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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tibial plateau fracture

Monday, October 9, 2017

It’s difficult to understand why bad things happen to good people. It goes without saying that the Texans’ J.J. Watt is beloved in his adopted home of Houston. It is also true that his broken leg, a tibial plateau fracture, will call into question whether he will play again in the NFL.

His response on Twitter to his situation?

“I can’t sugar coat it, I am devastated. All I want to do is be out there on that field for my teammates and this city. I’m sorry.”

This from the man who raised tens of millions of dollars for the Houston hurricane relief efforts and who has played and been recognized as the best defensive player in the league. but the demon of injuries is blind to ability to play and a tibila plateau fracture is a big deal.

Broken bones are not all created equally. It’s all about location. The tibia (shin bone) connects to the femur to form the knee, and to the talus to form the ankle joint. Fractures that involve the joint surface have the potential to not heal appropriately and cause long term problems like arthritis, stiffness and loss of range of motion. This is especially true for the tibial plateau.

The top of the tibia, has two shallow surfaces lined with cartilage that allow space for the femoral condyles to slide and allow the knee joint to flex (bend) and extend (straighten). It takes a lot of force to fracture the tibial plateau and in addition to the trauma, there needs to be some bad luck involved, where the knee is just in the right position, so that the force drives the tibia into the femur and shatters that once smooth surface. Most often, these injuries occur in car wrecks or falls from height where a load is placed on an extended leg and all the force is transmitted into the knee.

Anatomy is important in understanding injury patterns. The top of the tibia is expensive real estate. There is a medial and a lateral tibial plateau, both covered with a meniscus or cartilage, and between the two is the intercondylar notch where the ACL (anterior cruciate ligament) and PCL (posterior cruciate ligament) attach. Because the knee is designed to be held in slight valgus, the medial tibial plateau tends to have thicker bone that that makes is less prone to injury than the lateral tibial plateau.

When the tibial plateau is forced into the femoral condyle the bone collapses and the surface where the cartilage sits, may or may not get crushed. The pain is immediate, the swelling occurs quickly and trying to walk on the injury may or may not be possible, depending on the severity of the break. X-rays can show the general injury, but they are only 2D images and the body is three dimensional. CT may be needed to look at the surface of the plateau and understand the extent of damage…and if there is concern that there are ligaments involved, an MRI might also be needed.

When it comes a decision about surgery, it’s all about making certain that the joint surface lines up properly. If there is any step off, inflammation will occur with each step taken as the femoral condyle rubs against the uneven surface. The long-term complications include pain, knee stiffness and arthritis, but other problems might arise, including malunion (failure of the bone to heal) or collapse of the fracture, so that the knee joint has no bone beneath for support.

The bottom line for Mr. Watt is that a tibia plateau fracture is a bad thing that happened to a good person. Depending upon the extent of the injury, his recovery and return to play might span a spectrum that runs months to never. The goal for all patients is to return them to the level of function that they had enjoyed prior to the injury. Unfortunately, most patients aren’t best in class NFL defensive lineman.

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