Liposomal Bupivacaine

A New Option For Managing Pain After Surgery

The use of opioid pain medicine, also referred to as narcotic medicine, has received much attention lately with the epidemic of patient addiction and the concern of over prescribing medications. The problem often begins with chronic pain or after a patient undergoes surgery. For the patient’s comfort, the physician typically prescribes narcotic pain medicine in a large dosage and prolonged duration of time to help ease the pain. This increases the likelihood of patient addiction, which can further lead to chronic dependency and in some instances, progression to street opioid use, such as heroin (a drug produced from morphine and sold illegally). The Center for Behavioral Health Statistics and Quality reports that 4 out of 5 new heroin users start out by misusing opioid pain medications.

The opioid epidemic has created a public health crisis, increased medical costs, and formed an ethical predicament for physicians. To overcome these problems, physicians are researching new ways to reduce pain while also reducing the use of opioids. Liposomal bupivacaine is a new treatment surgeons use to manage postoperative pain, which greatly decreases, and in some cases eliminates, the use of narcotic pain medicine.

Bupivacaine is a medicine that has been around for many years. Physicians inject it into a specific area or next to a nerve to decrease the feeling to that area, making it numb, and therefore painless. On its own,bupivacaine will only last 2 to 4 hours. Therefore, physicians combine it with a medicine called epinephrine, which narrows the small blood vessels around the area so the medicine can last longer. Combined with epinephrine, the bupivacaine can help ease a patient’s pain for 3 to 7 hours.
In the latest advancement, the bupivacaine is placed into liposomes. A liposome is a spherical vesicle that acts as a delivery device in our bodies, such as transporting nutrients and medications. In this setting, the bupivacaine slowly releases into the body and provides approximately 72 hours or 3 days of pain relief. This increase of time helps the patient past the initial surge of postoperative pain.

In December 2015, the FDA approved liposomal bupivacaine for “local surgical infiltration”. This means that the surgeon can inject the medication into the tissues surrounding the surgical incision during surgery. Today, surgeons use liposomal bupivacaine in conjunction with various orthopedic surgeries to include hip and knee replacements, shoulder, and spine surgery. Hip and knee replacements are 2 of the 7 most common surgeries that carry an increased risk of chronic opioid use. Recent studies on the use of liposomal bupivacaine used in hip and knee surgery show that patients have a decreased length of stay at the hospital, and initially walk better after surgery.

Patients, as well as their physicians, are concerned about the side effects of opioids, the risk of addiction, and prefer a pain management plan that decreases opioid use. Liposomal bupivacaine can help control postoperative pain and greatly reduce the use of opioids after surgery.

Author: Roman Ashmyan, DO

Reprinted with permission from the Hughston Health Alert, Volume 30, Number 4, Fall 2018.

Hip Arthroscopy

Hip arthroscopy has gained in popularity over the past 20 years due to the minimally

invasive nature of the surgery and the ability to address different types of disease or injury. Surgeons primarily use arthroscopic surgery (tiny camera and instruments inserted into the joint) to remove loose bodies, which are small pieces of cartilage (tissue that covers the ends of bones) that have broken off and then move around inside the hip joint. Surgeons also use this surgery to treat labral tears, injuries to the cartilage of both the femoral head (ball) and acetabulum (socket), and femoroacetabular impingement (Fig.1).

The hip joint is a ball-and-socket joint that connects the femur to the pelvis (Fig. 2). There are different elements in and around the hip joint that can be a source of pain, such as damaged cartilage and ligament (tissue connecting 2 bones) tears. When the physician evaluates a patient, it is critical to determine whether symptoms are intra-articular (coming from within the joint itself), or extra-articular (around the joint). For conditions that arise within the joint, hip arthroscopy can be a possible solution to address these problems.

Diagnosing hip pain.

Your physician will complete a thorough physical exam, record your health history, and order x-rays to determine the cause of your hip pain. X-rays are a good tool for evaluating the bony structures around the hip joint. Most patients with suspected intra-articular disease who do not have obvious arthritis on x-rays will also undergo a magnetic resonance imaging (MRI) scan. A MRI is especially useful to evaluate the soft tissue structures around the hip, such as the cartilage, labrum, and tendons, which may be injured.

Nonsurgical treatment

If you have no mechanical symptoms, such as catching, popping, or a clicking sensation in your hip, your physician often begins with nonsurgical treatment. Nonoperative treatments can include resting the joint if you are involved in regular exercise or athletic activity, anti-inflammatory medications, physical therapy, and steroid injections.
If these treatments fail to alleviate your pain and you continue to have difficulty either walking or standing, your physician may recommend hip arthroscopy.

Arthroscopic treatment

Your physician will discuss arthroscopic surgery with you if nonsurgical treatments have failed and your symptoms disrupt your normal day-to-day activities. Surgeons perform hip arthroscopy under general anesthesia and routinely use a special table to allow distraction (a gentle separation) of the ball from the socket to access to the intra-articular structures. Two common hip injuries treated arthroscopically are femoroacetabular impingement and labral tears (Fig. 3).

Femoroacetabular impingement

Femoroacetabular impingement (FAI) is a disorder of the hip in which the femoral head and neck rubs or “impinges” on the acetabulum. There are 2 types of FAI: cam impingement refers to a femoral-based disorder and is often seen in young athletic males and pincer impingement refers to an acetabular or socket-based disorder usually seen in active, middle-aged women. For both of these impingements, pain results from the proximal, or top of the femur abutting the acetabulum during range of motion, especially while bending. Patients often present with symptoms that include activity-related groin pain, difficulty sitting, and mechanical symptoms that includes a catching, clicking, or popping sensation during movement. If your physician suspects FAI, he or she will order x-rays to determine the shape and contour of the femoral head and neck as well as look for any abnormalities of the acetabulum. Your physician will also order a MRI to evaluate further the soft tissue structures in and around the hip.
At the time of arthroscopic surgery, the surgeon introduces the arthroscope into the hip joint to perform an initial diagnostic examination. Once inside the joint, the surgeon will look for disease or damage, such as cartilage defects of the femoral head and socket, loose bodies, and tears of the labrum.

