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Primitive Heart Tube It is shaped by fusion of two endocardial coronary heart tubes of mesodermal origin in the cardiogenic area pain treatment center of franklin tennessee generic imdur 40 mg without prescription. It develops into the endocardium innovative pain treatment surgery center of temecula imdur 20mg low cost, and the splanchnic mesoderm surrounding the tube develops into the myocardium and epicardium back pain treatment yoga purchase cheap imdur on-line. It varieties 5 dilations myofascial pain treatment center watertown ma safe imdur 40 mg, together with the truncus arteriosus, bulbus cordis, primitive ventricle, primitive atrium, and sinus venosus. It undergoes a folding right into a U-form, bringing the arterial and venous ends of the guts collectively and transferring the ventricle caudally and the atrium cranially. Bulbus cordis varieties conus cordis or conus arteriosus (easy part of right ventricle) and aortic vestibule (easy part of left ventricle on the root of the aorta). Sinus venosus varieties sinus venarum (easy part of right atrium), coronary sinus, and indirect vein of left atrium. Septum secundum varieties to the best of the septum primum and fuses with the septum primum to form the atrial septum, which separates the best and left atria. Foramen ovale is an oval opening in the septum secundum that provides a communication between the atria. This congenital coronary heart defect shunts blood from the left atrium to the best atrium and causes hypertrophy of the best atrium, right ventricle, and pulmonary trunk and thus mixing of oxygenated and deoxygenated blood, producing cyanosis. Symptoms of the defect are dyspnea (problem breathing), shortness of breath, and palpitations, and its indicators embody irregular coronary heart sounds, murmur, and coronary heart failure. Symptoms of the defect are shortness of breath, quick coronary heart fee and breathing, sweating, and paleness, and its indicators embody a loud, steady murmur and congestive coronary heart failure. Formation the arterial system develops from the aortic arches and branches of the dorsal aorta. Aortic Arch Derivatives Chapter four Thorax 161 Aortic arch 2 has no derivative as a result of it persists only during the early improvement. Aortic arch three varieties the widespread carotid arteries and the proximal part of the interior carotid arteries. Aortic arch four varieties the aortic arch on the left and the brachiocephalic artery and the proximal subclavian artery on the best. Posterolateral Branches Form the intercostal, lumbar, vertebral, cervical, inner thoracic, and epigastric arteries and arteries to higher and lower limbs. Vitelline arteries form the celiac (foregut), superior mesenteric (midgut), and inferior mesenteric (hindgut) arteries. Umbilical arteries form a part of the interior iliac and superior vesical arteries. Shunts blood from the best atrium to the left atrium, partially bypassing the lungs (pulmonary circulation). Ductus Arteriosus Is derived from the sixth aortic arch and connects the bifurcation of the pulmonary trunk with the aorta. Closes functionally soon after start, with anatomic closure requiring several weeks. Becomes the ligamentum arteriosum, which connects the left pulmonary artery (at its origin from the pulmonary trunk) to the concavity of the arch of the aorta. Shunts blood from the pulmonary trunk to the aorta, partially bypassing the lungs (pulmonary circulation). Become medial umbilical ligaments after start, after their distal elements have atrophied. Consists of the best vein, which is obliterated during the embryonic period, and the left vein, which is obliterated to form the ligamentum teres hepatis after start. Has three constrictions: higher or pharyngoesophageal constriction at the beginning of the esophagus on the stage of the cricoid cartilage (C6) is brought on by the cricopharyngeus muscle (the superior esophageal sphincter), middle or thoracic constriction by the aortic arch after which left primary bronchus, and inferior or diaphragmatic constriction on the esophageal hiatus of the diaphragm (T10). Has a physiologic sphincter, which is the circular layer of easy muscle on the gastroesophageal junction. Receives blood from the inferior thyroid artery in the neck and branches of the aorta (bronchial, and esophageal arteries) and from the left gastric and left inferior phrenic arteries in the thorax. It causes an obstruction to the passage of meals in the terminal esophagus and displays signs of dysphagia for solids and liquids, weight reduction, chest ache, nocturnal cough, and recurrent bronchitis or pneumonia. Systemic sclerosis (scleroderma) is a systemic collagen vascular illness and has medical features of dysphagia for solids and liquids, severe heartburn, and esophageal stricture. Descends on the left aspect of the vertebral column after which approaches the median aircraft to end in entrance of the vertebral column by passing through the aortic hiatus of the diaphragm.

