis, and buttock pain often is secondary to lumbar pathology. Pain radiating below the knee also generally indicates lumbar pathology. Gluteus minimus m. Gluteus minimus m. Gluteus medius m Gluteus maximus m. Gluteus minimus m. Gluteus medius m. Gluteus minimus m. Gluteus medius m.
The labia and buttocks are gently pressed upward and outward. If the child relaxes the abdominal and back muscles, the resulting lordosis should enable one to see the lower half of the vagina with an otoscope light. Children over age 3 may also be examined while they are supine in the knee-chest position, like a cannonball.
Patients often have sensitive skin at the anus due to the colonic cleansing regime. Jelly, therefore, should be used to perform the rectal exam and insert the rectal tube. Too much jelly, however, may make the catheter tip too slippery. A red rubber catheter (which is smaller and may be more comfortable than a barium enema tip), a Foley catheter, or a plain barium enema tip can be used. If using a barium enema tip, barium enema tubing can be cut into 9-in strips and one end attached to the catheter tip and the other to a hand-held bulb ( blue puffer ) for manual insufflation. Some investigators use a tip with a balloon cuff. The tip should be taped in place (butterfly style) to the buttock to minimize the likelihood of the tip dislodging later when the patient turns from the supine to the prone position.
The patient is placed in the direct lateral decubitus position. The pelvis is securely fixed with a pegboard device or its equivalent, carefully padding the contralateral peroneal nerve and proximal chest wall structures. The operative leg is draped free, and the perineum protected out of the operative field. The skin incision is centered over the greater trochanter. Distally it parallels the femoral shaft and proximally it is extended, in slightly curvilinear fashion, posteriorly. The ili-otibial band and gluteus maximus fascia are then split in line with the skin incision. The leg is then extended and internally rotated. The trochanteric bursa is incised and the short external rotators identified. The sciatic nerve is palpated, adjacent to the ischium, and protected throughout. The posterior border of the abductors (gluteus medius and minimus) is then identified and retracted anteriorly. (Figure 9.1.) This maneuver allows visualization of the piriformis, gemelli, obturators, and...
Trauma to the vulva can produce ecchymoses and or lacerations and may be associated with injury to the vagina and rectum. Straddle injuries may cause severe trauma to the mons, labia majora, buttocks, inner thigh, and periurethral areas. Injuries to the urethra may cause spasm and urinary retention, and it is important to ensure that the child is able to void prior to discharge. The hypoestrogenic skin of the prepubertal vagina tears easily with minor trauma, and there is a risk of wall perforation with a penetrating injury to both the vagina and rectum. All penetrating trauma requires a careful vaginal and rectal examination. It is prudent to refer all children with hymenal injury, or bleeding from the vagina or rectum, for prompt evaluation under anesthesia by a pediatric gynecologist.
Cutaneous findings are present in the great majority of TSC patients and are the most easily identified sign of the disease. 1,2 Most lesions are of minor clinical significance, but facial angiofibromas can be a significant cosmetic issue. Hypomelanotic macules or white spots typically have a lance-ovate shape (Ash-leaf) and are most common over the trunk and buttocks. Three or more of these lesions are very unusual in the general population and thus are considered a major diagnostic criterion (Table 1). The lesions are present at birth and do not change, although they are more easily observed following suntanning. Facial angiofibromas are red to pink papules or nodules with a smooth surface that are found in a malar distribution and extending down to the chin. 1,2 They typically first appear between the ages of 2 and 6, and progress to a variable extent during puberty. Histological findings are dermal fibrosis and angiogenesis with occasional large glial appearing cells. Forehead...
Diseases arising from the pelvic contents may first manifest themselves by signs and symptoms remote from their source of origin. Gastrointestinal tract perforations, in particular, may dissect along anatomic planes of the pelvis to first present in the buttock, hip, thigh, and even the lower leg and the retroperitoneal space of the abdomen. Pain, mass, or crepitation at these sites may be very misleading since the origin of the underlying inflammatory condition or the neoplastic, traumatic, or foreign body perforation of the bowel within the pelvis often remains clinically occult. Radiologic evaluation may be crucial in redirecting the diagnostic and therapeutic approach as well as in documenting the extent of disease. The most common extraabdominal extension of gastrointestinal tract perforations, beyond the development of ischiorectal abscesses, is to the buttocks, hips, and lower extremities. Spread of necrotizing fasciitis to the male genitalia (Fournier gangrene) is rare.1 Of...