Labral tears

The labrum is a horseshoe shaped structure that lines the outer rim of the hip socket. It is made of fibrocartilage and dense connective tissue. Sometimes when femoroacetabular impingement occurs, the labrum is torn. This tear can lead to pain during movement and you may experience catching, snapping, or locking. You may also feel a vague pain in your groin. If your doctor suspects a labral tear, as with FAI, you will undergo a MRI of the hip for further evaluation to confirm the diagnosis.

There are 2 main treatments of labral tears in regards to hip arthroscopy, labral debridement and labral repair. Labral tears not amenable to fixation are usually debrided, or trimmed back, to a stable base to the point that the unstable piece of torn labrum no longer causes symptoms. Your surgeon will remove any inflamed tissue in the hip joint and address any other underlying problems during surgery as well. This usually involves shaving some bone off the femoral head-neck junction as well as the hip socket so the bones do not rub against one another.

A labral repair often involves attaching the labrum back to its original site with the use of specialized anchors and sutures. Postoperatively, patients use crutches to aid in walking and are restricted to limited weightbearing and limited hip bending for approximately 4 to 6 weeks while the labrum heals.

Complications

Hip arthroscopy for either FAI or labral tears is not without complications, although the complication rate is low. Complications reported with hip arthroscopy occur at a rate between 1.3% and 6.4%. Most complications are minor and are often self-limiting, but there are several major complications that have been described in hip arthroscopy that the patient should be aware of. These include traction neurapraxia, where there is a temporary loss of motor and sensory function of nerves surrounding the hip. This occurs when traction is placed on the operative leg to help distract the hip joint in order to gain access for the arthroscope. This often resolves soon after surgery and most patients have a complete recovery. Damage to major nerves and blood vessel structures around the hip joint can also occur. Additionally, damage from instrumentation can happen; but with proper positioning and technique, the incidence of this complication is low.

On the mend

After surgery, you will be given instructions to follow for the weeks and months following surgery, including returning to see your physician for follow-up to see how you are progressing. Some of these instructions will include how to care for your portal sites and when you can shower or submerge the incisions in water. Additionally, you will be give crutches to use. Depending on the extent and type of repair, you may be on crutches for days, weeks, or months. When the hip has begun healing and the time is appropriate, your physician will refer you to rehabilitation. You should follow your rehabilitation program as instructed at the physical therapist’s office and at home. Physical therapy is a part of your treatment; therefore, you should adhere to the rehabilitation regime to achieve your best possible range of motion and functional outcome.

Hip arthroscopy can be an effective procedure and the risk of complications is low, although they do occur. Most patients are pleased with their outcomes and have resolution of symptoms, which allows them to get back to a more active lifestyle.

Author: Garland J. Gudger, Jr., MD

Reprinted with permission from the Hughston Health Alert, Volume 30, Number 4, Fall 2018.

 

Sports Broadcasting Hall of Famer Dick Vitale Cheers On Auburn University Hughston Style

Prior to the 2018 Auburn V. Kentucky men’s basketball game, Dick Vitale tweeted a video from the Auburn Arena. Do you see what we see? That’s one, big Hughston-style celebration!

 

Pelvic Fractures

The forces required to fracture the pelvis of a person with normal bone structure are nothing short of massive. These types of forces are generally the result of high energy blunt trauma that occurs in extreme situations such as motor vehicle accidents or falls from heights. Approximately 8 to 10% of patients who sustain a blunt force and are treated at a Level 1 trauma center have a pelvic fracture. Because of the forces involved, pelvic fractures are often associated with trauma to organs and vessels inside as well as outside the bony pelvis. Due to the extensive blood supply to the region, they are also associated with hemorrhage (bleeding). For these reasons, pelvic fractures should never be considered in isolation, but rather in the context of a polytrauma or multiply injured patient. Furthermore, despite modern treatment techniques and advances in trauma care, acute pelvic fractures can be fatal. Fatality usually results from trauma to organs or surrounding blood vessels and nerves. Pelvic fractures can carry mortality rates as high as 50% if they are open (caused a break in the skin) and up to 20% if they are unstable. Fortunately, pelvic fractures represent only about 3% of the total number of skeletal injuries sustained in the US each year.

Anatomy of the pelvis

The pelvis supports and stabilizes both legs and the trunk of the body. The word pelvis is Latin for “basin,” and the bones of the pelvis form a basin or bowl-like structure called the pelvic ring. The enclosed space, which houses and protects the reproductive organs and rectum, is known as the pelvic cavity. This cavity is typically wider in women to accommodate pregnancy and childbirth. The large bone on either side of the pelvic ring is innominate or nameless. Each of these paired bones is formed by the fusion of 3 smaller bones —the ilium, ischium, and pubis—and connects to the sacrum (the bone in the lower back formed by 5 fused lower vertebrae) (Fig. 1) and the coccyx or tailbone (formed by a fusion of the last 4 vertebrae) (Fig. 2). The ilium is the broad upper portion of the bone where we place our hands on our hips. The ischium makes up the inferior or lower portion of the posterior pelvis; it is the bone on which we sit. At the anterior or front portion of each innominate bone is the pubis bone. Between the left and right pubis bone is a fibrocartilaginous disc that helps to make up the joint called the pubic symphysis (Fig. 1). This joint, together with the posterior sacroiliac complex (area where the pelvis joins the sacrum), stabilizes the pelvic ring. The anterior structure of the pelvis contributes approximately 40% of its overall rigidity, and the posterior approximately 60%. The posterior portion is thus more important than the anterior to pelvic-ring stability, which makes it also more important to pelvic fracture classification.

Diagnosis and classification

Imaging studies are needed to accurately diagnose and classify a pelvic fracture. These can include x-rays with multiple views and stress views taken while the examiner manipulates the pelvis. A CT (computerized tomography) scan featuring multiple images of the pelvis can also be done for full assessment of the fracture pattern. A careful inspection of the entire structure must be made because following a trauma, a patient often has more than just a pelvic fracture.

Fractures of the pelvis are generally classified in 1 of 2 ways. The first is based on the stability of the pelvis and includes 3 subdivisions: 1) stable; 2) partially stable; and 3) unstable. The second, referred to as the Young-Burgess classification, is based on the mechanism of injury or the direction of the injuring force applied to the pelvis. It includes 4 subdivisions: 1) lateral compression (force is applied from the side of the pelvis); 2) anterior to posterior (force is applied from front to back ); 3) vertical sheer (part of the pelvis shifts upward or downward in relation to the remaining structure); and 4) a combined mechanism.

