Staph Infections of the Skin


The bacterium Staphylococcus aureus—staph for short—is so named because when viewed through a microscope, it is berry-shaped and exists in grapelike clusters that have a golden yellow pigment. The root staphyl(e), originally from ancient Greek, refers to a bunch of grapes; coccus, from Latin, refers to something spherical, like a berry; and aureus, also Latin, means golden. Staph is a gram-positive bacterium, meaning that it stains purple when tested because it has a single outer membrane rather than many, making it more permeable to antibiotics (Fig.). Staph infections are therefore often successfully treated with antibiotics; however, some strains are resistant to antibiotics and, consequently, more difficult to treat. Staph is also highly contagious and can be spread through hand-to-hand contact, airborne transmission, or contact with an object. Although most staph infections occur on the skin, they can also occur in the nasal and sinus passages, mouth, anus, and genital areas. If you have a fresh wound that comes in contact with an infected person or object, a staph infection can easily erupt and will often present itself as a boil or abscess (Box 1).

 

Are you at risk for a staph infection?

If you suffer from influenza, diabetes mellitus, and pulmonary (lung) disorders, or your immune system is compromised in any way, you are more likely to contract staph infections of the skin. Additionally, if you become a hospital patient or are an athlete, you may be more frequently exposed to staph inside a healthcare or athletic facility.

Hospitals
Staph infections are commonly found in hospitals and healthcare clinics

where they can constitute a major problem. For example, if proper sterilization techniques are not used, staph can easily spread throughout a hospital or healthcare facility. Additionally, humans tend to harbor staph bacteria in the mucous membranes of the nose and sinuses. As a way to prevent infection, some hospitals and healthcare clinics take nose swabs before surgery. If the swab comes back positive for staph, you will be treated with antibiotics before your doctor proceeds with surgery. Other hospitals have patients cleanse their entire skin surface with a chlorhexidine wipe and put Betadine gel in their nose the morning of surgery.

Athletic facilities
Likewise, athletic facilities, such as health clubs and gyms, including weight rooms, wrestling rooms, and locker rooms, are all places where staph bacteria can grow and you can easily pick up an infection. Staph bacteria can be hard to destroy and can live on unclean equipment and facility surfaces long enough to be transferred to anyone who touches them. If you have an open wound on your body, this makes it easy to contract a staph infection. Likewise, if you have a cut that is not covered or treated properly and it becomes infected, the bacteria could easily spread to other people or to objects. As an athlete, frequent close contact with other athletes and poor locker room hygiene, such as the use of unwashed towels and uniforms, can make you susceptible to contracting staph infections (Box 2).

 

Recognizing staph infections of the skin
In the initial stages, a staph infection often manifests as a small lesion that may look much like a pimple or mosquito bite. As the lesion enlarges, it becomes painful and inflamed. It may also contain pus. If the infection continues to spread, you may experience a mild fever. Skin infections caused by staph include boils, impetigo, and cellulitis.

 

A common type of staph infection
A common and well-known form of staph is methicillin-resistant Staphylococcus aureus (MRSA). This is a specific strain of the bacterium that is resistant to many of the antibiotics used to treat staph infections. Once a staph infection is classified as MRSA, it is considered much more dangerous because without effective antibiotic treatment it can quickly worsen. The Centers for Disease Control states that approximately 100,000 people contract and receive treatment for MRSA each year.

 

Treating staph infections
If you are worried that you may have contracted a staph infection of the skin, it is important to see your doctor promptly. The sooner the wound can be tested for bacteria the better. If not treated properly, a staph infection can spread quickly within the body and be transmitted to others.

The first route of treatment of the infection is usually antibiotics. You should receive a course of antibiotics as well as instructions on how to cover the wound with antibiotic ointment and a bandage. Your staph infection may return if it is not fully treated the first time or if it becomes antibiotic resistant. If the staph infection does return, your doctor may prescribe a second course of antibiotics. If the infection still does not clear up, you may need to be hospitalized for treatment with a more aggressive antibiotic regimen. At worst, you may need surgery to remove the infected tissue completely.

 

Keeping staph in check
Staph is a highly contagious infection that is spread primarily through hand-to-hand contact or through the air and can occur when you have a fresh wound that comes in contact with an infected object. If you start experiencing redness, swelling, and heat around a wound, you should see a physician right away and be tested for staph and put on a course of antibiotics, if appropriate. You should also receive instructions on how to keep a wound clean and covered. If you are an athlete, it is especially important to practice good hygiene and to keep all sporting equipment, clothing, and workout areas clean. To avoid a potentially dangerous situation and to shield those around you, it is crucial to act upon what may be a staph infection at the first signs of symptoms.

