Trigger finger – aka Stenosis tenosynovitis

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I often have patients who come into the clinic with complaints of a finger that gets stuck in the flexed position and when they try to straighten it, they have pain and the finger “pops” back into a straightened position instead of moving smoothly like usual.  Trigger finger is a form of tenosynovitis which is inflammation of a tendon and it’s protective layers.

Tenosynovitis :  A condition when the tendon  (strong band of tissue that connect the muscle of your hand to your finger bones) and the covering around it get inflamed.  It is most common in the hand and wrist but can occur in the ankle as well.

Causes:

1)     Repeated use of the hand or wrist – same movement over and over again

2)     Infections – bacteria can spread to the tissues usually underneath the skin where the infection started.

Symptoms:  Pain and/or stiffness in the finger that is usually worse in the morning.  It can also cause a popping, catching or clicking sensation of the finger as it is brought into extension. Sometimes the finger can get locked into a flexed position without being able to straighten it.  Often a small bump at the base of the palmar side of the affected finger is able to be felt.   Sometimes there is swelling of the fingers or hand and trouble grabbing or gripping objects.  It’s most common in the thumb and middle fingers.

Testing:  Usually your doctor can diagnose tenosynovitis by clinical exam but they may decide to do some further testing such as an x-ray, ultrasound, MRI or blood tests especially if there is a history of trauma/injury or infection.

Treatment:  Treatment will depend on the cause however it is often treated with a steroid injection into the area of the affected tendon.  This may reduce the swelling and allow the tendon to move more smoothly.  It may also be treated with surgery or antibiotics if there is an infection.  Often rest is the best treatment along with ice to reduce the swelling to the area.  Putting a cold pack, or bag of frozen vegetables on the swollen area every 4-6 hours for 15 minutes at a time can be helpful.

Ibuprofen or naproxen can also help with the pain and inflammation but are usually not curative.  Finger stretches after the symptoms improve may be helpful to get your fingers back to moving normally.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

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Elbow (Olecranon) Bursitis

 

shutterstock_159146555shutterstock_138510524A patient came in today complaining about a lump on her elbow and that is has been slightly painful for the last week.  She is a student and spends many hours reading books and resting her elbow on a table while studying.  This disorder called olecranon bursitis is a fairly common condition in which the bursa, which is a sac-like structure that protects the elbow from pressure injuries becomes inflamed.

Bursas are found all over the body including the shoulders, elbows, knees, feet and hips.   They contain a lubricating fluid that fills the sac and decreases the friction between ligaments, bones and tendons.

Bursitis of the elbow can be caused from:

1)     Prolonged pressure on a bursa (such as when leaning on the elbow while studying for long periods of time or resting the elbow on a car door during a long trip).

2)     Repetitive motions that cause irritation (laying carpet is an example).

3)     An injury or trauma

4)     Medical conditions such as gout or rheumatoid arthritis or pseudogout

5)     An infection within the bursa (called septic bursitis)

Usually a bursitis is not caused from an infection, but when there is redness and warmth to the skin there is a higher chance of infection.  If the skin overlying the elbow becomes punctured or injured there is a higher chance of a septic elbow bursitis.

How would I know if I have bursitis or some other type of problem causing the elbow pain?  A medial provider who has experience with joint conditions will likely be able to diagnose the problem after examining you and hearing about your symptoms.  If there is redness or increased warmth to the area in addition to the swelling, a medical provider might ask to use a syringe and needle to remove a sample of fluid from the bursa to test for infection.   The fluid from the elbow can also be tested for crystals that can be caused by gout or pseudogout.  If you have uric acid crystals in your elbow, the medial provider will help you lower your uric acid levels to prevent worsening symptoms and decrease the chances of crystals forming in other joints. For more information about gout, please see my blog article on that topic.

Sometimes an x-ray, ultrasound or MRI is ordered if there is still some uncertainty about the cause of the elbow problem.

