Terrell Suggs of the Baltimore Ravens reportedly ruptured his Achilles tenon on Saturday.  Will he return this season?

Anatomy

The Achilles tendon is the longest tendon in the human body.  It is made up of two muscles: the gastrocnemius muscle and the soleus muscle.  The muscular unit of the tendon attaches from the back of the knee to the heel bone.  About 2/3 of the way down the leg, the muscle bellys transition to the Achilles tendon.  The Achilles tendon is prone to injury in the area known as the watershed area.  This area goes from 2-6 centimeters up from the attachment site of the Achilles tendon to the heel bone. In the watershed area, the blood supply to the tendon is poor.  This is an area where the tendon has a poor ability to heal itself.  Most Achilles tendon tears occur in this area. 

The Achilles tendon functions to bring the ankle downward, similar to the motion of press on the gas pedal.  With jumping activities, the Achilles tendon sees forces 8 times that of one's body weight.  With sprinting activities, that force increases to 12 times that of one's body weight.

CAUSES

Achilles tendon tears or ruptures are commonly seen in weekend warriors and those who participate in sports with a lot of push-off actions.  Some patients who have been on an antibiotic from the fluoroquinolone family may be at risk of tearing the Achilles tendon.

SYMPTOMS

Patients will report a sudden pop in the back of the ankle and a rush of blood. Some will say they feel like someone has kicked them in the back of the ankle.  They will notice a loss of strength in the foot when trying to stand on the ball of the feet.  Pain, swelling, and bruising are common.  When carefully touching the Achilles tendon in the watershed area, a gap may be felt in the tendon. Achilles tendon tears can not be seen on xray.  Very rarely is an MRI or ultrasound needed to make the diagnosis.  The diagnosis is usually made with physical exam findings alone.

WHEN TO SEEK MEDICAL CARE

If you are concerned about an Achilles tendon tear, you should see a medical professional within hours or days of the injury.

TREATMENT

Treatment options range from non-surgical options to surgical options using a variety of techniques.

Non-surgical options are reserved for those patients who are against surgery, are elderly, are medically too sick to withstand surgery, or are not active. The treatment involves a short leg, non-weightbearing cast for 8 to 10 weeks, followed by extensive physical therapy.

Surgical options are recommended in the athletes and active population.  There are three techniques that are used:

1. The traditional open technique where an 8 to 10 centimeter incision is made on the back of the ankle.  The tear is cleaned out and the tendon ends are sutured together.  The number one complication of this approach is  wound healing issues. You can see a video of this technique at: http://www.youtube.com/watch?v=uzzV5BRWlIc

2. A percutaneous technique where needles are placed through the skin and Achilles tendon.  The tendon ends are never seen, so it is difficult to be sure that they are toughing when the tendon ends are sutured together.

3. A mini-open technique using a 2 to 3 centimeter incision on the back of the Achilles. In this technique, the tendon ends are seen and cleaned.  A small device is used to place the sutures in the tendon.  The tendon ends are then brought together. You can see a video of this technique at: http://www.youtube.com/watch?v=QgSeD8lyQaM

OUTCOMES

Nonsurgical patients have an 18-20% chance of re-tearing the Achilles and lose some push-off power.  This is a concern for elite athletes.  Surgically treated patients have approximately a 2% chance of re-tearing the tendon and have a more normal push off in the injured ankle.  

RETURN TO ACTIVITIES

We conducted a study on NFL players who had an Achilles tendon tear.  In general, only about 66% of players were able to return to the NFL and took about 11 months to do so.  Furthermore, when they returned to the NFL, their performance was severely affected. To read this paper, see:  http://www.lowerextremityreview.com/index.php/article/return-to-football-after-achilles-tendon-rupture

It is unlikely for Suggs to make it back this coming season. 

VIDEO/ANIMATIONS

To watch a live surgical video of an open Achilles repair, go to:

http://www.youtube.com/watch?v=24jAAZ2s-04&feature=plcp

To watch a live surgical video of a mini open repair, go to:

http://www.youtube.com/watch?v=rD3aI_7EneA&feature=plcp

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Guard, Derrick Rose of the Chicago Bulls injured his right knee.  He was diagnosed with an ACL tear.  

Will he be able to return next year?

