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N. Murat, M.A., M.D., Ph.D.

Deputy Director, University of Oklahoma School of Community Medicine

The causal mechanism is external rotation of the ankle when the foot is caught in a supinated position. Closed reduction therefore needs traction (to disimpact the fracture) and then internal rotation of the foot. If closed reduction succeeds, a cast is applied, following the same routine as for undisplaced fractures. Failure of closed reduction (sometimes a torn medial ligament is caught in between the talus and medial malleolus) or late redisplacement calls for operative treatment. Type B fractures may also be caused by abduction; often the lateral aspect of the fibula is comminuted and the fracture line more horizontal. Despite accurate reduction (the ankle is adducted and the foot supinated), these injuries are unstable and often poorly controlled in a cast; internal fixation is therefore preferred. Displaced Weber type C fractures the fibular fracture is well above the syndesmosis and frequently there are (a) (b) (c) (d) 914 31. It is vital, after reduction of the fibular fracture, to check that the medial joint space is normal; if it is not, the ligament has probably been trapped in the joint and it must be freed so as to allow perfect re-positioning of the talus. The fibula must be fixed to full length and the tibiofibular joint secured before the ankle can be stabilized. An isolated type C fibular fracture should raise strong suspicions of major ligament damage to the syndesmosis and medial side of the joint. Almost all type C fractures are unstable and will need open reduction and internal fixation. The first step is to reduce the fibula, restoring its length and alignment; the fracture is then stabilized using a plate and screws. If the joint opens out, it means that the ligaments are torn; the syndesmosis is stabilized by inserting a transverse screw across from the fibula into the tibia (the ankle should be held in 10 degrees of dorsiflexion when the screw is inserted). Fracture subluxations more than 1 or 2 weeks old may prove difficult to reduce because of clot organi- zation in the syndesmosis. Granulation tissue should be removed from the syndesmosis and transverse tibiofibular fixation secured. Postoperative management After open reduction and fixation of ankle fractures, movements should be regained before applying a below-knee plaster cast, or removable support boot. The patient is then allowed partial weightbearing with crutches; the support is retained until the fractures have consolidated (anything from 6ͱ2 weeks). Some advocate removal of the screw when the syndesmosis has healed, and before weightbearing has commenced (6 weeks is too early, 10 weeks is probably more appropriate). Others are happy to allow early weightbearing with the screw still (a) (b) (c) (d) (e) (f) 31. In this case the tibiofibular joint as well as the deltoid ligament had to be explored before the ankle could be reduced. If the fracture is not reduced and stabilized at an early stage, it may prove impossible to restore the anatomy. For this reason unstable injuries should be treated by internal fixation even in the presence of an open wound, provided the soft tissues are not too severely damaged and the wound is not contaminated. If internal fixation seems too risky, an external fixator can be used, often as a temporary spanning option. Unless the ankle is unstable, symptoms can often be managed by judicious analgesic treatment and the use of firm, comfortable footwear. However, in the longer term if symptoms become severe arthrodesis may be necessary. There is considerable damage to the articular cartilage and the subchondral bone may be broken into several pieces; in severe cases, the comminution extends some way up the shaft of the tibia. The ankle may be deformed or even dislocated; prompt approximate reduction is mandatory. The ankle should be immediately reduced and held in a splint until definitive treatment has been initiated. Wound breakdown and infection Diabetic patients are at greater than usual risk of developing wound-edge necrosis and deep infection. In dealing with displaced fractures, these risks should be carefully weighed against the disadvantages of conservative treatment; casts may also cause skin problems if not well padded and are less effective in preventing malunion. X-rays this is a comminuted fracture of the distal end of the tibia, extending into the ankle joint.