An unusual genetic condition in sheep results in animals with hypertrophied muscles primarily in their hindquarters. The word callipyge was derived from the Greek calli beautiful and pyge buttocks. The phenotypic trait only appears after the lambs are 4 to 6 weeks of age. The callipyge condition is transmitted by a remarkable inheritance mode called polar overdominance, where only heterozygous offspring from carrier males express the phenotype. The mutation locus appears to be a single A- to -G replacement on chromosome 18. 11 Callipyge carcasses have increased muscle content and reduced fat
The entry point for the proximal trochanteric portal is just cephalad of the tip of the greater trochanter, equi-distant from the anterior and posterior margins of the greater trochanter. The cannula is directed towards the center of the acetabulum and is passed through the musculotendinous junction of the gluteus medius and gluteus minimus muscles before reaching the hip capsule. This route into the hip joint is relatively safe with regard to neurovascular structures. However, if the surgeon fails to maintain the cannula direction towards the center of the femoral head, there is a risk that the scope could deflect anteriorly and injure the femoral neurovascular structures. Because the trochanter is displaced distally due to the longitudinal traction, the direction in which the cannula is advanced is medial and slightly superior. If the portal is initiated too cephalad, the superior labrum is at risk of injury as the scope cannula penetrates the joint capsule. Conversely, if the...
HEMORRHAGE Hemorrhage is estimated to be the cause of death in about 50 percent of total pelvic injuries.18 Retroperitoneal bleeding is an inevitable complication, and up to 4 L of blood can be accommodated in this space until vascular pressure is overcome and tamponade occurs. It is thought that approximately 90 percent of pelvic bleeding is from the fractures and low pressure venous plexus. Both small and large vessels, especially the superior gluteal and internal pudendal branches of the internal iliac artery, can also be disrupted, with hemorrhage dissecting from the back to the buttocks.
PHYSICAL EXAMINATION48,1 H The physical exam should be performed thoroughly and compassionately. A female chaperone should be present if the examining physician is a man. Document a general medical examination, including vital signs and level of consciousness. Bruises, lacerations, or other signs of trauma should be described in detail a body map may be useful. As many as 290 percent of rape survivors will have nongenital injuries. - H.2,13 The examiner should carefully inspect the victim's face, oral cavity, neck, breasts, wrist, thighs, and buttocks. Areas of tenderness should also be recorded. A pelvic examination should be performed, noting any vaginal discharge or genital lacerations or abrasions. Toluidine blue can be used to detect small vulvar lacerations. 4 Lacerations expose the deeper dermis, containing nuclei that absorb this stain. Prior to inserting the speculum, the dye is applied to the posterior fourchette with gauze and wiped away with lubricating jelly. A linear...
Distortion of the pelvic anatomy is common in malignant disease. Therefore, the surgical procedures for tumor removal are often difficult, and injuries, especially to veins, are sometimes unavoidable to make radical excision possible. The injury becomes obvious by the bleeding, and because it is usually veins that are injured, control is accomplished by compression. Definitive repair is often more difficult. If major veins such as the iliacs are damaged, suturing of the hole is possible during inflow and outflow control, either manually or by sponge-sticks. It is necessary to reduce bleeding sufficiently so that the hole can be visualized adequately for repair. Often, however, it is the internal iliac or, rather, branches from this vein that bleed. Sufficient control for repair is then almost impossible to achieve, and attempts to apply blind sutures often make the bleeding worse. When the bleeding is moderate, simple compression sometimes permanently stops it. If not, fibrin glue...
Initially, hidradenitis suppurativa begins as a painful deep erythematous nodule usually in the axilla or groin. The inflammatory nodule may resolve on its own or develop into a sterile abscess that may open to the surface and drain. Such a lesion may persist and periodically drain, develop a sinus tract and continually drain, or heal with scarring. New lesions may develop in the same area and interconnect. Open comedones, which normally are not present in these body regions, may be seen. Comedones with multiple openings are characteristic of hidradenitis suppurativa. Scarring may be pitted, bridging, or hypertrophic ( Fig. 240 4). The extent of involvement is variable with some patients experiencing only localized intermittent lesions with minimal scarring and others with continuously active disease in the axilla, groin, intergluteal cleft, and buttocks.
Largest horizontal circumference around the buttocks Level of iliac crest circumferences measured at four sites (immediately below the lowest rib, at the narrowest point, midpoint between the lowest rib and the iliac crest, and immediately above the iliac crest) have been compared and found to differ from each other. Other work has shown that the highest correlations with risk factors were obtained when WHR was calculated as the waist measured at the point midway between the lower rib margin and iliac crest (approximately 1 inch ( 2.5 cm) above the umbilicus) or when the waist was measured at the umbilicus and hips measured at the widest point of the buttocks. Although two different waist measurements have been demonstrated to perform equally well, the bony landmark measurement (the point midway between the lower rib margin and iliac crest) may be preferred since the umbilicus may shift position when an individual gains or loses weight. The World Health Organization (WHO) has...