What can I do for the bursitis?  Treatment of elbow bursitis involved decreasing the pressure or motion that is causing the inflammation.  If there is infection, treating with antibiotics is important.  If the bursitis is not due to an infection however, then draining the fluid usually is not very helpful because the bursa will create more fluid and only enlarge again.  In addition, there is a risk of introducing infection into the joint if a needle is put poked through the skin and into the bursa.  If there was not an infection already present within the bursa or joint, there is a greater chance of introducing infection by attempting to withdraw the fluid.  It is important to rest the joint and apply ice.  We also usually prescribe an anti-inflammatory medication such as naproxen or ibuprofen.  Sometimes heat or a steroid injection is also used to help decrease the inflammation.  Heat can be applied to the elbow with a hot pack, a heating pad or hot water bottle.  Ice can be applied using a frozen gel pack or a bag of frozen peas.  I usually don’t recommend using either ice or heat for more than 20 minutes at a time and recommend caution so you don’t burn the skin.

How can I prevent bursitis?  Irritation to the small bursal sacs can be minimized by decreasing repetitive motions, using cushions or pads to reduce the pressure on joints and taking periodic short breaks from tasks that increase joint pressure.  If you start having pain in a joint, this is a warning that there is too much stress and the activity should be modified or avoided.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

References:

Valeriano-Marcet J, Carter jD, Vasey FB. Soft tissue disease. Rheum Dis Clin North Am 2003; 29:77

Keeping your Bones Strong and Healthy – All about Osteoporosis Prevention and Treatment

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Osteoporosis:  A medical disorder that causes the bones to become weak, thin and fragile.  Bones that are weaker are more likely to break (fracture).  Women are more commonly affected by this disorder because after menopause lower levels of estrogen are produced by the body.  Estrogen is a hormone that helps keep the bones strong.

It is very important to detect low bone density (weak bones) because there are treatments available which can protect and actually help build up bone and prevent bone fractures in those people who are at the greatest risk.

Why do we care?  Bone fractures, especially in the hip cause a huge change in lifestyle and lead to decreased mobility, decreased ability for patients to care for themselves, and increased risk of death due to physical deconditioning, increased risk of infection (from surgery and also from decreased mobility respiratory illness).   In fact, people who sustain a hip fracture are more likely to die than a person of the same age who does not experience this injury. About 20 percent of people who have a hip fracture die within a year of their injury. It is estimated that only one in four persons have a total recovery from a hip fracture.  Most people spend from one to two weeks in the hospital after a hip fracture. The recovery period may be lengthy, and may include admission to a rehabilitation facility. People who previously were able to live independently will generally need help from home caregivers, family, or may require the services of a long-term care facility. Hip fractures can result in a loss of independence, reduced quality of life, and depression, especially in older people.

Fractures that occur in the spine due to osteoporosis can lead to pain and cause changes in the curvature of the spine.  We’ve all seen older folks who have difficulty walking due to having abnormal curvature of the spine and these patients often have osteoporotic fractures in the vertebra of the back.

Risk factors for osteoporosis:

1)  Sex – women are more likely to get osteoporosis than men

2)  Age – risk of osteoporosis is higher with increasing age

3)  Race – there is a higher risk of osteoporosis in people of white or Asian descent

4)  Family history – you are at higher risk of osteoporosis if you have a parent or sibling with osteoporosis, especially if there is a family history of bone fracture

5)  Body frame size – men or women who have a smaller body frame size are at higher risk because they have less bone mass to draw from as they age

6)  Hormone levels – osteoporosis is more common in patients who have too much or too little of certain hormones  (estrogen, testosterone, thyroid, parathyroid or adrenal hormones for example)

7)  Low calcium in the diet – a lifelong lack of getting enough calcium increases the risk of developing bones that are thinner and more fragile.

8)  Eating disorder – Patients with anorexia are at increased risk of osteoporosis due to decreased nutritional intake of calcium

9)  Weight loss surgery – those patients who have surgery to help them lose weight are at higher risk of osteoporosis because of a reduction in the size of the stomach or a bypass of some of the intestines.  This may decrease the absorption of calcium or vitamin d.

10)  Certain medications – see below

Prevention:  Several important steps to maintaining proper bone formation and density can be done without the need of medication.  These include proper diet, exercise and not smoking.

A)  Diet:  Preventing the bones from thinning involves getting enough nutrients, especially calcium and vitamin D.