Management

The initial management of an unstable pelvic fracture often involves applying a sheet or pelvic binder around the patient’s pelvis to compress the area and halt any ongoing bleeding from the fracture. Once the fracture patient has been resuscitated and stabilized and the injury accurately diagnosed and classified, the goal then becomes definitive treatment. The unstable pelvis must be treated early on, not only to mobilize the patient and control pain, but also to control blood clots and chronic instability or deformity. Current pelvic fracture management employs a substantial amount of percutaneous reduction and fixation. This involves making small incisions through the skin to get the fractured bones back into the correct alignment and then fixing them in place with screws applied though these incisions. The introduction of these modern techniques and treatment options has resulted in fewer pelvic reconstructive surgeries involving large open incisions, though they are still sometimes necessary to stabilize the pelvis.

Rehabilitation

The type and amount of rehabilitation the patient needs largely depend on the particular fracture pattern and the fixation obtained during surgery. For stable injuries, immediate weight bearing as tolerated is often recommended, whereas for an unstable pelvic fracture, full weight bearing is often halted for at least 8 to 12 weeks after surgical treatment.

Residual problems

Following severe pelvic fractures, almost all patients continue to experience some degree of pelvic pain. In addition, limitations in sexual and excretory (elimination) function as well as nerve injury are common. Patients should therefore be counseled appropriately. While women who have sustained pelvic injury may still be able to give birth vaginally, the rate of cesarean, or C-section, delivery is higher than for women who have never sustained such injuries.

Toward better outcomes

As pelvic fractures can be fatal and often occur in tandem with other types of traumatic injuries, they should not be considered in isolation but in the context of a polytrauma patient. Consequently, although pelvic injury classification based on overall pelvic stability and the direction of the injuring force has become more standardized, it remains only a general guide to treatment. Over the past 30 years, major advances in the ability to evaluate and treat pelvic ring disruptions have led to more individualized treatment and improved outcomes.

Author: Aaron D. Schrayer, MD Lewisville, Texas

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 1,Winter 2017.

Reverse Total Shoulder Arthroplasty Explained

Today, there are 2 radically different kinds of total shoulder arthroplasties or replacements for individuals who suffer from severe shoulder joint pain due to arthritis or injury. While traditional shoulder arthroplasty has concentrated on replacing normal joint anatomy with plastic or metal components, the reverse total shoulder arthroplasty (RTSA) involves not only replacing joint components, but also repositioning them and altering the normal biomechanics of the shoulder. In cases where patients have sustained major muscle or tendon damage, making conventional replacement constructs more likely to fail, RTSA has become a viable solution for shoulder pain and disability. To understand how an RTSA works, a patient should first understand basic shoulder anatomy.

Shoulder anatomy

The glenohumeral, or shoulder, joint is classified as a ball-and-socket joint. It is formed by the articulation of the head (ball) of the humerus, or upper arm bone, with the glenoid cavity (socket) of the scapula (shoulder blade) (Fig.1). Since the cavity is shallow, there is little contact between the bones, but the glenoid labrum, a ring of cartilaginous fiber that lines its circumference, deepens the cavity by about 50%, allowing for more surface contact and a better fit. Nevertheless, the joint capsule, or envelope of fibrous connective tissue that attaches to the bones of the joints to seal the joint space and to help provide stability, is very loose. This makes the glenohumeral joint the most mobile of the body, capable of flexion (bending), extension (straightening), adduction (pulling toward the body), abduction (pulling away from the body) medial and lateral rotation (turning toward or away from the midline of the body), and circumduction (moving in a circle). The capsule consists of a number of tendons (tissues that connect muscle to bone) along with bursae, or small fluid-filled sacs, strategically located to aid movement and prevent friction. Because it lacks strong ligaments (tissues that connect bone to bone) to support it, the glenohumeral joint is also known as a muscle-dependent joint. It is primarily stabilized by the biceps brachii, or muscle on the anterior (front) side of the upper arm, and the tendons of what are called the rotator cuff muscles. These include the supraspinatus, subscapularis (Fig. 2), infraspinatus, and teres minor muscles (Fig. 3). Each of these muscles originates from the scapula and has a tendon that attaches to the head of the humerus. Together they form “a cuff” around the shoulder joint, called the rotator cuff, which provides stability. This cuff is also important to shoulder movement and is frequently injured from playing sports or doing other activities involving repetitive arm and shoulder motion.

Variations on shoulder arthroplasty

In traditional shoulder replacements, a plastic cup is used for the glenoid cavity of the scapula and a metal ball for the head of the humerus (Fig. 4). Outcomes from this procedure are generally good, but when a patient with shoulder arthritis also has a massive rotator cuff tear, conventional anatomic total shoulder replacements have higher complication rates. This is because, without an intact rotator cuff to stabilize the glenohumeral joint, its centers of force shift upward, causing the arthroplasty to loosen and fail.1 The problem with patients who also have rotator cuff injuries was recognized decades ago when it led to the development of the RTSA. This new type of prosthesis or implant reversed the normal anatomic configuration of the shoulder by placing the ball component of the implant in the glenoid socket of the scapula and the socket component in the humerus. In the 1970s, early designs of this arthroplasty often failed because the implant would loosen, break, or otherwise become unstable. Over time, the prostheses were designed to use the deltoid muscle (the rounded muscle on top of the shoulder) as a lever to compensate for the deficient rotator cuff. However, the early versions of this new design also frequently failed as the replacement constructs proved to be too constraining.

The Grammont arthroplasty

In 1985, French orthopaedist Paul Grammont advanced the design for RTSA when he came up with the idea of altering the normal biomechanics of the shoulder joint. Over the next 20 years, engineering of the Grammont RTSA evolved to provide a viable solution for patients with arthropathy (joint pain) and rotator cuff deficiency (Fig. 4). The construct functioned by converting the forces acting on the joint and, as in the previous designs, using the deltoid muscle in the absence of an intact rotator cuff as a lever so the patient could lift his or her arm. As it gave the glenohumeral articulation a larger contact surface area, the implant was more stable than earlier models and was able to prevent the humerus from shifting upward in patients with rotator cuff deficiency. Lastly, patients who were having pain from shoulder arthritis could get relief from the resurfacing provided by the stable implant. While various manufacturers have since produced prostheses that feature their own specific modifications, all of these are based on Grammont’s original design. Additionally, even though the procedure is still largely used in cases of arthropathy and rotator cuff deficiency or as revision surgery when traditional arthroplasty fails, indications for RTSA have now expanded to include some fractures of the humerus.