Compressed parts of the body result in areas of normal-colored skin demarcated by lividity. If a deceased individual is supine, pressure points are observed on the occipital scalp, midback, buttocks, posterior thighs, calves, and heels (Fig. 10). If prone, pressure is applied to the forehead, nose, cheek (if the head is turned), chin, chest, lower abdomen, and anterior thighs. Pressure points also develop in areas of constriction or Fig. 10. Person found dead in supine position. Livor on back. Pallor on upper back and buttocks corresponds to typical pressure points. Note pale bands at waistline created by constriction of belt and underwear. Refrigeration had turned the lividity partly red. (See Companion CD for color version of this figure.)
Small defects can be closed by primary suturing, especially where only the pliable scrotal skin is involved. Split thickness skin grafting is most often used and yields acceptable results, even in large defects (Hessel-feldt-Nielsen et al. 1986). Healthy skin from the legs, buttocks, and arms can be used, in a single or multiple settings. Skin defects on the penile shaft should be liberally grafted so as to prevent fibrotic scar formation with future erectile problems.
Henoch-Schonlein purpura (HSP) is a disease that manifests symptoms of purple spots on the skin, joint pain, gastrointestinal symptoms, and glomerulone-phritis. HSP is a type of hypersensitivity vasculitis and inflammatory response within the blood vessel. It is caused by an abnormal response of the immune system. The exact cause for this disorder is unknown. The syndrome is usually seen in children, but people of any age maybe affected. It is more common in boys than in girls. Many people with HSP had an upper respiratory illness in the previous weeks. Purpuric lesions are usually over the buttocks, lower legs, and elbows. Besides purpuric lesions, nephritis, angioedema, joint pains, abdominal pain, nausea, vomiting, diarrhea, and he-matochezia can be seen. The scrotum can also be affected in 13 -35 of cases (Ioannides and Turnock 2001). While the testis and or scrotum can rarelybe involved, usually the scrotum is diffusely tender with erythema distributed all over the scrotum....
Women's and men's waist-hip ratios differ strikingly (about 0.7 vs. 0.85). Women's waist-hip ratio changes, thickening with both pregnancy and menopause thus a ratio of 0.7 in a woman sends the message I am young, and not pregnant. Across a variety of cultures, men find women's typical waist-hip ratio of 0.7 most attractive (Singh, 1993 Singh & Luis, 1995), and women do not find wide hips in men attractive. Related physical sexual differences may be exaggerated in specific environments for example, in some populations in harsh environments, women store fat on the buttocks, giving an exaggerated shape that reflects ability to thrive in harsh conditions (Low, 2000).
In HSP, some children may present with joint pain, abdominal pain, or seizure. Usually, there is a petechial or purpuric rash on the buttocks and lower extremities. Many children have guaiac-positive stools but rarely present with bleeding unless there is associated intussusception. Treatment is usually symptomatic and on an outpatient basis unless the child appears ill or has a complication of the disease.
Sunlight exposure is an established independent risk factor for the development of SCC. SCC arises more commonly in the sun-exposed areas, including the head, neck and arms, but also occurs on the buttocks, genitals and perineum.14 Other risk factors for SCC include older age, male sex, Celtic ancestry, increased sensitivity to sun exposure, increased number of precancerous lesions and immunosuppression.4,15,16 Exposure to oral psoralens, arsenic, cigarette smoking, coal-tar products, UVA photochemotherapy and human papilloma virus have been associated with SCC. Genetic disorders that predispose to SCC include epidermodysplasia verruciformis, albinism and xeroderma pigmentosum.
Studies of adipose tissue distribution, its causes, and its effects on morbidity and mortality are fundamental in the field of obesity. An ideal measure of body fat should be ''precise with small measurement error accessible, in terms of simplicity, cost, and easy to perform acceptable to the subject well documented with published reference values.'' There is no consensus as to which methods best define and describe adipose tissue and its distribution. Several studies have noted that the increased risk of obesity is related to mesenteric and portal depots of adipose tissue. However, subcutaneous adipose tissue, particularly around the hips and buttocks, appears not to increase health risk.
Both the upper and lower buttock are another source of skin and fat tissue for breast reconstruction.9 These free flaps can be harvested with muscle based on the superior or inferior gluteal vessels (free superior gluteal flap or free inferior gluteal flap), or as perforator flaps leaving gluteus muscle intact (S-GAP or I-GAP flaps). There is a large scar created across the buttock with mild flattening of the buttock contour but this is imperceptible in normal clothing. The best candidates for a gluteal free flap reconstruction are healthy women who have a flat abdomen (no TRAM donor site) and a small or medium size breast with little natural sag.
The sister condition of celiac disease is dermatitis herpetiformis, which is the skin manifestation of gluten-sensitive enteropathy. It is an extremely itchy immunobullous disease that affects the extensor surfaces of elbows, knees, buttocks, the hairline, and the torso and is much less common than celiac disease. Probably the ratio between the two in geographic areas where both have been estimated is approximately 10 1. However, in countries where there has traditionally been less celiac disease awareness, such as North America, the ratio may be closer to 3 1.