 

Authors: Marissa Turturro, ATC, and Amanda Guethlein, ATC | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 28, Number 2, Spring 2016.

 

Rotator Cuff Tears

The rotator cuff is a group of muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) and tendons (tissue connecting muscle to bone) that surrounds the shoulder joint (Fig). This group of muscles provides stabilization while also allowing movement, which is why the shoulder is one of the most flexible joints in the body. Interestingly enough, many patients with rotator cuff tears have no symptoms at all, while others complain of pain and weakness in the shoulder. A rotator cuff tear can range from small to large in size, it can be a partial tear in 1 of the muscles, or it can be a partial or complete tear of a tendon. Almost 1 out of 3 people over the age of 60, and 2 out of 3 people over the age of 70 have full thickness rotator cuff tears. Depending on the severity of the tear, there are various treatment options, which include nonoperative management and shoulder arthroscopic surgery.

 

 

What causes a tear?
The rotator cuff can become injured in a number of ways. Most commonly, the tear is due to chronic muscle and tendon degeneration that comes with aging. Additionally, they often occur in conjunction with a shoulder dislocation in patients over 40 years old. You can injure your rotator cuff by falling on an outstretched arm or develop an injury over time doing repetitive activities at work or while playing a sport. Another possible mechanism is from impingement (weakening and tearing at the tendons) of the rotator cuff on the acromion (the bone right above the shoulder joint). The acromion process can develop bone spurs that can rub on the rotator cuff tendons, causing impingement.

 

Risk factors
There are several risk factors associated with rotator cuff tears, but advanced age is one of the most significant. Others include having a rotator cuff tear on the other shoulder, smoking, family history, poor posture, high cholesterol, history of trauma, and occupations demanding heavy labor and repetitive movement.

 

Seeking medical advice
When to seek medical advice can be a difficult question to answer since patients have a wide range of how much pain and dysfunction they can stand before it triggers a visit to the doctor’s office. Where some patients develop a small discomfort in their shoulder and immediately see their doctor, others wait until their pain is unbearable and they have lost most of the function in their shoulder. Certainly, any amount of pain and discomfort, weakness, and loss of shoulder function should warrant a visit to a sports medicine or shoulder-trained orthopaedic physician.

 

Screening and diagnosis
Your physician will examine the shoulder, moving it through various positions and maneuvers in an attempt to localize the problem. Radiographs or x-rays, will also be obtained to evaluate for any bony involvement. Depending on the length of time the problem has been going on, or if there has been a recent traumatic injury, the physician may decide to order magnetic resonance imaging (MRI, a scan that shows the bones, muscles, tendons, and ligaments) of the shoulder. Additionally, your physician may also decide to perform an injection into the subacromial space (the space between the rotator cuff muscles and the acromion) (Fig). This is not only a treatment option, but it can also provide the physician with valuable information regarding your diagnosis by whether you experience pain relief or not.

 

Treatment
Most rotator cuff tears can be initially managed with nonoperative treatment. These include physical therapy, anti-inflammatory medications, and subacromial corticosteroid injections. It is important to consider patient expectations and symptom severity when deciding on nonoperative treatment as this is different for every patient.

If the injury is severe or an acute tear following some sort of traumatic episode, such as a fall or shoulder dislocation, or if nonoperative management is not working, the physician may recommend surgery. Surgery is performed arthroscopically (using a small camera to look inside the shoulder joint). This is typically done using 3 or 4 small incisions around the shoulder. The surgeon will examine the shoulder anatomy and clean up any loose and frayed tissue, remove any bone spurs, and then repair the tear depending on the appearance of the rotator cuff and the size of the tear.

The surgery usually takes an hour to an hour and a half depending on what needs to be done. After surgery, your shoulder will be placed in an abduction shoulder brace (a sling that holds the arm out to the side) and you will be given specific instructions that help the healing process and encourage a positive outcome.

 

Postoperative rehabilitation
Postoperative protocols for rehabilitation vary by physician; however, most exercise treatments follow the same general principles. Initially the shoulder is kept immobilized. Then a period of passive range of motion exercises follows, which mean that your arm is moved without you exerting any effort. Then active range of motion begins, which will progress to a resistance-training program.