Outcomes and complications

RTSA offers new hope to patients suffering with shoulder pain and disability. According to doctors at Rush University Medical Center in Chicago, having this type of surgery substantially reduced shoulder pain in 9 out of 10 patients and led to a stabilized shoulder in at least 75% of cases. Despite these statistics and advancements in prosthesis design, outcomes for RTSA can vary widely and the procedure is associated with high complication rates ranging from 19 to 68% of cases.2 For example, scapular notching or erosion caused by the humerus or the humeral prosthesis impinging on the inferior or lower neck of the scapula, is unique to reverse total shoulder surgery. Other common problems include instability and dislocation of the prosthesis. These complications have been attributed to poor soft tissue tension, implant misplacement, an improperly-sized implant, mechanical impingement, bone loss, and neurologic dysfunction. For instance, acromial (pertaining to the protruding bone on the top of the shoulder) and scapular fractures have been reported after surgery and attributed to minor postoperative injuries. Fractures can also occur during surgery through a variety of mechanisms including bone preparation and placing instrumentation in bone that is already weak and porous. Moreover, nerve injury can result from over-lengthening the arm with the implants and overstretching nerves. Additionally, the unavoidable dead space (opening in the tissues created by the procedure itself, which allows the accumulation of blood or serum) can permit a hematoma, a solid swelling of clotted blood within the tissues, to develop. As with other joint arthroplasties, infection associated with hematomas, dead space, revision surgeries, a breach in sterile technique, or a compromised immune system, can occur. Given these possible complications, RTSA should be recommended only for select patients and performed only by experienced surgeons. Even after a successful reverse total shoulder procedure, some patients may continue to experience limitations in joint mechanics and function.

A good option for a bad shoulder

Historically, shoulder pain and arthritis have been difficult to treat in patients with a rotator cuff deficiency or following failed conventional shoulder replacement surgery. Although there can be complications, reverse total shoulder surgery addresses the problems involved directly and, to-date, offers the best treatment option available for many patients with damaged rotator cuffs.

Author: David A. Lalli, DO Niceville, Florida

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 1,Winter 2017.

 

Staying Active with Exercise-Induced Asthma

Exercise-induced asthma (EIA), or more accurately, exercise-induced bronchoconstriction, is a narrowing of the airways of the lungs triggered by vigorous physical activity. EIA constitutes a form of respiratory difficulty in which the airways become hypersensitive and inflamed. The muscles of these airways then contract or spasm; this reaction manifests as the symptoms of asthma.

Who is at risk? 

According to the American Academy of Allergy, Asthma and Immunology, EIA affects 12 to 15% of the population. Most people who suffer from chronic asthma also experience symptoms when exercising. EIA often begins in childhood and typically occurs in athletes who participate in sports with an aerobic component, such as running, soccer, and rowing. Athletes who play winter sports, particularly hockey or skiing, are also more susceptible to EIA due to the effects of exercising in a cold environment. Many professional and Olympic athletes, including former British footballer (soccer player) David Beckham and women’s marathon world-record holder Paula Radcliffe, have been known to suffer from EIA.

The respiratory tract

The upper respiratory tract, including the nose, nasal passages, sinuses, mouth, and pharynx (throat), is primarily involved in taking in air to breathe, then warming, moistening, and filtering it. The lower respiratory tract begins just below the vocal cords with the trachea (windpipe) which, as it descends toward the lungs, branches off into 2 main bronchi (bronchus, singular) or airway tubes. Within the lobes of the lungs, the bronchi branch into smaller airways, called bronchioles, which divide into ever-narrower branches. These terminate in the alveoli or tiny membranous air sacs rich in capillaries (small blood vessels) where the actual exchange of carbon dioxide for oxygen takes place (Fig).

Bronchial structure

The walls of the bronchi are made up of 3 layers. The outer layer consists of hyaline (bluish or transparent) cartilage rings. The lumen or inner space of the airway’s tube is covered with smooth or involuntary muscle which is, in turn, lined with respiratory epithelial or membranous tissue. Microscopic hairs on the surface of this tissue called cilia filter out dust and other inhaled particles. Moreover, the connective tissue of the smooth muscle harbors various immune cells, such as mast cells and basophils, which release histamines (chemical compounds that cause smooth muscle to contract and capillaries to dilate); it also contains goblet cells that produce mucus. A thin, protective layer of mucus covers the epithelial tissue, helping to purify the inhaled air. During an asthma attack, mast cells and basophils release histamine and the smooth muscle of the bronchi contract or spasm, making it difficult to breathe.

What causes exercise-induced asthma?

During strenuous exercise, the body demands more oxygen and breathes faster. However, when someone with EIA exercises vigorously, a bio- and neurochemical pathway is triggered resulting in bronchospasms. While the precise mechanism governing these spasms remains unknown, 2 theories predominate; both are based on the notion that consistent and repetitive air movement can alter conditions in the bronchial tubes causing airway muscles to react. The first theory assumes that the movement of the air through the airways causes dryness that the body then combats by channeling a lot more blood into the region. This results in airway edema (swelling) and bronchospasm. The second theory assumes that the air movement decreases the temperature within the bronchi; this triggers excess blood flow in an attempt to heat the airways. As many people breathe through their mouth when they exercise, the air they inhale is cooler than when they breathe through their nose, and this could trigger bronchospasms and an attack of EIA. Some researchers believe that a combination of these 2 theories explains an attack. There are also many other asthma triggers, including food, airborne allergens, smoke, pollution, and upper respiratory infections. Evidence, however, suggests that the cascade of events that lead to bronchospasms in people with EIA do not follow the same inflammatory pathways that lead to such spasms in people with allergic asthma.

Preventing attacks

The best way to treat EIA is to prevent the onset of symptoms. Patients who are prone to attacks of EIA should therefore take the time to warm up adequately before vigorous activity. If the weather is cold, a mask or scarf can be used over the mouth to reduce the effect of breathing in cold air. Alternatively, sufferers who typically breathe through their mouth while exercising should try to breathe through the nose instead so that the air is warmer. Furthermore, those with EIA should avoid outdoor activity if the pollen count or pollution level is high.