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Carina could also be distorted pain treatment gout generic imdur 40 mg with mastercard, widened posteriorly inpatient pain treatment center effective imdur 40 mg, and immobile in the presence of a bronchogenic carcinoma shoulder pain treatment guidelines imdur 20 mg amex. The mucous membrane over the carina is among the most delicate areas of the tracheobronchial tree and is related to the cough reflex pain treatment center brentwood ca best purchase imdur. Anterior Superior lobar bronchus Superior Inferior Anteromedial basal Lateral basal Posterior basal Inferior lobar bronchus Chapter 4 Thorax 139 B. Right Main (Primary) Bronchus Is shorter, wider, and more vertical than the left main bronchus; therefore, more foreign bodies that enter by way of the trachea are lodged in this bronchus or inferior lobar bronchus. Runs underneath the arch of the azygos vein and divides into three lobar or secondary (superior, middle, and inferior) bronchi and eventually into 10 segmental bronchi. The right superior lobar (secondary) bronchus is named the eparterial (above the artery) bronchus as a result of it passes above the extent of the pulmonary artery. Left Main (Primary) Bronchus Runs inferolaterally inferior to the arch of the aorta, crosses anterior to the esophagus and thoracic aorta, and divides into two lobar or secondary bronchi, the upper and decrease, and eventually into eight to 10 segmental bronchi. Is also crossed superiorly by the arch of the aorta over its proximal part and by the left pulmonary artery over its distal part. Dilates its lumen by sympathetic nerves and constricts by parasympathetic stimulation. It consists of persistent bronchitis and emphysema, which are the commonest varieties and is caused primarily by cigarette smoking. Chronic bronchitis is an irritation of the airways, which end in extreme mucus manufacturing that plugs up the airways, causing a cough and breathing difficulty. Emphysema is an accumulation of air in the terminal bronchioles and alveolar sacs (air is trapped in the lungs) because of destruction of the alveolar walls, decreasing the floor area available for the change of oxygen and carbon dioxide and thereby decreasing oxygen absorption. Barrel chest is a chest resembling the form of a barrel, with increased anteroposterior diameter that happens on account of lengthy-time period overinflation of the lungs, typically seen in cases of emphysema or bronchial asthma. It causes an airway obstruction and is characterized by dyspnea (difficulty in breathing), cough, and wheezing due to spasmodic contraction of easy muscle tissue in the bronchioles. Bronchiectasis is a persistent dilation of bronchi and bronchioles ensuing from destruction of bronchial elastic and muscular parts, which can cause collapse of the bronchioles. Signs and symptoms embody a persistent cough with expectoration of enormous volumes of sputum. Pleura Is a thin serous membrane that consists of a parietal pleura and a visceral pleura. Parietal Pleura Lines the internal floor of the thoracic wall and the mediastinum and has costal, diaphragmatic, mediastinal, and cervical parts. The cervical pleura (cupula) is the dome of the pleura, projecting into the neck above the neck of the primary rib. Diaphragmatic pleura the endothoracic fascia, and is hooked up to the primary rib and the transverse means of the seventh cervical vertebra. Is separated from the thoracic wall by the endothoracic fascia, which is an extrapleural fascial sheet lining the thoracic wall. Is innervated by the intercostal nerves (costal pleura and the peripheral portion of the diaphragmatic pleura) and the phrenic nerves (central portion of the diaphragmatic pleura and the mediastinal pleura). Is provided by branches of the internal thoracic, superior phrenic, posterior intercostal, and superior intercostal arteries. Forms the pulmonary ligament, a two-layered vertical fold of mediastinal pleura, which extends alongside the mediastinal floor of each lung from the hilus to the bottom (diaphragmatic floor) and ends in a free falciform border. It helps the lungs in the pleural sac by retaining the decrease parts of the lungs in place. Is provided by bronchial arteries, but its venous blood is drained by pulmonary veins. Is insensitive to ache but is delicate to stretch and accommodates vasomotor fibers and sensory endings of vagal origin, which can be involved in respiratory reflexes. Chapter 4 Thorax 141 Pleurisy (pleuritis) is an irritation of the pleura with exudation (escape of fluid from blood vessels) into its cavity, causing the pleural surfaces to be roughened. This roughening produces friction, and a pleural rub could be heard with the stethoscope on respiration. The exudate varieties dense adhesions between the visceral and parietal pleurae, forming pleural adhesions. Treatments encompass relieving ache with analgesics, as necessary, and lidocaine for intercostal nerve block. Contains a film of fluid that lubricates the floor of the pleurae and facilitates the motion of the lungs.

