Tuesday, September 12, 2017
One would think that some injuries are easier to diagnose than others. Broken bones and dislocated joints seem like prime examples of no-brainer injuries. There should be some major deformity or at least the x-rays would show the damage. One would think, wouldn’t one. But some parts of the body hide damage well and that brings us to the sad injury of David Johnson, running back for the Arizona Cardinals.
In the third quarter of the season opener, Mr. Johnson was tackled and landed on an outstretched hand. He immediately grabbed his wrist and went to the sideline. Initial exam by the medical staff allowed him to return to the game, but on the next play, he had trouble hanging onto the ball, fumbled it and was done for the day. X-rays were done and the diagnosis was a sprained wrist. Only hours later was the final diagnosis made of a dislocated wrist. Welcome to the world of medical uncertainty.
The wrist is a complicated joint. It is made up of the radius and ulna, (the bones of the forearm) and eight carpal bones aligned in two rows. Most doctors aside from orthopedic surgeons cannot name these bones without looking up an anatomy diagram.
Bones of the Wrist
They are held in place by a complex system of ligaments: interosseous (between the bones), volar (palm) side and the dorsal (back). The dorsal ligaments are weaker than the volar, so falling on an outstretched hand can potentially cause the backside of the wrist to collapse, sometimes fracturing the scaphoid bone and sometimes dislocating either the lunate by itself or the capitate bone from where it rests on the lunate. The specific type of dislocation isn’t as important as appreciating that even with bones out of place, the diagnosis can be easily missed on physical exam and sometimes on plain x-ray.
People fall on their hands all the time and most often, there is little damage done, except for a skinned palm and bruised pride. But if there is greater force applied like in football or a fall from height, major damage can occur. However, the initial exam can be pretty unexciting. There may perhaps be a little swelling and tenderness on the back of the wrist and perhaps a little tingling of the index and middle fingers if the median nerve is irritated. Otherwise, people may ignore the injury and seek medical care only after developing chronic wrist pain and weakness.
The problem arises when plain x-rays are normal or perhaps misinterpreted, since evidence for a scaphoid fracture or dislocation may be very subtle or not there at all. Based on mechanism of injury, physical exam and care provider gestalt, the diagnosis may be suspected and then confirmed by CT scan or MRI.
If the diagnosis is made in the acute phase, attempts at reducing the dislocation can be made at the bedside, but often these fail and the patient is taken to the operating room where an open reduction and pinning of the bones occurs. Fortunately, there is a pretty big window of a couple of weeks to make the diagnosis and treat the injury. For many, return to play occurs relatively quickly, once all is healed, but that time frame is measured in months. However, there are complications to this injury and they include, decreased wrist range of motion, decreased power in the hand, carpal tunnel syndrome from medical nerve inflammation and failure of the scaphoid or capitate bone to heal (avascular necrosis).
From media reports, it’s not quite clear what happened to Mr. Johnson. A wrist dislocation is a non-specific term and may refer to a combination of many injuries or just an isolated one. It is reasonable for him to seek second opinions regarding treatment, but this is bread and butter work for most orthopedic surgeons, especially those who specialize in hand injuries. The big deal is getting the diagnosis made in the first place.
Images: learningradiography.comThis entry was tagged Arizona Cardinals, capitate, CT, David Johnson, fall, lunate, MRI, outstretched hand, scaphoid, wrist dislocation, x-ray
Tuesday, October 28, 2014
Fans always want to know the ins and outs of NFL injuries. Understanding what happens on the sidelines or in the locker room may help their fantasy football predictions or perhaps satisfy their prurient interest, like slowing down when driving by an accident, but it also engenders a false expectation of what the real world can bring to medical care. If technology was used on every person with a back injury like it was on the Cowboy’s Tony Romo, Medicare would be in a deeper financial hole than it already is.
