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Different injuries of the musculoskeletalsystem its management and care
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ARTICULAR DISOR DERS
y Osteoarthritisy R heumatoid arthritisy Gouty arthritis
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Rheumatoid Arthritisy Chronic, systemic, inflammatory
disease of the synovium/synovial membrane
y W ith remission and exacerbationy Commonly affecting the smaller
synovial joints
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P athophysiology y A utoimmune response leukocytes
infiltration of synovium stage 1: synovitis
accumulation of inflammatory exudates joint effusion joint capsule thickens withconnective tissue stage 2: p annusformation erosion of articular cartilageand subchondral bones stage 3: fibrousankylosis stage 4: bony ankylosis
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S igns and S ym p tomsy B ilateral/symmetrical involvement y F every Inflammatory response (pain, swelling,
heat, redness)y E arly morning stiffness (15-30 mins)y Limited ROMy M uscle fatiguey A nemia and Leukocytosis
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Laboratory/Diagnostic Testsy Increased A lkaline P hosphatase,
Erythrocyte Sedimentation R ate (E SR ), c-reactive protein
y M oderate anemia and leukocytosisy X-ray findings ( soft tissue swelling, joint
space narrowing, cartilage erosion)y A rthrogramy A rthroscopy
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Rheumatoid arthritis y Pannus formation
secondary tosynovitis
y Thickening of thejoint capsule
y Knobby wrist andknuckels
y Ulnar drifty Z-hand deformityy Swan neck and
buotonniere
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M anagementy
S ym p tomaticy R elief of pain
y A nalgesics, R est, Ice/Hot packs, A ssistivedevices
y NSAI Ds or corticosteroidsy P revent deformity
y P rovide support to joint at all times, provide
passive or active ROM exercisesy Surgery
y S ynovectomy, A rthrodesis, A rthroplasty, A rthrotomy, Osteotomy
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O steoarthritisy Chronic, nonsystemic, non-
inflammatory disease characterized by d egeneration and loss of articularcartilage in synovial joints
y Idiopathic and slowly progresssive
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Osteoarthritisy Chronic, nonsystemic,
and noninflammatory
form of arthritisy Commonly affecting weight-bearing joints of the body
y
Cartilage degenerationsecondary to aging,obesity or wear and tearof the joint
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y P atho p hysiology y
O besity, wear & tear of jt., agingdegeneration of articular cartilagethinning of the cartilage destruction of cartilage exposure of underlying bonefriction develops bone spurs/ bony overgrowth formed deformity fatigue
immobility y S ame management as with RA (symptomatic)
y R elief of painy P revent deformity y Surgery
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Gouty A rthritisy S ystemic and inflammatory disorder of the
diarthrodial joint secondary to h yperuricemiay Exessive accumulation of serum uric acidy M ay be hereditary due to abnormal purine
metabolismy Characterized with recurring acute attacks and
intervals of freedom from painy Causes crippling, deforming arthritis, nephritis,
renal calculi, cardiovascular lesions
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y Commonly affecting d istal jointsy P
rimarily in men 40 y/o and
abovey Stages of Gouty A symptomatic hyperuricemia
y Elevated serumuric acid level but produce nosymptoms
y A cute gouty arthritisy P odagray M ay subsidee quickly or last for days/weeks
y Intercritical gouty 2nd attack may occur within 2 mos-10 yrs
y Chronic tophaceous gouty Skin may ulcerate and release a chalky, white
exudate or pus
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Gouty arthritisy Common sites of
tophus: ear lobe, wrist,and fingers
y Skin may ulceratey Tophus
characterized ascheesy, chalky, whiteand pasty appearance
y Secondary tohyperuricemia
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Gouty arthritisy Chronic
tophaceous goutstagey Tophus/tophi
formationy Deposits of
monosodiumurate crystals
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M anagementy A ntigout medications ( Colchicine, A llopurinol,
P robenecid)y NSAI DS to control inflammationy Bed rest, affected extremity may be immobilized
in a pillow; bed cradley Ice pack y Gradual weight reductiony A dequate hydration (3 L/day)y Diet: High CHO , alcohol restriction, low purine
(avoid organ meats, yeasts, fish, mushrooms,poultry products, shellfish, asparagus, spinach)
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M usculoskeletal Traumasy SP RAI Ny
STRAI Ny F RACTUR Ey DISLOCATIO Ny CO NTUSIO N
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SP RAI N V S. STRAI Ny A sprain is a stretching or tearing of ligaments, the tough,
fibrous bands of tissue that connect bones to one anotherat a joint.
y
A strain is a stretching or tearing of muscle tissue,commonly called a pulled muscle.y A nything that places sudden or unaccustomed stress on --
or chronic overuse of -- joints or muscles may cause asprain or strain.
y Falls, lifting heavy objects, and the exertion of anunfamiliar sport are common culprits.
y Being overweight, inactive, or in poor physical condition boosts the likelihood of injury. Improperly warming upand not stretching muscles before intense physicalactivity can also result in injury.