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This refusal must have surprised the Germans no finish pain medication for dogs after spay order genuine imdur on-line, since it appeared so "illogical" for a government to pain solutions treatment center hiram order imdur 40 mg on line defend folks to st john pain treatment center order imdur toronto whom it had categorically denied naturalization and even permission to pain center treatment for fibromyalgia imdur 20 mg overnight delivery work. This was one of many few cases in which statelessness turned out to be an asset, although it was after all not statelessness per se that saved the Jews however, quite the opposite, the truth that the Danish government had decided to defend them. Thus, none of the preparatory moves, so essential for the paperwork of murder, may carried out, and operations were postponed till the autumn of 1943. What happened then was truly wonderful; compared with what took place in other European international locations, everything went topsy-turvy. In August, 1943 - after the German offensive in Russia had failed, the Afrika Korps had surrendered in Tunisia, and the Allies had invaded Italy - the Swedish government canceled its 1940 settlement with Germany which had permitted German troops the proper to cross by way of the nation. Thereupon, the Danish staff decided that they may assist a bit in hurrying things up; riots broke out in Danish shipyards, the place the dock staff refused to restore German ships after which went on strike. The German army commander proclaimed a state of emergency and imposed martial legislation, and Himmler thought this was the proper moment to deal with the Jewish query, whose "resolution" was lengthy overdue. Not only did General von Hannecken, the army commander, refuse to put troops on the disposal of the Reich plenipotentiary, Dr. The night of October 1 was set for their seizure and quick departure - ships were prepared within the harbor - and since neither the Danes nor the Jews nor the German troops stationed in Denmark could possibly be relied on to assist, police items arrived from Germany for a door-to-door search. They found precisely 477 folks, out of a complete of more than 7,800, at home and prepared to let them in. Duckwitz, having most likely been tipped off by Best himself, had revealed the whole plan to Danish government officers, who, in flip, had hurriedly informed the heads of the Jewish group. They, in marked contrast to Jewish leaders in other international locations, had then communicated the news brazenly within the synagogues on the occasion of the New Year providers. The Jews had simply time sufficient to go away their apartments and go into hiding, which was very easy in Denmark, as a result of, within the phrases of the judgment, "all sections of the Danish folks, from the King down to easy citizens," stood able to obtain them. They might need remained in hiding till the tip of the struggle if the Danes had not been blessed with Sweden as a neighbor. It appeared affordable to ship the Jews to Sweden, and this was done with the help of the Danish fishing fleet. The price of transportation for folks without means - about a hundred dollars per individual - was paid largely by rich Danish citizens, and that was maybe the most astounding feat of all, since this was a time when Jews were paying for their very own deportation, when the rich amongst them were paying fortunes for exit permits (in Holland, Slovakia, and, later, in Hungary) either by bribing the local authorities or by negotiating "legally" with the S. Even in places the place Jews met with genuine sympathy and a sincere willingness to assist, they had to pay for it, and the chances poor folks had of escaping were nil. It took the better a part of October to ferry all of the Jews across the 5 to fifteen miles of water that separates Denmark from Sweden. The Swedes received 5,919 refugees, of whom no less than 1,000 were of German origin, 1,310 were half-Jews, and 686 were non-Jews married to Jews. The few hundred Jews whom the German police had been capable of arrest were shipped to Theresienstadt. They were old or poor folks, who either had not received the news in time or had not been capable of comprehend its which means. In the ghetto, they enjoyed higher privileges than some other group due to the endless "fuss" made about them by Danish establishments and personal individuals. Forty-eight individuals died, a determine that was not significantly excessive, in view of the typical age of the group. When everything was over, it was the thought-about opinion of Eichmann that "for varied causes the motion against the Jews in Denmark has been a failure," whereas the curious Dr. Best declared that "the objective of the operation was to not seize a large number of Jews however to clear Denmark of Jews, and this goal has now been achieved. It is the one case we know of in which the Nazis met with open native resistance, and the end result appears to have been that those exposed to it changed their minds. They themselves apparently no longer seemed upon the extermination of an entire folks as a matter after all. That the perfect of "toughness," except, maybe, for a number of half-demented brutes, was nothing however a fantasy of self-deception, concealing a ruthless want for conformity at any value, was clearly revealed on the Nuremberg Trials, the place the defendants accused and betrayed one another and warranted the world that they "had at all times been against it" or claimed, as Eichmann was to do, that their greatest qualities had been "abused" by their superiors. Werner Best claimed at Nuremberg that he had played an advanced double function and that it was due to him that the Danish officers had been warned of the approaching disaster; documentary proof confirmed, quite the opposite, that he himself had proposed the Danish operation in Berlin, however he defined that this was all a part of the sport. He was extradited to Denmark and there condemned to demise, however he appealed the sentence, with surprising results; due to "new proof," his sentence was commuted to 5 years in prison, from which he was released quickly afterward.