 

Outcomes and complications
A rotator cuff repair can offer predictable success with a long track record of pain relief and patient satisfaction. Medical literature shows excellent outcomes in patients with partial and full thickness tears.

Failure to heal is the most common cause of a failed rotator cuff repair. Patients at risk for failure include those who are 65 years of age and older, smokers, diabetics,
and those who have large size tears, muscle atrophy (shrinking), and those who do not follow the surgeon’s postoperative rehabilitation plan. More rare complications include injury to nerves in the shoulder, infection, and stiffness. Often, postoperative stiffness can be managed with physical therapy.

 

Don’t shoulder the pain alone
Rotator cuff tears are common in the aging population and can debilitate patients with extreme pain and functional limitations. For most circumstances, conservative treatment should be attempted first as many patients will respond positively. Surgical treatment has shown to have excellent results and should be weighed between the patient’s pain and function, as well as avoiding progression of the tear. If you have shoulder pain, see an orthopaedist who specializes in the shoulder. A speciality-trained shoulder physician will quickly and accurately diagnose your problems and get you on the road to recovery.

 

Author: Roman I. Ashmyan, DO | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 31, Number 1, Winter 2019.

 

Complex Regional Pain Syndrome

In the 16th century, King Charles IX experienced endless pain and contractures after he underwent a surgical procedure. Ambroise Pare (known as the father of modern surgery) recorded the King’s treatment, which is thought to be the earliest documented description of complex regional pain syndrome (CRPS).1 Formerly known as reflex sympathetic dystrophy (disorder of the sympathetic nervous system) and causalgia (affecting a peripheral nerve), it was not until 1994 that the International Association for the Study of Pain renamed these pain syndromes as CRPS Type 1 and CRPS Type 2, respectively.2

 

Who does it affect?
CRPS is a rare and debilitating disease that affects less than 2% of individuals in the United States. Race is not a factor, but females are affected more than males, and the peak age of patients is 40 to 49 years. Additionally, the upper extremities are affected more often than the lower extremities.2

 

What are the symptoms?
CRPS patients experience chronic pain with sensory and motor symptoms in their limbs. With CRPS, there is usually a damaging or inciting event that causes injury, such as trauma, surgery, or a period of immobilization. The difference between the 2 types is that Type 1 does not have a distinctive injury to a nerve, whereas patients with CRPS Type 2 have a known nerve injury. To help diagnose CRPS, the Budapest criteria (Table) were established in 2003. In patients who have continuing pain that is disproportionate to any inciting event, they must report 1 symptom in 3 of the 4 following categories: sensory, motor/trophic, vasomotor, sudomotor/edema.1 The patient must also display at least 1 sign at the time of evaluation in 2 or more of the categories. Lastly, there cannot be another condition that would account for the degree of pain and dysfunction that the patient is experiencing.

There are 3 stages of CRPS: acute, subacute, and chronic.2 The acute stage lasts 3 months. During this stage patients usually have a burning type pain, swelling, skin redness, increased sweating, and decreased range of motion. After 3 months, the patient enters the subacute stage. During this stage patients have continued severe pain, swelling, skin dryness, and paleness or bluish coloration of the skin. After 12 months, the patient progresses to the chronic stage that can last for multiple years or even become permanent. In the chronic stage, the patient’s pain is variable and can continue to be severe or it may subside. The patient’s skin is dry, shiny, and cool to the touch. Also, since the patient has not been using their extremity, the underlying bones can develop osteoporosis (a disease that weakens bones).3

 

How is CRPS diagnosed?
There are no specific laboratory studies that make the diagnosis of CRPS; however, it is imperative to obtain laboratory studies so that other disease or disorders can be excluded as the cause of the patient’s symptoms.2 Imaging studies that are useful include radiographs (x-rays) and bone scans (an imaging test that helps diagnose bone disease). Since CRPS Type 2 involves a known nerve injury, a nerve conduction study can provide useful information as well.4

 

How is CRPS treated?
The best treatment for CRPS is to use a multidisciplinary team approach to alleviate the patient’s pain and help the patient regain function of the extremity.1 For example, a pain specialist helps control the patient’s pain using medications and injections. A surgeon is needed for procedures that help control pain and regain extremity function. A primary care physician can help with the patient’s pain control as well as helping with other symptoms, such as swelling, inflammation, and depression. Physical therapists and occupational therapists are critical in improving the functional outcome of the affected extremity with range of motion exercises and other modalities.5

 

Getting help
CRPS results in debilitating pain and significant loss of function in the extremities. In order to improve patient outcomes, CRPS should be recognized early on and treatment initiated as soon as possible. Pain specialists, surgeons, physical therapists, and other healthcare providers each play a role in helping the patient get back to a normal routine. If you are experiencing chronic pain, talk to your doctor, getting help is the first step toward a pain-free life.

