always a chance for a second injury

Monday, April 2, 2018

In hockey and basketball, it’s all about controlling the rebound. The first shot may be saved but it means nothing if the second shot scores. Defense isn’t done until the second change is denied. Medicine is no different. When looking after the injured patient, the doc can’t celebrate finding the first injury because there is almost always associated damage. Diagnosing the second potentially hidden problem makes all the difference in patient outcome. There is not one system in the body that is immune to this injury phenomenon; it’s how we’re built. One injury begets another and sometimes it’s injury number two that’s the big deal.

Since medicine is often taught by example:

the ankle                                               


 Deltoid ligament                                                                         Normal ankle joint               Lateral maleolus fracture. See wider joint line?=deltoid tear

Imagine an ankle fracture.  The most common injury is damage to the lateral or outside part of the ankle, whether there is a broken bone or not. With enough swelling and pain, attention may not be paid to the medial or inner part of the ankle, home to the deltoid ligament, whose job it is to keep the ankle joint stable. If the deltoid is completely torn (a third-degree sprain), the ankle may be subtly shifted out of alignment or frankly dislocated. If subtle changes aren’t recognized, complications may include arthritis and loss of ankle function.

And not to stray too far from the ankle injury, the tibia and fibula, the shin bone forms a bony circle. Just like it’s hard to break a pretzel in just one spot, the same is true for this circle of bone. If a bone is broken in the ankle, the twisting mechanism may also break a bone in that same ankle joint, but it may also damage the knee. The lesson to be learned is to examine the joint above and below an injury for more potential damage.

Because the radius and ulna form a bony circle in the forearm, the same principle applies. An injured wrist may be associated with an elbow injury and vice versa.

Chest wall


Chest wall injuries can be painful, making it difficult to breathe, and they can hide damage below the surface. Regardless of whether a rib is broken or bruised, it’s important to check out the structures that the ribs protect. It seems obvious to check out the lung just beneath the ribs for contusion (bruising) or collapse (pneumothorax), but the lower ribs are also the protective armor for the upper abdomen including the liver and spleen. It’s bad form to diagnose a rib fracture but miss a ruptured spleen that might cause the patient to bleed to death.

Ribs protecting liver and spleen


The same thought process is involved in trauma patients who break a vertebra in the spinal column. A fracture in the cervical (neck) or thoracic (chest) can be catastrophic damaging the spinal cord damage. And there is often more than just one broken vertebra. Finding one fracture leads to the search for another, and the whole spine needs to be examined and imaged. Vertebral fractures may also be associated with non-spinal cord injuries just because of the location and force of injury. A fracture of the lumbar spine might be associated with damage to a kidney or ureter, the tube the leads from the kidney to the bladder.

Fractures in general


radial nerve                        popliteal artery

Almost all fractures have the potential for damage to an artery or nerve. Finding the break is just the first step in assessing the patient. Knowing anatomy helps look for the second injury. The radial nerve wraps around the humerus in the upper arm. Break that bone and the nerve may stop working, leading to wrist drop, weak grasp and hand numbness. Wrist fractures can affect the carpal tunnel where the median nerve runs. Dislocated knees can cause damage to the popliteal artery and potential loss of blood supply to the leg. There is always a second step in even the most routine injuries to assess circulation (blood flow) and nerve function (movement, power and sensation). That second step may have to be repeated more than once, because swelling that develops over time can wreak havoc causing problems like compartment syndrome.

Diagnosis doesn’t stop when the first injury is found. Looking for the next problem continues until the patient is stabilized and all foreseeable problems have been considered. It’s no different than any other profession or trade that troubleshoots problems. From electricians to plumbers and basketball players rebounding on the defensive glass to hockey players clearing the puck away from their goal, the job isn’t finished until the situation is under control. Lose control and bad things can happen, on the court or in the ER.


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fracture times three: the shoulder, the back and the ankle

Tuesday, November 4, 2014

In the past few days, what we’ve learned from football is that not all fractures are created equally. From Nick Foles’ collarbone to Laquon Treadwell’s ankle and Tony Romo’s back, all broken bones are not the same and the approach to treatment is tailored to not only the bone but also to where in the bone the damage has occurred and what surrounding structures are damaged. Perhaps the first lesson is a reminder that broken, fractured, cracked all mean the same thing. One word does not make an injury more or less significant. It’s uncomfortable to watch the replay of an injury but those slow motion images can help explain the mechanism of injury and the stress that is put on the skeleton of the body.

Eagle quarterback Nick Foles was sacked and as he was being tackled and taken to the ground, lands directly on the point of his shoulder. This force of the fall is transmitted to the clavicle or collarbone and can cause the fracture or a separated shoulder where the AC (acromio- clavicular) joint is torn. The damage depends upon which structure cannot withstand the force applied. For Mr. Foles, his collarbone injury will be allowed to heal without surgery since the bone is not displaced, meaning that it aligns reasonably well and nature will fix it over time. That will take weeks and cannot be rushed. Last year, Aaron Rodgers same injury took a little less than two months to recover and return to play.

ac joint

For Dallas’ Tony Romo, a knee to the back caused the psoas muscle to go into spasm. The force of that spasm avulsed or tore off the transverse processes of two vertebrae in his lumbar spine. Muscles and tendons attach to bone to help support and move the body. In Mr. Romo’s case, the muscle attachments were stronger than bone and when the injury occurred, the tendon didn’t tear which would be a strain, instead, the bone tore away. The purpose of eh back, aside from allowing the body to be erect, is to protect the spinal cord and when the words broken vertebrae are spoken, the fear is that there is damage to the cord or the nerves. In this situation, the injury is far removed anatomically and functionally from the spine canal and while painful, is treated like a contusion or bruise. Return to play happens when the muscle spasm and pain can be control to allow the player to run, twist and bend over.

psoasTP fracture

Psoas muscle insertion                                  Transverse process fractures



Ole Miss receiver Laquon Treadwell is not as lucky. A twisting injury to his leg cause a fracture dislocation of the ankle and is a reminder that the body cannot easily tolerate a torsion or twisting force. As he reached for the end zone, Mr. Treadwell’s lower leg was caught up in the pile. Not only did his fibula fracture but the ligaments that held his ankle stable were torn (a sprain). The tibia and fibula that connect the knee to the ankle form a circle and like trying to breaking a pretzel in just one place, a twist will always have two injury sites. In the ankle, it is either two bones or one bone and a ligament that give way. Either way, the stability of the ankle joint is compromised and the muscles that cross the joint cause it to dislocate. In most cases, surgery is required to stabilize the bone and fix the ligament to keep everything in place to allow healing to occur.

ankle ankle dislocation


Three fractures, three different mechanisms of injury, three different treatments and three different healing times. It’s a reminder that the body does a good job of self-healing but sometimes it needs a little help. The bottom line is that like in real estate, the key to injury diagnosis, treatment and outcome has to do with location. Understanding the mechanism and anatomy can help decide what treatment will best help Mother Nature repair the body.

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