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Varicose veins develop within the superficial veins of the decrease limb due to decreased elasticity and incompetent valves within the veins or thrombophlebitis of the deep veins pain treatment with laser buy imdur once a day. Superficial Lymph Vessels Are shaped by vessels from the gluteal area treating pain after shingles purchase 40 mg imdur with visa, the belly wall pain medication for dogs list discount imdur 20 mg on line, and the exterior genitalia bellevue pain treatment center purchase discount imdur line. Are divided into a medial group, which follows the good saphenous vein to end within the inguinal nodes, and a lateral group, which follows the small saphenous vein to end within the popliteal nodes, and their efferents accompany the femoral vessels to end within the inguinal nodes. Deep Lymph Vessels Consist of the anterior tibial, posterior tibial, and peroneal vessels, which follow the course of the corresponding blood vessels and enter the popliteal lymph nodes. The lymph vessels from the popliteal nodes accompany the femoral vessels to the inguinal nodes, which enter the exterior iliac nodes and ultimately drain into the lumbar (aortic) nodes and vessels. Superficial Inguinal Group of Lymph Nodes Is located subcutaneously near the saphenofemoral junction and drains the superficial thigh area. Receives lymph from the anterolateral belly wall beneath the umbilicus, gluteal area, decrease parts of the vagina and anus, and exterior genitalia besides the glans, and drains into the exterior iliac nodes. Sacrotuberous Ligament Extends from the ischial tuberosity to the posterior iliac spines, decrease sacrum, and coccyx. Converts, with the sacrospinous ligament, the lesser sciatic notch into the lesser sciatic foramen. Greater Sciatic Foramen Provides a pathway for the piriformis muscle, superior and inferior gluteal vessels and nerves, inner pudendal vessels and pudendal nerve, sciatic nerve, posterior femoral cutaneous nerve, and the nerves to the obturator internus and quadratus femoris muscular tissues. Provides a pathway for the tendon of the obturator internus, the nerve to the obturator internus, and the internal pudendal vessels and pudendal nerve. Include the pudendal nerve, the internal pudendal vessels, and the nerve to the obturator internus. Helps form the fibrous capsule of the knee joint and is essential in sustaining posture and locomotion. Fascia Lata Is a membranous, deep fascia masking muscular tissues of the thigh and forms the lateral and medial intermuscular septa by its inward extension to the femur. Is hooked up to the pubic symphysis, pubic crest, pubic rami, ischial tuberosity, inguinal and sacrotuberous ligaments, and the sacrum and coccyx. Gluteal gait (gluteus medius limp) is a waddling gait characterised by the pelvis falling (or drooping) toward the unaffected aspect when the opposite leg is raised at each step. It results from paralysis of the gluteus medius muscle, which normally functions to stabilize the pelvis when the opposite foot is off the bottom. Injection ought to always be made within the superior lateral quadrant of the gluteal area to keep away from damage to the underlying sciatic nerve and other neurovascular buildings within the medial and inferior quadrants. This referred pain, referred to as "sciatica," within the decrease back and hip radiates down the back of the thigh and into the decrease back. If this fails, then a corticosteroid may be administered into the piriformis muscle. If the proper gluteus medius and minimus muscular tissues are paralyzed, the unsupported left aspect (sound aspect) of the pelvis falls (sags) as an alternative of rising; normally the pelvis rises. The origin of the hamstrings from the ischial tuberosity may be avulsed, resulting in rupture of blood vessels. Avulsion of the ischial tuberosity may end result from forcible flexion of the hip with the knee prolonged, and tearing of hamstring fibers may be very painful. Femoral Triangle Is bounded by the inguinal ligament superiorly, the sartorius muscle laterally, and the adductor longus muscle medially. Has the