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Ankle Sp rain* M ay be due to suddentwisting/ankleinversion* M ost common:Talofibular ligament
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ST RAIN*
Tendinitis/ elbow strain
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F RACTUR Ey SALT ER -H ARRRIS CLASSI F ICATIO N
W hen I explain bone structure to my patients, I tellthem to think of the bone like an Oreo cookie.
You have the top cookie (metaphysis), the bottomcookie (epiphysis), and the creamy middle (growthplate). Salter Harris fractures can occur to either thetop or bottom part of the bones, or both.
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SALT ER -H ARRIS CLASSI F ICATIO N
y S alter Harris T y p e I Fracturesy T ype I growth plate fractures involve a fracture
through the growth plate. Imagine taking the oreocookie and seperating the top and bottom halves.This type of fracture may not be visible on an X-ray,and usually doesn't cause any growth problems.
y
Treatment usually consists of immobilization for aperiod of time, 4-6 weeks.
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y
T y p e II Fracturesy This is the most common type of Salter Harris
fracture. A type II fracture involves a break in the bone through the metaphysis and extending into the
growth plate.y So, in the O reo example, imagine breaking off part of
the top cookie.y T ype II fractures usually do not cause growth
problems, and are treated with immobilization. I t isimportant that the fracture be aligned correctly inorder to heal properly.
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y T y p e III Fractures
y T ype three fractures extend through the epiphysisinto the growth plate. This type of fracture is morelikely to cause growth problems because of theinvolvement of the epiphysis and the disruption of the growth plate.
y They may also require surgical intervention in orderto re-align the bones for optimal recovery.
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T y p e IV Fractures
y This Salter Harris F racture extends through both themetaphysis and the epiphysis.
y Imagine breking your Oreo cookie in two.y Long term disability and growth problems are
common with this type of fracture because of thedisurption of both the metaphysis and epiphysis.
y Surgical intervention is common in order to re-alignthe bones correctly.
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DISLOCATIO N
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CO NGEN ITAL BONE D ISOR DERSy Congenital Hip Dislocation/ Developmental Hip
Dysplasiay
Clubfoot/ Talipes Equinovarusy Osteogenesis Imperfecta
y ACQUIR ED DE F ECTy Coxa plana/ Legg-calve-perthes disease
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Congenital Hip Dislocationy A .k.a. hip dysplasiay Displacement of
femoral head from theacetabulum
y M ay be secondary to breech delivery orabnormal release of maternal hormonesduring the 3 rdtrimester
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Special testsy Ortolanis test
y Barlows testy Telescoping
y
Galleaziy Trendelenburg
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MA N A GEM EN T
1. R eduction2. Immobilization3. R ehabilitation
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CLU BF
OOT
Combinations:1. Tali p es equinovarus2. Talipes equinovalgus
3.Talipes calcaneovalgus4.Talipes calcaneovarus
y A genetic malformation in which the foot is twistedout of its normal position
y Variations:y Talipes equinusy Talipes calcaneusy
Talipes varusy Talipes valgus
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M anagementinclude:
Careful footmanipulation
Serial casting
Surgicaloperation
Use of Dennis Brownesplint
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Osteogenesis imperfectay Congenital
brittle-bonediseasey M ay be
secondary togenetic defecty Blue sclera
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Osteogenesis Imperfectay Hyperextensibility
of ligamentsy Secondary to
aberration of
p rocollagen
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Osteogenesis Imperfecta
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C oxa planay A lso known as Legg- Calve-
P erthes diseasey F lattening of femoral head
secondary to avascularnecrosis
y Self-limiting commonamong boys
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S igns & S ym p tomsy K nee pain (may be the only symptom, initially)y P ersistent thigh or groin painy A trophy (wasting) of muscles in the upper thighy Slight shortening of the leg, or legs of unequal
lengthy Hip stiffness restricting movement in the hipy Difficulty walking, walking with a limp (which is
often painless)y Limited range of motion
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T reatmenty The aim of treatment is to protect the bone and jointfrom further stress and injury while the healingprocess takes place.
y Bedrest or crutches may be needed during the initialphase.
y A brace, cast, or splint to immobilize the hipsposition may be used while bone regrowth takes
place.y Surgery may be performed to keep the hip in its
socket.
