Managing the Polytrauma Patient

Every day, individuals are brought to emergency rooms or trauma centers with multiple injuries as a result of traumatic events such as car or motorcycle crashes or other high-energy impacts to the body, including falls from heights, crush injuries, or gunshots. A person involved in a traumatic event who has sustained multiple injuries is a polytrauma patient (Fig.). The term polytrauma comes from the ancient Greek words poly-, meaning many or multiple, and trauma, meaning a wound or an injury to living tissue caused by an external agent. The Centers for Disease Control (CDC) reports that 192,000 people under the age of 46 died from traumatic injuries in 2014. The CDC also states that, after heart disease and cancer, trauma is the leading cause of death for adults over the age of 45. However, current advances in treatment are helping to improve outcomes for polytrauma patients.

 

A multidisciplinary approach
Treatment of the polytrauma patient requires both a multidisciplinary approach and the proper timing of musculoskeletal care. Thus a coordinated effort by several highly specialized medical teams is usually required to manage and stabilize the polytrauma patient. The first responders take care of the initial resuscitation and transport of the patient by ambulance or helicopter to either the hospital or trauma center. There the patient is triaged and initially listed as being in 1 of 4 possible conditions: 1) physiologically stable; 2) unstable; 3) borderline; or 4) in extremis (extremely unstable). As traumatically sustained injuries often cause either internal bleeding or bleeding from an injured extremity, the amount of blood lost usually determines the patient’s condition. This blood loss is initially treated by administering fluids directly into the patient’s blood stream or through blood transfusions. The emergency medicine team then works to further stabilize the patient through lifesaving protocols and to evaluate the patient’s injuries by obtaining the proper imaging. Based on these images, the radiologist then aids in diagnosing these injuries, and an interventional radiologist can often treat ongoing bleeding through minimally invasive techniques.

Next, the orthopaedic trauma surgeon is responsible for stabilizing the patient’s musculoskeletal injuries based on his or her condition. As fractures can cause ongoing bleeding—for example, patients with pelvic or femur fractures can lose several liters of blood—temporarily splinting, and so stabilizing, a fracture can be lifesaving.
Afterward, depending on the patient’s clinical condition, treatment consists of 1 of 2 basic approaches for musculoskeletal stabilization: damage control orthopaedics (DCO) or early total care (ETC). Once the patient has been stabilized through 1 of these treatment protocols, intensive care unit (ICU) physicians and nurses assume the major responsibility for the patient’s care. The patient will remain in the ICU until his or her clinical condition improves enough to allow transfer to a regular hospital floor bed.

 

What is damage control orthopaedics (DCO)?
DCO is the performance of lifesaving interventions through rapid fracture stabilization to stop the cycle of ongoing musculoskeletal injury and bleeding. In patients with unstable pelvic fractures, the pelvis can be a source of ongoing bleeding. Thus pelvic binders or sheets are often applied around the patient’s pelvis to compress the area and stop the bleeding. Additionally, external fixators—pins placed into the bone that are connected to bars and clamps applied outside the body—are frequently positioned to stabilize fractures and soft tissue injuries of not only the pelvic area, but also the extremities. These interventions are able to stabilize the patient quickly without the added insult to the body that more invasive surgery would entail.

 

What is early total care (ETC)?
ETC is the performance of definitive fracture stabilization at the time of the initial surgery. One advantage of this approach is that it can enable the patient to get back on his or her feet sooner. It can also help prevent other health issues, such as pneumonia, ulcers from lying in bed, blood vessel abnormalities (such as blood clots), gastrointestinal problems, and even mood disorders, from occurring due to the more rapid mobilization of the patient after surgery. However, as surgery involving definitive fracture stabilization often takes more time and is more invasive, performing this type of treatment on an otherwise unstable patient can add insult to injury. ETC should therefore be performed only on those patients who are already in stable condition.

 

Better management, better outcomes
Two major factors affecting early survival of the polytrauma patient are the initial status of the patient (determined largely by the amount of blood loss sustained) and the time to transfer the patient to a trauma center. Brain injury, which is often the result of blunt trauma, can cause early death in the polytrauma patient, while sepsis (an inflammatory response caused by infection and involving the entire body) typically causes death later on. Fortunately, advances in diagnosis and treatment of traumatic musculoskeletal injuries—including prehospital, interventional, surgical, and intensive care—have led to increased survival rates for polytrauma patients.

 

Author: Aaron D. Schrayer, MD | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 28, Number 3, Summer 2016.

 

 

Lateral Epicondylitis: Taming Tennis Elbow

Lateral epicondylitis is a common painful condition of the elbow caused by overuse of the muscles of the forearm. Popularly known as tennis elbow because of its association with the sport, it is both a repetitive strain injury and a tendinopathy (diseased or abnormal condition of the tendon). Various studies have identified the repetitive wrist extension or forearm rotation and supination (turning toward the outside) involved in such activities as racquet sports and using heavy tools for manual labor as the primary risk factors for lateral epicondylitis. In many cases, however, the condition cannot be linked to any kind of precipitating activity and so is said to be of insidious onset (coming on slowly without obvious symptoms). Regardless of the cause, once the muscles and the tendons (tissue that connects muscle to bone) that attach to the lateral epicondyle become chronically irritated and the attachment begins to degenerate, everyday activities, such as gripping or holding household objects, can be painful. Lateral epicondylitis affects 1 to 3% of the adult population, most often those between the ages of 30 and 50, and affects women slightly more often than men.

 

Elbow anatomy
The elbow joint is held together by muscles, tendons, and ligaments (tissue that connects bones) (Fig. 1). It is a hinge joint that allows us to flex (bend), extend (straighten), and rotate the forearm. The bony projection that can be palpated on the outside of the elbow is the lateral epicondyle. It extends off the condyle, or rounded, knuckle-like bone ending, of the humerus (upper arm bone) which articulates with the radius and ulna (forearm bones) to form the joint (Fig. 2). The muscles that extend the wrist, such as the extensor carpi radialis brevis (ECRB), originate from the lateral epicondyle.

