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Such prolapse is usually localised to the affected quadrant and usually heal by itself buy levonorgestrel 0.18mg amex birth control yes or no. Any aetiological factor of complete prolapse may cause partial prolapse in the beginning before it turns into complete prolapse purchase 0.18 mg levonorgestrel birth control zoloft. The mother is taught how to replace the protruded bowel through the anal sphincter buy cheap levonorgestrel 0.18mg on line birth control for 5 years in the arm. By the index finger the protrusion is pushed up through the anal canal and the finger is gradually withdrawn purchase 0.18 mg levonorgestrel overnight delivery birth control pills late period. Attention of bowel habit, avoiding straining at stools, control of diarrhoea and dietatic adjustments in case of malnutrition are supportive treatments to be followed. This submucous injection treatment may also be tried in adults in early partial prolapse. The apex of the prolapse is injected circularly and the tip of the needle should reach the submucosa. The base of the prolapse should also be injected similarly and the needle must reach the submucosa. Aseptic inflammation following these injections will lead to fibrosis and the mucous membrane becomes fixed to the muscular coat and is drawn in. Two small midline incisions are made one in front and the another behind the anal opening about V inch away from it. A piece of silver wire or stainless steel wire 20 gauze is threaded through the eye of this needle. The needle is brought out through the anterior incision and now the wire traverses V of the2 circumference of the anus. The needle is reinserted through the same incision behind the anus and passed round the opposite side of the anus to emerge through the incision in front of the anus. The other end of the wire is threaded and the needle is withdrawn through the anterior incision. When the finger can be just sufficiently passed through the anus, the twisted wire ends are cut short. This gives not only a mechanical support but also a chemical support by the fibrous deposits around the anal canal. In this case strong chromic catgut may be used instead of silver or stainless steel wire. The main complication of this operation is that the wound may be complicated with the result of a discharging sinus. In this case the wire must be removed and usually by that time fibrosis has occurred to prevent further prolapse. By this the base of the prolapse is transfixed twice and the ligature is then tightened. Now the redundant mucosa is excised and if required the cut margins are sutured interruptedly. This technique may be adopted in case of partial prolapse associated with 3rd degree haemorrhoid. If palpated between a finger and the thumb, double thickness of the entire wall of the wall of the rectum can be palpated. It must be remembered that a complete prolapse usually contains a pouch of peritoneum anteriorly between its walls. When the prolapse is a very large one this peritoneal cavity contains even coils of small intestine. Even if the prolapse is not apparent on inspection, it can be readily induced by asking the patient to strain. This is same as a sliding hemia where the hemia forms the posterior wall of the peritoneal pouch. That is why a complete prolapse is often considered to be a type of sliding hemia. The apex of the intussusception is generally 6 to 8 cm above the anus probably at the level of the peritoneal reflexion. During straining it has been noted that there may be descent of the floor and gaping of the anus. The anterior surface of the rectum is left uncovered to prevent constriction of the lumen. A curved incision about 2 inches in length is made midway between the anus and tip of the coccyx. The incision is deepened and through it the fibres of the external sphincter muscle and the anococcygeal ligaments are cut. The incision is further deepened and the fascia of Waldeyer is transversely incised. The rectum is stripped off from the anterior surface of the sacrum upto the third sacral vertebra. The resulting cavity is packed with long strips of gauze of polyvinyl alcohol sponge. The effect of this sponge is to provoke vigorous fibrous reaction which will anchor the rectum against the sacrum. The free ends of Ivalon sponge is sutured to the presacral fascia, then wrapped this band of teflon are sutured to the presacral fascia over the rectum and sutured. The sling must be loose enough to allow one finger to pass between the rectum and the sacrum. The anal canal mucous membrane is now sutured to the rectal mucosa which remains at the tip of the prolapse. So the prolapse is reduced and a ring of muscle surrounds the anal canal which narrows its orifice. Only difference is that the dissection should be close to the rectum to prevent injury to the nerve supply of the bladder and to prevent impotence in males. The rectum just above the anterior peritoneal reflexion, which is considered to be the starting point of the