  1. Calcium:  Most experts agree that men and women who have not reached the age of menopause yet consume at least 1000 mg of calcium each day (combination of diet and supplements).  Women who have already gone through menopause should consume at least 1200mg of calcium each day (combination of diet and supplements).   Foods that have calcium include dairy milk, cottage cheese, yogurt, hard cheese, green vegetables (especially kale and broccoli).  A way to calculate the amount of calcium from food is to multiply the number of servings of calcium rich foods by 300 mg.  One serving size of dairy milk or yogurt is 8 oz.  1oz of hard cheese or 16 oz of cottage cheese is one serving size.
  2. Vitamin D:  Most experts also agree that men over age 70 and women who have gone through menopause consume at least 800 international units (IU) for vitamin D each day.
  3. Alcohol:  Drinking more than 3 drinks per day can increase the risk of fracture due to increased risk of falling and poor nutrition.

B)  Exercise:  We understand that our bones maintain their strength if we continue to use them.  Patients who become immobile are at increased risk of bone fractures because their bones tend to become thinner with decreased use and activity.  Patients who are more physically active are generally stronger and less prone to falling as well.  Exercising 30 minutes or more three times per week or more is recommended to maintain bone strength.

C)  Smoking:  Smoking cigarettes is known to speed bone loss.  One study suggested that women who smoke one pack per day throughout adulthood have a 5-10% reduction in bone density by menopause.  If you smoke, I suggest you get help with stopping to help prevent osteoporosis.

We can reduce the risk of bone fractures by reducing falls.  Several ways to reduce falls in older adults include:

1)  Avoiding (as much as possible) medications that can cause dizziness

2)  Provide adequate lighting to areas both inside and outside the home

3)  Ensure there are no loose rugs or electrical cords that could lead to tripping or falling

4)  Avoid walking in areas outside that are unfamiliar

5)  Avoid slippery surfaces such as ice or wet/polished floors

6)  Ensure good eye care by visiting an eye doctor regularly

Screening for Osteoporosis:  There are several different recommendations for when to start screening for osteoporosis.  The U.S. Preventative Service Task Force (USPSTF) recommends screening women who are age 65 or older who has no increased risk of fracture as compared to a 65 yo women of Caucasian decent.  If a woman has a previous bone fracture or an early family history of osteoporosis (especially a mother with an early bone fracture) or has thyroid disease or take medications that can increase the risk of thinning the bones, screening earlier is generally recommended.

Assessment tools:  There are several tools that have been developed by the WHO (World Health Organization)  – (see FRAX) to help assess risk for osteoporotic fractures.  These tools ask questions that relate to risk factors for osteoporosis and attempt to calculate a probability of hip fracture even without knowing exact measurements of bone density measured by special x-ray tests.

DXA Bone Mineral Density Test:  A bone density test uses special x-rays to determine how many grams of calcium and other bone minerals are packed into a bone segment.  Bones that are commonly tested include the spine, hip and forearm.  We do this test to identify patients who are at higher risk for bone fracture, as well as to monitor the progress of therapy for patients who are being treated.   Bone density tests are not the same as bone scans.  Bone scans usually require the patient to get an injection before the procedure and are used to detect bone fractures, bone cancer or bone infections.

Medications that increase the risk of bone thinning:  If you take any of these medications, ask your doctor about whether you should have your bone density tested:

1)  Glucocorticoids such as prednisone or dexamethasone

2)  Anti-Seizure medications such as Dilantin, Tegretol, Phenobarbital or Primadone

3)  Heparin – medication to treat abnormal blood clotting

4)  Acid reducing medications called proton pump inhibitors (PPIs) such as Prilosec may increase the risk of osteoporosis or fractures but more research is needed.

Treatment for osteoporosis:  The treatment really depends on the reason for the decrease in bone density.  We might change the patient’s current medications to different medicines that are safer and have less risk for decreasing bone mineral density.  Correcting a patient’s thyroid, parathyroid or testosterone imbalance may improve their bone density without the need for other medications.  We usually try to ensure that they are getting adequate dietary intake of calcium and vitamin D and may due some lab tests to look for excessive loss of calcium in the urine.  We might test the patient’s vitamin D levels along with the hormone levels mentioned above.  If there has already been a hip or vertebral compression fracture we will also usually check a bone mineral density (DXA or DEXA) scan to confirm the level of osteoporosis.

