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HPV testing proved to be tions and free-download books are available at more reliable in correctly diagnosing CIN 2 or http://www purchase cheap levonorgestrel on-line birth control for women youtube. We strongly recommend you to superior performance of HPV DNA testing as a go and visit that page discount 0.18 mg levonorgestrel visa birth control womens liberation. Visual inspection with acetic acid and Lugol’s In another landmark study Sankaranarayanan iodine et al purchase genuine levonorgestrel online birth control pills walgreens. There are three approaches: of care which involved no screening as the control group. Women who had positive tests underwent ‘Screen-and-treat’ approach colposcopy with directed biopsies and those with cervical cancer precursors were treated. The inci- In this approach, treatment decisions are based on dence rate of cervical cancer stage 2 or higher and the results of the screening test, without a prior death rates from cervical cancer were significantly diagnostic test. Most screen-positive women can be higher in the cytologic and VIA groups compared treated with cryotherapy at primary healthcare to the HPV-testing group. In the HPV-testing level at the time of screening; this could reduce loss group the hazard ratio (the probability that an inci- to follow-up and have an impact on cervical cancer 323 GYNECOLOGY FOR LESS-RESOURCED LOCATIONS control. However, tissue will not be available for Note: visual methods are not recommended for use in histological confirmation. Colposcopy-based ‘see-and-treat’ approach The following materials and equipment are needed To address the issue of potential overtreatment for visual methods: with the screen-and-treat approach, an intermedi- ate approach can be used. Patients with a positive • Soap and water for washing hands. If a pre-cancerous • A speculum, high-level disinfected (it need not lesion is detected, it can be treated immediately. This approach is contingent on the avail- • Dilute acetic acid solution (3–5%) or white ability of equipment and trained and experienced vinegar. Explain the procedure, how it is done, and yet been implemented, healthcare workers can what a positive test means. Ensure that the apply acetic acid (white vinegar) during each specu- woman has understood and obtain informed lum examination that is performed for any other consent. Adjust the light source in order to get the best view of the cervix. Use a cotton swab to remove any discharge, Visual screening method blood or mucus from the cervix. In VIA we inspect the transformation or transition 5. Apply acetic acid or Lugol’s iodine to the epithelium of the uterine cervix). In a visual test, cervix; wait a minute or two to allow color the provider applies acetic acid (in VIA) or Lugol’s changes to develop. Observe any changes in iodine solution (in VILI) to the cervix, and then the appearance of the cervix. A VIA test is attention to abnormalities close to the transfor- positive if there are raised and thickened white mation zone. Inspect the SCJ carefully and be sure you can positive if there are mustard or saffron-yellow see all of it. Either test is suspicious for cancer if a plaques or aceto-white epithelium if you used cauliflower-like fungating mass or ulcer is noted on acetic acid or saffron-yellow colored areas after the cervix. Visual screening results are negative if application of Lugol’s iodine. Remove any the cervical lining is smooth, uniform and feature- blood or debris appearing during the inspec- less; it should be pink with acetic acid and dark tion. For a schematic overview of the test, brown or black with Lugol’s iodine. Figure 7 shows examples of 324 Cervical Cancer Prevention and Treatment (a) Figure 6 Schematic overview of the cervix and the aceto-white area. Courtesy of Screening Group (SCR), International Agency for Research on Cancer (WHO- IARC) a negative and positive VIA tests and non- invasive cervical cancer. Use a fresh swab to remove any remaining (b) acetic acid or iodine solution from the cervix and vagina. Draw a map of any abnormal findings on the record form. A sample of a record form and map can be found at: http://screening.

