it hurts to watch

Tuesday, January 11, 2011

Watching sports from the comfort of your living room allows the opportunity to get up close and personal with the action on the field, whether it is the basketball court, hockey rink or the football gridiron. It seems that one of the perverse pleasures given to the viewing public by television producers are injury replays, from multiple angles and usually in super slow motion. Some injuries are too painful to watch (perhaps the worst was Joe Theisman’s fractured leg bending at a grotesque angle where it wasn’t supposed to bend) and yet television knows that we want to watch. Perhaps it is the same reason we stare at car wrecks as we slow down to get a good look.

One benefit team physicians have when caring for a pro athlete is that they can see the mechanism of injury. For the rest of the medical world, understanding what happened when the injury occurred can provide insight as to what injury might be likely. If a person jumps from a height and lands on their feet, the force of the fall causes predictable injuries to the body. While the patient may complain of pain in their heels from a potential fracture, the doctor needs to look up the body at other sites that are injured as the body absorbs the force of landing, including the ankle, the tibial plateau at the knee, the hip, pelvis and the lumbar spine. If a person falls onan outstretched arm, injuries to consider include a broken wrist, radial head fracture at the elbow and a dislocated shoulder.

Sometimes it can work in reverse where the type of injury can give a clue as to what happened. Most shoulders dislocated anteriorly, meaning that the head of the humerus pops out in front of the joint. But if a person wakes up with a posterior shoulder dislocation, where the humeral head ends up behind the joint, it is likely due to a seizure. There are always other reasons but most people know if they have been electrocuted or struck by lightening.

The history can also guide treatment. Ankle sprains are one of the most common orthopedic injuries and a source of many normal x-rays. The sprain is often due to an inversion injury where the foot turns inward, stretching the ligaments located on the outside of the ankle. Add mechanism of injury to a relatively normal exam and x-rays may not be needed. The Ottawa ankle rules were developed to decrease the numbers of x-rays done, the amount of radiation and the cost to the patient. X-rays are needed only if the patient cannot weight bear either on the scene or in the ER or there is bony tenderness over the last two inches (or 6 cm) of lateral and medial maleoli. These are the two bony prominences on the outer and inner aspects of the ankle. By using these rules the number of xr-ays ordered decreased by more than 35%. The Ottawa people are a busy group; they have rules for when to take x-rays with knee injuries and reasons to perform a CT scan in patients’ with head bonks.

Taking a history is one of the great skills in medicine. Learning how to ask questions takes a lifetime to learn. Listening to answers, understanding nuance, appreciating cultural background and having patience to ask questions from different angles may be needed to understand what is happening inside the patient. The patient may feel under siege, barraged with so many questions. In a teaching setting, the nurse may ask questions medical students may ask questions, residents and attending doctors may ask questions. Don’t these guys talk to each other and read what they write? However, each person may ask their question in a different way to help unravel the patient’s story, and the patient may remember something along the way, all to uncover the key that makes the diagnosis. While technology can help with the final answer, talking to the patient gets the train going in the right direction and if the doctor doesn’t know what’s going on after talking with the patient, it’s likely that more talking may need to happen.

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