Tuesday, September 20, 2016
Injuries happen in football. Whether a player can return to play quickly or perhaps needs weeks of rehab depends on the injured body part and the player’s position. Demarcus Ware, a Denver Bronco lineman might play within 4-5 weeks after a forearm fracture but the Bears’ quarterback Jay Cutler may have a season ending injury because of an injured thumb on his throwing hand. The hand is a complicated machine with tendons and pulleys manipulating multiple joints to allow precise, minute movements…or the ability roughly grasp a football and be able to throw a spiral.
The language of medicine has allowed many hand injuries to be described with colorful terms or eponyms that can be confusing when the general public tries to understand what might actually be wrong.
Gamekeeper’s or skier’s thumb described a torn ulnar collateral ligament. This is the ligament that attached the thumb to the rest of the hand and if it is damaged, the ability to grasp with power is lost. The damage occurs during a fall on an outstretched hand where the thumb splays away from the rest of the hand. The ligament needs to heal and this may be allowed to occur naturally by keeping the thumb and hand casted for weeks. Otherwise, surgery is an option to reattach the torn ends. Occasionally, a piece of bone gets torn off where the ligament attaches and potentially makes surgery more of an option.
The metacarpals are the long bones of the hand that attach the carpal bones to the digits (thumb and fingers). The first metacarpal is the long bone just proximal to the thumb. Should the thumb be flexed just as a fall occurs, the base of the first metacarpal can break (fracture, crack mean the same thing) and potentially become unstable. As well, if the bone does not heal well, the joint between it and the carpal bone can become arthritis and cause chronic pain and weakness with grasp. Surgery is often required to wire the bones into good alignment and hopefully produce a normally functioning hand.
If the tip of a finger is hit by a ball and is forcibly flexed, it can tear the extensor tendon off the distal phalanx (the tip of the finger where the nail is located). The last joint in the finger, the distal interphalangeal joint (DIP), cannot extend and the fingertip droops. While not a terrible injury, a droopy finger gets in the way when the hand tries to grasp or if one tries to put their hand in a pocket. The finger can be splinted for a few weeks and the tendon often reattaches. Surgery is an alternative to reattach the tendon or if a significant chunk of bone gets pulled of the distal phalanx when the injury occurred.
The proximal interphalangeal joint (PIP) is a construction wonder, since tendons have to attach to move it while at the same time allow other tendons to span the joint and get to the DIP joint. It’s a complicated engineering feat and includes tendons that slide on each side of the joint with a central hood that then protects the PIP. If the finger is forcibly flexed or dislocated, this central slip can be torn, the tendons displaced and the joint gets pushed through the central slip. The joint gets stuck and leads to the deformity. Hand function may or may not be affected but the finger but looks weird. Chronic pain and arthritis may develop, like in any other joint injury. Splinting or surgery may or may not work to fix the problem.
This seems simple enough. If one were to hit a wall, or some other immoveable object, bones in the hand can break. A Boxer’s fracture describes a broken fifth metacarpal head, the bone just proximal to the little finger and the metacarpophalageal joint. If the fracture does not involve the joint, then the body can tolerate significant amount of angulation and still have a normally functioning hand. Attempts to manipulate and cast this injury usually fail and the bone tends to heal but the bone remains misshapen but does not affect how the hand moves, grasps or looks.
Just a Bruise
And sometimes, the hand just doesn’t break but can look bad. Viking quarterback, Sam Bradford, had the back of his hand smack up against a defensive player and had immediate swelling. The dorsum of the hand (the side opposite of the palm) has little padding and if one of the prominent veins breaks, there can be significant bleeding. The skin is loose and there is nothing to tamponade or place pressure on the broken vein to make the blood clot quickly. It is sometimes hard to tell whether the bleeding is due to just that or a broken bone underneath. Bradford’s x-rays were negative and al that ugly swelling was no more than a bad bruise. There is no eponym for that yet.
This entry was tagged Bennett, boutonniere deformity, boxer's fracture, Demarcus Ware, finger, fracture, gamekeeper's thumb, Jay Cutler, mallet finger, Sam Bradford, skier's thumb
Tuesday, September 13, 2016
First rib displacement, not a fracture or a broken bone. Philadelphia Eagle coach, Doug Pederson, talking about an injury sustained by his receiver, Zach Ertz. The trainer thought he had strained a shoulder, but later decided that it was a first rib issue. Sometimes it’s difficult to appreciate the type of injury based on a medical report relayed by a coach, but it is helpful to understand that the source of pain is not always where the pain is felt.
The body is sometimes evil in trying to trick patients and doctors by having a diagnosis made that misinterprets symptoms.
- In the back of every doctor’s mind is the fact that a leaking abdominal aortic aneurysm is masquerading as renal colic, an awful waxing and waning pain from kidney stones. Not treating a kidney stone leaves you with a very unhappy and painful patient, but missing a leaking aneurysm leaves a very dead patient.
- Indigestion can be just that, an irritated stomach and esophagus, uncomfortable because of acid buildup. But woe is the patient and doctor who forgets that indigestion is also a common symptom of angina or pain due to narrowing of blood vessels to heart muscle. Inferior myocardial; infarction, a heart attack that affects the bottom part of the heart is notorious for causing GI complaints.
- Bell’s Palsy looks frightening; one side of a patient’s face stops working and droops. It’s due to inflammation of a peripheral nerve (the 7th cranial nerve) and is not due to a stroke. The way that the face muscles are wired, in Bell’s, the patient cannot wrinkle their forehead on the affected side but in the midst of a stroke, the patient’s forehead can wrinkle and move, but the lower two thirds of the face may be weak or paralyzed.
Thoracic Outlet Syndrome
In the case of thoracic outlet syndrome, shoulder and arm pain may be due to narrowing of the space between the collarbone and the first rib. That space is filled with the brachial plexus, (the bundle of nerves that allow the arm, wrist and hand to feel and move), the subclavian artery that sends blood to the arm and the subclavian vein that returns blood to the heart. If the space narrows enough, symptoms of numbness tingling, pain, and weakness in the neck, shoulder, arm and hand may develop; but the cause of the symptoms isn’t where they are felt but instead are due to not having enough real estate around the first rib. Sometimes, surgery is needed to remove the first rib and allow enough room for that important stuff to live peacefully. Matt Harvey of the New York Mets and Kyle Zimmer of the Kansas City Royals both had surgery to fix thoracic outlet syndrome this summer.
The injury suffered by Zach Ertz may potentially cause his first rib to narrow the thoracic outlet space.
In the world outside of the NFL, the patient complaint allows the doctor and patient to develop the differential diagnosis, a list of ailments that might be the cause of the symptoms. Sometimes, that list is short; imagine an ankle injury where the list might include an ankle sprain or fracture. Sometimes the list is long; an infant who is colicky. Common things are common and colic would be good bet, but other potential diagnoses might include issues within the abdomen like a hernia, intussusception or testicular torsion. Colic doesn’t have to come from the abdomen and children can be irritable because of a corneal abrasion, pneumonia, meningitis or food intolerance. Not every diagnosis is evident and it sometimes takes work to sort things out.
For that reason, the trainer is allowed to miss the diagnosis on the first patient touch, examining the player in full pads on the field, in front of 70,000 fans and with too many television cameras zooming on the scene. As the game progressed, Mr. Zach likely was repeatedly evaluated and the diagnosis came to light. The medical lesson to be learned is that the body is a complicated machine and one needs to be wary of the tricks it can play on unsuspecting patients and doctors.
This entry was tagged differential diagnosis, Doug Pederson, first rib, thoracic outlet syndrome, Zach Ertz