 

Sources of pain
The most common source of the pain associated with lateral epicondylitis is the ECRB muscle. Repetitive or overuse activities can cause microtrauma to the fibers of the muscle, resulting in microscopic tears and the release of inflammatory chemicals that induce pain. The pain may also be caused by the tendons that attach to the epicondyle or, alternatively, from conditions inside the joint, such as synovitis (inflammation of the synovium or joint lining) or plica band (inflammation and enlargement of a part of the joint lining). Typically, the pain is felt on the outside of the elbow in the portion of the ECRB closest to the joint, and the lateral epicondyle itself may be tender. The pain of lateral epicondylitis can be reproduced with resisted wrist and finger extension, and most patients complain of a weak and painful grip.

 

 

Nonsurgical treatment options
The majority of lateral epicondylitis or tennis elbow cases resolve on their own without formal treatment. When pain persists, it usually prompts a person to visit a physician or orthopaedist. The appointment will include a detailed history, physical exam, and x-rays; if the problem is severe enough, the doctor may order an MRI.

Standard nonoperative treatment for lateral epicondylitis consists of taking oral nonsteroidal anti-inflammatory drugs (NSAIDs), modifying activity, using orthotic braces (such as tennis elbow straps), and undergoing physical therapy. Another nonsurgical measure is to inject steroidal medication directly into the identified site to decrease pain and inflammation. As the effectiveness of steroid injections is generally mixed, some novel injection techniques have emerged. For example, an autologous (from one’s own body) platelet concentrate (consisting mainly of blood plasma and platelets or cell fragments involved in clotting) can be injected into the affected elbow to stimulate a healing response. Also known as platelet-rich plasma (PRP) therapy, these injections have shown promising results in some studies, but more research is needed to determine their real efficacy.1,2 It is also important to note that between 80 and 95% of all cases of epicondylitis resolve without operative treatment.

 

Surgical treatment options
When refractory or stubborn cases of lateral epicondylitis fail to respond to nonoperative treatment, surgical options can be considered. Traditional surgery for tennis elbow has consisted of large, open techniques that expose the extensor muscles and identify and excise (remove) the damaged tissue (Fig. 3). Such procedures have typically included tendon repair where the healthy tissue is reattached to the bone. More recently, less invasive surgical techniques, such as arthroscopy (inserting a tiny fiber-optic video camera and instruments into the joint) have been developed. Unlike traditional open surgery, arthroscopic treatment of lateral epicondylitis requires only a small percutaneous (through the skin) incision and a shorter recovery period. It also allows the surgeon to identify and treat any additional intra-articular pathology (disease process within the joint).

 

New treatment
A new minimally invasive technique known as a percutaneous tenotomy (tendon resection) that uses the Tenex Health TX System™ is currently evolving. The procedure uses a percutaneous incision and ultrasound guidance above the skin rather than a scope to identify diseased tissue (Fig. 4). A special hand-held tool is then used to mechanically break up the tissue and flush it out.3 Preliminary research on this treatment has been promising. One recent study including a 3-year follow-up showed excellent functional outcomes and high patient satisfaction.4
Additionally, postprocedure ultrasound evaluation of the tendon showed a good tissue-healing response in the diseased area. The theoretical advantages of this technique over other techniques include a much smaller incision, the ability to target the diseased area with minimal disruption to healthy tissue, decreased postoperative pain, and a shorter recovery period. Despite these advantages, more research is needed to establish this procedure as a preferred treatment for lateral epicondylitis.

 

Good results
Lateral epicondylitis or tennis elbow is a common yet potentially debilitating condition that can limit the performance of everyday activities. While most cases resolve on their own or with nonsurgical treatment, more difficult or refractory cases may require surgery. When surgery is needed, new arthroscopic and other minimally invasive techniques, particularly percutaneous tenotomy with Tenex Health TX System™, have shown good results for patients.

 

 

Author: David A. Lalli, DO | Columbus, Georgia

 

References:
1. Peerbooms JC, Sluimer J, et al. Positive effect of an autologous platelet concentrate in lateral epicondylitis in a double-blind randomized controlled trial: platelet-rich plasma versus corticosteroid injection with a 1-year follow-up. American Journal of Sports Medicine. 2010;38(2):255-62.
2. Gosens T, et al. Ongoing positive effect of platelet-rich plasma versus corticosteroid injection in lateral epicondylitis: a double-blind randomized controlled trial with 2-year follow-up. American Journal of Sports Medicine. 2011;39(6):1200-08.
3. Barnes DE, Beckley JM, Smith J. Percutaneous ultrasonic tenotomy for chronic elbow tendinosis: a prospective study. Journal of Shoulder and Elbow Surgery. 2015;24(1):67-73.
4. Seng C, Mohan PC, Koh SB, et al. Ultrasonic percutaneous tenotomy for recalcitrant lateral elbow tendinopathy: sustainability and sonographic progression at 3 years. American Journal of Sports Medicine. 2016;44(2):504-10.

 

Reprinted with permission from the Hughston Health Alert, Volume 28, Number 3, Summer 2016.

 

 

Hydrate Well to Play Well

Did you know that your body is mostly water? In fact, 60% of your body consists of water. Two-thirds of this water is intracellular (contained within your cells) and 1/3 extracellular (existing outside your cells). Extracellular fluids include your blood plasma, lymph (the fluid from the spaces between body tissues that collects in your lymphatic vessels), and various bodily fluids such as your cerebrospinal (within the cavities of your brain and spine) and pleural (around the membranes of your lungs) fluids. Without plenty of water, your body cannot operate efficiently. Just to maintain proper functions, such as regulating your temperature, carrying out metabolic reactions, delivering vitamins and minerals to your cells, transporting nutrients, and eliminating waste, your body requires ½ to 1 fluid ounce (fl oz) of water per pound (lb) per day. Exactly how much water you need therefore depends on your overall weight and other factors. If, for instance, you weigh 150 lbs, this means you need approximately 2.5 quarts of water per day.

Following an exercise routine or playing sports will cause you to sweat more and to burn more fuel. This is because sweating is your body’s primary mechanism for cooling itself off during exercise. When sweat breaks out on your skin it transforms and evaporates, carrying heat away from the body. Sweating also helps you maintain constant energy levels while working out. All of this means you will need additional fluids to maintain a healthy water balance. It is therefore important to drink plenty of water before, during, and after exercise.

 

Recommendations for fluid replacement

The National Athletic Trainers’ Association recommends that you drink 17 to 20 fl oz of water 2 to 3 hours before an athletic event and 7 to 10 fl oz every 10 to 20 minutes during an event. However, due to such factors as your height and weight, fitness level, hydration status, and clothing, as well as the humidity, temperature, and the type of activity involved, you may perspire more and therefore need to hydrate more.

