hip dislocation

Monday, September 22, 2014

Bo knew football. Bo knew baseball. Bo knew hip dislocation. Now Dennis Pitta knows what Bo knew…hip dislocation leads to badness. For the second time in two years, Mr. Pitta, the Baltimore Ravens tight end, dislocated his hip and required surgery to repair the damage. A year ago, the hip injury occurred while being tackled. This time, he twisted on the field and went down in a heap without being touched, the hip popping out of joint without significant trauma.

In 1991, Bo Jackson, then of the Oakland Raiders, was tackled in a playoff game and felt his hip pop out of joint. Even with having the dislocation reduced, or having it put back into place immediately, and even with surgery and rehabilitation, he developed avascular necrosis of the femoral head (the ball of the hip joint). This is a common complication of hip dislocation that occurs because of hip has been poorly structurally engineered. Some of the blood supply to the femoral head comes from arteries that have to travel across the joint from the acetabulum (the socket of the hip joint) to the femoral head. When the hip dislocates, that blood supply is lost and the potential exists that the femoral head will not get enough oxygen and nutrients from other arteries to survive. This is called avascular necrosis (a=without + vascular=blood vessels +necrosis=death) and it damage the femoral head no matter how good the treatment is or how fast the hip is repaired. Mr. Jackson underwent hip replacement surgery and was able to return for a brief time to baseball but soon his career was over.

hip xray 1

For Mr. Pitta, surgery and rehabilitation for his first hip dislocation went well and he was able to return to play football late in the season. Dislocation number two raises questions about the potential for him to return a second time.

The hip is a strong structure and it takes a significant amount of force to cause a dislocation. Aside from the bony protection of the acetabulum and the five large ligaments that help stabilize the hip joint, the angle that the femoral head enters the acetabulum provides even more stability. Most often, hips are dislocated in car wrecks, where the dashboard is driven into the knee of the driver or front seat passenger. By sitting with a bent knee the direction of the force drives the femoral neck through the back of the acetabulum, breaking that bone.

Aside from avascular necrosis and arthritis, which are long term complications, the big risk in the acute situation is damage to the sciatic nerve, the large nerve that leaves the back and runs through the buttock, behind the hip, to supply the leg. When the hip dislocates posteriorly or toward the back, it can damage the nerve in a variety of ways, from having generalized swelling inflame the nerve to specific damage done because of bony fragments injure the nerve.

Mr. Pitta required surgery again to repair the injuries and time will tell whether he will escape the complications that can plague hip dislocations. Most certainly, his second hip dislocation occurred because the structures that held his hip in place, the muscles, tendons ligaments and joint capsule had loosened. He had the bad luck to have his injury witnessed by an audience of thousands in the stadium and millions more in the television audience, but the injury could have just as likely happened in a parking lot, twisting to get out of a car or playing in the backyard with his family.

Dennis Pitta now knows what Bo knows. 20 years of medical progress still cannot guarantee perfect healing. Injury and trauma have a way of humbling those in the medical profession. Even with the best care, the body cannot always be put back together like it was before. There are complications that cannot be prevented. There are injuries that cannot be completely rehabilitated. Sometimes badness happens.


Xray image attribution: www.wikiradiology.com



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child abuse

Monday, September 15, 2014

Football is supposed to be about great catches, amazing runs, open field tackles and your favorite team winning in the last minute. It is supposed to be about joy and community, the celebration of individual performance and team accomplishment. It is not supposed to be about injuries and Robert Griffin’s dislocated ankle, Knowshon Moreno’s dislocated elbow, Ryan Matthews sprained knee or DeSean Jackson’s separated shoulder. But football is a violent sport and behavior on the field should not expected to be acceptable away from the stadium and for that reason, it is difficult to read about Adrian Peterson’s indictment on child abuse for disciplining his son with a switch.

The facts are not in dispute. Peterson used a switch or tree branch to hit his son and leave cuts and bruises on his back, legs, buttocks, scrotum and hands. The child was hit between 10 and 15 times but Mr. Peterson could not remember the exact number and it was not the first time that the child and his siblings had been punished in that way. CBS Houston has summarized the police reports. However, what is in dispute, and what is frustrating for those who care for beaten children, is the pretense that a parent bestowing corporal punishment on a child is a legally accepted form of child abuse.

Celebrity athletes have come to the defense of Mr. Peterson, describing their upbringing where “whooping” a child was an accepted form of behavior. Charles Barkley felt that his beatings as a child did not affect his personal development and had no trouble admitting in a CBS interview that he continued the tradition saying that his daughter was “spanked pretty good”. I’m from the South. Whipping — we do that all the time.” He tried to distinguish between using a switch and beating or child abuse, but also admitted that perhaps his grandmother had sometimes crossed the line. During a radio interview, Tony Dungy, former NFL coach and now NBC analyst, wanted to wait to see what the courts had to say whether, the whooping with a switch was child abuse. He talked about getting the same disciplinary beatings as a child.

The issue is not one of action but presumably of intent. Abuse is rage against the child, while corporal punishment that inflicts the same physical and emotional damage is somehow different. Because one generation felt it appropriate to beat children does not make it the norm. Physical violence is not acceptable, except perhaps on the football field, and on the field there are referees to enforce the rules. It is unacceptable to hit a defenseless receiver or an exposed quarterback. Players who attempt to injure are thrown out of the game. The same protections are not in place in a home where a large adult has chosen to beat a defenseless child.

What is child abuse? For most people, it’s like pornography, and paraphrasing Justice Potter Stewart: it’s hard to define but they know it when they see it. The Child Welfare Information Gateway  has a summary of signs and symptoms and how to recognize abuse and neglect, and explains the different forms that child abuse can take. But the legislature and legal system give wide latitude to parental discretion and each state has its own acceptable forms of behavior that are allowed when beating a child in name of parental discipline. From a legal paper on where and how to draw the line between reasonable corporal punishment and abuse:

Twenty-one states, along with the District of Columbia, except reasonable physical discipline from their statutory definitions of physical abuse. Theseprovisions typically use the term “reasonable” to describe legally acceptable corporal punishment, although some employ the term “excessive” to describe corporal punishment that has crossed the line of acceptability. For example, the District of Columbia’s statute provides that abuse “does not include discipline administered by a parent, guardian, or custodian to his or her child;provided, that the discipline is reasonable in manner and moderate in degreeand otherwise does not constitute cruelty. ”The statute then provides an illustrative list of specific acts that are unacceptable forms of discipline for purposes of the exception. Among these acts are “burning, biting, or cutting a child” and “nonaccidental injury to a child under the age of 18 months.” Similarly, in Florida, physical discipline can be considered excessive when it results in “significant bruises or welts,” among other enumerated injuries.

Whatever the NFL and Adrian Peterson decide must happen with his playing career matters little. He is but one player out of many in the league who have been accused of violent crimes. They are in the minority of the millions of people who have played on high school, college and pro teams, but they are also representative of what happens when star athletes are not held accountable because their performance on the field counts more than in real life.

Mr. Peterson got caught and because of his indictment, there is an opportunity to discuss openly, a subject that most of us want to pretend does not exist. In 2012, there were more than3.1 million reports of child abuse. 1,593 children died of their injuries. The NFL is the number one program on television and we celebrate, as a nation, the holiday that is Super Bowl Sunday. Perhaps if we concentrated more on our neighborhood children we wouldn’t have to be silent spectators to the child abuse that surrounds us. Adrian Peterson, Charles Barkley, and Tony Dungy have given us a wake-up call, but I refuse to thank them.

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