intussusception is resected. The proximal line of resection should be at a convenient point at the rectosigmoid junction or in the sigmoid colon so that the redundancy is removed. A circular incision is made through the outer layer of the prolapse 2 cm proximal to the dentate line. Anteriorly as this incision is deepened the peritoneal cavity will be opened transversely. The pelvic colon should be pulled down as far as possible until it becomes taut from above. The peritoneum is now sutured to the side of the pelvic colon as high as possible. The pelvic mesocolon with the vascular pedicle is ligated Vi inch below the proposed level of section of the pelvic colon. The sigmoid colon is completely divided below the anus in such a way that there is a greater length posteriorly.
These strictures usually occur either in the bulb of the urethra or just inside the external meatus discount levonorgestrel 0.18mg with amex birth control for women how to climax. In late cases it may be necessary to cut the dense fibrotic stricture with optical urethrotome buy generic levonorgestrel on line birth control that stops periods. When the bony changes have already taken place buy levonorgestrel 0.18 mg on line birth control pills online pharmacy, the posterior surface of the symphysis pubis is incised and the necrotic cartilage and bone are curetted out cheap 0.18mg levonorgestrel with amex birth control for 50. The particular complications which may occur after transurethral resection of prostate are :— 1. This usually occurs when the field of vision has been obscured by heavy haemorrhage. A second attempt should be made when bleeding has completely subsided and the patient is fit for operation. During transurethral surgery, if resection is limited to above the verumontanum, injury to external sphincter is impossible. If transurethral resection is extended downwards beyond the verumontanum, there is a chance of injuring the external sphincter. Sometimes urodynamic investigations have shown that not all of these patients have sphinc ters damaged. In the first method the probe is used to vaporize the prostatic tissue under direct vision. The advantage of this technique is that the bleeding is minimal and bladder neck incision can be carried out. Such energy can be applied transurethrally under direct vision or transurethrally with the help of ultrasound. The necrotic tissues slough out and a suprapubic catheter is kept for several weeks for this purpose. But newer machines can provide temperature more than 50° C and destroy more areas of prostate to improve the obstructive symptoms. Laser treatment is however better than microwave treatment in improving the symptoms of the patients. Intraurethral stents — are now being used in the management of retention who are grossly unfit for surgery. The treatment for these cases, which is recommended nowadays, is immediate one-stage prostatectomy for patients with good general condition without clinical signs of infection or renal insufficiency. Those patients, in whom immediate prostatectomy cannot be performed, should have preliminary drainage with indwelling urethral catheter followed within 7 to 10 days by prostatectomy (semiurgent prostatectomy). Preliminary suprapubic cystostomy, which was often practised previously, not only introduces infection into the bladder but makes the prostatectomy more difficult. Of the two types of treatment, which are advocated nowadays, preliminary drainage by indwelling ure thral catheter finds greater acceptance. During the 7 days period, the surgeon will do all necessary investigations and at the same time will improve the patient’s general conditions. It increases in frequency there after and probably afflicting 25% of men in the 8th decade. The true cause of prostatic carcinoma is not definitely known, but its growth is strikingly influenced by sex hormones. Administration of androgens usually increases the rate of growth of this tumour and increases the acid phosphatase level of the serum. Oestrogen therapy or orchidectomy slows down the growth of these tumours and maintains the amount of acid phosphatase in the blood at a normal level. Determination of the amount of acid phosphatase in the serum is therefore an index of the presence and aggressiveness of the tumour. Carcinoma arises in atrophic, not hypertrophic areas and in particular in posterior lobe compressed by nodular hyperplasia. It is obvious that a prostatectomy, which leaves most of the posterior lobe, is no guarranty against subsequent development of carcinoma in that lobe. It must be remembered that a few carcinomas may be found within the hyperplastic benign prostatic lobes. These tumours are usually very small and are called ‘occult’ or ‘academic’ cancers. These are often completely removed by intracapsular enucleation of the enlarged gland. When the tumour is cut it imparts the same gritty sensation to the knife as is felt in scirrhous carcinoma. So the hard consistency, irregular surface and lack of lobulation are the characteristic