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A dh erence/C ompliance: 91% adherence A N A L Y SIS: IT T :no Postrandomizationexclusions:yes(5) A DEQ U A T ER A N DO M IZ A T IO N : ProcedureN R A DEQ U A T EA L L O C A T IO N N R C O N C EA L M EN T : B L IN DIN G O F O U T C O M E N o A SSESSO R S: A T T R IT IO N (overall): O verallattrition:9% attrition Differentialattritionh igh :no A T T R IT IO N (treatmentspecific): psyllium placebo T otalattrition: 6 buy 0.18mg levonorgestrel otc birth control pills norethindrone. Y ear: 2004 C ountry:U SA F U N DIN G : N R R ESEA R C H O B JEC T IV E: Toevaluatethesafetyof PE G 3350inchildrenunder2forthetreatm entof constipation 0.18mg levonorgestrel birth control pills name brands. DESIG N : Studydesign:R etrospectivechartreview Setting:outpatient Samplesize:75 IN T ER V EN T IO N : PEG 3350 Dose: Startedat1m g/kg/dayadjustedbyparentstoproduce2softstoolsperdayasneeded Duration: 6m onths Samplesize: 75 IN C L U SIO N C R IT ER IA : A llchildren<2yearsof ageattim etheystartedPE G ;idiopathic constipationdefinedbyN A SPG H A N criteria;seenbetween2000and2003 EX C L U SIO N C R IT ER IA : H irschsprung’sdisease;chronic intestinalpseudo-obstructionorprevioussurgeryonthecolonoranus; diseasestatesplacing lim itsontheactof defecationlikehypotonia purchase genuine levonorgestrel online birth control zovia side effects,cerebralpalsy,severem ental retardation O T H ER M EDIC A T IO N S/ N R IN T ER V EN T IO N S A L L O W ED: Constipation Drugs Page 115 of 141 Final Report Drug Effectiveness Review Project A uth ors:L oening-B auckeetal. Y ear:2004 PO PU L A T IO N G roupssimilar atbaseline:N /A C H A R A C T ER IST IC S: PEG 3350 M eanage(years): 17m onths Patientsaged 65 yearsor older (% ): 0 Sex(% female): 52. Y ear:2004 A DV ER SEEV EN T S: PEG 3350 (treatment4 month sor less) PEG 3350 (treatment6 month sor more) O veralladverseeffectsreported: N R N R • diarrhea 7 2 • headache • nausea • abdom inalpain • flatulence • treatm entrelatedupsets • distension Significantdifferencesinadverse A E swerenotdefined,som ewerepre-specified. L ab tests— CBC,electrolytes,L F Tsperform edoccasionallyandallcheckedwerenorm al. A dh erence/C ompliance: N oncom pliance1% short-term and2% long term A N A L Y SIS: IT T :N /A Postrandomizationexclusions:N /A A DEQ U A T ER A N DO M IZ A T IO N : N /A A DEQ U A T EA L L O C A T IO N N /A C O N C EA L M EN T : B L IN DIN G O F O U T C O M E N /A A SSESSO R S: A T T R IT IO N (overall): O verallattrition:N /A Differentialattritionh igh :N /A A T T R IT IO N (treatmentspecific): PEG 3350 T otalattrition: W ith drawalsdueto adverseevents: N onereported Q U A L IT Y R A T IN G : Poor Constipation Drugs Page 117 of 141 Final Report Drug Effectiveness Review Project C h ronicC onstipationandIB S-C 42 ST U DY : A uth ors,article#: M cR orieetal. Y ear: 1998 C ountry:U SA F U N DIN G : ProctorandG am bleCom panyandtheO klahom aF oundationforD igestiveR esearch R ESEA R C H O B JEC T IV E: Com pareclinicalefficacyandsafetyof psyllium anddocusatesodium DESIG N : Studydesign:doubleblindR CT Setting:N R ,m ulti-center Samplesize:187 IN T ER V EN T IO N : psyllium docusatesodium Dose: 5. Y ear:1998 PO PU L A T IO N G roupssimilar atbaseline:N R C H A R A C T ER IST IC S: psyllium docusate O verall M eanage(years): Patientsaged 65 yearsor older (% ): 37. Y ear:1998 A DV ER SEEV EN T S: psyllium docusatesodium O