 

Author: Mudassar A. Khan, DO | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 31, Number 1, Winter 2019.

 

References
1. Sebastin SJ. Complex regional pain syndrome. Indian Journal of Plastic Surgery. 2011;44( 2):298-307.
2. Goh EL, Chidambaram S, Ma D. Complex regional pain syndrome: A recent update. Burns & Trauma. 2017;5(1):ecollection. doi:10.1186/s41038-016-0066-4.
3. Baron R, Binder A. Complex Regional Pain Syndromes. Baron R, Binder A, Pappagallo M, editors. In: The Neurological Basis of Pain. New York, NY: McGraw-Hill; 2005:359-378.
4. Harden RN, Oaklander AL, Burton AW, et al. Complex regional pain syndrome: Practical diagnostic and treatment guidelines, 4th ed. Pain Medicine. 2013;14(2):180-229.
5. Stengel M, Binder A, Baron R. Updates on the diagnosis and management of complex regional pain syndrome. Advance Pain Management. 2007;1(3):96-104.

 

 

Ice Skating Injuries

Recreational ice skating and related sports, such as hockey, are popular winter activities. Regular participation in ice skating has shown to help individuals maintain balance as they age, but the activity is not without risk. About 1 in every 700 ice skaters will experience an injury,(1) and the average age of those injured is 33 years old.(2) Most incidents occur during falls on the ice, with inexperience and the slippery surface adding to the risks. Before you head to the rink, you should be aware of common injuries, how they occur, and understand what treatments are available.

 

Concussion
Head trauma only accounts for about 0.5% of ice skating injuries,(1) but the rate increases significantly with participation in ice hockey. Concussion is a traumatic injury to the brain that can occur after a blow to the head, face, or neck (Fig. 1). When you experience a concussion, your motor skills, coordination, balance, and cognitive abilities may be impaired. Concussions range in severity; which means it can be so slight you may not know that you have a concussion or it can be so severe you are rendered unconscious. In addition to the severity, more than 1 concussion can cause serious effects. If you have sustained multiple concussions, you have an increased risk of another and the cumulative effect can be permanently damaging or deadly. After a blow to the head, you should seek immediate medical attention if there has been a loss of consciousness, continued confusion, worsening symptoms, weakness, numbness, slurred speech, vomiting, seizure, or blood or clear fluid coming from the nose or ears.

Symptoms from concussion can last from a few days to several months, and include: headache, dizziness, nausea, trouble paying attention, memory problems, irritability and depression. If you have sustained a concussion, you should stop sports participation immediately and avoid further at-risk activities until all symptoms have resolved. While recovering from a concussion, stimulation should be minimal, which means reducing screen time, avoiding loud music and noise, and limiting cognitive tasks.

 

Distal radius fracture
Almost all fractures sustained in ice skating occur in the upper extremity, with fractures of the distal radius (wrist) being the most common of these.(1,2) Wrist fractures often occur during a fall on an outstretched hand, resulting in immediate pain and deformity at the injury site (Fig. 2). Once you present to an emergency department, doctors will often reduce (align the fracture) and place a splint to hold the bones in place.

Further treatment will be determined with your orthopaedist and depends on many factors such as: if the break includes the wrist joint, how many fracture lines you have, or if a splint can hold the bone fragments in the correct position. Closed reduction and percutaneous pinning or CRPP, (a procedure to align the bone using metal pins through the skin to hold the fracture while the bone heals), or open reduction with internal fixation (ORIF, a procedure to hold the fracture with metal plates and screws under the skin) are 2 treatment options that offer good results. Particularly in women, a distal radius fracture can be a sign of decreased bone mineral density;(3) therefore, you should ask your doctor if further testing, such as a DEXA (dual energy x-ray absorptiometry, a type of bone scan) scan is needed.