features of carcinoma of the prostate. When the tumour is anaplastic, the diagnosis is easy, but when it is differentiated, it is difficult to distinguish this lesion from benign hyperplasia. The first carcinomatous change is the loss of this layer, so that the glands seem to lie adjacent to each other with no stroma separating them. Mitoses are infrequent, and their absence is no evidence of the benign nature of the lesion. Invasion of the perineural sheaths may be seen even in a fully differentiated tumour. So loss of normal configuration is more important than the appearance of individual cells. Confluence of acini, infiltration ofthe stroma, the perineural lymphatics and the capsules are the characteristic features of this condition. These are highly malignant and usually cause osteolytic bone metastases which are usually hormonal independent. These tumours respond poorly to radical surgery, so radiation therapy is indicated. It cannot extend backwards due to the presence of the strong fascia ofDenonvilliers. So the lesion tends to grow upwards along the line of the ejaculatory ducts and emerge at the upper border of the prostate to involve the seminal vesicles. In very late cases the rectum may become stenosed by infiltrating growth around it. Either of the two groups of lymphatics may be involved — (i) growth may involve lymphatics which pass along the sides of the rectum to reach the lymph nodes along the internal iliac vein, (ii) Growth may involve the lymphatics which pass over the seminal vesicles and follow the vas deferens to drain into the external iliac lymph nodes. From both internal iliac group and external iliac group of lymph nodes, the growth reaches the retroperitoneal lymph nodes, later on the mediastinal lymph nodes and occasionally the left supraclavicular lymph nodes (Virchow’s nodes) may become involved. There is an abundant nerve supply in and around the prostate and these nerves are accompanied by lymphatics. Cancer prostate is the most common site of primary neoplasm for skeletal metastasis, which is followed by the cancers of the breasts, the kidney, the bronchial tree and the thyroid gland in that order of frequency. The tumour embolus penetrates into the periprostatic venous plexus from where the tumour cells pass along the vertebral system of veins during coughing or sneezing. Through these veins the tumour cells easily reach the pelvis and vertebral bodies of the lower lumbar vertebrae.
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However 0.18mg levonorgestrel fast delivery birth control pills migraines, these factors appear to be minor dis- advantages buy levonorgestrel 0.18mg free shipping birth control pills quitting, and these products have made catgut an obsolete Suture Material suture material for many purposes generic levonorgestrel 0.18 mg with visa birth control pills viorele. Absorbable Sutures Nonabsorbable Sutures Plain Catgut Plain catgut is not commonly used during modern surgery order genuine levonorgestrel line birth control 6 months no period. Natural Nonabsorbable Sutures Although its rapidity of absorption might seem to be an advan- Natural nonabsorbable sutures, such as silk and cotton, have tage, this rapidity is the result of an intense inﬂammatory reac- enjoyed a long period of popularity among surgeons the tion that produces enzymes to digest the organic material. They have the advantage of easy handling and Plain catgut is acceptable for ligating bleeding points in the secure knot tying. Electrocautery the other hand, they produce more inﬂammatory reaction in has largely rendered that application unnecessary. Silk and cotton, Chromic Catgut although classiﬁed as nonabsorbable, disintegrate in the tis- Chromic catgut has the advantage of a smooth surface, which sues over a long period of time, whereas the synthetic mate- permits it to be drawn through delicate tissues with minimal rials appear to be truly nonabsorbable. It thus may be good for splenorrhaphy or hepator- disadvantages, silk and cotton have maintained worldwide rhaphy. Moisten the chromic catgut with saline and allow it popularity mainly because of their ease of handling and sur- to soften for a few seconds before inserting the suture. Because there are no Chromic catgut generally retains its strength for about a clear-cut data at this time demonstrating that anastomoses week and is suitable only when such rapid absorption is performed with synthetic suture material have fewer compli- desirable. It is completely contraindicated in the vicinity of cations than those performed with silk or cotton, it is not yet the pancreas, where proteolytic enzymes produce premature necessary for surgeons to abandon the natural nonabsorbable absorption, or for closure of abdominal incisions and hernia sutures if they can handle them with greater skill. Chassin With the exception of the monoﬁlaments, a major disad- Prolene size 4-0 on atraumatic needles has been used for the vantage of nonabsorbable sutures is the formation of chronic seromuscular