veralladverseeffectsreported: • diarrhea N R N R • headache N R N R • nausea N R N R • abdom inalpain N R N R • flatulence N R N R • X • Y Significantdifferencesinadverse events: A dh erence/C ompliance: N R A N A L Y SIS: IT T :no Postrandomizationexclusions:yes(9%) A DEQ U A T ER A N DO M IZ A T IO N : N R A DEQ U A T EA L L O C A T IO N N R C O N C EA L M EN T : B L IN DIN G O F O U T C O M E Y es A SSESSO R S: A T T R IT IO N (overall): O verallattrition: N R Differentialattritionh igh :N R A T T R IT IO N (treatmentspecific): psyllium docusatesodium T otalattrition: N R N R W ith drawalsdueto adverseevents: N R N R Q U A L IT Y R A T IN G : Poor Constipation Drugs Page 120 of 141 Final Report Drug Effectiveness Review Project C h ronicC onstipationandIB S-C 77 ST U DY : A uth ors,article#: M ich ailetal. Y ear: 2004 C ountry:U SA F U N DIN G : N R R ESEA R C H O B JEC T IV E: E valuatethesafetyof PE G 3350inchildrenagedlessthan18m onthsorlesswithchronic constipation DESIG N : Studydesign:retrospectivecohort Setting:N R Samplesize:28 IN T ER V EN T IO N : PEG 3350 Dose: 17g/240m L water(titratedafter24hourstoproduceonenonform edbowelm ovem entperday) Duration: 3weeksto21m onths Samplesize: 28 IN C L U SIO N C R IT ER IA : M aleandfem alechildrenlessthan18m onths;constipationdefinedbyR asquin-W eberetal. Y ear:2004 PO PU L A T IO N G roupssimilar atbaseline: C H A R A C T ER IST IC S: PEG 3350 M eanage(years): N R Patientsaged 65 yearsor older (% ): N R Sex(% female): N R Eth nicity(% C aucasian): N R M eanbodymassindex: N R O th er germanech aracteristics: • D urationof constipation N R (m ean) N R • Bowelfrequency(BM /week) 2. Y ear:2004 A DV ER SEEV EN T S: PEG 3350 O veralladverseeffectsreported: • diarrhea 14. Y ear: 2003 C ountry:U SA F U N DIN G : BraintreeL abs R ESEA R C H O B JEC T IV E: Toassessthelong-term safetyprofileandacceptanceof PE G 3350inchildrenwithchronic constipation. DESIG N : Studydesign:Prospectivecohortstudy Setting:Pediatric clinicsatareferralcenter Samplesize:83 IN T ER V EN T IO N : PEG 3350 w/o electrolytes N o C omparison Dose: 0. EX C L U SIO N C R IT ER IA : Childrenincludedin2otherstudiesconductedbytheauthors;historyof H irschsprung’sdisease; anorectalm alform ation;system ic diseaseleading toconstipation O T H ER M EDIC A T IO N S/ N R IN T ER V EN T IO N S A L L O W ED: Constipation Drugs Page 124 of 141 Final Report Drug Effectiveness Review Project A uth ors:Pash ankar etal. Y ear:2006 PO PU L A T IO N G roupssimilar atbaseline:N /A C H A R A C T ER IST IC S: PEG 3350 w/o electrolytes M eanage(years): 7. T imingofassessments:V ariable,notstandardized R ESU L T S: H ealth O utcomeM easures: • N /A Constipation Drugs Page 125 of 141 Final Report Drug Effectiveness Review Project A uth ors:Pash ankar Y ear:2003 A DV ER SEEV EN T S: PEG 3350 w/o electrolytes O veralladverseeffectsreported: • diarrhea 10% • headache N R • nausea 1% • abdom inalpain 2% • flatulenceorbloating 6% • fatigue 1% • thirst 1% • elevatedA L T 11 • elevatedA ST 4 Significantdifferencesinadverse A lllab resultswerenorm alex cept9patients(11%)withabnorm alA L Tsand3(4%)withelevated events: aspartateam inotransferase. A dh erence/C ompliance: A cceptance/tolerability:PE G likedby93% of thetreatedchildren;allchildren(n= 62,82%)whohad usedothertherapiespreferredPE G tootherlax atives;dailycom pliance,assessedbyparents’recalland diarywas“good”(notdefined)in90% of group. A N A L Y