Managing symptoms

When an EIA attack occurs, proper management of symptoms is key. While over the counter drugs are available, these are not long-lasting and should not be used by patients who also suffer from hypertension (high blood pressure), diabetes, thyroid, or heart disease. Doctors typically prescribe medications known as beta 2 adrenergic receptor agonists or bronchodilators. These drugs cause smooth muscle to relax and the bronchial passages to dilate; some also work to stabilize the cells that release histamine. They can be short-acting or long-acting and are usually dispensed through an inhaler. Albuterol is an example of a short-acting beta agonist. It can be taken either as pretreatment 10 minutes before exercising or for quick relief during or directly after exercising. Most asthma medications, however, need to be taken up to 60 minutes before vigorous activity in order to be effective. For best results, a long-acting bronchodilator should be taken every day. Asthma medication is now also available in pill or liquid form. Some liquid medications can be used in a nebulizer or vaporizing machine that transforms the medicine into a fine mist. Strong anti-inflammatory drugs known as corticosteroids are also sometimes prescribed for EIA sufferers.

Stay active

Athletes and other EIA sufferers should not avoid exercise or sports. By planning ahead, doing warm up exercises, using medications as prescribed, taking extra precautions in cold weather, and avoiding allergens and pollutants, they can stay active.

Author: Meagan Dunn, MS, LAT, ATC, and BreAnna Hankins, LAT, ATC

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 1,Winter 2017.

Pediatric Forearm Fractures: When Both Bones Break

Pediatric forearm fractures account for approximately 50% of all pediatric fractures with an incidence of about 1 in 100 children. A common type of fracture involves both forearm bones, the radius, or bone on the thumb side, and the ulna, or bone on the little finger side (Fig). This fracture type is often referred to as a “both-bone forearm fracture” and can occur when a child falls on an outstretched hand, or, less commonly, when there is a direct trauma to the forearm. Pediatric forearm fractures are also typically described as being in the proximal (upper), middle, or distal (lower) portion of the forearm and can be angulated (deviating from a straight line), rotated (turned away from the midline of the body), displaced, or non-displaced. The severity of these characteristics will determine treatment. Additionally, pediatric forearm fractures can be either complete fractures, where the break goes through the cortex or hard outer surface of the bone, or greenstick fractures where the cortex remains intact. Greenstick fractures are common because children’s bones are pliable and often bend, but don’t completely break.

Diagnosis

A child who sustains a forearm fracture will usually present with immediate onset of pain, unwillingness to use the arm, and obvious deformity of the forearm. The orthopaedist will carefully inspect the arm for swelling and deformity, as well as for open wounds that could indicate an open fracture where the bone has actually come out of the skin. In order to assess the neurological and vascular status of the hand, a thorough neurovascular exam is performed. To determine the full scope of injury, the joints above and below the fracture, namely the wrist and elbow, are also assessed. Finally, x-rays should be taken to determine the pattern and severity of the fracture.

Treatment

Once the nature of the forearm fracture has been pinpointed, treatment can be discussed. The primary treatment goal for pediatric forearm fractures is to restore the length, alignment, and rotation of the bones so they will heal in a position where the arm can function normally. While most of these fractures can be treated non-surgically, some will require surgery.

Non-surgical

Fractures that are displaced, angulated, or rotated can often be closed reduced, or brought into proper alignment without surgery, and then immobilized in either a cast or splint. This is usually done in the emergency room with the patient sedated and on pain medicine. The physician may use fluoroscopy, a type of medical imaging that shows a continuous x-ray image on a monitor, to guide the reduction.

The age of the patient dictates how much rotational and angular deformity is acceptable for both-bone forearm fractures. Younger children can tolerate more deformity as their bones have a greater potential to remodel and heal in correct anatomic alignment. Thus in children less than 10 years of age, up to 15° of angulation and up to 45° of rotation is acceptable while in older children, only up to 10° of angulation and 30° of rotation is acceptable.

Both-bone forearm fractures are initially immobilized in a long arm cast or in a splint that can later be converted, or overwrapped with fiberglass, into a cast. Within the coming week, an orthopaedist follows-up with the patient and x-rays are repeated to ensure that the reduction has been maintained. As long as the reduction and alignment remain within the acceptable parameters, the only treatment needed is 6 to 8 weeks of immobilization.

Surgical

While most pediatric fractures can be treated without surgery, some will require surgery. Surgical indications for both-bone forearm fractures include open fractures, unstable or irreducible fractures that fail initial attempts at closed (nonsurgical) reduction, floating elbow injuries (where there is a break both below and above the elbow joint), and soft tissue swelling about the forearm that will not allow the safe application of a cast. Additionally, up to 30% of patients may experience an early loss of reduction. Risk factors that contribute to this include older age, a fracture that is more proximal, and greater initial displacement. Children with less than 1 to 2 years of growth left who suffer both-bone forearm fractures are usually treated as adults and require surgical intervention.When surgery is necessary, the 2 most common options for internal fixation are intramedullary nails (metal rods set into the medullary cavity or inner canal of a bone) and plate and screw constructs. Intramedullary nails are placed through small incisions down the intramedullary canal of both the radius and the ulna in order to restore length, alignment, and rotation. They are left in place until several months after the fracture has healed and then removed. Plate and screw construct fixation is achieved with open techniques similar to those used for adults. Whether the construct should be removed once the fracture has healed is controversial.

Complications

In most children, forearm fractures heal with full return of function. Refracture occurs in 5 to 10% of patients. Malunion, where the bones fail to heal or are not aligned correctly, is rare as the potential for remodeling and aligning fractured bones is greater in children than adults. Malunion can result in a loss of range of motion and of arm function. Risk factors for malunion include poor reduction or casting technique, incomplete surgical correction, and failure to monitor the fracture with x-rays after the initial reduction. Additionally, compartment syndrome, one of the most serious complications in both-bone forearm fractures, can occur in either surgical or nonsurgical cases. Compartment syndrome happens when the swelling under the fascia or membrane that surrounds the muscles of the forearm becomes severe enough to compromise the blood flow to these muscles, which can lead to muscle necrosis (death). Compartment syndrome constitutes an emergency and must be treated immediately with fasciotomy (releasing the fascia) or, in some cases, a fasciectomy (excising strips of fascia) to decompress the compartment and prevent the limb from being permanently compromised.