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Stages of
LCPD
y A vascularnecrosis
y R evascularizationy R eparativey
R egenerative
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SP IN AL DISOR DER y Herniated Nucleus P ulposus/ R uptured
Intervertebral disk y Scoliosisy Lordosis
y K yphosisy P otts disease
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Herniated nucleus
pulposusy Slipped discy May be secondary to
fall or improper
back mechanicsy Displacement of the
nucleus pulposusfrom annulusfibrosus(intervertebraldiscs)may causecompression ofspinal nerves
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Herniated
NucleusP ul p osus
*L5- S1** Sciatica ( radiating
p ain from low back tothe buttocks andp osterior thigh)aggravated by coughing valsalvamaneuver andsneezing***P ro p er back mechanics
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Scoliosis
y Lateral
curvature of thespine withrotation
y Curvature ismeasured throughCobb method
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ClassificationI . A ccording to etiology
y Idiopathicy
Structuraly Nonstructural/postural
II . Severity III . Convexity y M ild * dextroscoliosis y M oderate * levoscoliosis ( L)y Severe
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LOR DOSIS vs. K Y P HOSISy S wayback deformity Humpback deformity y Cervical, lumbar Thoracic spiney P
regnancy, obesity TB, compressionlarge abdominal tumor spine fx,osteoporosisy Excessive pelvic angle, >40 degrees, canP rotruded abdomen/buttocks cause pulmonary
and G I dysfunctiony P ostural exercises
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P athophysiology of
metabolic bone disorders
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P redisposing factors toM etabolic bone conditions
y Inadequate exposure to sunlighty
Hypothyroidism, hyperparathyroidismy Osteopenia
y Steatorrheay Very low fat diet
y Strict vegetarianismy Chronic renal failure
y Liver disease
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OST EOP OROSISy porous bonesy Characterized with greater bone resorption than
formation; low Bone M ass Density y M odifiable risk factors Non-modifiable risk factor
y A lcohol consumption * age, sex, race, long termy Calcium low glucocorticoid usey Corticosteroid usey Estrogen low y Smokingy Sedentary lifestyle
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Sympt o matic
management:H igh Calcium dietPostural exercisesPrevent complications
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R ickets and Osteomalaciay S oftening of bones
among children and
adults, res p ectively y Secondary to vit. D
deficiency y P igeon-chesty Genu varumy W eak and brittle bones
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y Encourage highcalcium diet
y Vit. D supplementy P revent
complicationsy Exercisesy Use of assistive
devices, bracesy Surgery to correct
deformities
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Osteitis Deformansy A .k.a. P agets diseasey Characterized with
excessive osteoclasticactivity
y Honeycombedappearance of bones seenon X-ray
y Expanded skull, barrel-chest, wider hips, genu
varum are the commondeformities
y IM calcitonin may be indicated
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P OTT S DIS E ASEy caused by M ycobacterium tuberculosis .y P otts caries , Davi d' s d isease , and
extrapulmonary TB, is a medical condition of thespine.
y A .k.a. tuberculous spondylitis (one of the oldestdemonstrated diseases of humankind, having
been documented in spinal remains from theIron A ge and in ancient mummies from Egypt
and P eru)y In 1779, P ercivall P ott, for whom P ott disease is
named, presented the classic description of spinal tuberculosis
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P athophysiology Direct / metastatic infection
A ccumulation of tubercle bacilli in the spine
Inflammatory response
P us/ A bscess develops
Liquefaction of the spine
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Destruction of vertebral bodies
Collapse of vertebral bones
K yphosis/ Gibbus deformity
Narrowing of spinal canal
Compression of spinal nerves/ SC
P otts paraplegia
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Signs and symptomsy back pain, night sweats, fever, weight loss,
and anorexiay may also develop a spinal mass, which
results in tingling, numbness, or a generalfeeling of weakness in the leg muscles
y K yphosis/gibbus deformity y walking in an upright and stiff position due
to painy P araplegia in the late stage
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P athophysiology y P ott disease is usually secondary to an extraspinal
source of infection. The basic lesion involved in P ottdisease is a combination of osteomyelitis andarthritis that usually involves more than one
vertebra. The anterior aspect of the vertebral body adjacent to the subchondral plate is area usually affected.
y Tuberculosis may spread from that area to adjacentintervertebral disks. In adults, disk disease issecondary to the spread of infection from the
vertebral body. In children, because the disk is vascularized, it can be a primary site. 3
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y P otts disease is caused when the vertebrae becomesoft and collapse as the result of caries or osteitis.
y T ypically, this is caused by mycobacteriumtuberculosis .
y A s a result, a person with P ott's disease oftendevelops kyphosis , which results in a hunchback.This is often referred to as P otts curvature/gibbus
y In some cases, a person with P ott's disease may alsodevelop paralysis, referred to as P otts paraplegia ,
when the spinal nerves become affected by thecurvature.
