Tuesday, October 3, 2017
Every Sunday, the NFL can teach us about the philosophy of treating patients. While textbooks give doctors and nurses, the background to understand anatomy, physiology and disease processes, case reports help teach how to care for patients. Case reports are a quick review of specific topic regarding a patient’s presentation, diagnosis or treatment. Medicine is learned through experience, and this week it is provided by Cliff Avril’s neck, Ty Montgomery’s ribs and Derek Carr’s back.
Cliff Avril, of the Seattle Seahawks, fell awkwardly while making a tackle and then sat on the ground, vigorously shaking both hands. The announcers suggested that he might have a stinger, an electric shock that radiates down the arm from the shoulder. It often arises from irritation to the brachial plexus, the complex of nerves that is the junction box of nerves located in the (axilla)armpit of the neck to those in the arm. It sometimes can arise from a narrowed spinal canal (spinal stenosis). But stingers are usually one-sided and Mr. Avril was shaking both hands. Stinger on both sides? Or perhaps the injury wasn’t from the brachial plexus but rather in the spinal cord.
Now it’s time to decide how to image the neck. Plain x-rays might be alright but they just look at bone and in muscular people, it’s hard to see all seven vertebrae of the neck. CT is great for looking at bone, and if there is an injury or narrowing, one can infer what might be happening inside the spinal cord itself. In trauma, CT tends to be the way to go to get the best views of the bony anatomy. But x-ray and CT can be normal and a spinal cord injury may still exist; this is SCIWORA (spinal cord injury without radiographic abnormality). For patients with neurologic concerns, an MRI may be needed.
Teaching point: the patient’s condition and physical exam determines the best test to order.
Chest wall injury
The Green Bay Packers running back, Ty Montgomery, took a hit to his right ribs and immediately was taken out of the game. Subsequently, he was found to have rib fractures. The test of choice for him was a plain chest x-ray, looking for lung contusion (bruising) or collapse (pneumothorax). If broken ribs are seen…great…but ordering numerous rib views does not help in the treatment of the patient.
Whether ribs are broken or bruised doesn’t really matter. Once the chest wall has been damaged, the breathing mechanism has been compromised and it’s all about pain control. It’s difficult to rest ribs because 24-14 times a minute, a breath causes the injured area to become irritated. For that reason, the recovery time frame is measured in weeks, not days and the goal of therapy is to make certain deep breaths occur, even though they hurt. The major complication to fear is pneumonia, when areas of the lung do not expand and aerate, making them prime targets for infection. Another issue has to do with damage to the abdomen. The lower ribs protect the spleen on the left and the liver on the right. Physical exam needs to include the upper abdomen to make certain there is no concern for organ damage. If there is a CT is the next step.
Teaching point: Don’t worry about looking for broken ribs. Make certain that the organs underneath, the lungs, liver and spleen, are normal.
Derek Carr, the Oakland Raider quarterback was hit in the lower back and came off the field with spasms. Subsequent x-rays found a fracture of the transverse process of the lumbar spine. This is an area that does not involve the spinal cord or the nerves that come out of the back; this is where the major muscles of the back attach to help with movement. But this is part of the back that is well protected by those muscles and it takes significant force to fracture a transverse process.
Plain x-rays can make the diagnosis and there can be just one process fractured because of a direct blow, or multiple may be fractured, if the psoas muscle goes into spasm and the pull of the muscle is stronger than the integrity of the bone. The treatment for Mr. Carr is time to heal the injury and his return to play depends upon pain tolerance and the ability to perform on the field.
It takes significant force to break a transverse process (remember that break, crack, fracture all mean the same thing), and it seems to reason that there can be associated other injuries. Studies suggest that more than 10% of patients with transverse process fractures have other lumbar spine injuries and CT may be a reasonable test to look for other bony injuries. As well, in major trauma, not necessarily Mr. Carr’s football injury but think car accidents, almost 50% of those with transverse process fractures had abdominal organ injuries.
Teaching point: Minor appearing injuries can have major associated hidden injuries. Look for them when assessing the patient.
Three case reports, Does it makes watching NFL games all weekend educational television?