The reconstruction is permanent, ages naturally, and rarely requires touch up procedures later in life. The main disadvantages are that there will be a scar left at the site where the tissue is taken from and that the operative procedure can be lengthy. The most common area used to donate tissue for breast reconstruction is the lower abdomen. This is called a TRAM flap. The term relates to the muscle supplying vascularity to the lower abdominal block of tissue that is transferred (Transverse Rectus Abdominis Myocutaneous flap).3-6 The back tissues (latissimus myocutaneous flap) can be used in some situations, but often an implant is needed in addition for adequate breast projection. The buttock, hips, and other areas of the body can also be used in special situations.
Body Dysmorphic Disorder (BDD) is a fixation or preoccupation with an imagined defect in appearance or, if a physical defect or anomaly is present, the individual's concern is clearly excessive (APA, 2000). Although prevalence rates remain largely unknown, APA (2000) suggests that BDD may range from under 5 to a high of 15 in medical cosmetic settings. Individuals with BDD can focus on flaws of the head and face such as hair thinning, acne, asymmetry, excessive hairiness, or the shape and size of body parts including the eyes, mouth, head, buttocks, legs, or genitals. The concern may be limited to one or many areas and can range from extremely specific to vague and diffuse (APA, 2000).
Sumerian temple records from the middle of the third millennium bc mention gala priests, who for centuries served the goddess Inanna Ishtar. These priests and their later equivalents in Babylonia and Assyria adopted female dress and manners and engaged in passive anal intercourse with other men. The written word for gala combined the symbols for penis and anus. Babylonian and Assyrian omens even instructed men to have sex with these priests to bring good luck. But not all types of homosexuality were considered positive. Middle Assyrian laws from 1250 bc decreed severe punishments for men who falsely accused others of passive homosexuality or who raped companions (Roscoe, 1997). Similar associations of passive homosexuality with humiliation come from Egypt. In one ancient myth the god Horus rapes the god Seth to humiliate him (Roscoe, 1997), and in the Book of the Dead (after 2000 bc) a dead man argues that the god Atum has no power over me, because I copulate between his buttocks...
It consists of a single band of twine worn around the waist. To this band is attached a pocket watch sized piece of bark in the rough shape of a quadrilateral that sits on the pubis just above the genitals. A long thin cord leads from this bark through the buttocks, to reappear as a kind of protruding tail in the rear. (Gregor, 1977, p. 164)
Not surprisingly, this revolution sent shock waves through even the sheltered confines of the jurisprudential world. Ebbing and flowing with larger intellectual tides, the efforts to apply evolutionary ideas to law and legal development have continued during the intervening 150 years. However, it is not my intention to offer one more account of how the common law's development somehow manages to conform to a Darwinian dynamic. On the contrary, it is my objective is to show that any jurisprudential effort to mine the fields of biological research or trade off its prestige is fraught with perils. There is no reason at all to suppose (and many reasons not to suppose) that evolutionary science can be of any assistance in understanding the common law's historical operation or in grounding future initiatives in common law reform. However, there is much in the Darwinian canon that can be helpful in illuminating more clearly the failed efforts of modern jurisprudence to appreciate the...
Below is an example of the instructions used in this phase Breathe with calm, regular breaths and feel how you relax more and more with each breath Just let go Relax your forehead eyebrows eyelids jaws . tongue and throat . lips . and your entire face Relax your neck . shoulders . arms . hands . and all the way out to your fingertips Breathe calmly and regularly . and let the relaxation spread to your stomach . waist and back Relax the lower part of your body, your buttocks . thighs . calves . feet . and all the way down to the tips of your toes Breathe calmly and regularly and feel how you relax more and more with each breath Continue to relax like that for a while Pause for about 1 minute. Now take a deep breath, hold it . and let the air out slowly . slowly . Notice how you relax more and more.
The pain is most often felt in the calf but may develop in the foot, thigh or buttock. It is usually relieved by resting for 2-3 min after which the patient may walk further. This must be differentiated from other causes of intermittent leg pain such as Disease causing isolated calf symptoms is often limited to the superficial femoral or popliteal artery and balloon angioplasty of these lesions tends to be technically feasible. However there is no level one evidence that angioplasty is superior to conservative management. Supra-inguinal disease often causes thigh and or buttock symptoms and may have a poorer response to conservative management. It would seem sensible to offer balloon angioplasty, with a complication risk of 1-4 , to patients with short lesions (
The lower extremity, as defined by this volume, consists of the femur, tibia, fibula, and the bones of the ankle and foot (Fig. 1). These lower limb long bones are the strongest within the human body, building on our evolutionary heritage of bipedal locomotion. The lower extremity has evolved to accommodate large amounts of compres-sive stress, a condition that has been compounded by modern life, with its hard surfaces and the potential for concentrated forces from certain types of footwear (e.g., high heel shoes). The hip joint provides for a wide circular range of movement with limitation of movement largely defined by the interference of soft tissue. The thigh angles inward so that pressure on the femur must be redirected into the hip joint. This structure leaves the femoral neck relatively weak, although it is well supported by the large muscles of the buttocks and thigh.