ANATOMY

The knee is a complex joint, with four main ligaments that stabilize the joint: the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the lateral collateral ligament (LCL) tear, and the medial collateral ligament (MCL).  Together, these four ligaments help to stabilize the knee in all planes of motion. 

The ACL stabilizes the knee and prevents it from "giving out," particularly when twisting or bending on the knee.  

CAUSES

An ACL tear is usually seen in the athlete during sporting activities, but it can happen with other mechanisms, such as motor vehicle accidents and falls. Usually these injuries are "non-contact" injuries, occurring when the athlete lands on the knee after jumping.  The pivoting or twisting of the knee stresses the ACL and causes it to tear.  

Female athletes are at a higher risk of developing an ACL tear.  It is not enirely clear why this is the case.  However there are thoughts that the anatomical differences in a woman, hormones, or even biomachanical differences in a female versus a male may account for this higher risk.  

WHEN TO SEEK MEDICAL CARE

If you believe you have an ACL tear, you should seek medical attention immediately.

SIGNS

When one tears the ACL, there is usually a pop that is heard with sudden pain in the knee. There may be swelling of the knee (effusion), black and blue discoloration, knee stiffness, or the feeling of instability.  The individual may have difficulty walking on the knee.  An MRI can diagnose the ACL tear and any other injuries of the knee.

TREATMENT 

Not all individuals with ACL tears require surgery.  If there are symptoms of instability of the knee or if one is a high level athlete, then the surgery would be preferred.  If you do not fall into any of these categories, then a knee brace, followed by extensive physical therapy can be used to treat these injuries.

Surgical reconstruction of the ACL can be performed in a variety of different ways.  The ACL can be reconstructed with the patients own tisssues (autograft) or tissues from a person who has died (allograft).  Autograft reconsturction may require harvesting the "new" tendon from either the patellar tendon or the semitendinosus tendon (one of the hamstring tendons).  Different techniques can also be used to reconstruct the tendon, such as single bundle or double bundle techniques.  These discussions are beyond the scope of this blog.

Rehabilitation is critical to the success of surgical or non-surgical treatments for ACL tears.  

OUTCOMES

In 2005, we presented data on NFL athletes with ACL injuries.  Of the 31 running backs and wide receivers with 33 anterior cruciate ligament injuries, more than one fifth of players never returned to a National Football League game. Returning players first competed in a game 55.8 ± 5.4 weeks (mean ± standard error) after injury. For the 24 anterior cruciate ligament–injured players with a minimum total power rating (sum of all 7 seasons) of 200 points, power rating per game played decreased from 9.9 ± 1.1 preinjury to 6.5 ± 0.9 postinjury. This decline in power rating per game played was statistically significant (P = .002) when compared with the change for the 146 control players.  http://ajs.sagepub.com/content/34/12/1911.abstract

RETURN TO ACTIVITIES

If we use the above study as a guideline for the return to professional sports, it is likely that Rose will be back on the court somewhere between six and nine months.  He will need a lot of work and rehabilitation in order to return to his pre-injury level.

VIDEO/ANIMATIONS 

Good luck Rose.

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

The Orlando Magic received devastating news today: center Dwight Howard will be undergoing back surgery for a herniated disc.  When will he be back?

ANATOMY

The spine is made up of vertebral bodies that make the vertebral column.  In the neck (cervical) region, there are 7 bones, in the back (thorax) region, there are 12 bones, and in the lower back (lumbar) region there are 5 bones.  

Each bone interacts in a complex manner with the bone above and beneath it. Furthermore, the spinal canal is home to the spinal cord.  Throughout the length of the spinal cord, nerves (known as nerve roots) come off the cord to provide function to that level of the body. 

In addition, between the bones are cushioned disks, known as vertebral discs, which act as shock absorbers along the length of the vertebral column. The intervertebral disc acts as a shock absorber for the spine.  It is made of two parts: a soft inner core and a tougher fibrous outer wall.  Finally a series of ligaments and muscles attach to the bones to provide stability and flexibility to the spine.

CAUSES

Herniated discs can occur for a number of reasons.  Most disc herniations occurring in the lower back occur with the normal aging process.  People who perform a lot of bending and twisting activities are at particular risk.  However, traumatic herniations are also possible. 