layer of intestinal anastomoses. This problem is and various braided polyester sutures have achieved great especially marked when material larger than size 3-0 is used popularity for vascular surgery. For this reason, many surgeons do not use nonabsorbable sutures Monoﬁlament Stainless Steel Wire above the fascia. Monoﬁlament stainless steel wire has many of the character- istics of an ideal suture material, but it is difﬁcult to tie. Also, Synthetic Nonabsorbable Braided Sutures when used for closure of the abdominal wall, patients have Synthetic braided sutures include those made of Dacron occasionally complained of pain at the site of a knot or of a polyester, such as Mersilene, Ticron (Dacron coated with broken suture. True suture sinuses and suture granulomas silicone), Tevdek (Dacron coated with Teﬂon), and Ethibond have been rare when monoﬁlament stainless steel has been (Dacron with butilated coating). All these braided synthetic wire has been used for single-layer esophagogastric and materials require four or ﬁve knots for secure closure, com- colon anastomoses. Three square throws are adequate for a pared to the three required of silk and cotton. Stainless steel has largely been supplanted by the synthetic monoﬁlament sutures but is Synthetic Nonabsorbable Monoﬁlaments still used for closing median sternotomy incisions and for Monoﬁlament synthetics such as nylon and Prolene are so other highly selected applications. They and monoﬁlament stain- Knot-Tying Technique less steel are the least reactive of all the products available. For this reason, 2-0 or 0 Prolene has been used by some sur- The “three-point technique” for tying knots is important geons for the Smead-Jones abdominal closure in the hope of when ligating blood vessels. Because of the large number of ing one end of the ligature, the vessel being ligated, and the knots, this hope has not been realized, but there are fewer surgeon’s right hand grasping the opposite end of the ligature sinuses than when nonabsorbable braided materials are used. For heavy monoﬁlament suture material such as 0 or 1 a Prolene, we have used modiﬁed ﬁsherman’s 3-1-2 knot: First, make a triple-throw “surgeon’s knot” (Fig. For superﬁcial bleeding points in the skin and subcutaneous tis- sues, one- or two-hand knots are efﬁcacious. Single-layer continuous ver- sus two-layer interrupted intestinal anastomosis: a prospective randomized trial. An experimental contribution looking to an improved technique in enterorrhaphy whereby the number of knots is reduced to two or even one. If this is not the case, as the surgeon’s hands draw apart when Shikata S, Yamagishi J, Taji Y, et al. Single versus two- layer intestinal tightening the knot, they exert traction against the vessel. For other exposure does not allow enough room to insert a stapling purposes, such as joining colon to a rectal remnant after a instrument into a body cavity. If this is the case, do not apply low anterior resection, stapling is easier and faster, or it cre- traction to the tissues to bring them within stapler range. The advantages and disadvantages of various tech- Characteristics of Staples niques are pointed out throughout this volume in the appro- priate chapters. Modern gastrointestinal staplers are designed to preserve the Stapled anastomoses, when constructed with proper tech- viability of the tissues distal to the staple line. This is analo- nique, are no better and no worse than those done with gous to the “approximate but do not strangulate” principle sutures. Stapling has the disadvantage of increased expense used when a bowel anastomosis is hand sewn. This eﬁt in the poor-risk patient who is critically ill and who may allows blood to ﬂow through the staple line. Even with the avail- tissue thickness are appropriately matched, one sees blood ability of skilled anesthesiologists expert in the physiologic oozing through the staple line. This tech- Stapled anastomoses cannot be expected to succeed under nique is contraindicated if the tissues are so thick; compres- conditions that would make construction of a sutured anasto- sion by the stapling device is likely to produce necrosis. There is no evidence that staples are safer the other hand, if the tissues are so thin the staples cannot than sutures, for instance, in the presence of advanced peri- provide a ﬁrm approximation, bleeding and anastomotic tonitis or poor tissue perfusion. Whereas sutures can be inserted and tied to appropriate There is some leeway when approximating tissues of vary- tension to approximate but not strangulate a wide range of ing thickness. Two standard staple sizes are available for the tissue thicknesses, staplers are much less tolerant. Even when tissues are stapled in ever- sion, with mucosa facing mucosa, satisfactory healing takes place. This is in contrast to sutured everting anastomoses, which are generally weaker than inverting anastomoses. Some stapling devices are continuously variable within this range, and the thickness The 55 mm linear stapler applies