Communication Guidelines and Professional Conduct q Visitors are allowed in the service reception area only. Visitors are not allowed in the classrooms, student lounge, or clinic classroom area. Conducting unauthorized hair, skin, barber or nail services outside of school will be reported to the state board and may result in your inability to receive a professional license. All kit, equipment, tools, and personal items must be secured in the Future Professionals assigned locker. The Future Professional will not receive theory credit if they are not in theory class attendance. If a Future Professional chooses to leave theory class for any reason he/she will not be allowed to return to theory class. The school requires a Future Professionals to complete all theory hours as part of their graduation requirements. Paul Mitchell the School Sacramento and Paul Mitchell the School San Jose manages lockers to ensure responsible use of property and for the health and safety of individuals. Agreement - Paul Mitchell the School Sacramento and Paul Mitchell the School San Jose establishes rules, guidelines and procedures to ensure responsible use and to control the contents of its lockers. After that time, any lockers that have not yet been vacated will be emptied, and the contents stored for 60 days, at which time they become the property of the school. Locker content is the sole responsibility of the registered occupant of the locker. To reduce the risk of theft, students are encouraged to keep their lockers locked. Students should not store money, wallets, jewelry, credit or debit cards, or any other personal item of high value. The following is a partial listing of examples of when Paul Mitchell the School Sacramento and Paul Mitchell the School San Jose will exercise its discretion without notice: a. Suspected contents that may be illegal, illicit or deemed by the school to be harmful, offensive or inappropriate. Investigative purposes related to suspected or alleged criminal, illegal, or inappropriate activities. Such police activity may include but is not limited to: random drug or weapon searches of lockers, backpacks, book bags, brief cases, containers, jackets and winter coats. The school team will coach all Future Professionals to correct noncompliant or inappropriate behavior. The following actions may be inspected for noncompliance: q Attendance and Documentation of Time Guidelines: Attendance, promptness, and documentation of work are cornerstones of successful work practices. Future Professionals may be clocked out, released for the day, or suspended when they do not comply with guidelines. Future Professionals may be coached and receive an advisory when they do not meet professional image standards. Future Professionals may be coached and receive an advisory when they do not follow sanitation and personal service procedures. Staff and all contribute to a mutually respectful learning environment that fosters effective communication and professional conduct. Future Professionals who fail to follow communication guidelines and who do not conduct themselves in a respectful and professional manner may experience suspension or termination. Positive behavior is required to create a mutually beneficial learning environment for all Future Professionals. Future Professionals who fail to meet the guidelines and create challenges for other Future Professionals or staff may be released from school, suspended, or terminated. Corrective Action Steps Once a Future Professionals has received five (5) coaching sessions, the Future Professionals may be suspended from school for five (5) days. Suspended Future Professionals may only be re-admitted to school upon paying the administrative re-entry fee. A Future Professional may be terminated without prior coaching sessions for improper and/or immoral conduct. When monitoring Future Professionals for unofficial withdrawals, the school is required to count any days that a Future Professional was out of school on suspension as a part of the 14 consecutive days of non-attendance used to determine whether the Future Professional will be returning to school. We believe in providing a quality environment with an exceptional educational program. Paul Mitchell the School will provide reasonable accommodations to students with disabilities.

