Tuesday, October 3, 2017
Every Sunday, the NFL can teach us about the philosophy of treating patients. While textbooks give doctors and nurses, the background to understand anatomy, physiology and disease processes, case reports help teach how to care for patients. Case reports are a quick review of specific topic regarding a patient’s presentation, diagnosis or treatment. Medicine is learned through experience, and this week it is provided by Cliff Avril’s neck, Ty Montgomery’s ribs and Derek Carr’s back.
Cliff Avril, of the Seattle Seahawks, fell awkwardly while making a tackle and then sat on the ground, vigorously shaking both hands. The announcers suggested that he might have a stinger, an electric shock that radiates down the arm from the shoulder. It often arises from irritation to the brachial plexus, the complex of nerves that is the junction box of nerves located in the (axilla)armpit of the neck to those in the arm. It sometimes can arise from a narrowed spinal canal (spinal stenosis). But stingers are usually one-sided and Mr. Avril was shaking both hands. Stinger on both sides? Or perhaps the injury wasn’t from the brachial plexus but rather in the spinal cord.
Now it’s time to decide how to image the neck. Plain x-rays might be alright but they just look at bone and in muscular people, it’s hard to see all seven vertebrae of the neck. CT is great for looking at bone, and if there is an injury or narrowing, one can infer what might be happening inside the spinal cord itself. In trauma, CT tends to be the way to go to get the best views of the bony anatomy. But x-ray and CT can be normal and a spinal cord injury may still exist; this is SCIWORA (spinal cord injury without radiographic abnormality). For patients with neurologic concerns, an MRI may be needed.
Teaching point: the patient’s condition and physical exam determines the best test to order.
Chest wall injury
The Green Bay Packers running back, Ty Montgomery, took a hit to his right ribs and immediately was taken out of the game. Subsequently, he was found to have rib fractures. The test of choice for him was a plain chest x-ray, looking for lung contusion (bruising) or collapse (pneumothorax). If broken ribs are seen…great…but ordering numerous rib views does not help in the treatment of the patient.
Whether ribs are broken or bruised doesn’t really matter. Once the chest wall has been damaged, the breathing mechanism has been compromised and it’s all about pain control. It’s difficult to rest ribs because 24-14 times a minute, a breath causes the injured area to become irritated. For that reason, the recovery time frame is measured in weeks, not days and the goal of therapy is to make certain deep breaths occur, even though they hurt. The major complication to fear is pneumonia, when areas of the lung do not expand and aerate, making them prime targets for infection. Another issue has to do with damage to the abdomen. The lower ribs protect the spleen on the left and the liver on the right. Physical exam needs to include the upper abdomen to make certain there is no concern for organ damage. If there is a CT is the next step.
Teaching point: Don’t worry about looking for broken ribs. Make certain that the organs underneath, the lungs, liver and spleen, are normal.
Derek Carr, the Oakland Raider quarterback was hit in the lower back and came off the field with spasms. Subsequent x-rays found a fracture of the transverse process of the lumbar spine. This is an area that does not involve the spinal cord or the nerves that come out of the back; this is where the major muscles of the back attach to help with movement. But this is part of the back that is well protected by those muscles and it takes significant force to fracture a transverse process.
Plain x-rays can make the diagnosis and there can be just one process fractured because of a direct blow, or multiple may be fractured, if the psoas muscle goes into spasm and the pull of the muscle is stronger than the integrity of the bone. The treatment for Mr. Carr is time to heal the injury and his return to play depends upon pain tolerance and the ability to perform on the field.
It takes significant force to break a transverse process (remember that break, crack, fracture all mean the same thing), and it seems to reason that there can be associated other injuries. Studies suggest that more than 10% of patients with transverse process fractures have other lumbar spine injuries and CT may be a reasonable test to look for other bony injuries. As well, in major trauma, not necessarily Mr. Carr’s football injury but think car accidents, almost 50% of those with transverse process fractures had abdominal organ injuries.
Teaching point: Minor appearing injuries can have major associated hidden injuries. Look for them when assessing the patient.
Three case reports, Does it makes watching NFL games all weekend educational television?
This entry was tagged cervical spine, Cliff Avril, CT. MRI, David Carr, diagnosis, lumbar spine, rib fracture, test, transverse process, Ty Montgomery, x-ray
Sunday, December 7, 2014
The concept of transparency does not exist when it comes to trauma. For that reason, docs need a high index of suspicion when any victim walks or is carried through the door. The idea is this…most injuries can be taken at face value, but complications can exist, even in the most stable patient. For that reason, the concept of ruling out bad things is a routine thinking pattern in medicine. It does not mean that every test known to man has to be ordered, history and physical exam are powerful tools, but at least the doctor has to go through the mental gymnastics to be comfortable with the patient’s stability.
Every week, the NFL provides medical teaching moments. This time, it was learning that Dallas quarterback, Tony Romo, may have been playing for weeks with broken ribs. Bear receiver, Brandon Marshall goes down after a tackle, struggles to get up and ends up in the hospital with broken ribs and a collapsed lung. Same injury but Romo escapes without the complication that beset Marshall.
Breathing seems so simple and yet becomes very complicated when the chest wall is damaged. Normally, we breathe like a bellows, the ribs swing up and out, the diaphragm pushes down and air gets sucked into the lungs. That happens because the lungs are held against the chest wall by negative pressure between the two pleura, one lines the lung and the other lines the chest wall. Most people recognize pleural as the shiny skin when eating ribs. A pneumothorax or collapsed lung occurs when air gets into the space between those two linings and breaks the seal between the two. In trauma, a broken rib can cause a small tear into the lung tissue allowing that air leak to happen, but not always.
The pneumothorax is just one of the complications that have to be considered. It’s easy to be distracted by the pain of the broken fib and not concentrate on what’s important, the ability of the patient to breathe. The lung collapse is not all or nothing, it may be tiny and only seen as an incidental finding on a chest x-ray or Ct scan, it can be a complete collapse or the collapse can be somewhere in between. A smaller pneumothorax may not be appreciated on physical examination and for that reason a plain chest x-ray is an important screening tool in patients with chest injury. In addition to the collapsed lung, the doc will be looking for a contusion or bleeding in the chest. It is not meant to look for broken ribs. While more broken ribs presume increased force of trauma and increased risk of pneumothorax, the purpose of the test is to look for the lung damage and not any rib injury.
So Tony Romo keeps playing and Brandon Marshall goes to the hospital and gets a tube put in his chest. The way a traumatic pneumothorax is treated depends on how much air has escaped into the pleural space and how much the lung has collapsed. A tiny pneumothorax can be watched but larger ones need to have the air sucked out and the negative pressure re=established for the breathing mechanism to work again. A chest tube is placed through a stab incision in between the ribs and threaded into place. It is then hooked up to suct8ion and the patient is observed. If all goes well, the lung injury heals itself, the air leak stops and the tube can be removed in a couple of days. If all doesn’t go well, surgery may be required to repair the lung.
Aside from the lung, the ribs protect all sorts of vital structures from the heart and great vessels (think aorta, vena cava and others) in the chest, to the liver and spleen in the abdomen. Predicting the future is a fool’s game for doctors caring for trauma patients. Some, like Romo, will have an injury and do well. Others like Marshall will gradually decompensate with complications. Trauma is a worthy adversary and can lull doctors into a false sense of security when victims initially don’t look “too” injured. Just a reminder why medicine is a combination of science and art.
education-portal.com, dreamstime.com. @bmarshall twitter feed
This entry was tagged Brandon Marshall, chest tube, collapsed lung, pneumothorax, rib fracture, rib injury, Tony Romo, trauma