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

Vertebrae

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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knowing when things are right

Monday, March 11, 2013

The problem with technology in medicine is that it gives patients the false sense of security that if a test is normal, all is well. Never mind that the test may have limitations and that history and physical examination may more accurately reflect the clinical situation. Such is the case with the Chicago Bull’s Derreck Rose and the LA Dodgers’ Zack Greinke. While the tests on their knee and elbow respectively, have come back clean, that does not necessarily mean that all is well in the world.

Let’s start with Mr. Rose and his ACL tear. After successful surgery, he has spent months in physical therapy and rehab to the point where his doctor has decided that he is cleared to play. Still, Mr. Rose is not quite confident in the knee and this is where the athlete and the patient can trump the doctor. While the medical staff can say that the knee has full range of motion and the muscles that support the knee, the quad and hamstring, have return to full strength, they cannot know the exact time when the player trusts the knee to perform. While there can be some hesitancy, the other issue has to do with proprioception, the perception of space where the knee is in relation to the rest of the body and the amount of strength required to keep it there. Trust is an emotion that the player can willfully address, but proprioception is an unconscious reflex. The combination of the two allows the player to perform without hesitancy.

While Bulls’ fans wonder why Adrian Peterson can play football 6 months after ACL surgery and Derrick Rose is still working hard in practice, they need to be reminded that every patient recovers in their own time. Rehabilitation guidelines that take a patient from one step to the next on the road to recovery are just guidelines. Physical therapists are trained to gauge recovery and pushing the patient to the next level until they are ready. However, athletes participating in contact sports are a special case. While a construction worker can control their work environment, Mr. Rose has a constantly evolving workspace, where other players can force unexpected body movement and landing zones. Proprioception needs to be functioning to prevent another injury.

Mr. Greinke’s elbow is another story.  With $147 million dollar contract at stake, the Dodger management wants to make certain that there are no structural issues within and surrounding his elbow joint. For anybody else, a physical examination may be perfectly adequate to sort out minor injury from major disaster, but pitchers are not normal people. They place enough torque on their muscles and joints that a small twinge may be the early signal of a mechanical and anatomic flaw. However, it is once again a problem of proprioception. Greinke’s elbow doesn’t feel right and that sensation of twinge may cause changes in his pitching motion. Or was a subtle change of his pitching motion enough to cause a twinge of pain. The MRI may be normal, but the pain is still there.

Too often, patients demand blood tests and x-rays because having a tangible result is more satisfying than the doctor’s proclamation that he thinks all is well. The word “think” gets in the way of the message. Patients would much prefer the word “know”. Most medical people have enough experience not to be 100% sure of anything. The body has a way of reminding us that it can be devious in how it can disguise injury and illness. The same can be said for testing. Occult fractures, those that are not initially seen on an x-ray, plague physicians and patients who are subsequently found to have a broken bone. Normal white blood cell counts in the face of major infection are a reminder that it is how the patient looks in person that matters, not how they appear on paper.

Rose and Greinke may appear well on paper but that doesn’t mean that they are ready to perform at their accustomed level of athletic prowess. As with eve3rything else in medicine, if you listen hard enough, the patient will tell you what’s wrong…and what’s right.

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