The DEXA scan gives us a numerical value that corresponds to the degree of osteopenia (low bone density) or osteoporosis (greater risk of fracture).  A normal bone density is when the T-score (measured on the bone density test) is between 0 and 1 standard deviation below the mean.  A normal T score may be reported as a T-score of +1 to -1.  If the T score is -1 to -2.4 the patient is said to have osteopenia which means that they have a risk of developing osteoporosis if not treated.  If the T score is -2.5 or less, the patient is diagnosed with osteoporosis.  The lower the T score (higher the negative number), the greater the risk of fracture.

Medical treatment of osteoporosis:

1)  Calcium – at least 1200 mg of calcium/day but no more than 2000 mg/day.

2)  Vitamin D – at least 800 international units/day – sometimes very high doses such as 50,000 IU/week may be prescribed if your levels are measured to be very low.

3)  Bisphosphonates such as Fosamax , Actonel  or Boniva are medications that slow the breakdown and removal of bone (bone resorption).  These are taken first thing in the morning on an empty stomach with an 8oz glass for still water.  There has been some concern about the use of bisphosphonates in people who require invasive dental work – it may lead to avascular necrosis or osteonecrosis.  Most experts do not think that it is necessary for most people to stop bisphosphonates before invasive dental work (tooth extraction or implant) because the risk is very small for those people who take bisphosphonates for osteoporosis treatment or prevention.  People who take a bisphosphonate as part of a treatment for cancer should consult their doctor before having invasive dental work however.

There is some concern about atypical (stress) hip fractures associated with long-term use of bisphosphonates.  Patients who have been taking them for more than 5 years may need re-evaluation to see if further continuation of the medication is recommended.

4)  Selective Estrogen Receptor Modulators (SERMs) produce estrogen-like effects on the bone.  They include Evista and tamoxifen.  In addition to osteoporosis treatment/prevention there is a decrease in the risk of breast cancer in women who are at high risk.  These medications are not recommended for women who have not started menopause.

5)  Calcitonin is a hormone produced by the thyroid gland that, together with parathyroid hormone, helps regulate calcium concentrations in the body.  This may be administered via nasal spray or injection.  Nasal administration is usually preferred due to ease of use and less chance of nausea and/or flushing.  It’s not clear if calcitonin improves bone in places in the body other than the spine.

6)  Parathyroid hormone (PTH) – (prescription preparation name Forteo) produced in the parathyroid glands(non-prescription form) stimulates bone resorption and new bone formation.  Clinical trials suggest the PTH therapy is effective in both prevention and treatment of osteoporosis in post-menopausal women and men.  It has been proven to reduce spine fracture risk more than any other treatment that we know about.  It does, however require a daily injection and is expensive so it’s usually reserved for patients with severe hip or spine osteoporosis with a T score of  less than -2.5 (higher number) and osteoporosis-related fracture.

When taking Forteo, we often check a blood uric acid and calcium level at the start of the medication, after 6 weeks, 6 months later and then after 12 months of therapy.

We generally do not use this medication in pediatric and young children whose bones are still growing or in patients with bone cancer,  Paget’s disease of the bone and extreme caution is needed in patients who have a history of recent calcium kidney stones.

7)  Prolia is a medication that helps improve bone mineral density and reduce fracture in postmenopausal women with osteoporosis.  It is an injection under the skin once every 6 months.  It’s usually well tolerated but can have side effects such as skin infections or eczema.  It should not be given to patients who have a low blood calcium level.

For more information, please check out the following resources:

National Library of Medicine

Osteoporosis and Related Bone Diseases National Resource Center

National Osteoporosis Foundation

National Women’s Health Resource Center (NWHRC)

Osteoporosis Society of Canada

The Hormone Foundation

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

My Young Child Won’t Move his Arm – Is it Nursemaid’s Elbow?

Photo credit:  http://www.tamilbrahmins.com/share-your-knowledge/14868-nursemaid-s-elbow.html

 

A parent brought her young child in to see me today and told me that she was holding hands with her and then the child suddenly jerked her hand away and attempted to twirl around in a dance move.  After the little girl yanked her arm away, she cried and didn’t want to move her left arm at all.  This is a common scenario and classic story for what we call nursemaid’s elbow or radial head subluxation (RHS).

Nursemaid’s elbow is the most common elbow injury in young children.  It usually affects kids between one and four years of age.  The left arm is more commonly affected than the right.

Mechanism:  With sudden traction of the child’s arm with the elbow extended, a portion of a ligament in the elbow slips over one of the elbow bones and gets trapped in this position.  By 5 years old, this ligament becomes thicker and more resistant to being displaced.