Following an event or competition, you should aim to restore your body to its fully hydrated state, but how do you know how much liquid to consume? It is standard procedure in some sports, particularly football, to record an athlete’s weight before and after practice because weight loss from perspiration should not exceed more than 2% of total body weight for any single training session. This means that if you are a 150-pound athlete you should not lose more than 3 lbs in 1 exercise session. As a rule, you will need to consume 16 to 20 fl oz of water per pound of body weight lost in order to rehydrate. Thus if you lose 5 lbs, you will need to drink at least 80 fl oz of water. While this may sound like a lot of liquid, keep in mind that a typical soda bottle holds 20 fl oz.

 

Sports drinks or water?
Nutrients such as sodium, calcium, and potassium—also known as electrolytes—play a key role in hydration. They transport water throughout your body and are essential for proper water retention as well as muscle contraction. As you sweat, you lose electrolytes along with water. If as an athlete, you eat proper meals before and after a sporting event, water is your best option for fluid replacement. If, on the other hand, you are in a competition environment where you may be sweating excessively and not have the opportunity to eat or hydrate right away, a sports carbohydrate beverage (such as Gatorade™ or Powerade™) may be preferable for replenishing water and lost electrolytes quickly. Be aware, however, that sports drinks should always be used in combination with water and not as a replacement for it. Drinking them in excess is known to cause an upset stomach and can raise sodium levels. It is also important to note that while water has 0 calories, sports drinks may pack over 90 calories per serving—an important consideration if you are exercising for weight loss.

 

Dehydration
It is easy to become slightly dehydrated while exercising because your body cannot replenish the amount of water lost through sweat and evaporation quickly enough. As discussed, a loss of more than 2% of your total body weight indicates that you are moderately to severely dehydrated. At the severe level, your body can no longer carry out proper cardiovascular and thermoregulatory responses. The amount of blood that your heart can pump is also significantly reduced which, in turn, means that there is less oxygen moving through your body. Moreover, with less water available for sweating, less heat is dissipated; consequently, your body temperature rises, putting you at risk for heat-related illnesses. Furthermore, dehydration impedes athletic performance. For instance, it can decrease the duration for which you can exercise by over 50%. You should therefore begin every exercise session completely hydrated. If you exercise on consecutive days or multiple times a day, you are at increased risk of dehydration.

 

How do you know you are dehydrated?
Thirst is a message from your brain that you are becoming dehydrated. Another symptom of dehydration is a pale or white tongue. If dehydration progresses, you may also experience excessive thirst, dry-mouth, fatigue, dizziness, headache, chills, cramps, nausea, and vomiting. Additionally, you should be aware that dehydration is a contributing risk factor for heat-related illnesses such as heat cramps, heat exhaustion, and heat stroke.

 

Skin turgor test
A simple test you can perform yourself to determine whether or not you are dehydrated is the skin turgor test. Just pinch the skin on the back of your hand. If your skin is well-hydrated, the pinched area will return to its normal position right away. If your skin is dehydrated, it will remain elevated, taking longer to return to normal.

 

The color of urine
Another way to gauge whether you are properly hydrated is to note the color of your urine (Fig.). Normal urine is a light yellow, similar to the color of lemonade. If your urine is darker in color, it indicates that you are dehydrated. Noting the color of your urine is also a good way to check whether you have fully rehydrated after a sporting event or competition. Overall, it should take no longer than 6 hours for you to rehydrate after an event.

 

Pay attention and carry a water bottle
By taking precautions and cultivating good hydration habits, you can easily avoid dehydration and its consequences. It is also important to know your own body. Pay attention to the signs and symptoms of dehydration and know when you may need to take a break to rehydrate. Additionally, keep in mind the amounts of water you should optimally drink before, during, and after your athletic events. Finally, try to practice good hydration habits, such as carrying a refillable water bottle with you at all times. You’ll drink more water than you think when it’s constantly at your disposal.

 

 

 

 

Author: Brittany Partlow, LAT, ATC, and Alan Ray, MS, LAT, ATC | Columbus, Georgia

Reprinted with permission from the Hughston Health Alert, Volume 28, Number 3, Summer 2016.

 

 

Platelet-Rich Plasma Therapy: A Promising Option

 

Platelet-rich plasma (PRP) therapy has been around in some form since the mid-1990s. Lately, it has received considerable attention in the news and in medical journals for its potential for treating chronic tendonitis (inflammation of the tissue connecting muscle to bone) and acute sports injuries. PRP therapy is a nonsurgical treatment for bones, cartilage, muscles, tendons, and ligaments (tissue connecting one bone to another) shown to slow, halt, or possibly even heal progressive damage. It also has the potential to reduce pain and improve joint function. PRP therapy works by making use of the natural healing properties of the platelets found in blood plasma.

 

What is PRP?

Plasma and platelets are 2 of the 4 components of blood; the other 2 include red and white blood cells (Fig.1). Plasma is the pale yellow liquid component of the blood. It consists of 95% water and makes up 55% of the total blood volume. Plasma transports blood cells along with platelets and other molecules such as hormones and antibodies throughout the body. Platelets, or thrombocytes, are colorless, microscopic disc-shaped cell fragments with no nucleus that are made in the bone marrow or spongy center of bones. While known primarily for their role in clotting blood, platelets also transport smaller proteins called growth factors that can stimulate the body’s own healing response. For example, when soft tissue is injured, the body’s first reaction is to deliver platelets to the area where they prevent bleeding, initiate tissue repair, and can attract the assistance of stem cells (cells capable of reproducing and differentiating).

To produce plasma that is rich in platelets, a sample of blood is drawn and spun in a machine (centrifuge) at an extremely high speed to separate the platelets and plasma from the blood cells. The resulting fluid has a high concentration of platelets and thus of growth factors. This PRP fluid can then be injected into an injured area to help accelerate healing.


What are the potential uses of PRP?

Treatment with PRP can help reduce pain in patients who suffer from chronic conditions such as a tendon injury, muscle strain, ligament sprain, or osteoarthritis. PRP treatment may also promote healing in surgical patients.

