lessons learned from the playing field

Monday, January 18, 2016

Learning about medicine from the playing field.

Randall Cobb of the green Bay Packers, leaps to catch a pass, lands awkwardly and sustains a pulmonary contusion, or bruised lung. After coughing up some blood, never a good thing but many times not disastrous, he is observed in hospital and is discharged home where his lung will slowly heal, just like any other bruise. The injury is a reminder that with chest trauma, and many people fall and hit their ribs, the x-rays done are to evaluate the lungs and not the bones. Doctors are more interested in whether there is a collapsed lung (pneumothorax) or lung contusion, while the patient is more interested in whether there is a broken rib. Regardless of whether the ribs are bruised or broken, the treatment is the same: pain control so that the patient can take a deep breath and expand the lung to prevent pneumonia, the most important complication of a minor chest injury.

Steeler receiver, Antonio Brown, suffered a concussion in the game against the Cincinnati Bengals and within 24 hours there were reports that he would be recovered within the week to play in the team’s next game. He did not. After his concussion, Green Bay Packer, Sam Shields took a month to recover before play9ing again. It is a reminder that there is no way to predict the brain’s path to recovery from concussion and there is no definitive test to determine that a brain has fully recovered and is able to withstand another blow. No matter the NFL protocols, concussion remains a diagnosis made at the bedside and return to play has no standard playbook to follow.

finger bony anatomy

Carson Palmer of the Arizona Cardinals had a new splint on the right index finger of his throwing hand to protect the PIP joint that had been dislocated. Fingers have three joints (the thumb has two), the metacarpophalangeal (MCP) that connects the finger to the hand, and the proximal interphalangeal (PIP) and the distal interphalangeal (DIP) joint. The PIP joint is commonly dislocated and can heal relatively easily but because of the complex anatomy of the hand, the bones can damage the tissues and tendons that surround the joint when they dislocate. Complications include a volar fracture of the thin plate of bone on the palmar surface of the joint can be broken, leading to joint instability and a boutonniere deformity where the tendons slide to the side of the joint and prevent the finger from completely straightening. It’s a reminder that hands are complicated and minor injuries may lead to major long term complications.

Joakim Noah of the Chicago Bulls dislocated his shoulder and will undergo surgery to stabilize the joint. In most people, surgery is not the first step in rehabilitation. They are allowed to undergo physical therapy to strengthen the shoulder and return range of motion before considering an operation. But in athletes or those who may not be able or willing to limit their activities, surgery is often the first and potentially curative step. Studies of young athletes and military recruits, that surgery after the first shoulder dislocation can prevent future dislocation 95% of the time. Without an operation only 5% will have stable shoulders. The reason has to do with the inherent instability of the shoulder. It is designed to have a wide arc of range of motion in all directions and for that reason, the surface area of bone in the joint is very small. The stability has to do with the soft tissues that hold the shoulder together from the capsule and the labrum to the ligaments and surrounding muscles.  When the shoulder dislocates, all these structures are damaged and stretched. Surgery, either arthroscopic or through an incision, is meant to tighten all the structures that have been torn apart. Rehabilitation takes months to return range of motion and power; Mother Nature does not like to be rushed when she heals soft tissues.

More lessons from the playing field next week.

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the knee bone’s connected to the rib bone

Monday, August 19, 2013

Doctors who care for trauma victims think differently than the rest of the world. It’s not the injury that they can see but the hidden complication that might rear its ugly head that causes all the worry and hand wringing. It’s also how Dustin Keller’s knee is related to Barkevious Mingo’s chest. The injury that is apparent is not what the doctor cares about; instead, it’s the damage that can happen beneath the surface. It also helps patients and families understand why the doctor is hovering over the foot when it is obvious that the knee is the damaged part.

Football is a great medicine teaching tool but it requires an injured player to provide the lesson. Mr. Keller was newly signed tight end by the Miami Dolphins, but his season ended when he dislocated his knee during a preseason game. The injury involved tearing three of the four ligaments that hold the knee together, the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL) and the medial collateral ligament (MCL). Even strong quads and hamstrings, the knee cannot tolerate the damage and becomes unstable and can dislocate. This is a critical diagnosis to make because the popliteal artery that runs behind the knee can be stretched or torn and blood supply to the lower leg and foot cut off. If blood flow cannot be re-established, the leg might be lost. As well, the nerves that supply the foot run behind the knee as well and nerve damage would prevent normal ankle and foot function including walking and running.

The recognition of a knee dislocation can be sometimes tricky. Often the knee relocates spontaneously and on exam may look somewhat normal, though the exam will find it to be swollen, floppy and somewhat instable. X-rays may or may not be helpful. Most important will be to assess the pulses in the foot and ankle. Even if pulses are present, there is the possibility that the artery is damaged and delayed problems can occur. How to proceed is debatable. Some patients are observed, others get arteriograms, where dye is used to evaluate the artery anatomy, but all patients get the knee immobilized and admitted for observation. When the focus of the care is on an isolated injury, dislocations are rarely missed, but in the multiple trauma victim, for example a car wreck, a relatively normal looking, unstable knee might be overlooked while other injuries are addressed. The hand wringing is all about the dislocated knee being a limb threatening injury.

It’s the complications that weigh on the minds of the doctor caring for the chest injury sustained by Barkevious Mingo of the Cleveland Browns. There is a disconnect between their worry and that of the patient. A chest x-ray is done to look for the complications of a blow to the chest, including a pneumothorax (a collapsed lung) or pulmonary contusion (a bruised lung). Looking for a broken rib isn’t a priority but often that is the question that the patient want answered. Explaining physiology helps but deep down, patients want to know. In major trauma, the doctor wants to know as well, since the more ribs that are broken, the more likely that the patient will do poorly. When the ability to take a deep breath is compromised, the ability to get oxygen into the body is compromised as well. Interestingly, a pulmonary contusion can occur without any associated rib fractures.

The lung is composed of clusters of small air sacs (alveoli) divided by thin, elastic walls or membranes. Capillaries, the tiniest of blood vessels, run within these walls between the alveoli and allow blood and air to come near each other. The distance between the air in the lungs and the blood in the capillaries is very small, and allows molecules of oxygen and carbon dioxide to transfer across the membranes. If the lung is bruised, not only does blood leak from the capillaries into the alveoli but it sets into motion the body’s inflammatory response and swelling occurs. The swelling increases the distance that oxygen molecules have to travel to get into the blood stream and that may not happen and the more lung that is damaged, the sicker the patient can become. There is also a physiologic problem called pulmonary shunting. When blood is pumped to the lungs, it expects to pick up oxygen molecules but if the alveoli are filled with fluid, some blood returns to the heart without its oxygen load. This is a ventilation perfusion mismatch where blood is flowing to lung tissue that doesn’t work. Even breathing 100% oxygen may not be able to fix this problem if enough lung is involved.

With a pulmonary contusion, the patient usually complains of pleuritic chest pain that hurts to take a deep breath, as well as shortness of breath. Small contusions may have no symptoms but it may take some time for the contusion to fully blossom. Often the chest x-ray lags and the patient may appear sicker than they look in the picture. There is little treatment except for supportive care, observation and hand wringing hoping that the lung recovers before the patient tires from the work of breathing and needs to be put on a ventilator for breathing support.

Mr. Keller and Mr. Mingo will fade from the headlines as newly injured players take their place. Mr. Keller’s knee injury will require surgery and take almost a year of rehabilitation to recover. Mr. Mingo’s chest will heal in 4 -6 weeks with just ice and deep breathing. Time will also fade the fact that both were potential medical disasters.

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