In a disc herniation, small tears develop in the tough outer wall of the disc.  Damaged pieces of the soft inner core bulge through the tear and out of the disc wall.  This part of the disc bulges into the spinal canal.  It can then push on the nerves.

SYMPTOMS

In the lower back, depending on the location of the herniation, the pressure on the nerve can cause pain, numbness, tingling, and loss of strength into one or both legs and feet, or even the buttocks region.  Some time bowel and bladder incontinence can develop, in a condition called cauda equina syndrome.

WHEN TO SEEK MEDICAL CARE

If you have pain shooting in to the legs or feet with associated weakness that does not improve, you should seek the care of a health care provider.  If you develop symptoms of cauda equina syndrome, you should seek help emergently.

A thorough physical exam, xrays, and often an MRI is needed to evaluate the spine.

TREATMENT

Most disc herniations are minor and can often be treated without surgery.  Anti-inflammatories, steroids, physical therapy, back supports, and epidurals can help relieve symptoms.

Surgery is considered for larger herniations, for patients whose pain does not improve or worsens.  In surgery, the herniated part of the disc is removed to decompress the nerve (discectomy).  If this is done through a small incision, it is known as a microdiscectomy.  Sometimes, a part of the vertebral bone, known as the lamina, may need to be removed as well. 

OUTCOMES

Most individuals are able to return to activities with associated pain relief.  This can take up to two years to occur.  Furthermore, at times, the disc can herniate again.

RETURN TO ACTIVITIES

With a microdiscectomy, Howard can take up to 4 to 6 months to return to sporting activities.  

VIDEO/ANIMATIONS 

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Linsanity will be pausing briefly.  Jeremy Lin, point guard for the New York Knicks, was diagnosed with a meniscal tear in his left knee.  He will undergo surgery later this week.  What is being done?

ANATOMY

The knee consists of 3 bones: the knee cap (patella), the thigh bone (femur), and the leg bone (tibia).  These three bones interact to give range of motion to the knee.  Inside the knee joint, the bones are covered with a substance known as cartilage.  The cartilage allows the bones to glide together, painlessly.  This substance is critical to the function of any joint in the human body.  Between the bones are cartilage discs, known as menisci.  These discs cushion the knee.

The meniscus can tear anywhere along its course.  These tears come in a variety of forms and can lead to pain, catching, popping, or clicking of the knee.

CAUSES

Meniscal tears can occur with trauma, twisting injuries, and arthritis.  Tears that are towards the central portion of the knee can be cleaned up, whereas those that are towards the periphery may be repaired.

SYMPTOMS

Not all meniscal tears cause symptoms.  However, symptoms can include pain, swelling, clicking, popping, or even catching.

TREATMENTS

Meniscal tears are treated with shaving procedure to “clean-up” the tear.  

Occasionally, if the tear is located towards the periphery of the meniscus, a repair can be attempted.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have symptoms concerning for a cartilage injury of the meniscus, you should seek medical attention.  A good physical exam, x-rays, and an MRI may be needed to evaluate the injury.

RETURN TO ACTIVITIES/OUTCOMES

Most athletes with meniscal tears that are treated with a shaving procedure are out of competitive play for 3-4 weeks. Those with meniscal tears that need to be repaired are out from competitive plays for at least 3 to 4 months. Extensive rehabilitation is needed to optimize the range of motion and strength of the knee.

VIDEO/ANIMATION

For a video animation of "Anatomy of the Knee", please see the “Education” tab of my website.  Click orthopaedics, then knee, then conditions, then "Anatomy of the Knee".

For a video animation of "Meniscus Tears", please see the “Education” tab of my website.  Click orthopaedics, then knee, then conditions, then "Meniscus Tears".

For a video animation of "Partial Meniscectomy", please see the “Education” tab of my website.  Click orthopaedics, then knee, then procedures, then “Partial Meniscectomy".

For a video animation of "Meniscal Repair", please see the “Education” tab of my website.  Click orthopaedics, then knee, then procedures, then “Meniscal Repair ".

Lin will be out for 4-6 weeks. If the Knicks make it to the payoffs, he may be ready for play in mid to late May.

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Joba Chamberlain, pitcher for the New York Yankees, suffered from a serious open ankle dislocation on Thursday and underwent surgery for the injury.  After recovering from Tommy John last June, this will be another big setback for this young pitcher.    

