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.


This entry was tagged , , , , , ,

words and anatomy matter

Monday, October 7, 2013

“They took an X-ray a little bit lower [of Joeckel’s leg]. They didn’t see it,” Bradley said. “They went up and took a little higher X-ray and saw it.” –

When a pro athlete gets injured, the minions of medicine descend and to make certain that a diagnosis is not missed. According to Gus Bradley, coach of the Jacksonville Jaguars, it took a couple sets of x-rays to find the break in his star lineman’s leg. For Luke Joeckel, the good news is that the injury was identified; the bad news is that his leg is broken, may need surgery and is season ending. Press releases describe the break as a high ankle fracture but that term isn’t quite appropriate. It’s a tib-fib fracture and while semantics are important, understanding the injury helps predict potential complications.

The tibia and fibula are the two bones found in the shin and connect the knee and ankle. It’s difficult to break just one bone in the pair. They make a circle with the knee and ankle joints, and just like it’s difficult to break a pretzel in just one spot, it is also hard to break the bony circle in just one place. For that reason, it’s important to examine the joint above and the joint below any injury, to look for that second fracture. Depending upon the mechanism and twisting motion placed on the leg, when the tibia breaks near the ankle, the fibula may break near the ankle, in the midshaft or high up by the knee at the fibular head.


Now why it’s important to sort out ankle versus tib-fib fractures. Ankle fractures can involve the bony outcroppings of the tibia and fibula called the malleoli (single=malleolus). Ligaments attach to them to provide stability to the ankle joint. The lateral malleolus on the outside of the ankle and at the bottom of the fibula has three ligaments while the medial malleolus of the tibia on the inner aspect of the ankle has one thick band of tissue called the deltoid ligament. If the fibula’s lateral malleolus is fractured (remember that fracture, break crack all mean the same thing), it is important to check the stability of the deltoid ligament because if it is damaged, the ankle can dislocate. If the tibia’s medial maleolus is fractured, the associated injury may be high up at the knee with a fibular head fracture. This is the can’t miss injury since the peroneal nerve wraps around the fibular head and can be damaged, causing foot drop and the inability to pick up the toes to be able to walk normally.

Tibia and fibula shaft fractures may or may not need surgery, but many treatment options exist. There may be non-operative casting or an operation can be performed to have rods placed through the shaft of the tibia or have plates screwed in across the fracture site to hold it in place. The can’t miss complications aren’t necessarily related to the bone but to the skin and muscles. The skin across the front of the tibia is very thin and has the potential to be torn when the fracture occurs, or break down in the days afterward. The skin acts as a barrier protecting the inside of the body from infection and if the skin is compromised, the bone itself runs the risk of infection. Osteomyelitis is a bad thing and can take months and many operations to resolve (see Rob Gronkowski). The other potential disaster that haunts tib-fib fractures is compartment syndrome. The muscles of the lower leg are encased in tight sheaths and should the broken bones cause swelling or bleeding into a compartment, the pressure inside can rise dramatically and prevent blood from flowing to the muscles. Muscles without blood die and compartment syndrome is a true emergency, where the orthopedic surgeon filets open the leg to allow room for the swelling. It’s like cutting into the casing of a hot dog and watching the insides expand when released.

The good news for the pro athlete is that injuries tend to be diagnosed correctly. The good news also extends to the general public in that not only are injuries diagnosed correctly, but that potential complications are also anticipated. Using the right words to describe a fracture helps the family or emergency doctor explain the injury, not only to patient but also perhaps to an orthopedic doctor who may not be able to see the x-rays. The advice that an orthopod can give depends upon the ability to visualize the injury based upon the words used, not only in deciding what treatment might be appropriate but also what disasters to expect and to avoid. It works like an insurance policy. Teach the patient and family about compartment syndrome and it will never happen. Forget just once and that may be the time that it occurs. Anatomy matters and so do words.

This entry was tagged , , , , , ,