The typical story is that the wrist was pulled while the child’s palm was pointed down towards the ground.  This is common when the parent or caregiver grabs the child’s arm to prevent them from falling or pulling away.  It can also occur when the child is swung by the forearms during play.

Falling onto the elbow, minor trauma, or twisting motion of the arm can also cause radial head subluxation.  Younger children sometimes roll over in bed and this can somehow trap the forearm under the body and result in longitudinal traction.

Symptoms:  When the child comes in, I usually hear the story that she’s not using the affected arm.

Treatment:  Most of the time after explaining the procedure to the parents, we can treat the displaced ligament by relocating it by putting the child’s arm/elbow through a range of motion technique.  No anesthesia or sedation is required, although the procedure is painful briefly.

Complications/Recurrence:  Nursemaid’s elbow can sometimes occur again if the child sustains another injury with the typical mechanism.  There are no long term complications associated with nursemaid’s elbow.  As previously mentioned, the annular ligament strengthens with age and therefore radial head subluxation rarely occurs after age five.

The little girl who came into the clinic today is doing great.  The procedure to fix her elbow took a few seconds and after a few minutes she was using her arm again and practicing her dance moves.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Elbow Pain: Several causes and treatment

shutterstock_56557723Pain in the elbow is a common musculoskeletal complaint seen in the urgent care.  It can happen as a result of sports injury or trauma or can be symptoms of underlying infection, gout or bursitis.  Several causes are listed below:

Elbow tendinopathy:  This is usually called golf or tennis elbow and is caused when then tendon, or strong band of tissue that connects muscles to bones is injured or inflamed.  The symptoms are pain, swelling and even weakness in the elbow.

Olecranon bursitis:  A “bursa” is a small fluid-filled sac that sits near a bone.  Bursitis happens when the bursa gets irritated and swollen and can happen when a joint is moved over and over again in the same way over a short period of time.  It may also happen if the elbow sits on a hard surface or stays in a position that presses on the bursa for a long time.

Nerve entrapment: The ulnar, median and radial nerves course in close proximity to the elbow.  Ulnar neuropathy is the most common compression neuropathy and it can cause sensory loss, pain and paresthesias over the ring and small fingers.

Osteoarthritis:  Degenerative processes of the elbow are rare because it is non-weight bearing.  When present however osteoarthritis is usually related to prior fractures that involve the joint.  If there is an elbow deformity, we often think about underlying inflammatory arthritis.

Radial head fracture:  Fracture of the radial head of the elbow most often occurs when the patient falls on an outstretched hand.  The radial head and neck make up the proximal portion of the radius.  Pain and swelling over the lateral elbow can be a sign of this type of fracture.

Elbow dislocation:  Posterior elbow dislocation is the most common dislocation in children younger than 10 years of age and the second most common in adults, after shoulder dislocation.  Posterior elbow dislocations usually occur after a fall or a twisting injury to the elbow.

Radial head subluxation (nursemaid’s elbow):  This is a common elbow injury in young children typically between 1-4 years old.  The mechanism of injury is sudden traction on the distal arm with the forearm pronated and the elbow extended.  A portion of the annular ligament of the patient’s elbow slips over the head of the radius and slides into the radiohumeral joint where it becomes trapped and causes pain.   The treatment is generally fairly easy by an experienced healthcare provider and the patient has immediate relief of pain when it is done properly.

Gout:  Usually characterized by the sudden onset of severe elbow pain often with redness, swelling and tenderness.  There is no history of trauma.  It is caused from the uric acid crystals that develop in the joint (usually a single joint) and is less common in the elbow than the big toe.

Treatment of elbow pain:  Identifying the cause of the patients elbow pain and treating that is the most efficient way to treat the patient’s pain.  Treatment may involve manipulation of the joint, using a shoulder sling and ice, or medication such as anti-inflammatories, and pain relievers, and possibly antibiotics.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Shoulder Pain: Several Causes and Treatments

Photo credit:  http://leitnerphysicaltherapy.com/what-is-rotator-cuff-syndrome/

One of the most common injuries that bring patients into the urgent care is related to the shoulder.

The shoulder is an inherently unstable joint.  The glenoid is shallow, allowing for a wide range of motion, with only a small portion of the humeral head articulating with the glenoid in any position.  The anatomy of the shoulder allow for increased mobility, but also predispose the shoulder to increased risk of injury.