ANATOMY

The ankle is made up of three bones: the fibula (on the outer part of the ankle), the tibia (on the inner part of the ankle), and the talus (on the central part of the ankle).  Between the tibia and fibula, at the level of the ankle joint, is a ligament which holds these one together, called the syndesmosis.  

In an ankle dislocation, the talus comes out of the “socket”.  When coming out of the joint, the skin may or may not rip open.  If the skin opens, this is known as an open dislocation.  If the skin does not rip open, then it is known as a closed dislocation. 

When the ankle dislocates, any of the bony structures can fracture/break or the tendons around the ankle tear.  Finally, the ankle joint or the subtalar joint (the joint beneath the ankle that allows the foot to move in and out) can be damaged.

CAUSES

An ankle dislocation can occur whenever the ankle is twisted to its maximum point.  Rarely, can this happen with bad ankle sprains.  More often, the athlete turns or twists the ankle with a fall, motor vehicle accident, or jumping activity.

SYMPTOMS

Individuals who dislocate the ankle will have pain, swelling, loss of motion, and bruising.  A lump or bump will be seen around the ankle.  If the skin breaks open, the ankle bone may be seen.   

WHEN TO SEEK MEDICAL CARE

If you suspect that you are suffering from a dislocated ankle, you should seek medical attention immediately.  A physical exam and x-rays are usually performed. A CT or MRI scan at times may be needed.  The ankle will need to be placed back into the alignment. 

TREATMENT

Ankle dislocations that are closed can often times be put back in place, or reduced, without surgery.  If there is no associated break of a bone or tendon injury, the leg is kept in a cast for a few weeks to allow the soft tissue to scar in and stabilize.  Then a lot of physical therapy is needed to work on the range of motion and strength.

If an ankle fracture is open, the athlete must go to the operating room so that the wound can be washed out.  The joint is put back in place and any broken bones, if present are fixed.  Depending on how large the skin laceration is, infection is a serious and real risk.  Again, the leg is kept in a cast for a few weeks to allow the soft tissue to scar in and stabilize.  Any bones that may be broken will take 6-8 weeks to heal before the athlete can walk on the leg.  Once the cast is off, a lot of physical therapy is needed to work on the range of motion and strength.

OUTCOMES

Ankle dislocations can be career ending for an athlete, especially if there are associated injuries.  Pain, loss of motion, and loss of strength can be long term issues that do not allow the athlete to return to competitive sports.   

RETURN TO ACTIVITIES

From the current reports, it is unclear if Chamberlain has any associated injuries.  This is a serious injury.  If Chamberlain is able to return to the pitching mound, it will be late in the season this year. 

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.d

UNC celebrates making it to the Sweet 16, but sophomore point guard, Kendall Marshall suffered a scaphoid fracture in his wrist.  Will he be back for the rest of the tournament?

ANATOMY

The hand and wrist are made up of 27 bones.  At the base of the hand, in the wrist, there are 8 bones.  The scaphoid bone is a wrist bone that sits at the base of the thumb.  

The scaphoid can be most easily recognized when one makes a “hitchhiker’s” sign.  At the base of the thumb, a hollow is created.  At the base of the hollow lives the scaphoid bone.

CAUSES

A fracture of the scaphoid is usually caused by a fall on an outstretched hand, with the weight focusing through the palm.  This type of injury is seen in young adults, but can really happen in any group. 

There are different types of scaphoid fractures.  Those closer to the thumb do better, as the blood supply to this part of the bone is good.  Those that are more central, or in the “waist” of the bone, or closer to the forearm may have more of a difficult time healing.  This part of the bone has a poor blood supply and the bone may not heal. 

SYMPTOMS

Individuals who break the scaphoid will have pain, swelling, loss of motion, and bruising.  Their can be pain in the “hollow” or “snuffbox”, difficulty with creating the “hitchhiker” posture,  or pain with grip.

WHEN TO SEEK MEDICAL CARE

If you suspect that you are suffering from a broken scaphoid, you should seek medical attention within a day or two of the injury.  A physical exam and x-rays are usually performed. A CT or MRI scan at times may be needed.

