What Spring Means to Our Musculoskeletal Health

Spring has finally arrived and time isn’t the only thing jumping forward.  Our enthusiasm for the outdoors is renewed and our activity schedule is ramped up.  From the slopes to spring sports, new plantings and training for one of the biggest bike rides in Texas, the potential for overuse injuries is particularly high this time of year – following less active winter months.

Some of the musculoskeletal injuries and conditions most commonly seen in the spring include:

  • Skier’s Thumb
  • Friction Blisters
  • Allergy-Related Muscle Fatigue / Joint Pain
  • Carpal Tunnel Syndrome
  • Golfer’s Elbow

Skier’s Thumb

Though the skies and poles are packed away, signs of a common injury following an active ski season may linger a bit longer.  Skier’s thumb, also known as Texter’s Thumb skiers-thumb gardening cycling MLB: Oakland Athletics at Chicago White Sox golfing tennisamong millennials, refers to injury of the unlar collateral ligament (UCL) of the thumb’s metacarpal phalangeal (MP) joint.  This occurs when the abnormal pulling of the thumb, such as that from a fall or harsh pull while affixed to the ski pole/hoop, causes a forced abduction or hyperextension of the proximal phalanx of the thumb. If unaddressed, this injury is further exacerbated by the repetitive use of the injured thumb in texting.

Friction Blisters

While the most common concerns during baseball season include pitch count and the stress that excessive pitching and throwing has on a player’s elbow and shoulder over the course of a baseball season, these generally occur mid to late season following many practices and games.

A lesser known injury often occurs as the season gets started and impacts pitchers in particular – friction blisters.   The repeated trauma created between the baseball seams and the fingers of the pitching hand, predominately at the tips of the index and long fingers, can result in friction blisters.

Friction blisters, which are the result of repetitive friction and strain forces that develop between the skin and various objects, are also common this time of year among those increasing gardening efforts and tennis players hitting the court.

Friction blisters form in areas where the “stratum corneum” and “stratum granulosum” are sufficiently robust such as the palmar and plantar surfaces of the hands and feet [1].

 

Allergy-Related Muscle Fatigue / Joint Pain

With the vibrant colors of spring come seasonal allergies and a host of symptoms that can sometimes make involvement in many of these long-awaited activities a challenge.  While pollen allergies most commonly cause nasal congestion, a runny nose, a sore/scratchy throat and itchy eyes, they can also cause hives, itchy skin, chronic cough, mood changes and body aches/muscle and joint pain. After exposure to pollen, the body reacts to it as a foreign invader by releasing antibodies and natural chemicals called histamines. Histamine is a substance that causes inflammation in the body. Sometimes allergies can advance to bronchitis and mimic flu-like symptoms, including a low-grade fever, body aches and muscle fatigue which can make everyday activity and exercise more challenging if unaddressed. Continuing to train or play while the body fights to overcome allergy challenges can predispose the musculoskeletal system to injury.

 Carpal Tunnel Syndrome

Carpal Tunnel Syndrome (CTS) is one of the most common overuse conditions seen in hand and upper extremity orthopedic care.  In the spring, it is often the result of new activity excessively engaging the hand and wrist such as gardening and cycling. It is generally the result of irritation and swelling, which causes compression within the narrow carpal tunnel located at the wrist – through which one of the major nerves in the arm, the median nerve, passes.  This nerve becomes irritated in the compressed tunnel and can cause numbness, pain, tingling and weakness in the thumb, index and middle fingers.  CTS can come on quickly and command attention or linger with varying degrees of pain that becomes gradually more intense over time.

Another hand and wrist condition, Handlebar Palsy, also known medically as ulnar neuropathy, is an overuse or repetitive stress condition that affects cyclists, though generally after completion of a long, competitive ride.  It is the result of direct pressure placed on the ulnar nerve at the hand and wrist – from the grip of a cyclist’s hands on handlebars, causing stretching or hyperextension of the nerve.

 

Golfer’s Elbow

While the greens are rarely bare in Houston, golfing tournaments really ramp up in the spring and so too do one of the most common overuse conditions associated with the sport – Golfer’s Elbow.  Also known as medial epicondylitis, Golfer’s Elbow affects the muscles and tendons on the inside (medial) portion of the elbow. The repeated activity of swinging the golf club places strain on the elbow, irritating and inflaming the tendons and muscles at the elbow joint.  This inflammation can cause pain on the inside of the elbow, as well as in the forearm and wrist.

 Preventing Injury

Easing into new activity gradually and preparing appropriately can reduce risk of overuse injuries and conditions.  Strengthening muscle groups equally and stretching sufficiently both before and after activity are key, particularly after less active winter months.