There can be numerous causes for shoulder pain, some of which are presented here.

Shoulder Impingement Syndrome:  This occurs when the tendons of the rotator cuff and the subacromial bursa (a fluid-filled sac that separates the bones of the shoulder joint) are compressed between the bones of the shoulder.  Doing work with the arms outstretched overhead can cause shoulder soreness but does not necessarily lead to impingement.  Shoulder impingement is only diagnosed when symptoms continue and interfere with normal daily activity.  Chronic impingement can lead to bursitis, rotator cuff tendinopathy, and if left untreated, thinning or tearing of the rotator cuff tendons.

Separated Shoulder:  A separated shoulder is a condition that causes shoulder pain and swelling.  It happens when certain ligaments in the shoulder joint tear or get stretched too much.  Ligaments are strong bands of tissue that connect bones to other bones.  The shoulder joint is made up of 3 bones:  The collar bone, the shoulder blade, and the upper arm bone.  The most common cause of a separated shoulder are falling on the shoulder or getting hit in the shoulder.

Biceps Tendonitis:  Tendons are tough bands of tissue that connect muscles to bones.  Repetitive activities and overuse can injur tendons leading to pain and impaired function.  The biceps muscle is located in the front of the upper arms, and is used when lifting, bending the elbow, and reaching up over the head.  The upper portion of the biceps muscle attaches to the front of the shoulder in two places and the lower portion attaches to the bone in the forearm.  Lifting, pulling, reaching or throwing repeatedly can lead to biceps tendinopathy or even tears of the upper biceps tendon.

Frozen Shoulder:  The term used to describe a stuff shoulder joint that has temporarily lost the ability to move freely; most people with frozen shoulder have difficulty reaching overhead and reaching to the low back.  The stiffening is the body’s natural response to inflammation that develops in or near the shoulder.  Stiffening is a protective reflex that protects the shoulder from further injury.

Rotator Cuff Injury:  The rotator cuff is made up of 4 shoulder muscles and their tendons.  One common injury is tendinopathy, and that is when people have a problem with 1 of their tendons.  In most people with tendinopathy, the tendons are not inflamed or swollen.  If they do get inflamed or swollen, doctors call it “tendonitis”.  Another type of rotator cuff injury is a tear in a tendon.  Tears can happen if a person falls on the shoulder or moves the shoulder too fast and with too much force.  Tears can also happen as a tendon wears out over time.

Shoulder Arthritis:  Fortunately, arthritis of the shoulder progresses slowly and is an uncommon problem.  In almost every case, the shoulder has been injured months or years earlier, leading to an abnormal wearing down of the cartilage.

Shoulder Dislocation:  Anterior dislocation of the shoulder is a painful condition that is usually caused by a blow to the abducted, externally rotated and extended arm (eg, blocking a basketball shot).  Less commonly, a blow to the posterior humerus or fall on an outstretched arm can cause an anterior dislocation.  Posterior shoulder dislocations are rare and are only about 2% of shoulder dislocations caused from a blow to the anterior portion of the shoulder.

Shoulder pain treatments are tailored specifically towards the cause of the patient’s pain.  Shoulder dislocations are usually treated by re-locating the shoulder joint after x-ray examination to rule out fracture of any of the bones of the shoulder.  Dysfunction of the tendons or ligaments of the shoulder are often treated with physical therapy, anti-inflammatory and pain medications and sometimes surgery.

Immobilization:  Depending on the type of injury, a shoulder sling may be recommended to help reduce pain and help with healing.  The patient should be careful not to remain in the sling for too long because the risks of frozen shoulder (ie. adhesive capsulitis) increase with shoulder immobilization.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Distal radius fracture or Colles fracture – The “FOOSH” injury

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Fracture of the distal radius (arm) is one of the most common fractures. The majority of these fractures are in two distinct populations:  youth who are involved in sports and sustain a relatively high-energy fall, and seniors with osteoporosis who fall with low energy.

How the injury occurs:  The most common mechanism is Falling On an Out-Stretched Hand (FOOSH), with extension of the wrist (backward bending).