 

Radial head and neck fractures
Another injury that can occur from a fall on an outstretched hand—radial head and neck fractures—occur about 10% less often than distal radius fractures.(2) The radial head is the portion of the radius that helps form the elbow joint, with the radial neck located just below it. Unlike distal radius fractures, these injuries rarely result in a noticeable deformity, with patients mainly complaining of severe elbow pain, swelling, and reduced elbow motion (Fig. 3).

The majority of these fractures can be treated without surgery, with an emphasis on regaining elbow motion early to avoid permanent stiffness. You may need surgery if the fracture involves multiple fragments or if the fragments have moved. Surgical treatments often involve holding the bone in position with metal plates and screws while the fracture heals, or replacement of the radial head with a metal prosthesis for more severe injuries.

 

Ice hockey
Ice hockey is a much more physical and high-risk activity than recreational ice skating. Hockey resulted in the highest injury rate at the 2010 Olympics, with up to 35% of participants experiencing some amount of missed playing time.(4) Since there is an increased risk of contact, common injuries in ice hockey involve the shoulder, hip, thigh, and knee rather than the elbow and wrist. Many of these injuries can be treated nonsurgically, with immobilization, rest, compression, and therapy. If the injury is severe or recurrent, surgery is sometimes needed.

Your best chance at avoiding an injury is to wear properly-fitted equipment, such as helmets, shoulder pads, hip pads and hockey pants, and skates. You should also properly maintain the equipment and replace it as it becomes worn or damaged. Furthermore, emphasis on playing “heads up” hockey with attention paid to surroundings and avoiding hard contact with another player can help reduce injury rates in this sport.

 

Protect yourself
Ice skating is a popular activity that has numerous health benefits, but the sport is not without risks. Understanding common injuries and taking proper precautions to avoid them can help you enjoy these activities without incident. You can reduce the risk or avoid trauma all together by wearing snug-fitting skates with a straight back over the blade, and by using commercial wrist protectors. You can purchase affordable protective gear at most sporting goods stores.

 

Author: Timothy R. Beals, DO | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 31, Number 1, Winter 2019.

 

References:
1. Kelsall NKR, Bowyer GW. Injuries sustained at a temporary ice-skating rink: Prospective study of the Winchester experience 2007–2008. Injury. 2009;40(12):1276-1278.
2. Barr L V., Imam S, Crawford JR, Owen PJ. Skating on thin ice: a study of the injuries sustained at a temporary ice skating rink. International Orthopaedics. 2010;34(5):743-746.
3. Rozental T, Deschamps L, Taylor A, Al E. Premenopausal women with a distal radial fracture have deteriorated trabecular bone density and morphology compared with controls without a fracture. Journal of Bone and Joint Surgery, American. 2013;95(7):633-642.
4. Laprade RF, Surowiec RK, Sochanska AN, et al. Epidemiology, identification, treatment and return to play of musculoskeletal-based ice hockey injuries. British Journal of Sports Medicine. 2014;48(1):4-10.

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Anterior Cruciate Ligament Reconstruction

The anterior cruciate ligament (ACL) tear is a common injury to the knee with approximately 400,000 reconstructions performed annually. Most people who experience the injury report feeling a pop after making a sudden move to change directions or pivoting during sports play. Soon after the sprain (tear) occurs you experience pain and swelling around the knee.

 

Knee anatomy

With its multiple structures and capsular attachments, the knee joint tends to be on of the most mobile joint in the body allowing for rotation, flexion (bending), and extension (straightening) during movement. The largest joint in the body, the knee is made up of the lower end of the femur (thighbone) and the upper end of the tibia, or shinbone (Fig. 1). The patella (kneecap) slides in a groove at the end of the femur. Furthermore, the knee is a diarthrodial joint, which is characterized by the presence of a layer of cartilage that lines the ends of the bony surfaces of the femur and tibia. Cartilage inside the joint helps to cushion and absorb shock providing stability to the knee, and tendons connect the muscles to the bones. Ligaments of the knee are tough, flexible, fibrous connective tissues at the end of the femur, tibia, and fibula that connect the bones, which also help stabilize and support the knee.

 

Knee ligaments

Four main ligaments help stabilize the knee; the medial (inner side) and lateral (outer side) collateral ligaments resist side-to-side motion, and the anterior (front) and posterior (back) cruciate ligaments resist forward and backward motion, respectively (Fig. 1). These 2 ligaments form a cross shape with their orientation in the center portion of the knee, which is why they are termed “cruciate” ligaments. The ACL provides most of the support that prevents the tibia from slipping forward against the femur. The ligaments work together with the medial and lateral menisci (crescent-shaped cartilage) and the leg muscles to stabilize the joint and allow the knee to generate and deliver the large quantities of power required for activities.