This entry was tagged cervical spine, Cliff Avril, CT. MRI, David Carr, diagnosis, lumbar spine, rib fracture, test, transverse process, Ty Montgomery, x-ray
Monday, October 21, 2013
“It kind of just nauseates me when something like that happens. It’s such a violent game sometimes. So many thoughts run through your mind.” TJ Lang
“That look he had in his eyes, that was something that stuck with me.” Andrew Quarless
It was the type of football play that makes the highlight reel. As Green Bay Packer receiver, Jermichael Finley, caught a pass running across the middle of the field, he was exploded upon by the defensive back who was trying to dislodge the ball. Both fell to the ground and but this time only one got up. Teammate Andrew Quarless was first to Finley’s: “He couldn’t move at the time…So I just told him, ‘Just stay here, just lay here, don’t move.” Football is a game of speed and finesse but also one of power and violence. In that one moment in Lambeau Field, the violence quieted the crowd.
Most accidents don’t happen in front of 77,000 spectators in the stands and millions more watching on television but when they do, the forces involved in the mechanism of injury are too apparent. Most often, pads and strong muscles can absorb the hit, but if the head is bent just right and the neck flexed at just the wrong angle, the potential for disaster exists. Mr. Finley was immobilized on a backboard and taken off the field by stretcher where waiting ambulance crew transported him to the ER. According to team sources, imaging tests were negative and he was regaining most of his movement. As this is written, he is still being observed in ICU.
The spinal cord connects the brain to the body, and perhaps its most vulnerable point is the neck, the swivel that lets the brain see the world. There are ligaments that help hold the seven cervical vertebrae of the neck in place and their job is to protect the spinal cord along with the large strap muscles of the neck, including the trapezius and sternomastoid. Unfortunately, traumatic forces can overwhelm the protective systems and injury can occur. The vertebra may or may not be fractured; there may or may not be a dislocation; there may or may not be a disc rupture. The spinal cord lives in a very small space and any irritation may cause it to stop working.
When a neck injury is suspected, the first job for bystanders and first responders is to do no harm. If a fracture or dislocation is present, moving the patient may convert a stable injury into an unstable one and that is the reason for the care taken in moving Mr. Finley. He was kept in the position he was found, on his side. A backboard was placed up against him and he was logrolled supine, onto his back, all the while one person has the designated responsibility of not allowing the head to move. This can be challenging because of the helmet and there are special techniques used to remove it. A drill removes the nuts that hold the facemask in place, from below the neck is held stable and the helmet is removed without any flexion of the neck. A hard collar is then placed to keep the neck still. The body is then strapped to the backboard and the patient, collar board and all can be lifted as one unit. This sequence happens thousands of times a day when caring for victims of car wrecks, worksite injuries and other traumas, but rarely witnessed by millions.
There are two considerations for spinal cord injury. First, is there a neurologic deficit, with weakness, paralysis and/or loss of sensation. Second, if there are broken bones in the neck, is the fracture stable or unstable. There are different parts of the spinal cord that have tracts or pathways that control movement and sensation. Physical examination may help define what part of the cord is injured and at what level the injury has occurred. The higher up the neck that the damage occurs, the more of the body is affected. The 4th cervical vertebra is crucial since this is the level that helps control the muscles that allow us to breathe. If some patients, the spinal cord can be concussed, just like the brain, where it stops working for a few minutes and then regains function. But just like the brain, an injured spinal cord can gradually deteriorate and lose function over many hours. A CT scan may be used to image the bony vertebrae of the neck and MRI can look at the spinal cord and nerve roots directly. Depending upon the situation, one or both test plus other may be required.
Aside from stabilizing any broken bones in the neck or repairing a ruptured disc, there is little that can be done acutely to “fix” a spinal cord injury. Observation and supporting the body, gives the best chance for the patient to recover. Unfortunately, a patient with a complete spinal cord injury has a small chance of complete recovery and it falls to almost zero if he remains paralyzed 72 hours after the injury. Those who have incomplete spinal cord injuries where only part of the pathways have been damaged, have a much better chance of recovery. Making a determination of long term outcomes cannot happen immediately.
There is always risk in life. Safety equipment, from airbags in cars and safety harnesses used by steel workers, does not make us invincible. While motor vehicle crashes account for more than half of spinal cord injuries, more than 7% occur because of injuries on the playing field and proper playing technique may provide the best safety. Leading with the crown of the helmet, with the chin down, puts the neck in a flexed position and increases the risk of neck injury. For that reason USA Football teaches heads up tackling techniques, wanting players to see where they are hitting. Dropping a helmet to deliver a blow on either side of the ball may be courting disaster.
Unlike video games where injuries don’t matter, football is a game of controlled violence played by real people, with families, friends and lives off the field. Prayers that Jermichael Finley will enjoy all of those fully for years to come.
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Attributions: Quarless quotes (espn.com). Lang quotes (jsonline.com)This entry was tagged cervical spine, Jermichael Finley, paralysis, spinal cord injury