SIS: IT T :Y es Postrandomizationexclusions:N o A DEQ U A T ER A N DO M IZ A T IO N : N /A (notrandom ized) A DEQ U A T EA L L O C A T IO N N /A C O N C EA L M EN T : B L IN DIN G O F O U T C O M E N /A A SSESSO R S: A T T R IT IO N (overall): O verallattrition: 0 Differentialattritionh igh :N. A A T T R IT IO N (treatmentspecific): PEG 3350 w/o electrolytes T otalattrition: 0 W ith drawalsdueto adverseevents: 0 Q U A L IT Y R A T IN G : Poor Constipation Drugs Page 126 of 141 Final Report Drug Effectiveness Review Project C h ronicC onstipationandIB S-C 66 ST U DY : A uth ors,article#:R ouseetal. Y ear:1991 C ountry:U K F U N DIN G : N R R ESEA R C H O B JEC T IV E: Com pareclinicalefficacyandsafetyof psyllium versuslactulose DESIG N : Studydesign:openR CT Setting:M ulticenter,outpatientbutthispointissom ewhatunclear Samplesize:124 IN T ER V EN T IO N : psyllium lactulose Dose: 3. Y ear:1991 PO PU L A T IO N G roupssimilar atbaseline: C H A R A C T ER IST IC S: psyllium lactulose M eanage(years): 49. Y ear:1991 A DV ER SEEV EN T S: psyllium lactulose O veralladverseeffectsreported: • diarrhea N R N R • headache N R N R • nausea N R N R • abdom inalpain N R N R • flatulence N R N R • treatm entrelatedupsets N R N R • distension N R N R Significantdifferencesinadverse A bdom inalpain events: A dh erence/C ompliance: 9. Y ear: 2005 C ountry:U SA F U N DIN G : N R R ESEA R C H O B JEC T IV E: Toex tendthetreatm entandsafetyex periencewithPE G 3350andtoevaluateanylasting effectiveness during a30-daypost-treatm entobservationalperiod DESIG N : Studydesign:openuncontrolledtrial Setting:outpatient,universitygastroenterologypractice Samplesize:50 IN T ER V EN T IO N : PEG 3350 Dose: 17gram sperday Duration: 2weeks Samplesize: 50 IN C L U SIO N C R IT ER IA : M enandwom enoverage19;satisfactorystoolslessthan3tim esaweek;m eetR om eII-basedcriteria forconstipationforatleast12weeksinthepreceding 12m onths(straining orlum pyorhardstoolsorthe sensationof incom pleteortheneedform anualm aneuverstodefecateorthesensationof ano-rectal blockageinm orethan25% of defecations) EX C L U SIO N C R IT ER IA : Thosequalifying foradiagnosisforIBS;pregnancy;breastfeeding;stooloccultbloodwhichhasbeen unevaluated;knownorsuspectedbowelperforation;obstruction;fecalim paction;gastric retention; inflam m atoryboweldisease;bowelresection;colostom y;using m edicationsknowntocause constipation;allergytoPE G 3350 O T H ER M EDIC A T IO N S/ N one IN T ER V EN T IO N S A L L O W ED: Constipation Drugs Page 130 of 141 Final Report Drug Effectiveness Review Project A uth ors:T ranetal. Y ear:2005 PO PU L A T IO N G roupssimilar atbaseline:N /A C H A R A C T ER IST IC S: PEG 3350 8 oz M eanage(years): 52. Y ear:2005 A DV ER SEEV EN T S: PEG 3350 O veralladverseeffectsreported: • diarrhea N R • headache 4% • nausea 2% • abdom inalpain N R • flatulence N R • treatm entrelatedupsets N R • distension N R • constipation 2% • chestcongestion 2% • highbloodpressure 2% Significantdifferencesinadverse N /A events: A dh erence/C ompliance: 4% of subjectsdroppedout A N A L Y SIS: IT T :yes Postrandomizationexclusions:N /A A DEQ U A T ER A N DO M IZ A T IO N : N /A A DEQ U A T EA L L O C A T IO N N /A C O N C EA L M EN T : B L IN DIN G O F O U T C O M E N /A A SSESSO R S: A T T R IT IO N (overall): O verallattrition:12% Differentialattritionh igh :N /A A T T R IT IO N (treatmentspecific): PEG 3350 8 oz per day T otalattrition: 6 