The measuring device should be checked for accuracy using a standard 2-m steel tape. Subjects should be measured to the nearest 0.1cm. Subjects, in minimal clothing with bare heads and feet, should stand straight, arms hanging loosely to the side, feet together and with heels, buttocks and shoulder blades in contact with the vertical surface of the stadiometer. Errors occur if subjects do not stand straight, do not keep heels on the ground, or overstretch. Diurnal variation results in people being 0.5-1 cm shorter in the evening than in the morning. Waist and hip circumferences are measured to the nearest 0.1cm using a flexible narrow nonstretch tape in adults wearing minimal clothing, standing straight but not pulling in their stomachs. Waist circumference is measured halfway between the lower ribs and the iliac crest, while hip circumference is measured at the largest circumference around the buttocks. Measurement error occurs if the tape is pulled too...
Coxsackievirus type A16, and occasionally types A4, A5, A9, and A10, are associated with hand, foot, and mouth disease. This entity is characterized by the development of a few small vesicles on the tongue, gingiva, soft palate, and buccal mucosa. These vesicles rupture, resulting in painful, shallow ulcers with a surrounding red halo. The lateral and dorsal aspects of the fingers and toes are frequently involved and aid the diagnosis. The buttocks, palms, and plantar surfaces of the feet may be affected. Fever is usually of short duration, and the disease lasts 5 to 8 days. Treatment is palliative. 11
Velmahos GC, Demetriades D, Cornwell EE, et al Gunshot wounds to the buttocks Predicting the need for operation. Dis Colon Rectum 40(3) 307, 1997. 9. Ferraro FJ, Livingston DH, Odom J, et al The role of sigmoidoscopy in the management of gunshot wounds to the buttocks. Am Surg 59(6) 350, 1997.
In this way, the fascial investments of the iliopsoas, piriformis, and obturator internus muscles and the fascial sheaths of the superior gluteal arteries provide anatomic pathways to the buttocks, hips, and thighs. Superiorly, the pelvic tissues above the levator ani and coccygeus muscles are continuous with the extraperitoneal portion of the abdomen.
If you had a vaginal delivery, you can nurse in bed by lying on your side with the baby facing you. You can also nurse in a chair by cradling the baby, holding the baby's head in the crook of your arm. Firmly support the baby's back and buttocks. Make sure the baby's entire body is facing your body, not the ceiling.
Many disease processes may be manifest by foot lesions. Acquired immunodeficiency syndrome may present with a variety of foot lesions, including Kaposi's sarcoma and nonhealing ulcers and those caused by bacterial and fungal infections such as histoplasmosis (which can present as maculopapular eruptions or depressed pits of the soles).49 These patients may develop neuropathies presenting as both paresthesias and dysesthesias. Secondary syphilis presents as a nonitching polymorphic rash that affects both the soles and palms. The rash of Rocky Mountain spotted fever, which is initially discrete, macular, and later petechial, is also found on the palms and soles. Cutaneous forms of tuberculosis have also been described that affect the feet. Hand-foot-and-mouth disease causes small vesicular lesions on the soles, palms, buttocks, and in the mouth. This entity is caused by coxsackievirus and occurs in the late summer and fall.
Femoral n The tensor fascia lata extends its tendinous fibers with the fibers of the gluteus maximus to form the iliotibial tract on the lateral aspect of the thigh. Muscles of this group are innervated by the superior gluteal nerve, which is composed mainly of fibers from the fourth and fifth lumbar nerve roots. The muscles of this group are required to maintain pelvic stability during of the stance phase of gait. During stance phase, body weight forces the bearing hip into adduction. Unless the Gluteus medius m (covered by facia) Gluteus maximus m. Gluteus medius m (covered by facia) Gluteus maximus m. The extensors consist of the gluteus maximus and hamstring muscles, including the long head of the biceps femoris, the semitendinosus, and the semimembranosus. Also an extensor is the posterior portion of the adductor magnus. The gluteus maximus is innervated by the inferior gluteal nerve, which is predominantly composed of fibers from the fifth lumbar and first...
Before applying a femoral traction splint at the scene, enough clothing must be cut or removed so that the extremity can be assessed for injury and distal neurovascular function. If the Hare splint (Fig 2-4) is used, the proximal half ring is placed in the crease of the buttocks against the ischial tuberosity. Traction is placed on the ankle with the padded ankle strap by one rescuer while the splint is strapped to the leg. The ankle strap is then attached to a ratcheting mechanism, and traction is applied. If a Sager splint (Fig.2-5) is used, the splint is placed on the medial side of the limb up against the groin. The padded ankle hitch is applied, and traction-applied elastic straps are then secured to hold the splint to the leg. With both splints, traction is applied until malalignment is reduced and pain is
Embalming is a funeral home procedure that prepares and preserves a body for an open-casket funeral and attempts to reduce the effects of various postmortem changes (75,76). Embalming leads to drying and hardening of soft tissues (75). Embalmed bodies eventually decay, beginning at pressure points such as the buttocks and legs, the areas least penetrated by embalming fluid (47,77).
