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
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