medical stuff we learn from the sports world

Monday, June 16, 2014

Medical stuff we might learn this week from the sports world:

How amazed are we about Erik Compton. Before this week, most pro golfers knew of his tenacity to make it on the PGA Tour and perhaps a few dedicated fans knew his name, but after his second place finish in the US Open at Pinehurst, the world should beat a path to his door to learn of the physical and emotional strength required to overcome adversity. At age 12, Mr. Compton required a heart transplant because he had developed cardiomyopathy, a condition where the heart muscle does not squeeze enough to supply oxygen rich blood to the body. Medications can help temporize but eventually, a new heart was needed. 6 years later, he reigned as the top junior player in the country and began his rise up the college and pro ranks. At age 28, his golf career was derailed again because of a second heart transplant, and now at age 34, he has qualified for another year on the pro tour and a starting time at the Masters.

The most common cause of cardiomyopathy in kids is idiopathic, meaning that in two thirds of cases, nobody knows. For the other third, myocarditis, an inflammation of the heart muscle and familial inherited diseases are the most common causes of this rare disease (less than one kid in 100,000). There are different types of cardiomyopathy and some children can lead relatively normal lives with treatment, while others deteriorate, leaving their only hope as heart transplant. The challenge facing these kids, including the 12 year old Mr. Compton, is that the one year survival rate after heart transplant is about 80%.


Jozy Altidore damaged his hamstring. Matt Besler tweaked his. Alejandro Bedoya cramped up. The body was not designed to exert itself in a high temperature, high humidity environment. The body cools itself by sweating, but if the air is already holding as much water as it can (high relative humidity), sweat doesn’t evaporate and body cooling fails. Increased sweating leads to dehydration and the combination of loss of body water and rising temperatures results in heat cramps and heart exhaustion. Foundry and construction workers, roofers and bakers can also get into trouble if the temperature is too high and not enough air circulates to allow sweat to evaporate. The US soccer team was given a pass by public opinion as they won their game against Ghana. LeBron James was not so lucky.


Tony Gwynn passed away, succumbing to salivary gland cancer. News articles will no doubt comment upon his tobacco chewing as a potential cause and this is not to give tobacco companies a free pass, but their product has not been associated with causing this type of cancer. Chewing tobacco increases the risk of other cancers of the mouth and tongue, but salivary gland cancers are more likely associated with things out of the patient’s control: old age, being male, family history and being exposed to medical radiation. This type of cancer is relatively rare, making up less than1% of cancers in the United States. Survival depends upon how early the cancer is found, smaller is always better, as is lack of spread. Still even the smallest cancers that haven’t spread, still have only a 90% survival rate after 5 years. That seems like a lot, unless you happen to be one of the unlucky 10%. Statistics are sometimes less than helpful in medicine. They describes what happens to population as a whole and can offer some guidance, but when it comes to the individual patient, they either 100% live or 100% die. May Mr. Gwynn rest in peace.


And finally, how the media affects medicine: the first pick in the NFL draft, Jadaveon Clowney, is recovering from surgery to repair a sports hernia. It seems pretty simple, except that there is no such thing as a sports hernia. The term has made its way into the medical literature after being propagated by the media. There are a variety of structures that make up the floor of the inguinal canal, where hernias do occur, and any of those structures can become inflamed or damaged, leading to lower abdominal pain. The specific cause may not be known and non-surgical treatment includes rest, physical therapy and anti-inflammatory medications. If that fails, surgery may be considered and only when the surgeon is inside the area may the actual diagnosis be made. The injury may occur to one of many structures: a torn external oblique or internal oblique muscle insertion into the pubic bone, a transversalis fascia tear, a conjoint tendon tear, inflammation of the pubic symphysis and more. The anatomy is complicated and every strand of tissue is a potential target to fail. The “official” medical term is athletic pubalgia (pubic + algia=pain)…or you can call it a sports hernia. As for Mr. Clowney, he is expected to recover in time for training camp in July. The textbooks say that it takes 6-12 weeks and more than 90% of players will return to form. But you know what they say about statistics.

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leading with the nose

Monday, March 3, 2014

We lead with our noses. The protuberance in the front of our face falls victim to tripping on the sidewalk, bumping into walls and other assorted misadventures. And then there is the danger of sports, where an inadvertent elbow and head butt can turn a player like LeBron James into the masked avenger. We lead with other noses and they are prone to break, accounting for almost 40% of facial injuries. Most of the time a fractured nose (remember that broken, fractured and cracked all mean the same thing and one term does not imply a more or less serious injury) is an inconvenience.

For all its simplicity, the nose performs a variety of functions as air gets inhaled and exhaled. There are the olfactory, or sense of smell receptors, that are also closely associated and needed for taste and why food is less appealing when we’re stuffed up. There are the tiny nasal hairs that trap large particles before they get into our lungs. Air is also warmed and humidified by the nose and is especially important for those who live in the frozen tundra of Wisconsin. The bony spine makes up the bridge of the nose and holds the cartilage in place, but it is the cartilage that makes most of its shape and length and separates the nostrils from each other.

As with any other injury, pain and swelling are the result of a nose injury but anytime the nose bleeds, it is likely that the cartilage may be broken. There is also the potential of whether the nose has become deformed. The initial care of a broken nose has little to do with the cosmetic issue and a lot to do with looking for the complications associated with the break. This is less than satisfying for the patient, since they often leave looking the same way they arrived and have been told that time will decide what happens. Those complications include a septal hematoma, a maxillary fracture and a cribriform plate leak. And not to forget that the face provides frontal protection of the face: a concussion is always a possibility with any injury to the face.

When injured, the blood rich septum will bleed but the nosebleed will usually resolve quickly with holding direct pressure on the nose. This can be painful because you have to squeeze something that is broken. But the doctor is more interested in looking inside the nostril at the septal wall, looking for a hematoma or clot that is trapped under the cartilage lining. Left there, its pressure will increase, damaging and potentially causing a sepal perforation or a hole that would connect the two nostrils. This can lead to infection, recurrent nosebleed and permanent changes to the appearance of the nose.

The cribriform plate is part of the ethmoid bone located at the base of the nose where it attaches to the skull. On the brain side of this bone are the meninges or the lining of brain tissue. Damage to the cribriform area can cause CSF, cerebrospinal fluid that bathes the brain with nutrients, to leak and more importantly allow the outside world, full of infection, into the brain. CSF leak from the nose appears thin and clear, and is definitely different than snot. Cribriform plate injuries with CSF leaks become a medical  priority.

While it is common to have an isolated nose injury, the maxilla or cheek bone can also be damaged. This is the bone that holds the upper teeth and is also the bone that supports the orbit and eye, and the doctor will want to check out not only the maxilla but also the mandible.

Once the complications are ruled out, there is little to be done right away. Even if the nose is obviously deformed, x-rays aren’t usually required and neither is an emergency visit to an ENT specialist or plastic surgeon. Waiting for a few days for an office allows the swelling to resolve and allow a better assessment of the way the nose looks. Ice, elevation and some pain medication is all that is usually required. After a few days, if the nose needs to be realigned, that procedure can happen using local anesthetic in the specialists’ office.

Broken noses hurt and the injury can make a dent in daily routines. Rolling over in bed and hitting the nose against a pillow is not pleasant. Habits like rubbing the nose, sniffing or blowing it will cause pain. Fortunately, the healing is relatively quick, though the badge of a broken nose may last much longer. Protective masks that form fit, like that worn by Mr. James, are not often worn by “normal” people but of course most of us also don’t have elbows flying around our heads as we rebound under the basket.

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