   Tendon injuries
For individuals with chronic tendon injuries, PRP has become an attractive option, partly because these injuries have traditionally been difficult to treat. Generally, rest, activity modification, oral or topical anti-inflammatory medications, selective cortisone injections, physical therapy, and bracing are recommended. When these treatment modalities fail to relieve the pain, surgery is usually the best option. During surgery, the damaged portion of the tendon is removed, and the tendon is then repaired by suturing the healthy ends together.

But what if we could instead stimulate the body to heal the damaged tissue?

Previous orthopaedic research has focused on the use of PRP to treat chronic tendon injuries such as lateral epicondylitis (tennis elbow), patellar tendonitis (jumper’s knee)(Fig. 2), Achilles tendonitis, and plantar fasciitis. PRP seems to be most effective in treating lateral epicondylitis, often working better than cortisone injections. Although pain relief was noted when PRP treatments were performed on the elbow, whether the tissue actually regenerated was not determined. Moreover, research has not yet confirmed whether PRP therapy is more effective than standard treatments for other types of chronic tendon injuries. There are 2 principal reasons for this uncertainty: 1) we do not know the exact concentration of platelets needed; and 2) we do not know the precise number or the proper timing of injections to treat each condition.

   Strains and sprains
PRP therapy may also be an option for treating other musculoskeletal conditions, including acute injuries such as muscle strains and ligament sprains, particularly of the knee and elbow. Recently, PRP therapy gained national attention in the sports medicine field when some professional athletes, including 2 members of the Pittsburgh Steelers and pro-golfer Tiger Woods, underwent treatments to speed up the healing process and their return to competition. While this does sound promising, only further research will confirm whether PRP therapy can truly produce these benefits.

   Osteoarthritis
Osteoarthritis, or loss of cartilage in the joints, is the most common type of joint disorder and a significant cause of pain for sufferers. Currently, there is no cure for osteoarthritis. Ultimately, when joints such as the knee or hip are severely damaged, arthroplasty (surgical joint replacement) is the only option for relieving pain and regaining mobility. Studies are currently underway to determine whether PRP injections are effective in reducing pain and even slowing down deterioration in these arthritic joints.

   Surgical supplement
Another potential use of PRP is as a supplement during certain types of surgeries—for example, rotator cuff tendon repairs and fracture repairs—to promote the healing of tendons and bones. It is also being considered for use in surgeries to help repair or reconstruct torn sections of cartilage. Further research into this treatment modality will help to determine whether PRP therapy can fulfill its promise.

 

PRP therapy: not for everyone
A patient who has tried various nonsurgical treatments, such as rest from activity, bracing, and physical therapy, but continues to experience symptoms for longer than 6 months, may be a candidate for PRP therapy. PRP therapy is not for everyone, however. First of all, because the treatment has not yet been approved by insurance companies, the patient must assume the full cost of PRP preparation and injection. Moreover, patients with cerebral palsy or Parkinson’s disease are not good candidates. The therapy is also not recommended for those patients who are undergoing treatment for cancer or for infections such as hepatitis. Additionally, PRP therapy is not suitable for patients who suffer from multiple medical conditions, bleeding disorders, or who have been prescribed a high dosage of Coumadin®, Plavix®, or other blood thinners

 

A promising option
When appropriate, PRP therapy presents an attractive option for patients and physicians alike. It may create a superior healing environment and speed healing time for certain types of surgically repaired tissues; it should thus allow individuals to return to work or sports sooner. Moreover, PRP therapy may offer pain relief or even eliminate the need for surgery in patients with a number of chronic conditions, such as tendon problems and arthritis. Furthermore, no significant side effects have been associated with PRP use; the chief complaint has been temporary pain at the injection site. PRP thus remains a promising option to treat and potentially cure a number of different types of musculoskeletal conditions.

 

Author: Kevin J. Collins, MD | Valdosta, GA

Reprinted with permission from the Hughston Health Alert, Volume 28,Number 3, Summer 2016.

 

 

May the Course Be With You

As your feet pound the pavement, you become keenly aware of the hard reality of training for a 5K, or 3.1-mile, road race. While training for a 5K is challenging, it can also be fun and beneficial. Before you begin a training program, however, you will need to plan accordingly. First, particularly if you are over the age of 40, you should schedule a physical exam with your doctor to make sure you are healthy enough to train for and participate in this type of event. Next, to be sure you get the most out of your training, you will want to put a nutrition and hydration program into place. You can then establish a realistic timeline and sound strategy for training.

 

Nutrition for optimal performance and recovery

As you train for an athletic event, it can be easy to focus too narrowly on the physical aspects of training, but it is just as important to train nutritionally. If you do not fuel or hydrate adequately, your endurance and overall performance can be compromised. A comprehensive nutrition plan for training should include carbohydrates, protein, and healthy fats. You should also drink plenty of water (Fig.).

   Fuel: Carbohydrates, proteins, and fat

Carbohydrates are a crucial dietary element as they supply the energy you need to run and work out. Ideally, calories from carbohydrates should make up at least 60% of your total calorie in-take. Some great carbohydrate choices are vegetables, fruits, whole grain breads, and pasta. Protein in appropriate portions constitutes another important component of your diet. Calories from protein should make up 20 to 25% of your total intake. Chicken, fish, eggs, beans, yogurt, low-fat cheese, and nuts are good, readily available sources of protein. Overall, eating protein along with energy-dense carbohydrates throughout endurance training has been shown to improve a runner’s performance; it has also been shown to decrease recovery time, probably because protein helps repair muscle tissue. Fats also contribute to a runner’s general good health, but because of the stigma associated with eating fat, figuring out which types are healthy to consume can be confusing. Your best bet is to choose the unsaturated, healthy fats found in avocados, almonds, cashews, and fatty fish, such as salmon or tuna, and to avoid saturated fats such as those found in lard and butter. Calories from fat should account for no more than 15 to 20% of daily calorie intake for the runner.

   Hydration

Hydration is another key element of an optimal nutrition program for training and racing. Simply put, without adequate hydration, your body cannot function properly. It is therefore important to hydrate well by drinking plenty of water—in staggered amounts so as not to feel too full—before, during, and after training and events. You may even want to carry a water bottle with you while training or, alternatively, choose running routes in places, such as a park, where you can pass by a water fountain. In the hours following a run or race, drink as much water as you can to rehydrate. When you are completely rehydrated, your urine will be a light yellow color. You can also use sports drinks to help replenish electrolytes—salts and minerals, such as sodium chloride and potassium, that control fluid balance and muscle contraction—but these should not replace water. The Summer 2016 issue (vol. 28, no. 3) of the Hughston Health Alert covers proper hydration for athletes in greater detail.