Admittedly, even for an elite athlete, Mr. Romo’s case is special. Last year, he required surgery to repair a ruptured disc in his back and he has had to limit his practice time so that he could play on Sundays. Still, the Cowboy nation held its breath when he lay on the turf after taking a knee to his low back when being tackled. After x-rays in the locker room were negative for broken bones, he came back to play. But physical exam, those x-rays and clinical judgment weren’t enough. Technology and an MRI was required to confirm the decision as to whether he could return to play.
More than 85% of the United States population will experience low back pain in their lifetime and almost all will have it resolve within a couple of weeks without doing much special. Still, mechanical back pain is the most common cause of disability for those younger than 45 and falls only to number three for those who are older. Almost all are work related, especially for people who use their body as a tool or machine. While a single traumatic event can be the cause of the low back pain, often it is a series of minor traumas that add up to cause the pain. The numerous structures that make up the low back, the bones, ligaments, tendons, discs and nerves, all have to work together to allow the back to function. An injury and subsequent inflammation to any one structure can lead to pain.
The back has many responsibilities including maintaining an erect or upright posture. But perhaps, its most important job is to protect the spinal cord its nerves from damage. Most often the cause of back pain arises from the muscles, tendons and ligaments. The decision point for the care provider is to decide whether the spinal cord or nerves are at risk. If the answer is no, then imaging the back with plain x-rays, CT or MRI is a waste of time, radiation and resources.
Most often, the diagnosis is made by talking to the patient and performing a detailed physical exam. When the pain started is important. Was it acute onset with movement? Or did it arise hours later, perhaps after laying down or getting up in the morning. Understanding the mechanism…was it rotation or torsion of the lower back, or the lumbar spine? or was it flexing or bending forward. That information can help point to what stabilizing structure of the back might be damaged. If the physical exam isn’t exciting and the diagnosis made that it’s all soft tissue (muscle, tendon, ligament), there’s not much to do, except pain control, activity as tolerated and perhaps physical therapy or chiropractic manipulation.
Perhaps the questions that are directed to the potential for nerve impingement or irritation are most important. Is there sharp pain radiating into the buttock or down the leg. Is there numbness or tingling in part of the foot? Nerves that run from the spinal cord can present with pain that follow predictable dermatome patterns and can help determine at what level in the spine damage has occurred. The sciatic nerve is the accumulation of all those nerve roots that supply the leg. Inflammation of any one root can cause significant pain called sciatica. Still, there is little to be gained by x-ray or MRI. The treatment remains pain control and activity as tolerated.
It’s only when signs of impending spinal cord damage does imaging become and urgency. Has the patient lost control of their bowel and perhaps become incontinent of stool? Has he or she lost the ability to empty their bladder and urinate? Is there numbness around the anus or vagina? The questions may seem unrelated to the back but are harbingers of spinal cord disaster and emergent MRI is required.
For most other patients, the best diagnosis and care for low back pain is time and support. Often, symptoms resolve in 2-4 weeks with a combination of rest, ice, heat and anti-inflammatories. Activity as tolerated is always better in mending a back than lying in bed. In some patients, back pain is progressive and further diagnosis and treatment is required, but as opposed to Tony Romo’s x-ray within a few minutes and MRI within 48 hours, the time frame is a lot slower. To be fair, one indication for plain x-rays is in a trauma victim and suspicion of fracture, and being hit by a linebacker qualifies. For most people, however, their trauma is bending over or twisting to pick up a box and that isn’t enough to break bones. (There are always exceptions in medicine and we’ll offer one to little old ladies with osteoporosis who can get compression fractures with little or no trauma).
The stakes are high in the NFL and with player salaries in the millions, there is a want to return the player to the field of play as soon as possible. It causes doctors and trainers yo use technology to bolster their medical opinion. In the real world, the stakes for o every patient are just as high, but it is just as reasonable to trust high touch instead of high tech in caring for their back. If the 85% of the population that will one day experience back pain demand the Tony Romo level of care, unemployment in this country will fall to zero. Somebody will have to build all those MRI machines.This entry was tagged back injury, back pain, dermatomes, MRI, physical exam, physical therapy, sciatica, Tony Romo, xray