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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knee ligament sprains

Tuesday, September 29, 2015

Writing about injuries is not always easy when relying on press releases, sports stories and snippets of interviews. Sometimes, the story falls in your lap. The Steelers’ Ben Rothlisberger gets hit, hurts his knee, hobbles off the field and by morning has an MRI confirming a medial collateral ligament tear…prognosis 4-6 weeks before return to play. Sometimes, though, there needs to be detective work because the information is more opaque. The NHL is a constant frustration with their upper body/lower body injury mantra.

But it’s Lionel Messi’s knee injury that posed a challenge. His team FC Barcelona tweeted that “Messi has a tear in the internal collateral ligament of his left knee. He will be out for around 7-8 weeks.” It seems relatively transparent and open, telling the world and especially Barca fans about Messi’s injury. The only problem is that the knee doesn’t have an internal collateral ligament, so tearing it is a little problematic. The challenge then, is to sort out the real injury.

Clue one is provided by photos of the injury. As he lay on the ground, Mr. Messi reaches down and rubs the inside part of his left knee.

messi-down-injured-1443278439399

Clue two is that the recovery time is measured in weeks, not months.

Clue three is that no surgery is planned. Argentina national team doctor, Donato Villani, was quoted by the Argentine paper, Ole: “The injury was to the ligament on the inner part of the knee, a ligament that is extra-articular, that obviously suffers injury like any other ligament, but this one is outside the joint. He avoided a valgus force injury of the joint; it is not a tear that needs surgery.”

As it turns out, the knee joint has four ligaments that provide it support and stability. The anterior and posterior cruciate ligaments prevent the knee from sliding forward and backward, while the medial and collateral ligaments prevent side to side motion. This allows the knee to do what it’s supposed to do, flex and extend, like a hinge. Each ligament has the potential to be torn and the treatment approach is different for each.

It’s important to remember that a torn ligament is called a sprain. Grade 1 sprains describe a ligament whose fibers have been stretch and a grade 2 sprain happens when the fibers are partially torn. A grade 3 sprain occurs when the ligament has been completely torn.

In athletes, each knee ligament has its own treatment, healing and return to play time frame.

  • Anterior cruciate ligament tears almost always need surgery and recovery time is measured in many months.
  • Posterior cruciate ligaments may not need surgery but rehabilitation may take 3 months or more to return range of motion, stability and strength. For those with a PCL tear who undergo surgery, the rehab time may stretch to 9-12 months.
  • Medial collateral ligament tears used to be treated with surgery but non operative treatment is found to be more successful. Grade 1 and 2 sprains often heal well enough in 1-2 weeks to allow return to play while a grade 3 sprain may need 6 weeks or longer. While early return to play is allowed, the MCL continued to heal for many more months. Surgery may be required if there is recurrent injury or chronic instability.
  • Lateral collateral ligaments tend to heal less well than the MCL and it completely torn, the LCL injury may also involve damage to the posterolateral corner of the knee. This is a group of structures that provide knee stability (and include the fibular collateral ligament, the popliteofibular ligament, the mid-third lateral capsular ligament, the biceps femoris head and the lateral gastrocnemius tendon and the IT band). A grade 3 tears often needs surgery and rehab time that can last a year.

Mr. Messi had an “internal” ligament injury that does not need surgery and will heal in 7-8 weeks. The medial collateral ligament fits that description but the clincher is that the medical collateral ligament has fibers that are both external (outside of) and internal to the joint. While it is a thick band of tissue that covers the whole of the m3edial or inner side of the knee, there are many layers that are outside of the knee joint and others that are internal to the joint. That division is based upon the capsule that is the boundary of the joint itself.

Medical commentary by proxy can be harrowing but sometimes, understanding anatomy, injury patterns and treatment options can uncover the mysteries that are contained in press releases and twitter feeds. And at the end of the day Ben Roethlisberger and Lionel Messi are related by MCL sprain.

 

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