 

Training: how much, how often

Once you have adopted an appropriate nutrition and hydration program, you can establish a training timeline and strategy. If you have not participated in any type of physical activity before, a realistic timeline for training to complete a 5K race would be 7 to 8 weeks. To allow both your cardiovascular and musculoskeletal systems to adjust to the new workload, you should train in a steady progression. For the first couple of weeks, mix walking and running, beginning with 15-minute training sessions, 3 days per week with at least 1 rest day in-between. Always adjust your running pace to be within your current fitness level. As you move, you should have the breath to carry on a conversation; if not, you are trying to go too fast. In the coming weeks, as you become more comfortable with your routine, you can gradually increase the amount of running versus walking. You should also be able to increase your overall training time in 5-minute increments or your overall mileage in half-mile increments each week. However, always listen to your body, and if you become sore or fatigued, back off. As muscles actually grow stronger during rest and not during training, lack of rest can lead to fatigue and even injury. You may also want to stretch your muscles before and after running. This will help keep them flexible and may prevent injury. The Fall 2008 issue (vol. 20, no. 4) covers stretching techniques in greater detail.

 

The benefits of training

Running has been proven by research to improve your mood and reduce mental stress. As you exercise, your body releases chemicals called endorphins to the receptors in your brain, producing a sensation of overall well being. Moreover, regular running can help you lose weight because your body not only burns calories while you run, but also continues to burn extra calories afterward, a phenomenon known as excess post-exercise oxygen consumption (EPOC). Furthermore, running has been shown to strengthen your knees, keep you mentally sharp as you age, and to decrease your risk of developing diabetes mellitus, certain types of cancers, and cardiovascular disease, as well as increase the number of years you have to live.  

 

Race day

As race day approaches, remember to adhere to the principles of fueling and hydrating well, particularly the day before. Continue to hydrate the morning of the race, but eat lightly or not at all, as running forces the blood away from the stomach to the working muscles. During the race, run at a pace that feels comfortable and smooth. If you need to drink water on the course, slow up slightly to grab a cup at one of the water stations and sip. If you want to push yourself, wait until you are well past the second-mile marker and don’t sprint until you are past the third-mile marker. Once you are over the finish line, get the recovery process going by drinking plenty of water. As a rule of thumb, it will take your body a day for every mile raced—in this case, just over 3 days—to fully recover.

 

May the course stay with you

Training for a 5K race is an amazing journey that begins with planning and preparation. Success is based on a realistic timeline and sound training strategy along with a good nutrition and hydration program. Following these principles can lead you not only to the finish line, but also to improved physical and mental well being. Whether or not you plan to participate in other events, by making running part of your everyday routine, you can continue to reap the benefits.

 

Author: Kamal Leak, MS, LAT, ATC, and Morgan Carr, MS, LAT, ATC | Columbus, GA

Reprinted with permission from the Hughston Health Alert, Volume 28,Number 4, Fall 2016.

 

 

Impetigo: A Concern for Athletes

 

If you are an athlete, you have a greater risk than most people of contracting impetigo, a highly contagious skin infection that affects about 2% of the global population annually. The term impetigo comes from the Latin verb impetere, meaning to attack, and refers to the breakouts or skin eruptions that characterize the disease. Impetigo has 2 forms: nonbullous and bullous. The nonbullous form is more common, accounting for 70% of all cases, and appears on the skin as a pustule or golden crusty sore surrounded by red infection. This form is usually caused by the Streptococcus pyogenes (strep) bacterium, but can sometimes be caused by the Staphyloccocus aureus (staph) bacterium. By contrast, the bullous form of impetigo manifests as a macule or red rash that resembles a burn mark. It is caused only by staph bacteria which release epidermolytic toxins or poisonous substances that cause the lesions to form blisters (bulla is Latin for “blister”) or fluid-filled sacs called vesicles. Such vesicles tend to be thin roofed and easily ruptured, revealing a moist red infected layer beneath. After a few days, a golden crust will form over the blisters. Impetigo lesions can erupt anywhere on your body, but the most common sites are the nose and mouth, followed by the arms or legs. While the lesions of either type of impetigo can be itchy, they are not usually painful. The bacteria are transmitted through skin to skin contact or through direct contact with contaminated objects. It usually takes 1 to 3 days after contact with strep, and 4 to 10 days after contact with staph, for the symptoms of impetigo to appear.

 

Who is at risk?
You are more likely to contract impetigo if you live in hot, humid climates. Additionally, poor hygiene and poor nutrition, as well as having diabetes or a compromised immune system, can make you susceptible to the infection. The condition occurs most frequently in pre-school and school-age children; in fact, 90% of all impetigo cases occur in children under the age of 2. Impetigo is the most common bacterial skin infection in children and is therefore sometimes referred to as “school sores.” Impetigo also occurs more frequently in athletes who play sports involving a high degree of physical contact than in the general population. For example, if you are a wrestler, boxer, swimmer, gymnast, or football player, your risk of contracting impetigo is high, due to direct skin contact with other players, gym mats, and the showers in the locker rooms. You can also transmit or contract the disease if you share personal items with people such as clothing, towels, and bedding. If you or a fellow athlete has a skin irritation from eczema, poison ivy, insect bites, cuts, or scrapes, it could easily become infected and develop into impetigo. For instance, one day you might notice that you have insect bites on your lower legs. You continue playing sports and doing your normal activities while waiting for these to clear up, but a couple of days later you find that the bites have now developed into crusty pustules. To avoid spreading the infection to your fellow athletes, you should abstain from playing and see your doctor.

 

How is impetigo diagnosed?
Your doctor can usually diagnose impetigo by taking a personal history and examining the appearance of your skin. However, as the skin patches associated with impetigo can resemble those seen in a host of other skin diseases such as eczema, psoriasis, poison ivy, lupus, or shingles, there is a chance that the condition could be misdiagnosed. To determine the particular type of bacteria causing your infection, and prescribe the best antibiotic, your doctor may take a culture using a swab.