The perianal abscess is the most common anorectal abscess and occurs when pus spreads caudally between the internal and external sphincters. It presents close to the anal verge, post midline, as a superficial tender mass, which may or may not be fluctuant. In contradistinction, ischiorectal abscesses tend to be larger, indurated, and to present more laterally, on the medial aspect of the buttocks. Deeper perirectal abscesses may not manifest cutaneous signs, but rectal pain and tenderness are invariably present. The isolated perianal abscess not associated with deeper, perirectal abscess(es) is the only type of anorectal abscess that can be adequately treated under local anesthesia in an ED setting.
During the history and physical, the clinician should note whether the hip pain is primarily in the anterior groin, in the buttocks or posterior thigh, or in the lateral aspect of the hip and thigh. Though there is some overlap, each of these regions has particular etiologies of pain associated with it. Buttock Posterior thigh gluteus maximus Patients with buttock and or posterior thigh pain can often be divided into those with radiating symptoms and others with tenderness. Patients with radiating symptoms often have a positive straight leg raise, indicating a possible herniated disc requiring a consult from a spine surgeon. Radiating symptoms can also be caused by a piriformis syndrome.8 These patients will complain of buttock pain and or sciatica that can increase with physical activity, including simple adduction and internal rotation. Sitting on hard surfaces can predispose to piriformis pain, causing a hip pocket neuropathy or wallet neuritis. A positive Pace sign, demonstrated...
This highly contagious infestation is caused by the Sarcoptes scabiei (0.2-0.4 mm in length). The infestation is transmitted by intimate contact or by contact with infested clothing. The female mite burrows into the skin, and after 1 month, severe pruritus develops. A multiform eruption may develop, characterized by papules, vesicles, pustules, urticarial wheals, and secondary infections on the hands, wrists, elbows, belt line, buttocks, genitalia, and outer feet.
Both the marked destruction of the epidermis and the tendency of the rash to heal in one area while developing in others. Lesions may occur anywhere, but the perineum, buttocks, groin, thighs, distal extremities, and perioral regions are most frequent. The rash also has a predilection for sites of friction, such as the intertriginous areas and sites of cutaneous trauma such as tight fitting garments and shoes. The rash characteristically waxes and wanes and is extremely pruritic. Secondary infections at the sites of excoriation can also occur.
The history of the acute illness may not alert the physician to the chronic nature of the underlying problem. The physical examination provides the clue to the diagnosis of long-standing malnutrition. Overall physical care and hygiene are frequently poor. Infants have very little subcutaneous tissue. The ribs protrude prominently through the skin, and the skin of the buttocks hangs in loose folds. There may be alopecia over a flattened occiput, reflecting that the baby has been allowed to lie on his or her back all day. Muscle tone is usually increased (although sometimes these babies are hypotonic). This increased tone is most notable in the lower extremities, and infants may manifest scissoring, similar to infants with cerebral palsy.2
The physical examination should note the child's overall hygiene and well-being. Normal children, especially toddlers who are just learning how to walk, may have multiple ecchymoses over the anterior shins, the forehead, and other bony prominences. Most falls result in bruises on only one body surface. Bruises over multiple areas, especially the low back, buttocks, thighs, cheeks, ear pinnae, neck, ankles, wrists, corners of the mouth, and lips suggest physical abuse. Handprints may be observed, or there may be uniform but bizarre bruises caused by belts, buckles, cords, or blunt instruments. 30 Bites produce bruising in a characteristic oval pattern, with teeth indentations along the periphery. Lacerations of the frenulum or oral mucosa may be present, especially in infants who have been force fed. Lacerations and abrasions in the genital area are seen in toddlers who are punished because of toilet-training accidents. Burns constitute another form of inflicted injuries.33 These may...
Progression to full weightbearing with restoration of an efficient gait pattern is not advised if the Trendelenburg test is still positive. These patients may require a cane used in the contralateral upper extremity to help reduce torque at the pelvis and minimize the demand on the gluteus medius, minimus, and tensor fascia lata. Stability in unilateral stance is the most difficult activity for these muscles to perform and is essential for progression to more challenging and functional gait activities.7 (Figure 17.15.) Patient's gait should have an even step length with good pelvic stability, push-off, and cadence.