W ith drawalsdueto adverseevents: 4 Q U A L IT Y R A T IN G : Poor Constipation Drugs Page 132 of 141 Final Report Drug Effectiveness Review Project C h ronicC onstipationandIB S-C 46 ST U DY : A uth ors,article#: V oskuijletal. Y ear: 2004 C ountry:N etherlands F U N DIN G : N R R ESEA R C H O B JEC T IV E: Com pareclinicalefficacyandsafetyof PE G withelectrolyteswithlactuloseinpediatric constipationand evaluateclinicalefficacy/sideeffects. DESIG N : Studydesign:D oubleblindR CT Setting:M ulti-center,referralpopulation(childrenreferredtopedsG I byG Ps,schooldoctors,and pediatricians) Samplesize:100 IN T ER V EN T IO N : PEG 3350 w/electrolytes lactulose Dose: 1sachet(2. EX C L U SIO N C R IT ER IA : H ypothyroidism ,spinabifidaocculta,H irschsprung’s,andotherorganic causesfordisease O T H ER M EDIC A T IO N S/ N oorallax ativeswereallowedduring the1weekrun-in;stim ulantlax ativeswereprescribedduring IN T ER V EN T IO N S A L L O W ED: treatm entphaseif treatm enttheywererandom izedtowasunsuccessfulatm ax im um doseallowedbythe protocol. Constipation Drugs Page 133 of 141 Final Report Drug Effectiveness Review Project A uth ors:V oskuijletal. Y ear:2004 PO PU L A T IO N G roupssimilar atbaseline:Y es C H A R A C T ER IST IC S: PEG 3350 lactulose M eanage(years): 6.

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Reliable indirect comparisons cannot be made by evidence from 3 long-term placebo-controlled trials of propranolol and atenolol order levonorgestrel now birth control pills jeanine. Angina Overall grade: Fair No significant differences in 6 head-to-head trials of carvedilol compared with metoprolol cheap levonorgestrel 0.18 mg line birth control for women after menopause, pindolol compared with propranolol discount levonorgestrel 0.18 mg birth control for 7 days, betaxolol, and propranolol, and betaxolol compared with metoprolol in patients with stable angina. Atenolol equivalent to bisoprolol in patients with chronic stable angina and chronic obstructive pulmonary disease. Atenolol equivalent to labetalol when added to chlorthalidone in patients with chronic stable angina. One short-term, placebo-controlled trial of propranolol did not add any meaningful evidence of comparative efficacy in the above parameters. Status-post coronary artery Overall grade: Poor Metoprolol did not benefit mortality or ischemic events bypass graft in a longer-term (>7 days) placebo-controlled trial (MACB). Recent myocardial infarction Overall grade: Fair-good One fair-quality head-to-head trial found no differences in mortality after 1 year between atenolol and propranolol, but this was a relatively small trial; 1 fair- quality head-to-head trial found no differences in time to serious cardiovascular events between carvedilol and atenolol. One fair-quality trial of carvedilol and metoprolol tartrate found no differences in time to first cardiac adverse event or all-cause mortality. Similar mortality reductions reported for acebutolol, Beta blockers Page 56 of 122 Final Report Update 4 Drug Effectiveness Review Project a Strength of evidence Conclusion metoprolol tartrate, propranolol, and timolol in placebo- controlled trials of patients following myocardial infarction without other complications. Similar reductions in sudden death and reinfarction were reported for metoprolol tartrate and timolol and in sudden death for propranolol. No studies of carvedilol phosphate (extended-release