 

How is impetigo treated?
While impetigo may clear up on its own within 2 to 3 weeks, primary treatment consists of topical antibiotic ointments; more severe cases will also require oral antibiotics. Since impetigo is highly contagious, you should avoid close contact with anyone until 24 hours after starting the medication. After this, you may return to your normal activities, but be aware that your impetigo sores will take at least a week to heal completely. As an athlete, you should not be allowed to participate in sporting events until you have completed a 72-hour course of antibiotic treatment, have no moist or crusty wounds, and have had no new lesions for at least 48 hours. Lesions should not be covered as a way to allow you to participate.

 

What are the possible complications?
Left untreated, impetigo can develop into a more serious form of the disease called ecthyma. This condition occurs when the disease invades the second layer of skin, causing painful fluid or pus-filled sores that turn into deep ulcers and may leave scars. If you develop ecthyma, you may also have swollen lymph nodes. Other complications of impetigo can include cellulitis, another serious infection that affects the underlying skin. Even more rarely, you could suffer kidney damage from the bacteria that cause impetigo.

 

How can you prevent impetigo?
To prevent impetigo, avoid contact with infected individuals. If you touch an open wound, wash your hands immediately with soap and warm water. You should also make sure to wash any surfaces, objects, clothing, towels, or bedding that may have come in contact with the infection with soap and hot water. If you have an open wound or a fresh abrasion, avoid scratching as this could allow the bacteria from the impetigo to enter and cause an infection; better yet, cover all open wounds and insect bites. If you do contract impetigo, avoid spreading the infection to other people and to other parts of your body by not scratching and applying antibiotic ointment and proper dressings to affected areas.

 

Know the facts, then act
Impetigo is a highly contagious bacterial infection of the skin that can sometimes have serious complications. It is spread through direct skin contact, which means everyone is at risk, but athletes, particularly wrestlers, are at increased risk for contracting the disease. If you even suspect that you have impetigo, avoid contact with others until you know for sure you are not infected or you have been on medication for at least 72 hours. Knowing the facts and taking measures to prevent contracting or spreading impetigo will benefit not only you, but also your fellow athletes.

 

 

Author: Heather Martin, MS, LAT, ATC and Ashley Wojnowski, LAT, ATC | Columbus, GA

Reprinted with permission from the Hughston Health Alert, Volume 28,Number 4, Fall 2016.

Getting the Facts on Fragility Fractures

If you are over the age of 50, especially if you are also female, you may be at risk for a fragility fracture. The American Academy of Orthopaedic Surgeons defines fragility fractures as fractures that result from a fall from a standing height or that occur in the absence of obvious trauma (Fig. 1). These types of fractures affect up to 50% of all women and 25 to 33% of all men over 50 and are often associated with low bone-mineral density. The hip, spine, and wrist are the most common sites where you could sustain a fragility fracture.

What causes fragility fractures?
Low-energy fragility fractures usually occur as a result of not just general low bone density, but the presence of osteoporosis. Osteoporosis is a bone disease characterized by the structural deterioration of both the inner and outer bone tissue, resulting in porous bones (Fig. 2). These changes lead to overall low bone mass, compromised bone strength, and an increased risk for fractures. If you do have osteoporosis, you are not alone: the National Osteoporosis Foundation estimates that 10 million people in the United States suffer from osteoporosis while another 34 million are at an increased risk of bone fracture due to osteopenia or low bone mass. One of the most serious injuries you can suffer as a result of osteoporosis is a hip fracture; 50% of those who suffer a hip fracture will lose the ability to live independently.

 

Additional risk factors
Once you have suffered a fragility fracture, you have a greater risk of sustaining another. Apart from age, gender, and a previous fracture, risk factors include a family history of fragility fractures, frailty, poor health, dementia, Caucasian or Asian race, calcium and vitamin D deficiencies, smoking, and excessive alcohol consumption. Moreover, certain diseases, such as rheumatoid arthritis, diabetes mellitus, and renal disease, as well as any kind of prolonged immobilization, can increase your risk of generalized osteoporosis and fractures. Furthermore, taking certain types of drugs, such as glucocorticoids, immunosuppressants, anticonvulsants, and testosterone antagonists, constitutes a risk factor for the disease. It is best to try to identify all of your risk factors before a fracture occurs.

 

Evaluation
Since an orthopaedic surgeon is the first, and often the only, physician you may see if you break a bone, it is important that he or she have you evaluated for osteoporosis. Your evaluation should include a medical history, physical examination, laboratory tests, bone mineral density tests, and possibly x-rays. Although your orthopaedic surgeon will typically initiate this evaluation while overseeing the care of your fracture, you may be referred to your primary care physician or a bone health clinic to treat the underlying causes of the disorder to prevent future fractures.

 

Treatment
As a fragility fracture patient, optimal care will involve not only treating your injury, but also identifying and treating the underlying cause. If it is determined that you have osteoporosis, your treatment will begin with counseling about diet, exercise, and fall prevention. You may be encouraged to perform regular weight-bearing exercises, such as walking, and to get sufficient amounts of calcium (1,200 mg/day) and vitamin D (800 IU/day) through your diet, dietary supplements, and exposure to sunlight. Your treatment plan may also include pharmacologic agents to prevent bone loss, such as bisphosphonates, or various hormone therapies such as selective estrogen receptor modulators, parathyroid hormone, and calcitonin.

 

Fracture care
When it comes to fragility fractures, both nonsurgical and surgical management have proven highly successful, depending on the particular fracture. As with other types of fractures, the basic principle for the management of fragility fractures is to first reduce the fracture (manipulate the broken bone back into its proper position); next hold the fracture in this position (non-surgically with a splint or cast, or surgically with plates, screws, or rods); and, finally, to rehabilitate the patient through exercise and physical therapy. Sometimes, in order to provide extra support for weak bone, special techniques can be applied surgically to create a more robust fixation construct. An example of this is the use of special locking screws. Additionally, after surgery you may be instructed to avoid weight bearing on the affected extremity for an extended period of time in order to help it heal.

 

Outcomes
You can both reduce your risk level and enhance outcomes for fragility fractures if you and your physician assume an active role in managing your osteoporosis and preventing additional fractures. While it is best to start a preventative program early (around age 30), it’s never too late to take care of your bones and improve your odds.

Author: Aaron D. Schrayer, MD | Lewisville, TX

Reprinted with permission from the Hughston Health Alert, Volume 28,Number 4, Fall 2016.