Pyomyositis (primary muscle abscess) is an acute bacterial infection of the skeletal musculature. Staphylococcus aureus is the organism most commonly cultured from the abscess it is seen in up to 90 of cases in tropical areas and 75 of cases in temperate countries. Group A streptococcus accounts for another 1 to 5 of cases. The term pyomyositis should be restricted to primary muscle abscesses arising within the skeletal musculature and should not be used to describe (1) intermuscular abscesses, (2) abscesses extending into muscles from adjoining tissues, such as bone or subcutaneous tissues, or (3) pyemic intramuscular abscesses secondary to previous sepsis. Fatal cases of pyomyositis seen in the forensic pathologic setting usually arise from a preceding trauma, such as a fall or assault.10 Intravenous drug abuse is another important risk factor for pyomyositis.10 The factors responsible are impaired cellular and humoral immunity, defective bactericidal capacity of neutrophils,...
During the detailed secondary survey, a concerted effort should be made to closely inspect the perineum. Blood on the underwear is an important finding. In both male and female patients, the folds of the buttocks should be spread in search of perineal lacerations, which often denote an open pelvic fracture. Such lacerations should not be probed lest a clot be disrupted and exsanguinating hemorrhage result. During the rectal examination, sphincter tone, the position of the prostate gland, and presence of any blood should be noted. If the prostate is riding high or feels boggy, there has been a disruption of the membranous urethra. Next, the scrotum is palpated and inspected for ecchymoses, laceration, and testicular disruption. Simultaneously, the length of the penis is palpated to inspect for blood at the meatus. In females, the labia are inspected for lacerations and hematomas. If there is any evidence of likelihood of trauma in this area, a bimanual vaginal examination is required....
The horse has a crease down the back. Spaces between the ribs are filled with fat so that the ribs are difficult to feel. The area along the withers is filled with fat, and fat around the tailhead feels very soft. The space behind the shoulders is filled in flush, and some fat is deposited along the inner buttocks. There is noticeable thickening of neck. 9 Extremely Fat. The crease down the back is very obvious. Fat appears in patches over the ribs, and there is bulging fat around the tailhead, withers, shoulders, and neck. Fat along the inner buttocks may rub together, and the flank is filled in flush.
The infant is grasped around the back with the left hand, and the right hand is placed, near the vagina, under the baby's buttocks, supporting the infant's body. The infant's body is rotated toward the operator and supported by the operator's forearm, freeing the right hand to suction the mouth and nose. The baby's head should be kept lower than the body to facilitate drainage of secretions.
Arthroscopy is not a substitute for clinical acumen. The myriad etiologies of inguinal and buttock pain include many extra-articular conditions. (See Chapters 1 and 2.) The vast majority of these cases are self-limited and will resolve with time and appropriate conservative management. Numerous psychological, emotional, and legal as well as physical issues can contribute to pain intensity, extent, and protractedness. Occasionally an intra-articular joint injection with Aristocort and
Until recently, radiographic demonstration of loose bodies within the hip joint required an open arthrotomy for treatment. The open procedure, however, carried with it a plethora of potential risks. These risks included avascular necrosis of the femoral head (especially if the hip was dislocated or a posterior approach was utilized), neurovascular injury (especially if a lengthy split was made in the gluteus medius during a direct lateral approach), and thromboembolic disease. In addition, open arthrotomy of the hip necessitated an inpatient hos-pitalization, was costly, and had a protracted rehabilitation period. For each of the above reasons, open hip surgery was performed with reluctance and only for the most compelling of reasons. Rarely was an arthrotomy performed for diagnostic reasons.
In breech presentations, the presenting fetal part is the buttocks. Normally, the delivery is C-section. Incidence 3.5 at or near term but much greater in early pregnancy (14 ). Those found in early pregnancy will often spontaneously convert to vertex as term approaches.
Accidental burns from hot objects usually occur on the hands.36 Contact burns in child abuse are often on the buttocks or perineum from the child being placed on a hot surface.17,19 The burn often shows a pattern corresponding to the hot object causing the burn, with a well-delineated edge.20,29 For example, the typical cigarette burn seen in child abuse is small and circular.24 Contact burns resulting from abuse are generally well defined and even in depth (Figure 9.3), whereas accidental burns usually show more intense burning on one side.29 Hot wax dripping from a candle or poured from a tea light will, under normal circumstances, not cause a burn.
The segmental arrangement of the spinal cord and spinal nerves is preserved in the thoracic regions, although for the limbs there is complicated crossing over and linking in plexi, for the arm the brachial plexus and for the buttocks and legs the lumbosacral plexus. A myotome is the muscle tissue supplied by a single spinal motor root and the dermatome is the area of skin which sends sensory information inwards through a single spinal sensory root.