Indications for referral to surgeon:  Most of the time distal radius fractures can be managed by your primary care physician.  There are some circumstances however which require referral to a surgeon such as:

1)   Open fractures – ie. Fractures with laceration of skin above the bone

2)   Fractures where there is pressure building up in the soft tissues of the wrist due to ongoing bleeding

3)   Fractures where the nerves of the hand/wrist are damaged

4)   Other fractures that are unstable

Treatment:  We usually don’t put a cast on immediately after the injury because of the swelling, and risk of decreased blood flow due the injured area that can occur inside the cast.  For non-displaced extra-articular fractures, we usually treat with a well-molded sugar tone, reverse sugar tong or double sugar tong splint.   The elbow is usually flexed to 90 degrees and the arm is in a neutral position.  The arm is kept in a splint for a few days following the injury and should do the following:

1)   Elevate the arm

2)   Apply ice to the fracture frequently (while keeping the splint dry)

3)   Begin active range of motion to the shoulder and fingers

4)   Use pain medication as needed

Patients are seen 3-5 days after the injury to evaluate, remove the splint and assess neurovascular status.  We often repeat x-rays at this time with the arm out of the splint.  If the fracture still looks non or minimally displaced, the healthcare provider then applies a short arm cast.  The cast will extend from the distal palmar crease to within 5cm of the antecubital fossa.  The patient is by their healthcare provider every 2-3 weeks until the healing is complete.  Patients should remain in the cast until there is evidence of radiographic healing or the fracture is non-tender and that is generally for 6 weeks.  At this point, a wrist brace can be used instead of the cast.  Complete healing can require 6-8 weeks.

If there is initial displacement of the bones on x-ray, the splint is usually kept in place for 2-3 weeks, then changed to a short arm cast with immobilization for another 4-5 weeks.  Healing of these displaced fractures usually takes 8-12 weeks.

Possible complications:  Injury to the medial nerve or compartment syndrome are the most important and early complications of a distal radius fracture.  Acute Carpal Tunnel Syndrome (ACTS) is a nerve injury to the medial nerve that sometimes occurs with a traumatic fracture.  Signs of compartment syndrome include increasing or constant severe pain or pain elicited by passive extension of the fingers.  These symptoms usually start within 12-54 hours after the injury, so it is important for the patient to tell their physician if their pain is worsening during this time.

Injury to other bones within the hand/wrist can accompany a distal radius fracture, but they are rare.  They are suspected in patients with persistent wrist pain despite acceptable alignment.

Return to work:  Patients with more sedentary jobs may return to work immediately.  Physical laborers may return to full duty of after they have regained near-normal wrist motion and strength.  It is reasonable for participants in contact sports also to delay return to play until they have achieved near-normal motion and strength, and to wear a protective palmar splint during the first few weeks of play.

Splint Care:  a cast or splint will help protect the injured bone or tendons and reduce pain as you heal.  It is important to take care of the splint to minimize risk of possible problems such as a skin infection.

Splint care instructions:

1)   Swelling is common and can make your splint feel tight initially.  To reduce the swelling we recommend keeping the splint above the level of your heart for 24-48 hours.  Resting the splint on pillows or having your arm or leg in a sling that keeps the extremity elevated is important.

2)   Gently move your fingers or toes (where the splint is located) frequently.

3)   Ice can help keep the swelling down.  Apply ice or a frozen bag of vegetables to the injured area.  Do not apply blue ice (mostly used for camping) directly to the skin because this can cause freezer burn.

4)   Do not get the splint wet.  Bathe with the splint covered in a plastic bag and tape the opening shut to prevent damaging it.  Hang the splint outside of the bathtub if possible.

5)   If the splint becomes wet, dry it with a hair dryer on the cool setting.  Using a hot setting can burn the skin.

6)   Keep the splint clean and avoid getting dirt or sand into it.  Do not apply powder or lotion on or near the splint and cover the splint when eating.

7)   Don’t place anything inside the splint, even for areas the itch.  Sticking things inside the splint can injure the skin and lead to infection.  Do not pull the padding out from inside the splint.

When to seek help for your splint:

1)   Your fingers or toes get cold or blue, hurt, get numb, tingle or throb – this may indicate the splint is too tight

2)   There are sore areas or a foul odor from the splint

3)   If the splint breaks or is damaged

4)   If you develop severe pain in or near the splinted arm or leg

5)   If the splint becomes soaking wet or does not dry with a hair dryer or vacuum.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com