a doubled staggered row of may be tested with a gauge and then dialed in. Become famil- staples approximately 55 mm long; similarly, the 90 mm lin- iar with the particular stapling devices used in your operating ear stapler applies a doubled staggered row about 90 mm room and learn their operating characteristics. There is also a 30 mm stapler that is occasionally use- The endoscopic linear cutting stapler compresses tissues ful for extremely short suture lines. These devices are used to approximate the walls of the stomach or intestine Stapling in Inversion in an everting fashion. They ﬁnd application in closure of the duodenal stump, the gastric pouch during gastrectomy, and The circular stapler and the linear cutting stapler create the end of the colon when a side-to-end coloproctostomy is inverted staple lines that mimic the equivalent hand-sutured performed. In many situations, both inverted and everted Linear staplers use an aligning pin to ensure that the sta- staple lines are created, as illustrated by the completed func- pler cartridge meets the anvil accurately. Here a lin- length of bowel that can be stapled to a length that can be ear cutting stapler was used to create the ﬁrst (inverting) contained between the closed end of the device and the pin. A single stitch at the apex of this (described below) when a long staple line must be produced. It may Linear Cutting Stapling Device also be used to divide the bowel prior to anastomosis. This avoids a narrow ischemic strip of stomach and The circular stapling device utilizes a circular anvil, a circu- anastomotic failure.
The tumor tends to metastasize late to lymph nodes and the lungs and only rarely spreads to other bones order line levonorgestrel birth control dangers. Diffuse order levonorgestrel 0.18mg visa birth control spotting, punched-out osteolytic lesions throughout the pelvis and proximal femurs levonorgestrel 0.18mg without prescription birth control pills blood clots. Diffuse permeative destruction led to a pathologic fracture of the midshaft of the femur buy 0.18mg levonorgestrel mastercard birth control pills 1990. Subtle areas of infection, or by direct introduction of organisms of metaphyseal lucency reflecting resorption of (trauma or surgery). Acute hematogenous osteo- necrotic bone are followed by more prominent myelitis tends to involve bones with rich red bone destruction producing a ragged, moth- marrow (metaphyses of long bones, especially eaten appearance (the more virulent the the femur and tibia, in infants and children; organism, the larger the area of destruction). Because the earliest changes Subperiosteal spread of inflammation elevates are usually not evident on plain radiographs until the periosteum and stimulates the laying down approximately 10 days after the onset of symptoms, of layers of new bone parallel to the shaft, radionuclide bone scanning is the most valuable producing a characteristic lamellated periosteal imaging modality for early diagnosis (increased reaction. Eventually, a large amount of new isotope uptake reflects the inflammatory process bone surrounds the cortex in a thick, irregular and increased blood flow). The radiographic find- bony sleeve (involucrum) and disruption of the ings, clinical history, and symptoms are generally cortical blood supply leads to bone necrosis and sufficient to make the diagnosis of osteomyelitis, segments of avascular dead bone (sequestra). Chronic osteomyelitis results in a thick, the subchondral bony plate with loss of the irregular, sclerotic bone with central radiolucency, sharp cortical outline. This may progress to total elevated periosteum, and often a chronic draining destruction of the vertebral body associated sinus. Unlike neoplastic processes, osteomyelitis usually affects the intervertebral disk space and often involves adjacent vertebrae. Diffuse permeative destruction destruction in the proximal humerus is associated with a with mild periosteal response involving the distal half of the pathologic fracture (arrow). Reactive response to ends of long bones (most commonly the knees, proliferating leukemic cells can cause patchy or ankles, and wrists). Though a nonspecific indication uniform osteosclerosis, whereas subperiosteal of severe illness younger than age 2, its presence proliferation of tumor cells incites periosteal after this age strongly suggests acute leukemia. In children, the knees, Diffuse skeletal demineralization (especially in ankles, and wrists are most often affected; in the spine where it leads to vertebral compression adults, leukemic bone lesions most commonly fractures) may result from both leukemic infiltration involve the vertebrae, ribs, skull, and pelvis. Lymphoma Hematogenous spread produces a mottled Other forms of skeletal involvement include (see Fig B 4-3) pattern of destruction and sclerosis that may dense vertebral sclerosis (ivory vertebra), discrete simulate metastatic disease. Fibrosarcoma Initially, an irregular, destructive lesion arising Rare primary malignant