ground, which is shaped by the iliopsoas, pectineus, and adductor longus muscular tissues. The pulsation of the femoral artery may be felt simply inferior to the midpoint of the inguinal ligament. Is bounded by the inguinal ligament anteriorly, the femoral vein laterally, the lacunar ligament medially, and the pectineal ligament posteriorly. Is a possible weak space and a website of femoral herniation, which happens most frequently in women due to the larger width of the superior pubic ramus of the feminine pelvis. Femoral hernia is more widespread in women than in males, passes through the femoral ring and canal, and lies lateral and inferior to the pubic tubercle and deep and inferior to the inguinal ligament; its sac is shaped by the parietal peritoneum. Strangulation of a femoral hernia may happen due to the sharp, stiff boundaries of the femoral ring, and the strangulation interferes with the blood supply to the herniated gut, resulting in death of the tissues. Femoral Sheath Is shaped by a prolongation of the transversalis and iliac fasciae within the thigh.

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It causes plantar flexion of the foot and checks its reflex center within the L5�S1 or S1�S2 segments of the spinal cord treatment guidelines for pain management generic 40mg imdur. Both afferent and efferent limbs of the reflex arc are carried within the tibial nerve pain management for dog in heat purchase imdur with amex. Superior Extensor Retinaculum Is a broad band of deep fascia extending between the tibia and fibula dfw pain treatment center generic imdur 20mg amex, above the ankle urmc pain treatment center sawgrass drive rochester ny order imdur cheap. Inferior Extensor Retinaculum Is a Y-formed band of deep fascia that varieties a loop for the tendons of the extensor digitorum longus and the peroneus tertius after which divides into an upper band, which attaches to the medial malleolus, and a decrease band, which attaches to the deep fascia of the foot and the plantar aponeurosis. Chapter three t a b l e Muscle Dorsum of foot Extensor digitorum brevis Extensor hallucis brevis Sole of foot First layer Abductor hallucis Flexor digitorum brevis Abductor digiti minimi Lower Limb 103 three-7 Origin Muscles of the Foot Insertion Nerve Action Dorsal floor of calcaneus Dorsal floor of calcaneus Tendons of extensor digitorum longus Base of proximal phalanx of big toe Deep peroneal Deep peroneal Extends toes Extends massive toe Medical tubercle of calcaneus Medial tubercle of calcaneus Medial and lateral tubercles of calcaneus Base of proximal phalanx of big toe Middle phalanges of lateral four toes Proximal phalanx of little toe Medial plantar Medial plantar Lateral plantar Abducts massive toe Flexes middle phalanges of lateral four toes Abducts little toe Second layer Quadratus plantae Lumbricals (4) Medial and lateral aspect of calcaneus Tendons of flexor digitorum longus Tendons of flexor digitorum longus Proximal phalanges, extensor growth Lateral plantar First by medial plantar, lateral three by lateral plantar Aids in flexing toes Flex metatarsophalangeal joints and prolong interphalangeal joints Third layer Flexor hallucis brevis Adductor hallucis Oblique head Transverse head Cuboid, third cuneiform Bases of metatarsals 2�4 Capsule of lateral four metatarsophalangeal joints Base of metatarsal 5 Proximal phalanx of big toe Proximal phalanx of big toe Medial plantar Flexes massive toe Lateral plantar Adducts massive toe Flexor digiti minimi brevis Fourth layer Plantar interossei (three) Proximal phalanx of little toe Lateral plantar Flexes little toe Medial sides of metatarsals three�5 Adjacent shafts of metatarsals Dorsal interossei (4) Medial sides of base of proximal phalanges three�5 Proximal phalanges of second toe (medial and lateral sides), and third and fourth toes (lateral sides) Lateral plantar Lateral plantar Adduct toes, flex proximal and prolong distal phalanges Abduct toes, flex proximal and prolong distal phalanges C. Flexor Retinaculum Is a deep fascial band that passes between the medial malleolus and the medial floor of the calcaneus and varieties the tarsal tunnel with