The mandibular 3rd molars are also often challenging to image, primarily due to the thickness of the overlying masseter muscle. If changing the technique as described above does not improve your image, then it is likely that the algorithms require adjustment by the technical support service provided by that particular software company. If the radiology system cannot image the stifle, then it will similarly be unable to image the mandibular molars. If the imaging software seems to be preventing proper contrast and detail of the area of interest, it may prove helpful to collimate the generator so that a smaller portion of the imaging plate/sensor is exposed, and the center of the plate/sensor is then centered on the area of interest. With some practice, the clinician should be able to obtain diagnostic quality radiographs with most of the portable radiographic systems currently in use. Summary Although the equine head has a complex anatomy, the teeth and sinus anatomy can be imaged quite well with portable digital radiographic systems that most equine practitioners have in clinical practice. The prerequisites for obtaining diagnostic images of the equine dentition are adequate sedation, proper positioning, and technique. Recognition of the "standard views" in an equine dental imaging study will assist the clinician in obtaining images that are of diagnostic quality for immediate use in the field, or for consultation. Clinicians are encouraged to obtain both right and left lateral oblique views for comparative purposes. The oblique lateral views are most informative if they are obtained with the mouth wide open. A standardized nomenclature for radiographic projections used in veterinary medicine. Introduction the primary dentition of the horse, also known as the deciduous dentition, is frequently encountered by the equine practitioner either during routine procedures or as a primary complaint, and is a neverending source of discussion. Questions regarding the first premolars, also known as "wolf teeth," will still elicit strong opinions regarding their extraction. In the past decade, little has changed about the way we approach the canines, but our knowledge of the unique nature of radicular hypsodont dentition in the horse, however, has evolved significantly. The Deciduous Dentition the Modified Triadan system designates the deciduous, or primary dentition, as the 500 through 800 teeth, with the 500 arcade indicating the upper right quadrant, 600 is upper left, 700 is lower left, and 800 is lower right. The central incisors are tooth number 001 and the teeth are numbered distally (towards the back of the mouth) to the third and last molar which is designated tooth number 011. For example, the deciduous right maxillary central inci- sor is tooth number 501 and the deciduous right maxillary fourth premolar is tooth number 508. The molars are always permanent teeth, so this discussion will focus on teeth number 001͠008. Deciduous teeth are present for up to 5 years in the horse, and they may be present longer in the donkey and draft breeds. The central incisors are Triadan tooth number one and the fourth premolars are Triadan tooth number eight. The deciduous incisors are small and round with an obvious "neck" at the intersection of the crown and root at the gingival margin. Exfoliation Schedule of Deciduous Dentition in the Horse (Modified Triadan) Table 1. Eruption Schedule of Primary (Deciduous) Dentition (Modified Triadan System) Primary (Deciduous Tooth) 501/601/701/801 (central incisors) 502/602/702/802 (lateral incisors) 503/603/703/803 (corner incisors) 506/606/706/806, 507/607/707/807, 508/608/708/808 (2nd, 3rd, 4th premolars) Approximate Eruption Time Age 0͸ d Age 4Ͷ wk Age 6͹ mo Age 0ͱ4 d 501/601/701/801 502/602/702/802 503/603/703/803 506/606/706/806 507/607/707/807 508/608/708/808 Age 2 1/2 y Age 3 1/2 y Age 4 1/2 y Age 2 y 8 mo Age 2 y 10 mo Age 3 y 8 mo ripheral enamel exposed. The occlusal surface is ovoid and becomes "level" or "in wear" approximately 6 months after eruption and has exposed secondary dentin inside the outer ring of enamel. An enamel infundibulum containing cementum is visible on the occlusal surface of the deciduous incisors, similar to the permanent incisors. The deciduous radicular hypsodont crowns undergo wear or "suffer attrition" while the permanent teeth are developing within the bone. Permanent (secondary or succedaneous) teeth develop in a dental follicle or sac just underneath the root of the primary tooth. The permanent premolars develop almost directly underneath the deciduous premolars. Within the dental follicle of the incisors and maxillary premolars, a blood vessel enters the developing permanent tooth from its crown to form the infundibula. For this reason, it is important to know the exfoliation schedule of the deciduous teeth and the eruption schedule of the permanent dentition. As the developing permanent tooth moves through the "eruption tunnel" underneath the deciduous tooth, pressure develops upon the root of the primary precursor.

Syndromes

• Nausea and vomiting
• Shortness of breath
• Fever
• Anti-glomerular basement membrane antibody
• Rash at birth (petechiae)
• Narrowings (strictures) due to radiation, chemicals, medications, chronic inflammation, or ulcers