Positive outcomes

Both-bone forearm fractures are common in the pediatric population. Most of the time, they can be treated nonsurgically with closed reduction and cast immobilization. Almost all fractures heal with appropriate length, alignment, and rotation; the patient suffers no lasting deformity and has full function of the limb. A small percentage of pediatric forearm fractures require surgical fixation, but the complication rate is low and the outcome overwhelmingly positive.

Author: Jake Gudger, MD Columbus, GA

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 2, Spring 2017.

Chest Muscle Injuries: Strains and Tears of the Pectoralis Major

Once rare, injuries to the chest muscles, particularly the pectoralis major muscle, are becoming more common. In fact, a recent study noted that of the 365 cases of pectoralis major ruptures reported in the medical literature from 1822 to 2010, 76% occurred over the past 20 years.1 Pectoralis major injuries can range from contusions (bruises) and inflammation to complete tears and frequently result in pain, weakness, deformity in the contour of the chest, and, ultimately, a decline in overall shoulder function. These injuries most often occur in active individuals who participate in sports or perform heavy labor and can be the result of either an acute traumatic event or chronic overuse. Pectoralis major tears are common in younger males who lift weights2 and in older athletes who do not warm-up adequately; however, these kinds of tears have even been reported in the elderly.3 When pectoralis major injuries occur, they can be disabling, especially to athletes.

The chest muscles

The 2 pectoralis muscles, the pectoralis major and the pectoralis minor (the larger and smaller muscles of the chest) connect the Humerus front of the chest wall with the humerus (upper arm bone) and shoulder (Fig). The pectoralis major is a thick, fan-shaped muscle consisting of 2 heads or portions, the clavicular and the sternal. The clavicular head originates from the anterior border of the medial half of the clavicle (collar bone) while the sternal head arises from the sternum (breast bone) and first through sixth ribs. The 2 portions of the muscle then converge on the outer side of the chest with the subclavius muscle (the small, triangular muscle between the clavicle and first rib) to form the axilla or armpit. The multiple origins and insertions of the pectoralis major muscle allow it to initiate a wide range of actions on the arm, enabling it to adduct (draw toward the body), flex (bend), extend (straighten), and internally rotate (turn toward the body).

 

 

Causes

Over time, repetitive or prolonged activity may cause the tendons of the pectoralis major muscle to degenerate, resulting in a strain. Chronic muscle imbalances, weaknesses, tightness, and abnormal biomechanics, especially when combined with excessive training, can also contribute to the development of a pectoral strain. By contrast, acute strains or tears to the pectoralis muscle happen when a force goes through the muscle and tendon that is greater than they can withstand. This can occur while weight training, especially when performing a bench press, chest press, or pectoral fly, and is more likely to happen when using free weights than machines. For example, if too great an external force is applied when the muscle is at its maximal stretch point, as during the downward movement of a bench press, it will rupture at the tendon juncture. When this occurs patients typically report a sharp pain with a pop.

Classification

Tears to the pectoralis major muscle may be small and partial or may constitute a complete rupture. Additionally, they can be classified as 1 of 3 grades, based on the number of muscle fibers torn and how much function has been lost, with grade 3 representing the most extensive damage. The majority of tears are grade 2.

Symptoms

Following a pectoralis major tear, the patient may have bruising, swelling, and deformity of the chest and upper arm. In addition, he or she may report pain and loss of strength when pushing with the extremity. The pain is localized to the chest and front of the shoulder or armpit, but may radiate into the upper arm or neck and may increase from an ache to a sharper pain with activity.

Diagnosis and assessment

In the acute phase of injury, a physical exam may be difficult to perform because swelling from the injury can distort the shoulder and pain can affect strength and motion testing. Once the swelling has resolved, the contour of the chest and shoulder may appear abnormal. The strength of the muscle can be tested by having the patient adduct while internally rotating (moving toward the body) the arm and adding resistance (pulling away from the body). The results can then be compared with results from the opposite arm.

Imaging is used to differentiate a pectoralis injury from other types of disorders and to determine its extent. X-rays should be taken to look for a possible bone fragment on the tendon or other associated fracture or dislocation. CT (computed tomography) can be used to evaluate fractures identified on x-rays for surgical fixation. Ultrasound is an inexpensive modality that can be used to assess the presence of a tear or retraction of the tendon while an MRI (magnetic resonance imaging) can be performed to determine the site and extent of the injury.

Treatment

The treatment for a pectoralis major injury depends upon the severity of the injury, the extent of muscle function, and the patient’s health and general activity level. Nonsurgical treatment must be considered in patients who have low demand, are elderly, or have either partial tears or tears in the muscle belly. Initial management with immobilization, rest, and cold therapy followed by strengthening and stretching can offer a satisfactory to excellent functional result. Shoulder motion returns and patients can resume daily activities.4 In those patients who either need to return to full strength and function or are concerned with cosmetic appearance, surgical repair is recommended. In a recent study, patients were highly satisfied with surgical repair of the pectoralis major, reporting a return of strength, structure, and overall function.5 The need for rehabilitation after surgery varies depending on how the muscle was repaired. In general, patients can return to normal activities 4 to 6 months after their procedure.

Outcomes

The management of pectoralis major injuries is patient specific. In sedentary or low-demand individuals with partial or complete tears, nonsurgical management can provide acceptable to excellent results. In those who demand function and form, surgical treatment may be the best option. While complications such as failure of repair, infection, and stiffness can occur, they are fairly rare. Generally, full return to activity and improved appearance can be expected following surgical repair and rehabilitation.

Author: Dan Morris, DO Columbus, GA

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 2, Spring 2017.

I Have Scoliosis, Which Sports Can I Play?

If your spine curves toward the side and is shaped like a “C” or an “S,” (Fig) you may have scoliosis. Scoliosis is defined as a curvature of the spine of more than 10 degrees combined with a rotation of the vertebrae, the small bones that form the spine and through which the spinal cord passes. The 2 most common locations for this abnormal curvature are the thoracic (upper to mid) and lumbar (lower) spine. The thoracic portion of the spine is made up of 12 vertebrae and the lumbar portion of 5. The signs and symptoms of scoliosis include uneven hips, musculature that is uneven from one side of the body to the other, a rotating spine, back pains, and possibly chest pain. If as an athlete you have scoliosis, you may be wondering which sports you can play without experiencing discomfort or worsening your condition.

