Anticipation of the discomfort of anintramuscular injection causes anxietyfor many patients.

Plaster of Paris itself can be hazardous because of the thermal reactions thatoccur as the material sets. When water is added to plaster of Paris powder, thewater molecules go from a liquid to a solid state by incorporating into the crystallattice of the calcium sulfate hemihydrate. This converts kinetic energy intoheat. If hot water is applied to plaster of Paris to begin this kinetic process, theheat given off from the resulting crystallization can actually burn the patient'slimb.

These temporary splints are associatedwith special complications relatedto both the action or condition ofthe patient and the nature of thesplint itself. At our orthopaedic clinic,we commonly see patients whohave been referred from the emergencydepartment in a temporarysplint after a minor ankle sprain or afracture of the lateral malleolus. Ifthe patient allows the foot to hang ina nonfunctional position withoutweight bearing, the injured anklemay swell like a sausage.

A 69-year-old man with a long history of lymphedema secondary to repeated cellulitis sought medical care for mildly pruritic, nontender, purple nodules that had erupted on the bottom and side of one foot 6 months earlier. Scale surrounded the nodules.

Although the cardiovascular death ratehas declined in the United States, thenumber of hospitalizations for cardiacdisease has not. The improvement incare has been offset by an increase inthe number of older Americans. By2050, more than 100 million Americanswill be 60 years of age or older,and about 30 million will be older than80 years.

The goal in managing manymusculoskeletal injuries isnow early mobilization-notimmobilization. This shift inemphasis encompasses injuriesranging from a strained backto a sprained ankle. Patients withsciatica who previously might havebeen kept at bed rest for severalweeks are now encouraged to avoidbed rest and to alleviate nerve irrita-tion with positional exercises. Similarly,patients with ankle sprainsgain faster pain relief and recoverfunction more rapidly when cast orsplint immobilization is avoided.Early mobilization is appropriate formany acute injuries without riskof significant bone or joint instability.Its advantages have emerged asthe many detriments or hazards ofeven brief periods of immobilizingmuscles, joints, and bones havebecome apparent.

Ulnar nerve problems can occurwhen the elbow is immobilized in flexionbeyond a right angle (ie, less than90 degrees). This can compress theulnar nerve as it travels through thecubital tunnel, a problem especiallylikely if the ulnar nerve is relativelymobile and moves up against the epicondyle,as it did in this patient whohad sustained a radial fracture. Ulnarneuropathy developed after a longarmcast was applied with the elbowhyperflexed.

A 65-year-old man with no significant medical history presented with mild abdominal pain-primarily in the left lower quadrant-and bleeding gums. He had a petechial rash over the entire body and hepatosplenomegaly 10 cm below the costal margin.

An intensely itchy dermatosis developed on the back of a 30-year-old Saudi Arabian renal transplant patient. The patient had never before experienced a similar eruption. He was taking prednisone and azathioprine to prevent transplant organ rejection, as well as amoxicillin for an upper respiratory tract infection.

Painful, erythematous plaques had erupted 4 to 6 weeks earlier on the left upper arm and lower abdominal wall of a 54-year-old woman.

A 25-year-old man presented with an erythematous, pruritic, scaly, macular rash that had begun behind his ears and spread over his neck, chest, trunk, and upper and lower extremities.

Hundreds of yellow papules developed on the trunk and extremities of this patient, whose diabetes was uncontrolled.