carvedilol) in patients with recent myocardial infarction were identified. Carvedilol reduced mortality and reinfarction in 1 placebo-controlled trial of patients with a mean left ventricular ejection fraction of <32. Four systematic reviews were not designed to assess comparative efficacy. Heart failure Health outcomes in Carvedilol more effective than metoprolol tartrate in head-to-head trials: Fair reducing total mortality in COMET in patients with mild to moderate heart failure. Symptoms in head-to- Carvedilol equivalent to metoprolol tartrate in improving head trials: Good symptoms (quality of life; NYHA) and exercise capacity in 4 head-to-head trials. Improvements in NYHA function class and on walking distance (6-minute walk test) were similarly slight for both carvedilol and nebivolol. Placebo-controlled trials Metoprolol succinate reduced total mortality, sudden in mild-moderate heart death, and death due to progressive heart failure and failure: Good improved quality of life (MERIT-HF). Carvedilol reduced total mortality, sudden death, and death due to pump failure (MOCHA). Nebivolol significantly reduced the composite outcome of all-cause mortality or cardiovascular hospital admission, but had nonsignificant effects each component as individual secondary outcomes. Bisoprolol reduced total mortality and sudden death. No studies of carvedilol phosphate (extended-release carvedilol) in patients with mild to moderate heart failure were identified. Placebo-controlled trials Carvedilol reduced mortality and the combined in severe heart failure: endpoint of mortality and hospitalizations in a Fair for carvedilol and prospective trial. Fair for metoprolol A post-hoc subgroup analysis of MERIT-HF suggests succinate that metoprolol succinate is similarly effective in comparable patients. No studies of carvedilol phosphate (extended-release carvedilol) in patients with severe heart failure were identified. Atrial arrhythmia Overall grade: Fair Bisoprolol equivalent to carvedilol in preventing relapse of atrial fibrillation in a head-to-head trial. Metoprolol succinate reduced incidence of atrial arrhythmia/fibrillation in a placebo-controlled trial. Carvedilol reduced 24-hour ventricular rate in patients with atrial fibrillation and heart failure in 1 placebo- controlled trial. These placebo-controlled trials did not offer Beta blockers Page 57 of 122 Final Report Update 4 Drug Effectiveness Review Project a Strength of evidence Conclusion comparative data. Migraine Overall grade: Fair Atenolol, slow release metoprolol, immediate release metoprolol, and timolol were all similar to propranolol in their effects on pain outcomes and acute medication use in 5 head-to-head trials. No significant differences were found between nebivolol and metoprolol on frequency of migraine attacks and severity. Bleeding esophageal varices Overall grade: Poor Results of 1 head-to-head trial of atenolol and propranolol, 1 placebo-controlled trial of nadolol, and 6 placebo-controlled trials of immediate release and 2 formulations of extended release propranolol, all fair quality, didn’t clearly differentiate one beta blocker from another. Adverse effects Hypertension, stable angina, Overall grade: Fair A few differences in specific adverse event rates were heart failure, atrial arrhythmia, noted across longer-term trials directly comparing one migraine, bleeding esophageal beta blocker to another.