How do I know whether I’m at risk?

Most forms of scoliosis (about 65%) are idiopathic, meaning that the cause is unknown, and current research reports that the disease is most likely caused by several factors. While anyone can have idiopathic scoliosis, it is most often seen in children between the ages of 10 and 13; in fact, it is the most common spinal disorder in pre- and early teens. Additionally, studies have shown that females are more susceptible to the condition than males, though no definitive reasons have been found to explain this greater risk. A popular theory is that altered sensitivity to leptin, a hormone involved in the regulation of bone and energy metabolism in children and the initiation of puberty in girls, may result in increased sympathetic nervous system activity and a consequent disorder in skeletal growth, such as asymmetry of the spine. Apart from gender, the most significant factor contributing to scoliosis is genetics. Therefore, if someone in your immediate family, such as parent or sibling, has the condition, you should get checked regularly.

Can I be diagnosed as an adult?

Adults are often diagnosed with either idiopathic or degenerative scoliosis. If you are diagnosed with idiopathic scoliosis as an adult, chances are that the condition began in your adolescent to teenage years. If, on the other hand, as an adult you suffer from degenerative scoliosis, then a degenerating vertebral disc (the cushioning fibrocartilaginous pad between vertebrae) is the cause of the problem. As this disc degenerates, gravity can place too much pressure on one side of it, causing your spine to bend and curve. Your symptoms will depend on the degree of curvature, and may include back pain, shortness of breath with activity, lumbar stenosis (compression of the spinal nerve roots in the lower back), or poor posture.

How will my scoliosis be treated?

Through regular checkups with doctors, a treatment plan can be established for you as a scoliosis sufferer. The type of treatment depends on several factors such as your age or pubertal status, the degree and location of the curvature, gender, and associated symptoms. Once the doctor has assessed all the factors in your case, he or she can determine the best course of treatment. This could consist of getting fitted for a brace and attending physical therapy or could mean having a surgical procedure. A combination of bracing and spinal casting may be prescribed as a way to avoid surgery.

Progressively worsening scoliosis may require surgical intervention. As a very young patient, your options may include the implantation of growing rods as a way to straighten the spine without damaging growing tissues. Using hooks or screws, these rods are attached to the spine, or sometimes to the ribs, both above and below the spinal curvature. For children with early onset scoliosis there are also magnetic growing rods which, once surgically implanted, can be controlled and lengthened remotely as the child grows.

If you are an older teenager or adult, your condition may warrant spinal fusion. This is a surgical procedure to correct problems with the vertebrae and prevent any deformity from worsening. It may also improve the appearance of the spine. The procedure fuses together the painful vertebrae so they heal into a single, solid bone. This usually involves the placement of screws, hooks, and rods. The majority of patients are able to resume their normal activities, including athletics, a few months after spinal surgery.

Which sports can I play?

When you hear that you have a disease of the spine, you may be worried that playing a sport is out of the question. This is not true. Having scoliosis does not dictate whether you can play sports, though it may limit which sports you can play. Sports such as gymnastics, football, and heavy weight lifting that put a great deal of stress on the bones in the lower back are discouraged for athletes with scoliosis. On the other hand, sports which are low-impact, such as swimming and certain types of cycling, are encouraged. Moreover, these sports rely on a strong core. Your core includes not only your abdominal muscles, but also the muscles in your lower back and hips. When these muscles are conditioned and equal in strength, they work together to align and stabilize your spine, creating an anatomical brace. If, however, these core muscles are weak and imbalanced, they cannot support your spine and the result is poor posture. Your physician or physical therapist may prescribe an appropriate stretching and strengthening routine that targets your core to help with your condition. You may also benefit from structured activities such as yoga.

Carrying on with scoliosis

Scoliosis is a curvature of the spine that calls for regular monitoring visits with a spinal specialist or an orthopaedist with spinal expertise. While anyone can have scoliosis, statistics show that it is more prevalent in young females. How your scoliosis is treated and which sports you can participate in will ultimately depend on the severity of your condition. With the proper oversight, care, and attitude, you can carry on an active lifestyle and play a variety of sports despite having scoliosis.

Author: Chelsea Adams, LAT, ATC, and Morgan Carr, MS, LAT, ATC

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 2, Spring 2017.

The Verdict on Vaping

Electronic cigarettes have been marketed as “healthier” alternatives to traditional cigarettes and as a good way to quit smoking. Only recently have people begun to look into the science behind these devices and ask the right questions. What exactly are electronic cigarettes? How do they work? Are they safer than tobacco cigarettes? Can they help me quit smoking? Unfortunately, the answers research is providing to some of these questions, especially when it comes to teens and young adults, are not what most people hope to hear.

The e-cigarette

Electronic cigarettes were invented in 2003 by Hon Lik, a Chinese pharmacist who was trying to quit smoking, and as of 2015, most were still made in China. Also known as electronic nicotine delivery systems (ENDS) and personal vaporizers, electronic or e-cigarettes are handheld, electrical devices designed to deliver nicotine to users in the form of vapor instead of smoke. They come in a variety of shapes, sizes, and styles, including cigars, pipes, and cigarette or pen look-a-likes. Most e-cigarettes have 3 main components. First, is the power source, which is usually a battery. Next, is the heating device, called an atomizer or vaporizer, which turns the liquid into an aerosol or vapor. Lastly is a cartridge or tank which holds the e-liquid and has a mouthpiece on one end. Sometimes the atomizer and cartridge are combined into a single unit called a cartomizer. As the user breathes into the mouthpiece, the heating device activates, and he or she then inhales or “vapes.”