What’s New in Knee Replacement Surgery?

 

As an orthopaedic surgeon who performs joint arthroplasty (replacement surgery), I am often asked about what’s new in regards to the surgery. Total knee replacement has been performed for many decades, and in short, over the years, many things have changed for the better.

 

Robotic technology

The first big change is the use of technology in the operating room. Robotic assisted joint replacement surgery was FDA approved in 2009. I was the first in the state of Tennessee to adopt this technology in surgery in 2011. Initially, it was only available for partial knee replacements and in 2014 I began using it for total hip replacements. In 2017, it was available for total knee replacement.

Robotic assisted surgery begins with a three-dimensional computer model of the actual knee of the patient. Using this model, I can precisely place the knee replacement components on the patient’s knee using their own anatomy. This allows for a more accurate placement of the implant which is matched to the patient’s anatomy. The end result is a more natural feeling knee while removing the lease amount of bone possible. During the procedure, I obtain real time information regarding the alignment of the limb and balance of the joint. A well-aligned joint will last longer than a knee replacement a few degrees out of alignment. I no longer need to place cutting blocks in a knee to perform the procedure, so there is less surgical dissection and exposure. This leads to a quicker recovery. The end result is a better positioned, well-aligned knee, less time in the operating room, and a faster rate of healing for the patient.

 

Anesthesia protocols

Great advances have been made in anesthesia techniques and postoperative pain control. Previously, joint replacements were performed under general anesthesia; however today, we use regional anesthesia techniques. Using nerve blocks and spinal anesthetics, we now perform joint replacement without general anesthesia. When using regional anesthesia techniques, patients begin to walk as early as 1 to 2 hours after surgery. This leads to less risk of blood clots and better postoperative pain control. Additionally, I use long acting numbing agents and oral medications to prevent postoperative pain. This has lead to higher patient satisfaction with the surgery as well as a quicker return to daily activities.

 

Rehab protocols

Finally, rehabilitation after knee replacement has had significant changes over the last several years. Previously, patients would begin their rehabilitation after the surgical procedure and often need to stay in rehabilitation facilities following surgery. Now we begin rehabilitation as soon as the decision for surgery is made. Physical therapy begins prior to surgery now and continues with immediate mobilization after surgery. Often, when patients receive preoperative therapy they are more physically ready for the surgery, which results in shorter hospital stays and faster return to activities.

With all the great strides made in surgical care, this is an exciting time for the patient and their orthopaedic surgeon. We are providing better outcomes with less pain and recovery time for our patients. However, each patient is unique, and their recovery is specially tailored to them. If you would like to discuss your knee and the pain you have been experiencing, I would be happy to talk with you.

 

Author: Jonathan P. Cornelius, MD | Hughston Clinic Orthopaedics, Lebanon, Tennessee

ACL Tears in Teens

With more and more young athletes participating in sports each year, injuries to the anterior cruciate ligament (ACL) of the knee have become quite common. Youngsters, particularly during the period of rapid growth—generally around age 12 for girls and 14 for boys—are at increased risk for ACL tears. For various reasons, adolescent girls may be 3 to 8 times more likely than their male counterparts to tear their ACL. Fortunately, new injury prevention programs have emerged that can help at risk athletes, particularly adolescent females, to avoid ACL tears.

 

 

Knee anatomy and the ACL
The knee is a complex joint made up of 3 bones: the femur (thighbone) and the tibia (shinbone) meet to form a hinge that allows for flexion (bending) and extension (straightening) with a minor degree of rotation while the patella (kneecap) covers its front and helps extension. These bones are held together by 4 ligaments: the 2 collateral ligaments and the 2 cruciate ligaments (Fig.1). The collateral ligaments run along either side of the knee, limiting side-to-side motion and providing stability. The outside ligament is known as the lateral collateral ligament and the inside as the medial collateral ligament. Inside the knee joint are the 2 cruciate ligaments, so called because they criss-cross, forming an X. The posterior cruciate ligament or PCL is in the back while the often-injured anterior cruciate ligament or ACL is in the front. The ACL slides within the intercondylar notch, or the space between the 2 rounded ends of the femur. Its primary function is to prevent the tibia from either moving too far forward or from rotating too far inward underneath the femur.

 

Risk factors for ACL tears in teens
While participation in demanding sports such as football, basketball, and soccer has been linked to a greater likelihood of ACL tears (Fig. 2), further investigation into risk factors has divided ACL tears into nonmodifiable and modifiable categories.1 Nonmodifiable risk factors include issues with knee structure, hip-knee alignment, hormone function, neuromuscular maturation, and reduced muscular strength. Modifiable risk factors include various neuromuscular imbalances and deficiencies. Both types of risk factors are more closely associated with being female.

 

Nonmodifiable
A narrow intercondylar notch of the femur or notch stenosis (narrowing) as well as variations in tibial plateau (the upper surface of the tibia within the knee joint) anatomy, such as an increased slope, can lead to pinching of the ACL by the femur and possible rupture. Also, by adolescence, females have a wider pelvis than males and thus a greater Q-angle or angle of hip-knee alignment, concentrating more force on the ACL and increasing the likelihood of a tear. Moreover, during their developmental phase, females exhibit less neuromuscular maturation along with greater inner knee rotation and valgus (knock-knee). They also have a greater ground reaction force—the force exerted on the body when landing a jump. Furthermore, young female athletes have less strength in proportion to bone size in the muscles that stabilize the knee than male athletes, yet experience the same twisting and loading forces on this joint. Lastly, hormone fluctuations may cause the collateral ligaments to become looser at certain points during the menstrual cycle and so unable to absorb the stresses placed on them, putting the ACL at risk of injury.

 

Modifiable
Modifiable risk factors for ACL tears include neuromuscular imbalances and deficiencies. Traditionally, boys have participated in sports, such as soccer, that involve twisting movements at an earlier age than girls. By adolescence, they may have developed the muscle coordination and reflexes needed to protect the knee while girls may have neuromuscular imbalances and deficiencies—such as knee ligament, muscle, or overall leg dominance, as well as various muscular weaknesses—that can make them more prone to ACL injuries.