Ensuring proper equipment (cycling and other ergonomic gloves and tools) and products (moisturizing to reduce calluses and blister risk) can protect the parts of the body most vulnerable to some of these spring activities and sports. Behavior/activity modification can also help to distribute stress to different parts of the body, reducing repetitive impact on one particular area.

While allergies are often unavoidable, antihistamines and corticosteroids can reduce symptoms and improve performance.  Understanding the associated muscle fatigue and joint pain will help you modify activity accordingly to avoid injury.

Periodically resting and refraining from the activity causing pain can help restore limb strength and prevent more serious injury or damage to the affected area.

 References

[1] McNamara AR, Ensell S, Farley TD. Hand Blisters in Major League Baseball Pitchers: Current Concepts and Management. Am J Orthop. 2016 March;45(3):134-36.

The Vitamin D Deficiency Dilemma and What It Means to Bones…and Our Health

Shedding some light on the high and low of it

Vitamin D deficiency has become a growing trend in the United States and is now prompting physicians in different areas of specialty to test Vitamin D levels in patients.Our Need for Vitamin D

While low Vitamin D levels have always played an important role in orthopedics, insufficient levels are now also linked to a wide range of other health issues – from Diabetes and Cardiovascular Disease to cancer (1).

Measuring Vitamin D status in blood levels of a form known as 25-hydroxyvitamin D [25(OH)D] has become an important part of health screenings.

While orthopedic specialists treating patients for a bone fracture today routinely test Vitamin D levels in patients, increasingly physicians in other areas of specialty are including such tests for their patients as well.

A Growing Trend in Vitamin D Deficiencies

A growing trend in low Vitamin D levels among a broad range of ages has prompted the National Institutes for Health (NIH) and Centers for Disease Control and Prevention (CDC) to assess possible causes, further exploring the link between Vitamin D in not only bone health but other diseases as well.  The growing trend, which is seen not only in the United States but worldwide, has been called a pandemic and prompted researchers to launch studies into the causes and the implications on overall health (2).

It is believed that lifestyle changes, growth in obesity, increase use of medication and changes in diet (reduction in nutrient rich foods and increase in processed, packaged nutrient deficient) are all contributors to this trend.

While some study results have caused daily intake recommendations to increase from 200 IU to 400 to 600 IU to address the deficiencies, many believe much higher amounts are required (4,000 to 10,000 IU daily) to reach optimal levels and achieve maximum health benefits.  Recommended daily intake and appropriate supplementation for those showing a deficiency continue to evolve. Recommendations established by the Institute of Medicine, 2011 are used as a general guideline. Ongoing research will continue to fuel this discussion.

Vitamin D and its Role in Bone Health

Vitamin D is a fat-soluble vitamin, which is essential for maintaining mineral balance in the body. Its most active form in humans is Vitamin D3 (cholecalciferol), which can be synthesized in the skin with exposure to ultraviolet-B (UVB) radiation from sunlight.

Vitamin D3 conversion and use within our body.

Vitamin D3 metabolism and use within our body.

Plants can synthesize ergosterol by ultraviolet light, which is converted to vitamin D2 (ergocalciferol), but is a less active form of vitamin D (less than 30% of Vitamin D3) (3).

Vitamin D is necessary for the proper absorption of calcium, which together have shown to reduce risk of osteoporosis, assist in the healing of bone fractures and decrease risk of future bone breaks. Vitamin D has other roles in the body as well, including modulation of cell growth, neuromuscular and immune function and reduction of inflammation (4).

When exposure to UVB radiation is insufficient, adequate intake of vitamin D from the diet (Vitamin D-fortified foods and supplements) is essential for optimal health.

After Vitamin D is consumed in the diet or synthesized in the skin, the biologically inactive form then enters the circulation and is transported to the liver, where 25(OH)D is formed.  This is the major circulating form of vitamin D and the indicator of vitamin D status in the body. Increased exposure to sunlight or increased dietary intake of Vitamin D-enriched foods and/or Vitamin D3 supplements increases blood levels of 25(OH)D, making the blood 25(OH)D concentration an effective indicator of Vitamin D nutritional status.

Causes of Vitamin D Deficiency

While studies continue to explore possible causes of the widespread Vitamin D deficiency, a number have already been identified.  Some are the result of societal changes such as increased use of sun blocks/sun screens for fear of skin cancer (limiting unprotected sun exposure) and changes in our diet (processed, nutrient deficient foods versus nutrient and Vitamin D-rich foods). Both of which have gradually reduced the amount of Vitamin D intake we receive.

 Other possible causes of Vitamin D Deficiency include:

1.) Obesity

Some studies suggest that a higher BMI leads to lower 25(OH) D (4). Greater amounts of subcutaneous fat sequesters more of the vitamin and alter its release into circulation (5).