Dermatitis herpetiformis This is characterized by an extremely pruritic papulovesicular eruption, which usually occurs symmetrically on the elbows, knees, buttocks, and back. About 80 of patients with dermatitis herpetiformis have small intestine histology indistinguishable from celiac sprue. The diagnosis is established by skin biopsy demonstrating granular IgA deposits in areas of normal appearing skin. A majority of patients with the skin lesion who undergo small bowel biopsy have intestinal mucosal changes of celiac disease. The skin lesions, as well as small bowel histology, improve on a gluten-free diet. Dapsone is an effective short-term treatment for dermatitis herpetiformis however, it does not have any impact on management of small bowel enteropathy. Also, those with dermatitis her-petiformis who are not compliant with the gluten-free diet are at higher risk for malignancy, as are those with celiac disease.
Potential donor sites include the lateral thigh, buttocks, and abdomen, since these areas provide thick skin with minimal donor-site morbidity. On average, a thickness of 0.016 to 0.018 in. is taken from the donor site using a dermatome. Thinner grafts of 0.012 to 0.014 in. are taken in elderly or very young patients. The skin graft is generally meshed at the ratio of 1 1.5 to allow for drainage from under the graft. Unmeshed grafts are more esthetic but require a very dry recipient site and pose a higher risk of incomplete healing due to the development of a hematoma or seroma from under the graft.
Coccygeal injuries are usually associated with direct falls onto the buttocks. Patients typically describe intense pain with sitting and straining. Diagnosis of fracture is made on rectal examination. Pain will be elicited with motion of the coccyx. X-rays are not needed. Treatment is symptomatic, and includes analgesics and use of a rubber doughnut pillow.
If peripheral veins are not available, a cutdown at the forearm veins or an attempt at cannulation of the external jugular vein should be the next choice. Cannulation of the femoral vein is another option, and will be facilitated by placing a towel under the ipsilateral buttock and having an assistant retract the panniculus. Venisection at the saphenous vein, a common alternative in patients of normal weight, will be challenging because of excess adipose tissue. Femoral catheterization is preferred over saphenous venisection in the obese patient with a palpable femoral pulse.
Inflicted scalds in children usually occur to the buttocks, perineum, or limbs because of deliberate immersion in hot water.2023 The resulting scald is typically deeper than those resulting from splashing and has a well-demarcated edge or tide mark (Figure 9.2).17,24,29,30 Occasionally immersion-type scalds have a central area of spared skin where the child's body has been pushed against the side or bottom of the container containing the hot liquid.29
In the second and third trimesters of pregnancy tracheal intubation is considered mandatory because of the potential for acid aspiration. For the same reasons rapid sequence induction (RSI) with cricoid pressure is also necessary. The hormonal changes of pregnancy, as pertaining to intestinal function, remain for some 48 H post partum and so it is wise to apply RSI for up to a week after delivery. The standard general anaesthetic technique involves a wedge under the right buttock to displace the uterus from the inferior vena cava, rapid sequence induction with thiopentone and suxamethonium (propofol has no licence for use in late pregnancy). Tracheal intubation should be followed by controlled ventilation of the lungs with 50-70 nitrous oxide and a volatile agent of choice. Suitable muscle relaxants include atracurium and vecuronium. Mivacurium should be used with care due to the reduced activity of plasma cholinesterase in late pregnancy which may delay its offset. At the end of the...
Once the patient can move smoothly through the range of motion it is time to further strengthen the affected muscles. Restoring strength to the hip-stabilizing muscles should begin in their shortened range. The gluteus medius functions primarily eccentrically in the initial contact to the midstance phase of gait to stabilize the pelvis on the femur in the frontal plane. Before developing eccentric strength, the gluteus medius must achieve isometric and concentric strength. Isometric contractions can be elicited in the hips during a lateral-push wall exercise. (Figure 17.9.) Isometric exercise duration should begin at 5-10 seconds. Isotonic strength can be attained through a side-lying leg lift. This exercise is often done incorrectly with the patient rotating the hip externally to substitute for the weak gluteus medius with the tensor fascia lata and hip flexor muscles. (Figure 17.10.) Leg lifts can also be performed into hip extension and hip adduction. Active hip extension in the...
Open areas should be evaluated carefully for evidence of tracts. Other wounds proximate to a pressure ulcer should be documented carefully with a suspicion that they may be connected by tracts. Evaluation should include probing for tracts, looking for undermined areas, obtaining radiographs to assess bony changes of osteomyelitis, and an erythrocyte sedimentation rate (ESR) or C-reactive protein determination. If cellulitis or bone changes are identified, consider admission for institution of intravenous antibiotics and a complete evaluation of bone involvement. Simple pressure ulcers without evidence of infection or extension can be treated successfully with local measures and pressure relief. Superficial wounds can be treated with sulfadiazine or duoderm wafers. Deeper wounds require wet-to-dry or gel dressings. Sulfadiazine, wet-to-dry dressings, and gel dressings are changed two to four times daily. Duoderm wafers are left in place for up to 3 days at a time if they remain dry and...
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