 

Dominance
Ligament dominance is a condition that results in decreased medial-lateral (side-to-side) neuromuscular control of the knee joint. This neuromuscular deficiency can lead to valgus collapse, or medial displacement, of the knee and possibly to an ACL tear. Quadriceps dominance—a condition where the quadriceps muscles in the front of the thigh overpower the hamstrings in the back of the thigh—can cause excessive anterior translation, or forward slippage, of the tibia and strain the ACL.1 Leg dominance, which predisposes the nondominant leg towards valgus collapse, can also be a factor in sustaining ACL injuries.

 

Muscular weakness
Weaknesses in the gluteal (buttocks), hamstring (back of the thigh), and gastroc soleus (back of the calf) muscles can lead to a valgus collapse and consequent ACL strain, especially during a jump landing.2 Moreover, weak core (abdominal and mid and lower back) muscles mean an unstable pelvis, resulting in too much lateral trunk motion and pronation (inward rolling of the feet), and thus increased risk of an ACL injury.

 

Prevention programs
Prevention programs have been created to train athletes to resist injury. Prevention programs for ACL tears focus on neuromuscular imbalances and deficiencies. While each program has its own specific regimen that combines plyometrics (jump training that makes the leg muscles exert maximal force in a brief amount of time in order to increase speed and power) with conditioning and strengthening exercises,1 all of them concentrate on developing more appropriate landing techniques along with better balance and stability in the lower extremity. For teens, the most effective regimens are those that implement neuromuscular training and emphasize plyometrics and strengthening both preseason and in season.

While not all studies have shown a reduction in ACL injury for their particular study group,3 the bulk of evidence indicates that these programs can work.1, 4 One study reviewing several prevention programs saw a 52% risk reduction for ACL tears in females, and for males the rate was even higher at 85%.4 Two programs that have been shown to significantly reduce ACL injuries in females are Sportsmetrics and Prevent Injury and Enhance Performance (PEP).5, 6 With all prevention programs, it should be noted that success depends largely on the athlete’s degree of compliance.1 As prevention is still the most efficient and cost-effective method to avoid ACL injuries, screening for at-risk athletes has been considered.

 

ACL surgery
Over the past 30 years, ACL reconstructive surgery to stabilize the knee and lessen further damage has advanced considerably. While such progress has led to improved outcomes that potentially allow the athlete to return to play, it has also heightened expectations. Affected athletes must realize that they may still have limitations after ACL reconstruction. In their study, Ardern et al. showed that among athletes with ACL injuries, 82% returned to sport, but only 63% to their pre-injury sport, and just 44% at a competitive level. Furthermore, the knee with the ACL tear has been shown to be more likely than the uninjured knee to develop arthritis.7

 

The best cure
An ACL tear can be a significant life-altering injury for a young athlete, and teens, particularly girls who participate in sports, are at increased risk. While more research is needed, appropriate ACL injury prevention programs have been shown to reduce the overall number of ACL tears. As with all types of injuries, prevention is the best cure. Such programs should therefore be seriously considered before a young athlete suffers an ACL tear.

 

Author: David A. Lalli, DO | Niceville, Florida

Reprinted with permission from the Hughston Health Alert, Volume 28,Number 4, Fall 2016.

 

References:
1. Hewett TE, Torg JS, Boden BP. Video analysis of trunk and knee motion during non-contact anterior cruciate ligament injury in female athletes: lateral trunk and knee abduction motion are combined components of the injury mechanism. British Journal of Sports Medicine. 2009;43(6):417-22.
2. Hewett TE, Lindenfeld TN, Riccobene JV, Joyes FR. The effect of
neuromuscular training on the incidence of knee injury in female athletes:
A prospective study. American Journal Sports Medicine. 1999;27(6):699-706.
3. Sadoghi P, von Keudell A, Vavken P. Effectiveness of anterior cruciate ligament injury prevention training programs. Journal Bone and Joint Surgery, American. 2012;94(9):769-76.
4. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and
meta-analysis of the state of play. British Journal Sports Medicine. 2011;45(7):596-606.
5. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: a 2-year follow-up. American Journal of Sports Medicine 2005;33(7):1003-10.
6. Pfeiffer RP, Shea KG, Roberts D, et al. Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate
ligament injury. Journal of Bone and Joint Surgery, American. 2006;88(8):1769-74.
7. Mather RC 3rd, Koenig L, Kocher MS, Dall TM, et al. Societal and economic impact of anterior cruciate ligament tears. Journal of Bone and Joint Surgery, American. 2013;95(19)1751-9.

Don’t “Just Do It” – Do It Right

 

In 1988, an upstart advertising firm in Portland, Oregon was approached by Buck Knight to help with his company’s print and television campaign. Interestingly, while developing the campaign,  Dan Weiden found inspiration in the last words spoken by Gary Gilmore—a convicted murder who was executed by firing squad in 1977. Just before his life ended, Gilmore shouted “Let’s do it.”  Born out of Gilmore’s final words, Weiden’s famous slogan “Just Do It” is considered one of the top 5 slogans of the 20th century. Weiden described his slogan as “a tough, take no prisoners, intensely personal” ad campaign targeted at all Americans, regardless of their level of physical fitness. After the “Just Do It” campaign, Nike’s athletic shoes market-share went from 18% to 43% in the United States. In recognition of the impact of Dan Weiden, Nike and its slogan are enshrined in the Americana exhibit at the Smithsonian National Museum.

 

Caring for orthopaedic patients and their injuries is not easy work. The doctor must quickly assimilate the information given by you, and put together a comprehensive plan for recovery. Teamwork is the key to successful outcomes in orthopaedic care. The team will always include at least two participants, known as the doctor-patient relationship team. The doctor uses his or her years of training and experience to create the game plan and you, the patient, uses your understanding, efforts, and biofeedback to execute that plan. Not only is it time to “Just Do It,” it’s time to “Do It Right.” Your health and recovery take focused and consistent effort. Although other team members, such as physical therapists may get involved in the patient-care episode, there is only one person ultimately responsible—YOU.

 

All too often, I see a patient and prescribe a comprehensive treatment plan, only to find out that this plan wasn’t properly executed, or wasn’t attempted at all. The patient returns with continued complaints, and seeks more options. Effort, energy, and ownership of your health and well-being are your option.  Don’t “Just Do It,”—Do It Right. You might not be enshrined in the Smithsonian, but your reward will be equally gratifying.

 

Author: Marc A. Tressler, DO | Hughston Clinic Orthopaedics, Hendersonville, TN