tarsal bones for the tibial nerve, posterior tibial vessels, and flexor tendons. It could also be attributable to repetitive stress with actions, flat ft, or extra weight. Avulsion or rupture of the Achilles tendon disables the triceps surae (gastrocnemius and soleus) muscular tissues; thus, the patient is unable to plantar flex the foot. Forced eversion of the foot avulses the medial malleolus or ruptures the deltoid ligament, whereas forced inversion avulses the lateral malleolus or tears the lateral collateral (anterior and posterior talofibular and calcaneofibular) ligament. Ankle sprain (inversion harm) results from rupture of calcaneofibular and talofibular ligaments and a fracture of the lateral malleolus attributable to forced inversion of the foot. Radiates from the calcaneal tuberosity (tuber calcanei) toward the toes and provides attachment to the quick flexor muscular tissues of the toes. Medial Longitudinal Arch Is formed and maintained by the interlocking of the talus, calcaneus, navicular, cuneiform, and three medial metatarsal bones. Has, as its keystone, the pinnacle of the talus, which is situated at the summit between the sustentaculum tali and the navicular bone. Flat foot (pes planus or talipes planus) is a condition of disappearance or collapse of the medial longitudinal arch with eversion and abduction of the forefoot and causes greater put on on the inside border of the soles and heels of sneakers than on the outer border. It causes pain as a result of stretching of the plantar muscular tissues and straining of the spring ligament and the lengthy and quick plantar ligaments. Pes cavus reveals an exaggerated height of the medial longitudinal arch of the foot. Is supported by the peroneus longus tendon and the lengthy and quick plantar ligaments. Proximal (metatarsal) arch Is formed by the navicular bone, the three cuneiform bones, the cuboid bone, and the bases of the 5 metatarsal bones of the foot. Long Plantar (Plantar Calcaneocuboid) Ligament Extends from the plantar facet of the calcaneus in entrance of its tuberosity to the tuberosity of the cuboid bone and the bottom of the metatarsals and varieties a canal for the tendon of the peroneus longus. Extends from the entrance of the plantar floor of the calcaneus to the plantar floor of the cuboid bone. Lies deep to the lengthy plantar ligament and helps the lateral longitudinal arch. Is called the spring ligament as a result of it accommodates considerable numbers of elastic fibers to give elasticity to the arch and spring to the foot. It may contain a deformity in which the foot is plantarflexed (equinus) or dorsiflexed (calcaneus) and the heel is turned laterally (valgus) or medially (varus), in which the heel is elevated and turned laterally (equinovalgus) or medially (equinovarus), or in which the anterior a part of the foot (forefoot) is elevated and the heel is turned laterally (calcaneovalgus) or medially (calcaneovarus). Obturator Nerve (L2�L4) Arises from the lumbar plexus and enters the thigh by way of the obturator foramen. Femoral Nerve (L2�L4) Arises from the lumbar plexus within the substance of the psoas major, emerges between the iliacus and psoas major muscular tissues, and enters the thigh by passing deep to the inguinal ligament and lateral to the femoral sheath. Gives rise to muscular branches; articular branches to the hip and knee joints; and cutaneous branches, together with the anterior femoral cutaneous nerve and the saphenous nerve, which descends by way of the femoral triangle and accompanies the femoral vessels within the adductor canal. Superior Gluteal Nerve (L4�S1) Arises from the sacral plexus and enters the buttock by way of the greater sciatic foramen above the piriformis. Passes between the gluteus medius and minimus muscular tissues and divides into numerous branches. Innervates the gluteus medius and minimus, the tensor fasciae latae, and the hip joint. Injury to the superior gluteal nerve causes a characteristic motor loss, leading to weakened abduction of the thigh by the gluteus medius, a disabling gluteus medius limp, and gluteal gait.

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