The e-liquid

The liquid in an e-cigarette cartridge contains 4 main ingredients: nicotine, flavoring, propylene glycol, and glycerin. While the amount of nicotine in e-cigarettes varies greatly, a low level generally corresponds to 6 to 12 mg of nicotine, a medium level to 18 mg, a high to 24 mg, and very high to 36 mg. E-cigarettes taste like conventional cigarettes, but also come in a variety of flavorings from menthol to mocha dream. Currently, there are as many as 7,700 flavors on the market.2 Sweet flavors appeal particularly to young people.
Until August of 2016, the US Food and Drug Administration (FDA) did not regulate e-cigarettes, so there were no requirements for ingredient disclosure, warning labels, or youth access restriction. Partly as a consequence of FDA involvement, scientific research into the components of e-cigarette liquid as well as the health effects of e-cigarette use and exposure has increased. The findings reveal that the e-liquid usually contains not only nicotine, a highly addictive substance, but also benzene (which is found in car exhaust) and heavy metals, such as nickel, tin, and lead. Even an ingredient used in anti-freeze, diethylene glycol, has been identified in the e-liquid.3 Moreover, 75% of flavorings contain a chemical called diacetyl, which, when inhaled, has been linked to bronchiolitis obliterans, or permanent scarring of the airways in the lungs, and severe respiratory disease (Fig).1-3

The e-vapor

The real danger of vaping, however, may derive from the process that turns the liquid into a vapor. At a temperature of about 100 to 250°C (212 to 482°F), the chemical compounds inside the fluid break down and are converted into other chemicals. Scientists have examined the resulting mix and found both formaldehyde (a carcinogen or cancer-causing substance) and formaldehyde-releasing agents.1 Therefore, although traditional cigarettes contain over 4,000 chemicals— including 43 known cancer-causing compounds and 400 other toxins like arsenic, acetone (the active ingredient of nail polish remover), carbon monoxide, ammonia, and methanol (found in rocket fuel)—the risk of developing cancer from electronic cigarettes may be 15 times higher than from tobacco cigarettes, according to a report by Agence France-Presse. Moreover, like smoking, vaping can expose others to dangerous second-hand emissions (Fig).

Can e-cigarettes help me quit smoking?

It has been well established that cigarette smoking is harmful to nearly every system of the body and can cause a host of serious illnesses from emphysema and lung cancer to heart attack and stroke (Fig). Smoking is also a notoriously difficult habit to break: approximately 80% of would-be quitters will relapse within the first month. E-cigarettes have not only been promoted as safer than traditional cigarettes, but also as a means for smokers to quit. As there has been no evidence until recently that the devices can help traditional cigarette smokers stop smoking or even cut back, the FDA has been trying to evaluate and regulate this claim. E-cigarettes that contain nicotine levels lower than the 1mg of nicotine in tobacco cigarettes have been marketed with the idea that vaping small amounts of nicotine might help smokers quit. However, as consumers typically refill e-cigarette cartridges, they may offset any benefit from the reduced nicotine, exposing themselves to greater quantities than recommended.1 On the other hand, in 2014, the first Cochrane review—an independent, non-profit collaboration of researchers from more than 130 countries who work to produce credible and accessible health information without commercial sponsorship and other conflicts of interests—reported that, based on 2 randomized, controlled trials of more than 660 individuals conducted in England, e-cigarettes could increase the chance of smokers quitting: 9% of those using such devices stopped smoking for at least 6 months, compared with only 4% of those using e-cigarettes without nicotine. In a larger survey, University College London Professor of Health Psychology Robert West estimated that for every 10,000 people who use e-cigarettes to help them quit smoking, approximately 580 will quit. In 2015 alone, e-cigarettes may have helped about 18,000 smokers quit who might not have otherwise. Other studies, however, have revealed more modest results, cautioning that only 1 out of every 5 of those who attempt to quit smoking permanently by substituting vaping succeed.3 Furthermore, debates about whether e-cigarettes are more effective or safer than nicotine patches or other aids to quit smoking continue. Unlike pills and patches, the devices offer the advantage of mimicking the behavioral and psychological aspects of smoking; they provide a substitute for hand-to-mouth action and a coping mechanism for conditioned smokers.

Smoking trends

According to both the US Centers for Disease Control and Prevention and the FDA, electronic cigarette use now exceeds that of conventional cigarettes.3 Everyday usage is common, and many vapers are middle-aged males who also smoke. Among teens, e-cigarettes, and even marijuana, are more popular than tobacco cigarettes. A survey performed by the CDC found that while the total number of teen cigarette smokers has declined over the past 2 decades to 1.6 million, 1.3 million youth have taken up vaping.1 In fact, according to a recent FDA News Release on new tobacco regulation, between 2011 and 2015, e-cigarette use among high school students jumped from 1.5 to 16%, an increase of about 900%. This is a disturbing trend as e-cigarettes have not been proven to be healthier than regular cigarettes. Additionally, vaping can be a gateway to tobacco use for the younger generation. A study conducted by the National Center for Chronic Disease Prevention and Health Promotion revealed that US teens and young adults who have never smoked but have used e-cigarettes were 8.3 times more likely to begin smoking after just 1 year than those who have never vaped.3

Nicotine is not for teens

While nicotine is not a known carcinogen, it is a highly addictive substance that is lethal in high doses. In 2015, the American Association of Poison Control Centers reported 3,073 calls involving issues with e-cigarette devices and liquid nicotine. Moreover, nicotine can have long-term effects on brain development. This is largely because the brain’s prefrontal cortex (PFC), which is responsible for executive functions and attention performance, is one of the last areas to mature, continuing to develop until age 25. Consequently, when young people smoke, they increase the risk of developing impaired judgment, cognitive dysfunction, and attention deficits, as well as psychiatric and mood disorders. Smoking can also reduce impulse control in youths and alter the way they will make decisions as adults. Furthermore, nicotine use can lead to an increased risk of cardiovascular, respiratory, and gastrointestinal disorders as well as a decrease in immune response, which can negatively impact reproductive health (Fig).

The verdict

On December 8, 2016, the Surgeon General’s Office released “E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General,” which comprehensively reviewed the public health issue of e-cigarettes, particularly their impact on US teens and young adults. Surgeon General Vivek H. Murthy has dubbed the devices “a public health threat to America’s youth” that is putting a whole new generation at risk for nicotine addiction. Fortunately, however, the upward trend in e-cigarette use among high school seniors has recently begun to reverse with just 12% saying they have used e-cigarettes compared with 16% in 2015.3 E-cigarettes may help some people quit smoking, and due to variable nicotine and chemical contents of the e-liquid, some controversy remains about whether they can be less harmful than tobacco cigarettes. Still the verdict on vaping, especially for teens, is simple: if you haven’t started, don’t; if you have, quit.

Author: BreAnna Hankins, MS, LAT, ATC and McKenzie Wakefield, LAT, ATC

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 2, Spring 2017.