TREATMENT

Scaphoid fractures that are closer to the thumb may be successfully treated with a short arm cast that captures and immobilizes the thumb.  The cast is usually worn for 6 to 8 weeks.

Scaphoid fractures that are at the waist of the bone or closer to the forearm can be problematic. Although a thumb immobilized cast can lead to healing, at times, this may not be enough.  Since the blood supply to this part of the bone is poor, the bone may not heal.  For this reason, often times, a surgical procedure is recommended. 

Surgery is considered in scaphoid fractures that occur at the waist of the bone, closer to the forearm, or those fractures that have not healed.  In any of these surgical situations, a screw is placed in the bone to hold the pieces of the bone together and optimize the contact between the pieces.  A cast is still required and can be worm for 3 months or more.

OUTCOMES

Scaphoid fractures can be career ending for an athlete.  These injuries can affect grip strength and motion.  Occupational therapy is critical to regain motion and strength. 

RETURN TO ACTIVITIES

From the current reports, it is unclear if Marshall will need surgery.  It is unlikely for him to return for the rest of the tournament.

VIDEO/ANIMATIONS

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Patriot's tight end, Rob Gronkowski, suffered from a high ankle sprain.  How effective will he be in the Super Bowl?  

Ankle sprains are very common injuries.  In the US alone, approximately 25,000 ankle sprains occur every day.  Not all of these individuals seek medical care.  Most walk it off and resume life with little or no consequences.  The question is when should you be concerned that you have a serious ankle sprain or something worse and see a doctor.   I will get to this question later in the blog.

ANATOMY

Most people sprain their ankle with an inversion type injury.  This is where the foot rolls in and the ankle rolls out.  This stretches and may tear the ligaments on the outer part of the ankle.  Outer ligaments of the ankle are always injured in the common ankle sprain.

However, in severe cases, the ligaments on the inner part of the ankle (medial ankle sprain) or between the ankle bones (high ankle sprain) can be injured.  The medial sprain will be a topic for future blogs.

A high ankle sprain occurs when the ankle rolls out to the point where the ligaments between the fibula (outer leg bone) and the tibia (inner leg bone) tear.  This ligament structure is known as the syndesmosis.   This can be a stable or unstable injury.  If the ligament is stretched or strained, the ankle is usually stable and does not require surgery.  If the ligament is fully torn, the ankle is unstable.  This injury pattern requires surgery.

Below is an xray of an individual with an unstable syndesmosis tear.

SYMPTOMS

When an individual has a high ankle sprain, walking and jumping on the injured ankle is difficult.  One may experience pain, swelling, bruising, weakness and even a black and blue mark.  Usually people have some level of pain with motion of the ankle.  Rest, ice, elevation, an ace wrap and antiinflammatories can help relieve some of these symptoms.  But if you suspect a high ankle sprain, you should see a physician sooner than later.

TREATMENTS

Initially, after a high ankle sprain, rest, ice, elevation, an ace wrap and antiinflammatories can help relieve some of these symptoms.  If xrays suggest a stable high ankle sprain, the patient is placed in a boot or short leg cast.  The individual is nonweightbearing (not allowed to placed any weight on the injured ankle) for 4 to 6 weeks.

If the syndesmosis is torn, surgery is needed.  In the operation, the tibia and fibula are put back in their proper position and held in place with screws or a device called a tightrope (see xrays).  These patients are not allowed to put weight on the ankle for 3 months.  

In either injury pattern, physical therapy is necessary to help regain range of motion and strength of the ankle.  Physical therapy has been shown in the medical literature to be very beneficial in preventing what is known as “chronic ankle pain”.  Some physicians may want you to use an ankle brace for a short period of time, while others may not want you to use one at all.  Rarely is surgery needed.

OUTCOMES

Most individuals with high ankle sprains are able to return to their lifestyles and activities after 6 to 8 weeks and a lot of therapy.  Being the Super Bowl, Gronkowski will play.  The question is how effective will be.  Just as Ben Roethlisberger's level of play decreased with this injury, it is likely that Gronkowski's will suffer as well.  Cutting, pushing off defenders, and blocking will all be problematic for him.  

VIDEO/ANIMATIONS

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.

In the first quarter of today's game, Dallas Cowboys Quarterback, Tony Romo was knocked out of the game with a right hand injury.  He is on the sideline with a tight wrap.  Pictures show a highly swollen hand.  Will he play next week?