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y OT HE R SI GNS A ND S Y M P TOMSy A person with P ott's disease may experience
additional complications as a result of thecurvature.
y F or example, an infection can more easily spread from the paravertebral tissue, whichcan cause abscesses to occur.
y R egardless of the complications that may occur, P ott's disease is typically slow spreadingand can last for several months or years.
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y MA N A GEM EN Ty prevention is possible through proper control
(the best method is reduce or eliminate thespread of tuberculosis)
y P ott's disease may be treated through a variety of options:
y He or she may utilize analgesics or antituberculousdrugs to get the infection under control. ( RI P ES)
y I t may also be necessary to immobilize the area of thespine affected by the disease, or the person may needto undergo surgery in order to drain any abscesses thatmay have formed or to stabilize the spine.
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y In addition, testing for tuberculosis is animportant preventative measure, as those
who are positive for purifie d proteind erivative (PP D) can take medication toprevent tuberculosis from forming.
y A tuberculin skin test is t h e most commonmet h od used to screen for tuberculosis,
y though blood tests , bone scans, bone biopsies, and radiographs may also be usedto confirm the disease.
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OST EOM YELITISy inflammation an d d estruction of bone cause d by
bacteria, mycobacteria, or fungi.y Common symptoms are localize d bone pain an d
ten d erness wit h constitutional symptoms (in acuteosteomyelitis) or wit h out constitutional symptoms(in c h ronic osteomyelitis).
y M ost common cause is the Staphylococcus aureus;affecting primarily long bones
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Etiology y Contiguous spread (from infected tissue or aninfected prosthetic joint)
y Bloodborne organisms (hematogenousosteomyelitis)
y Open wounds (from contaminated open fractures or bone surgery)
y
Trauma, ischemia, and foreign bodies predispose toosteomyelitis.y Osteomyelitis may form under deep decubitus ulcers.
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P athophysiology Direct/ M etastatic infection
A ccumulation of microorganism
Inflammatory response
P us/ A bscess formation
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Cutting off of blood supply
Lack of blood supply to the area
Necrosis
Septic shock
Death
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Signs and symptomsy acute osteomyelitis of peripheral bones:
y weight loss, fatigue, fever, and localized warmth,swelling, erythema, and tenderness.
y vertebral osteomyelitisy localized back pain and tenderness with paravertebral
muscle spasm that is unresponsive to conservativetreatment. P atients are usually afebrile.
y
chronic osteomyelitisy intermittent (months to many years) bone pain,
tenderness, and draining sinuses.
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D iagnosisy ESR or C-reactive proteiny X-rays, MRI , or radioisotopic bone scanningy Culture of bone, abscess, or both
T reatmenty A ntibiotics; meticulous wound & skin carey Surgery if abscess, constitutional symptoms,
potential spinal instability, or much necrotic boney A ntibiotics are selected to cover both gram-positive
and gram-negative organisms until culture resultsand sensitivities are available.
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T hi si nt r ao
per ati v e
phot o
s
how san
AH O
l esi on
w it hi n
t he
ti bi a.
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AM P UTATIO Ny W hat is am p utation?y W hen performing an amputation, a surgeon
removes a limb, or p art of a limb , that is nolonger useful to you and is causing you great pain, orthreatens your health because of extensive infection.
y P hysicians as well as patients consider amputation alast resort .
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CAUS ESy (P ERI P HE RAL ART ERIAL DIS E ASE) P A D is the
leading cause of amputation in people age 50 andolder, and accounts for up to 90 percent of amputations overall.
y traumatic injury, such as a car accident or a severe burn, can also destroy blood vessels and cause tissuedeath.
y cancerous tumor
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NURSI NG INTER VENTIO NSy Discuss
y R ehab.program and use of prosthesisy Upper extremity exercise such as push up in bedy Crutch walkingy
A mputation dressingy P hantom limb sensation as normal occurence
y O bserve stump dressing for signs of hemorrhage andmark outside of dressing so rate of bleeding can be
assessedy K eep torniquet readily available at bedsidey P revent edema
y R aise extremity with pillow for first 24 hrs.
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LEVEL S O F A M PUT A T IO N
1. B elow K nee A mputation2 . A bove K nee A mputation3 . B elow Elbow A mputation4 . A bove Elbow A mputation
5. Disarticulation-through the jt.
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B MD test
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P ersonundergoing a
bone scan on
the skull.
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An example of shoulder
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arthroscopy. Thesurgeon looks at a videoscreen which isconnected to a camerathat is inserted into thebody, together withworking instruments.
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L eft knee aspi r ati o nusing the medial
pa r apatella r app ro ach.
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