tumor of fibroblastic tissue (Fig B 7-9) in the medullary cavity that may cause thin- that most often involves tubular bones in young ning, expansion, and erosion of the cortex patients and flat bones in older ones. As slowly and to have a somewhat better prognosis the tumor develops, there may be massive than osteogenic sarcoma. Unlike most primary invasion of the cortex and extension into the bone tumors, fibrosarcomas tend to metastasize to medullary canal. Note the early periosteal new thick, irregular, bony sleeve, surrounds the sequestrum bone formation (arrows). Langerhans cell histiocytosis Initially, there is a small relatively well-defined Bone lesions are most characteristic of Langerhans (see Fig B 6-18) lucent area that enlarges to produce endosteal cell histiocytosis. A calvarial defect may demon- scalloping, a multilocular appearance, and bone strate a bony density in its center (button seques- expansion with associated periosteal new bone trum). May produce more confluent areas of a vertebral body, which assumes the shape of a of bone destruction simulating malignancy or thin flat disk (vertebra plana). Massive osteolysis of Initially, radiolucent foci in intramedullary or Rare disease of unknown etiology that usually is Gorham subcortical regions with slowly progressive detected before age 40. May affect the axial or atrophy, dissolution, fracture, fragmentation, appendicular skeleton. The olysis syndromes,” many of which affect the hands process spreads across joints and intervertebral and feet. Diffuse lymphangiomatosis Multiple cystic lesions throughout the skeleton Rare condition in children and adolescents that (Fig B 7-11) causing erosions and progressive osteolytic may be associated with widespread soft-tissue defects in various bones. Proliferation of neoplastic cells in the marrow has caused extensive destruction of bone in both femurs. Rare condition without the characteristic appear- hemangiomatosis ance seen in other forms of the disease (no verte- bral or skull hemangiomas). Weber-Christian disease Multiple punched-out or moth-eaten lesions Rare disturbance of fat metabolism resulting in involving the skull, pelvis, and medullary bone. Membranous lipodystrophy Multiple radiolucent cystic lesions symmet- Rare hereditary disease of unknown origin that rically distributed in the carpal and tarsal bones usually affects young adults and is associated with and the ends of long bones. Multiple lytic lesions, some with thin sclerotic rims, diffusely involve the pelvis. Primary malignant Localized periosteal reaction that may be solid, Most commonly, osteosarcoma and Ewing’s tumor of bone laminated, spiculated (perpendicular to the sarcoma. Periosteal reaction is rare in other pri- (Figs B 8-1 through B 8-3) shaft), or amorphous. There are various amounts of exuberant, irregular periosteal response and ragged bone destruction. Laminated periosteal reaction on one side of the bone and thin periosteal elevation (Codman’s triangle) on the other. Solid periosteal reaction with expanding cysts (Fig B 8-5) or tumors, especially if there is an underlying pathologic fracture. Elliptical and dense periosteal reaction in osteoid osteoma (radiolucent intra- cortical nidus). Subperiosteal spread of inflammation elevates the (Figs B 8-6 and B 8-7) periosteum and stimulates the laying down of layers of new bone parallel to the shaft. Eventually, a large amount of new bone surrounds the cortex in a thick, irregular bony sleeve (involucrum). Disruption of the cortical blood supply leads to bone necrosis with dense segments of avascular dead bone (sequestra) remaining. Most common in juvenile rheumatoid arthritis and reactive arthritis; rare in psoriatic arthritis. Vascular stasis Solid, often undulating, periosteal reaction Chronic venous or lymphatic insufficiency or (Fig B 8-8) primarily along the tibial and fibular shafts. Pronounced periosteal new bone formation cloaking (A) the femurs and (B) the tibias and fibulas. The involucrum (straight arrows) cyst-like lesion causes ballooning of the cortex and periosteal surrounds the sequestrum (curved arrows). Primarily involves the mandible, scap- perirritability, soft-tissue swelling, periosteal new (Caffey’s disease) ula, clavicle, ulna, and ribs. Syphilis (acquired)/yaws Extensive, solid, often undulating, periosteal Diffuse, widespread, and symmetric, periosteal (Figs B 8-10 and B 8-11) reaction occurring independently or in conjunc- reaction may reflect underlying infiltration by tion with gummas in the bone marrow. Diffuse lytic destruction of the proximal humerus with reactive sclerosis and periosteal new bone formation. Periosteal new bone of Africa that is caused by the Vincent types of blends with the cortex to produce the thickened, fusiform bacilli and spirochetes. Chronic ulcers sclerotic cortex (often exceeding 1 cm) of a most often affect children and young adults and are classic “ivory osteoma. Bone infarct Solid periosteal response overlying the shaft of Most common in sickle cell disease.