ANATOMY

The hand is made up of 27 bones.  In each finger there are 3 phalanges, whereas the thumb has 2.  In the palm of the hand, corresponding to each finger is a metacarpal.  In the wrist there are an additional 8 bones.  These bones work in concert to allow motion and stability to the hand. 

Michael Vick reportedly is suffering from a “hand” fracture.  It is unclear which exact bone is injured, however the fact that a CT scan is being ordered suggests that the base of one of the metacarpals, or perhaps one of the wrist bones was fractured. 

CAUSES

A fracture of the hand is usually caused by a trauma.  This can be in the form of sporting activities where something or someone crushes the hand or drops or twists on the hand. A punch, a fall on an outstretched hand, or even a gunshot can lead to a fracture of the hand. 

SYMPTOMS

Individuals who break their hand will have pain, swelling, loss of motion, and bruising. Depending on the location and position of the break, the finger may turn one way or the other when the fingers are flexed.  This is one of the reasons for surgery. 

WHEN TO SEEK MEDICAL CARE

If you suspect that you are suffering from a broken hand, you should seek medical attention within a week of the injury, A physical exam and x-rays are usually performed. A CT scan at times may be needed.

TREATMENT

Many hand fractures can be treated without surgery.  If one metacarpal is fractured, oftentimes a removable brace or splint can be worn for about 4 weeks.  If two or more metacarpals are fractured, but are located in the correct position, a short arm cast can be worn for 4 to 8 weeks. 

Surgery is considered if multiple metacarpals are broken, if the break is in the base of the metacarpal where it interacts with the wrist bones, if there is shortening of the metacarpal bone, or if one of the wrist bones is fractured.  Surgery can be as simple as the placement of 1 or 2 wires into the bone, holding it where it belongs, to placing plates and screws on the bone.  In any of these surgical situations, pressure is usually not allowed through the hand for 4 to 8 weeks.

OUTCOMES

Most athletes with a hand fracture have no long lasting issues.

RETURN TO ACTIVITIES

From the current reports, it is unclear of the nature of Romo's injury.  Given that this is his dominant, throwing hand, if a metacarpal is fractured it could be a big deal. A CT scan may be needed to evaluate the injury further.  If broken, he could be out next week.

VIDEO/ANIMATIONS

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

New Jersey Nets Center, Brook Lopez has a Jones fracture.  When will he return to this already shortened season?

ANATOMY

The metatarsal are a series of bones in the foot that lead to the toes.  There are five metatarsal in each foot, correlating to the five toes.  The fifth metatarsal interacts with the fifth or pinky toe.  This bone is particularly important, as breaks at the base of this bone can be difficult to heal. 

To understand breaks of the fifth metatarsal, one needs to know the type of break present.  The breaks at the base of the fifth metatarsal are divided into three types:

Type 1 – an avulsion break off the base of the fifth metatarsal. This break usually heals with little problem. 

Type 2 (also known as a Jones Fracture) – a break of the base of the 5^th metatarsal that goes into the area where the 4^th and 5^th metatarsal interact with one another.  This fracture is difficult to treat, as the blood supply to this area of the 5^th metatarsal is poor. 

Type 3 (also known as a Dancer’s fracture) – a break of the long shaft of the 5^th metatarsal.

CAUSES

Fractures of the base of the 5^th metatarsal occur when the ankle is twisted in inversion, or the ankle rolls outward.  Extra pressure is placed on the base of the 5^th metatarsal, causing it to break.

SYMPTOMS

A person who breaks their 5^th metatarsal may have pain at the base of the bone, with swelling pain, and possible difficulty with walking.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have a 5^th metatarsal fracture, you should see an orthopaedic surgeon.  They will require a thorough physical exam and x-rays will be needed to determine where the break is located.

TREATMENT

Treatment varies depending on the location of the 5^th metatarsal fracture and the type of break present.

Type 1 – an avulsion break off the base of the fifth metatarsal. This break usually heals with little problem. It usually requires a boot and walking cast for 4 weeks.