The long head of triceps and the surgical neck of the • Type: atypical synovial joint order levonorgestrel 0.18mg online birth control for women happy. As for the sternoclavicular joint buy genuine levonorgestrel birth control pills qatar, the the long head of triceps order levonorgestrel 0.18 mg overnight delivery birth control for women x x. The circumflex scapular artery passes articular surfaces are covered with fibrocartilage and an articular disc from front to back through this space to gain access to the hangs into the joint from above. The pectoral and scapular regions 75 33 The axilla Pectoralis minor Pectoralis major Short head of biceps Trapezius Coracobrachialis Clavicle Subclavius Long head Lateral cord of biceps Axillary artery Clavipectoral (tendon) Medial cord fascia Axillary vein Axillary space Posterior cord Latissimus Pectoralis dorsi (tendon) minor Chest wall Pectoralis major Fascial floor of axilla Serratus anterior Subscapularis Fig. The posterior cord is hidden behind the axillary artery 76 Upper limb The major nerves and vessels supplying and draining the upper limb anastomosis. It compensates for compromised flow that may occur due pass through the axilla. The principal arteries involved are the The axilla is a three-sided pyramid. Its apex is the small region suprascapular, from the third part of the subclavian artery, and the sub- between the 1st rib, the clavicle and the scapula through which the scapular, from the third part of the axillary artery with contributions major nerves and vessels pass. The walls of the axilla are composed as follows: • The axillary vein: is formed by the confluence of the venae comit- • The anterior wall is made up from the pectoralis major and minor antes of the axillary artery and the basilic vein (p. It becomes the muscles and the clavipectoral fascia. The named tributar- • The posterior wall is made up of the subscapularis, teres major and ies of the axillary vein correspond to those of the axillary artery. Running downwards from above are the corachobrachialis and In breast cancer surgery the axillary lymph nodes are cleared rou- short head of biceps as well as the long head of biceps in the intertuber- tinely. During the dissection for this procedure one must clearly iden- cular sulcus. Injury to the thoracodorsal nerve results in paralysis The contents of the axilla (Figs 33. Injury to the long thoracic nerve causes paralysis of • The axillary artery: an important anastomosis exists between the serratus anterior resulting in weakened arm abduction. On clinical subclavian artery and third part of the axillary arteryathe scapular examination the latter injury results in winging of the scapula. The axilla 77 34 The shoulder (gleno-humeral) joint Coracoclavicular Coraco-acromial ligament ligament Subacromial bursa Long head Acromion of biceps Supraspinatus Subscapularis Subscapular Infraspinatus bursa Glenoid fossa Teres minor Capsular ligament Long head of triceps Fig. It is formed by the articulation of the humeral head with the shallow glenoid fossa of the scapula (see p. The Shoulder movements glenoid is slightly deepened by a fibrocartilaginous rimathe glenoid The shoulder is a ‘ball and socket’ joint allowing a wide range of move- labrum. Both articular surfaces are covered with hyaline cartilage. Much of this range is attributed to the articulation of the shallow • The capsule: of the shoulder joint is lax permitting a wide range of glenoid with a rounded humeral head. It is attached medially to the margins of the glenoid and lat- of compromised stability of the joint. The capsule is significantly strengthened • Flexion (0–90°): pectoralis major, coracobrachialis and deltoid by slips from the surrounding rotator cuff muscle tendons. The latter comprise: three gleno-humeral ligaments ior fibres). The main • External (lateral) rotators (0–55°): infraspinatus, teres minor and stability of the shoulder is afforded by the rotator cuff. Each of these muscles can perform its own function anterior. Almost simultan- • Bursae: two large bursae are associated with the shoulder joint. The eously the scapula is rotated so that the glenoid faces upwards; this subscapular bursa separates the shoulder capsule from the tendon of action is produced by the lower fibres of serratus anterior which are subscapularis which passes directly anterior to it. The subscapular inserted into the inferior angle of the scapula and by the trapezius which bursa communicates with the shoulder joint. The subacromial bursa pulls the lateral end of the spine of the scapula upwards and the medial separates the shoulder capsule from the coracoacromial ligament end downwards. The subacromial bursa does not communicate with the joint. The tendon of supraspinatus lies in the floor of the bursa.

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