Physical Rehabilitation correcting muscle imbalances will be prone to acquiring acute or chronic injuries secondary to a cascade of compensatory mechanisms. For example, a competitive showjumping horse experiencing pain in the lower spine may compensate during takeoff by overusing muscles in the hind limbs. Over a period of time, soft tissues subjected to overuse will eventually break down, leading to potentially debilitating muscle trigger points, tendonitis or tendonosis, acute tearing of muscle and ligamentous tissues, and bony stress fractures. If injuries are severe enough, the equine athlete may be eliminated from competition for a period of time or indefinitely. Another example illustrating the importance of correcting muscle and soft tissue imbalances to restore harmony between horse and rider may be taken from the equine perspective. Take a case where a competitive showjumping horse has developed degenerative changes in the fourth through seventh cervical vertebrae. The bony changes may or may not be painful to the horse, however, they will most likely have created decreased segmental mobility in the zygapophyseal joint capsules resulting in decreased cervical sidebending range of motion. This will subsequently alter the optimal dynamic balance between horse and rider and result in a decrease in performance. The rider may describe the problem as, "My horse does not turn to the right or left very well," but in fact the horse has a very treatable condition from a physical therapy paradigm of clinical reasoning. A physical therapist will clinically address soft tissue and joint restrictions in the equine cervical spine utilizing a similar line of clinical reasoning as applied to humans; by incorporating skilled manual therapy and adjunctive techniques to treat myofascial and connective tissue dysfunction and restore normal joint arthro and osteokinematics. Successful clinical outcomes will be assessed by increased passive and active cervical side-bending range of motion and improved sport performance. Rider feedback will indicate a noticeable increase in cervical spinal mobility in the horse during performance and a sense of greater efficiency with dynamic trunk balance in saddle while showing. Finally, another interesting phenomenon occurring in both humans and horses relates to how even minor physical ailments or lesions in joints or soft tissues, if left untreated, may negatively impact musculoskeletal mechanics and sport performance. For example, with human athletes, ligament sprains or tendon strains that fail to heal properly over time may result in compensatory biomechanical faults and joint hypomobility ultimately leading to a reduc266 2016 Vol. The goals of therapy will be to eliminate signs and symptoms of pain and swelling, restore normal function of involved tissues, and properly recondition the involved athlete for a return to sport. In contrast, a complete lack of implementation or inadequately controlled rehabilitation may lead to a vicious cycle of repetitive injuries or chronic pain, which in turn may preclude an athlete from returning to sport altogether. A complete cycle of injury and recovery will occur when damaged tissues are subjected to appropriate internal and external environments that support the healing process. To illustrate, assume a competitive equine athlete sustains an acute micro-tearing of the deep digital flexor tendon on the hindlimb. A typical sequence of healing would include an inflammatory stage, followed by cellular proliferation, and finally remodeling and maturation of the tendon. If this reaction occurs, the horse may fall into a vicious cycle of pain, spasm, and dysfunction of involved tissues causing secondary lower back pain cascading into additional biomechanical faults in gait, and jumping ability. Intervention with this scenario by a qualified physical therapist, however, will help break the pain/spasm cycle and restore injured tissues back to a state of normal function. The primary emphasis of a structured physical therapy plan of care for any condition is to restore normal anatomic, physiologic, and biomechanical function, and return the athlete to all desired activities, including sport performance. To accomplish these goals, a physical therapist will create an individualized treatment plan based on a thorough evaluation and selection of appropriate interventions. Interventions may include such things as specific manual therapy techniques to restore normal function in joint and soft tissues, physical agent modalities to support the healing process, and tailored therapeutic exercises to address muscle, cardiovascular, and respiratory conditioning. Failure to achieve these goals during rehabilitation will result in inadequately healed tissues, lack of proper conditioning, and ultimately reduced sport performance, or possibly a complete end to an athletic career. Studies have been conducted on basic equine physiology with references to athletic performance, but data related to sport-specific demands has primarily centered on biomechanics, core strengthening exercises, foundational stretching techniques to enhance overall mobility, and parameters to improve speed and endurance. Studies that directly correlate how altering biophysical parameters in a horse specifically affect sport performance in relation to outcomes is significantly lacking. An even greater void of knowledge exists, however, regarding the best way to maximize training and conditioning programs for equine athletes based on sport-specific demands. Equine Training and Conditioning One of the key elements for any athlete to perform at peak levels in sporting activities is to be in absolute top condition both physically and psychologically.