Type 2 (also known as a Jones Fracture) – a break of the base of the 5^th metatarsal that goes into the area where the 4^th and 5^th metatarsal interact with one another.  This fracture is difficult to treat, as the blood supply to this area of the 5^th metatarsal is poor.  The break can be treated with a cast or surgery. For those patients who decide to have a cast, they may be non-weight bearing on the injured leg for 12 or more weeks.  There is approximately a 20% non healing rate of this fracture, when treated without surgery.  With surgery, the patient is usually allowed to wear protective boots or insoles and walk 4 weeks following surgery.  In surgery, a screw or plate with screws can be used to span the break and hold the pieces together.

Type 3 (also known as a Dancer’s fracture) – a break of the long shaft of the 5^th metatarsal, This break can be treated in a non-weight bearing cast for approximately 6-8 weeks.  It requires surgery if it has moved out of place, or is not positioned correctly.

OUTCOMES

Most patients with 5^th metatarsal fractures are able to return to play.  For type 1 and 3 breaks, return to competitive sports may take 3-4 months.  For type 2 breaks, return to competitive play occurs 6-8 weeks after the surgery.

RETURN TO ACTIVITIES

Depending on the type of fracture Lopez has sustained, he should be back to football in 6-8 weeks.

VIDEO/ANIMATIONS

A live surgical video can be seen at: http://www.youtube.com/NCOCatDuke

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Cowboys DeMarco Murray was hurt in tonights game against the Giants.  He has an ankle fracture and a high ankle sprain.  He was immediately taken out of the game.  What does this mean for his season?   

ANATOMY

The ankle is made up of three bones: the fibula (on the outer part of the ankle), the tibia (on the inner part of the ankle), and the talus (on the central part of the ankle).  Between the tibia and fibula, at the level of the ankle joint, is a ligament which holds these one together, called the syndesmosis.  

Any of these structures can be injured in an ankle fracture/break.  Typically, the fibula is fractured.  At the same time, the tibia can be broken and/or the syndesmosis can be torn. 

CAUSES

The ankle can break with any type of trauma that causes excessive energy to go through the ankle.  The energy can break 1, 2, or more bones.  Typically, the ankle breaks with a twisting mechanism, when the ankle "rolls", or if one trips and falls.  Occasionally, a direct blow to the ankle or the heel can break the ankle.

SYMPTOMS

A person who breaks their ankle usually experiences immediate pain and swelling.  A pop or crack may be heard or felt.  The ankle will get black and blue.  Often times, the person will not be able to walk on the broken ankle.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have an ankle fracture, you should seek medical attention within hours of the injury. A thorough physical exam and xrays will be needed to find out if you have an ankle fracture and the type of fracture you may have.

TREATMENT

Treatment varies depending on the severity of the ankle fracture.  If the fibula has broken, but has not shifted, a non-weight bearing cast may be worn for 8-10 weeks.  If the fibula is fractured and shifted out of place or the tibia is fractured or the syndesmosis is torn, then surgery may be necessary.  In the operating room, an orthopaedic surgeon will usually place a plate and screws in the fibula, screws or a plate in the medial malleolus part of the tibia, and/or screws or a similar device across the syndesmosis.  This allows for the broken bones and ligament to be held in place while the bones and/or ligament heals.  If the syndesmosis is torn, the patient is not allowed to put weight on the foot and ankle for 3 months.  If the syndesmosis is not torn, then the patient is not allowed to put weight on the foot and ankle for approximately 6-10 weeks.  

Below are representations of a type of ankle fracture where the fibula and the syndesmosis were torn and needed to be repaired.

OUTCOMES

Most patients with ankle fractures are able to return to their pre-injury activities with little or no difficulties.  However, there are some long-term implications of this injury.  First, about 30% of the time a "pot-hole" can develop in the ankle at the time of the injury.  This can lead to long-term pain.  Second, the cartilage is damaged at the time of injury.  This causes the development of post-traumatic arthritis in the ankle at a faster rate than an ankle that has never been broken.  Third, many patients will have stiffness and loss of motion following the injury.  Finally, extensive physical therapy is required to regain as much motion and strength in the ankle.

RETURN TO ACTIVITIES

Depending on the type of ankle fracture that Murray has, he will be out of football for at least 8 weeks.  If his syndesmosis is also torn, he will be out for 12 weeks.

VIDEO/ANIMATIONS

Dr. P

 ----------------------------------------------------------------------------------------------All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics