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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clavicle fracture and return to play

Tuesday, December 19, 2017

Primum non nocere – First, do no harm

It was a win or go home week in the NF and for many teams on the bubble, a loss brought an end to their playoff dreams for the year. For fans of the Green Bay Packers, their loss to Carolina effectively ended their season. But with still two games to go, the Packer faithful’s next worry was whether injured and almost rehabilitated Aaron Rodgers should be allowed to play those last two games. Though the team medical staff cleared him to play after surgery, was he really okay or had they rushed him back with the hopes of leading the team to victory and a run to the post-season.

Back up 2 months, where quarterback Rodgers breaks his right clavicle (collarbone) as he is tackled and thrown to the ground. It’s his dominant arm, the throwing shoulder, and a decision is made to undergo surgery, open reduction and internal fixation, with plates and screws to keep the bone fragments aligned while they heal. Now here we are almost eight weeks later, and Rodgers is cleared to play but after the loss there are effectively two meaningless games left and should he take the risk of playing. The question becomes, is there a difference between cleared to play and totally healed.

The clavicle lies just below the skin and is easily felt. its S-shape, from the breastbone (sternum) to the shoulder joint, allows the muscles that move the shoulder more room and freedom to do their job. As well, the bone protects the major arteries and veins that run from the heart to the arms and neck. It is a commonly broken bone, but no break is the same treatment depends upon  a variety of considerations: upon the type of break (one or multiple pieces, is the skin torn), where in the clavicle the break occurs (near each end when the bone attaches to another, or in the middle) and what stresses will be put on the bone once it heals. For most people, the treatment is a sling to allow the bone to heal on its own.

There are a variety of reasons to consider surgery, but the benefit of an operation should outweigh the risk. Some indications for surgery ( ORIF=open reduction and internal fixation) include shortening or overlapping of bone ends, tenting of the skin because of bone fragment, and displacement of the bone so that it potentially affects the arteriues, veins, nerves and other structures that run beneath it. But with surgery comes some risk including infection, blood clots (deep vein thrombosis or DVT), delayed or non-union where the bone at the fracture site doesn’t heal, and malunion, where the bones heal in an unacceptable position.

 

 

Shortened, overlapping fracture                Plate and screw ORIF

 

A quick aside. When it comes to bone: fracture, break, crack all mean the same thing.

 

Mr. Rodgers has surgery to repair the collarbone and is cleared to play, but is he healed?

There are four phases of bone healing:

  • During the first phase and lasting about a week, there is the inflammatory response. Bleeding happens where the bone ends break and this causes a nonspecific inflammation response, no different than what occurs with any other injury in the body. Signals get sent to the body to mobilize and deliver the cells that fix things and they show up at the fracture site to do their work.
  • Within a week, phase two begins with granulation tissue forming a bridge between the ends of the two ends of the fracture. It’s important to not have the broken bone ends move much so that the bridging can occur and a soft callus of immature bone can be laid down.
  • Once the initially bridging occurs, phase three starts and osteoblasts (osteo=bone +blast=immature) and chondroblasts (chondro=cartilage) invade the area to start the formal bone rebuilding process. In the next many weeks, from 4-16 (1-4 months), the body lays down bone and cartilage woven together to form a scaffolding to promote a bony callus, a glob of bone that has calcium laid down for strength.
  • The final fourth phase may take months or years to complete. The bony callus is replaced with harder and stronger lamellar bone that is layered in parallel to the bone and allows reshaping and remodeling.

And that is where the question now lies with Mr. Rodgers, the Packers, their fans and the medical staff. Once phase three is complete, a player can return to play, knowing that the bone has healed enough to function, but the healing process is not necessarily complete and there is no magic test to say that phase three is done. The question becomes whether the bone is strong enough to withstand another trauma and is there a risk for re-fracture? When Tony Romo, then of the Dallas Cowboys and now a television analyst broke his collarbone early in the 2015 season, he sat out seven weeks to heal, but two weeks later he reinjured the site and subsequently needed surgery for repair. With repeated exams, and x-rays, the science of medicine would have said that he was ready to go, but that was proven wrong retrospectively by the bone breaking again.

And the answer for Packer Nation? The art and science of medicine do not always align….so who knows.

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