 

Ligament tear

During an injury to the knee, 1 or multiple ligaments may be disrupted or torn; however a tear of the ACL is one of the most common ligament injuries (Fig. 2). Partial tears are rare, so when an ACL injury does occur it is usually a complete tear. The patient often describes a feeling of a “pop” and there is usually immediate swelling of the knee. This is commonly associated with a noncontact pivoting injury during a sporting event. Once an injury has occurred, it is essential to get a thorough examination, most preferably at the time of injury or soon thereafter to determine which structures have been damaged.

With today’s technology, nearly all patients with suspected knee ligament injuries undergo magnetic resonance imaging (MRI, a scan that shows the bones, muscles, tendons, and ligaments) to fully evaluate all the soft tissue structures as well as bony anatomy to determine the extent of the injury. Once the physician has determined what structures are injured, treatment options to restore normal function can be discussed with the patient.

 

Nonsurgical treatment

Nonsurgical treatment can be an option for low-demand patients with decreased flexibility and those who have no feeling of instability about the knee. This treatment plan involves physical therapy, bracing, and lifestyle modifications. On the other hand, for young, active patients, or patients who continue to have episodes of instability where they complain that their knee “buckles” or “gives way” or they “do not trust their knee”, surgery is the best solution.

 

Weighing the pros and cons of surgery

Deciding to have surgery can be a difficult decision, especially since patients must not only weigh the risks, they must also consider the time it takes for recovery. As with any surgery, ACL reconstruction has risks and possible complications and the outcome is not guaranteed to be 100% successful. For patients who live an active lifestyle, ACL reconstruction is a good option, especially if they want an early return to sport. Additionally, the surgery helps prevent future damage to the knee cartilage and provides the best option to regain a normal functioning knee.

 

ACL reconstruction surgery

There have been many techniques to “repair” the ligament back to bone with sutures; unfortunately, repair of the anterior cruciate has had a high failure rate. There have also been attempts at making a synthetic ligament out of Gore-Tex, carbon fiber, and modified silk scaffolds. None of these techniques have performed well over time; therefore, the gold-standard for the treatment of an ACL tear in skeletally-mature (the bones are no longer growing) patients remains reconstruction. Especially in young active patients with persistent instability, it is recommended that they undergo reconstruction of the ACL.

Reconstruction involves using a tendon graft, which is a piece of healthy tendon that is transplanted surgically to replace the torn ACL. The tendon graft can come from the patient (autograft) or from an organ donor (allograft). Autografts are primarily used in younger more active patients, while allografts are reserved for older patients. The graft can come from many different tendon donor sites to include the hamstring tendons, the quadriceps tendon, or the patellar tendon; however, the decision is often determined by the surgeon’s preference and experience. Most ACL reconstructions are performed arthroscopically (a tiny camera and instruments inserted into the joint through small portals). The new ACL graft is secured into tunnels or sockets placed into the anatomic position on the tibia and the femur using a variety of techniques and devices, such as metal screws, bio-absorbable screws, suspensory fixation devices, and others with the goal to recreate a new ACL and restore stability to the knee.

 

After surgery

Postoperatively, patients are allowed to weight bear as tolerated on the reconstructed knee with the aid of a hinged type knee brace that provides stability while enabling early range of motion. Early physical therapy focuses on exercises that do not place excess stress on the graft. The goals during the first 4 to 6 weeks are to minimize pain and swelling, restore patellar mobility, restore quadriceps activation, and to normalize motion and gait pattern. During the 6 to 12 week postoperative phase, the emphasis is focused on developing strength, stability, and endurance with expected full clearance for return to sport at 6 months or beyond.

 

A good option for active people

ACL reconstruction using a tendon graft is a reliable and proven way to restore stability to the knee and return patients to their pre-injury activity level. If you have torn your ACL and are facing the decision on whether or not to undergone reconstruction, you should discuss your options with an orthopaedic surgeon who is experienced in the surgery. Depending on your activity goals, ACL reconstruction may be the best decision for your active lifestyle.

 

Author: Garland K. (Jake) Gudger, Jr., MD | Columbus, Georgia

 

Reprinted with permission from the Hughston Health Alert, Volume 31, Number 1, Winter 2019.

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.