2.) Naturally dark-skinned individuals

Greater amounts of the pigment melanin in the epidermal layer (resulting in darker skin) reduces the skin’s ability to produce Vitamin D from sunlight.

3.) Certain Medications

Corticosteroid medications such as prednisone (often prescribed to reduce inflammation) can reduce calcium absorption and hinder Vitamin D metabolism. Other weight-loss, cholesterol-lowering and epileptic seizure medications have also been implicated in reduced calcium absorption and Vitamin D levels.

4.)  Age

As we age, our skin cannot synthesize Vitamin D as efficiently. The elderly are also likely to spend more time indoors, leading to inadequate intakes of the vitamin.

Increasing Vitamin D Levels

While it is difficult today to reach the recommended levels of Vitamin D without supplementation, below are some of the best sources that may reduce the quantity of supplements required.

Calcium and Vitamin D-rich foods can help support strong bones, decrease risk of disease.

Calcium and Vitamin D-rich foods can help support strong bones, decrease risk of disease.

  •  Unprotected sun exposure (10 – 20 minutes several times a week depending on skin color and geographical location).
  • Vitamin D-rich foods such as fatty fish (salmon, tuna, mackerel), beef liver, cheese and egg yolks.
  • Vitamin D-fortified foods such as milk, orange juice, margarine and butter.
  • Vitamin K2, which is linked toimproved use of Vitamin D3 and calcium (6).

 

References

  1. Holick MF. Vitamin D: importance in the preventioin of cancers, type 1 diabetes, heart disease, and osteoporosis.  Am J Clin Nutr. 2004;79(3):362-371.
  2. Holick MF. The vitamin D Deficiency pandemic and consequences for nonskeletal health: mechanisms of action. Mol Aspects Med. 2008;29(6):361-8.
  3. Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective than vitamin D3 in humans. J Clin Endocrinol Metab. 2004;89(11):5387-5391.
  4. Institutes of Health, Office of Dietary Supplements – https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ .
  5. Vimaleswaran KS, Berry DJ, Lu C et al. Causal relationship between obesity and Vitamin D status:  bi-directional Mendelian randomization analysis of multiple cohorts. 2013 – http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001383.
  6. National Institutes of Health, Office of Dietary Supplements – https://ods.od.nih.gov/factsheets/VitaminK-HealthProfessional/

 

Dr. Korsh Jafarnia is one of Houston’s leading board certified, fellowship trained hand and upper extremity specialists.  A member of UT Physicians, Dr. Jafarnia is affiliated with Memorial Hermann IRONMAN Sports Medicine Institute at Memorial City and the Texas Medical Center.  He also serves as an assistant professor in the Department of Orthopedic Surgery at McGovern Medical School. Call 713.486.1700 for an appointment, or go to www.korshjafarniamd.com to

SELFIE ELBOW -

Among the “Modern Day Maladies” of the Millennials

Medical conditions are often a “snapshot” of goings on in a society and a period of time. This couldn’t be more true as represented by one of the newest orthopedic hand and upper extremity conditions physicians have today coined “Selfie Elbow.”Selfie Elbow

Throughout history ailments have often reflected the activities and environment experienced during that period.  Gamekeepers thumb of the 1950s eventually became more commonly known as Skier’s Thumb.  Today it’s called by modern day millennials… “Texter’s Thumb.”

What may very well have been Archer’s elbow from a time preceding all of us, has over the years become popularized as Tennis Elbow (lateral/outside) or Golfer’s Elbow (medial/inside) – and today is referred to as Selfie Elbow, joining the growing list of “modern day maladies” afflicting millennials (those born from the early 1990s to early 2000s).

While the names and mechanism of overuse conditions may change, the end result is the same – tendonitis.

According to recent reports, millennials spend an average of five hours a week taking selfies.  And each one is expected to take over 25,000 in their lifetime (1,2).

The weight of the phone is not the concern. The repetition combined with the contortion of the elbow, held in unnatural positions while capturing the Selfie shot are actually what pose the problem.

Further adding to elbow stress is the Selfie Stick.  Selfie Sticks extend up to 51 inches.  Positioning and maintaining balance of a phone on the Selfie Stick further exacerbates the stress on the elbow and now also unnaturally engages the wrist as well.

Tendons work to anchor muscle to bone.  When the repetitive overuse and sometimes awkward positioning of the arm places continual stress (micro-trauma) on the muscles and tendons at the elbow, which help to extend and stabilize the wrist, irritation can result.

Currently Selfie Elbow more closely mimics Tennis Elbow and Olecranon Bursitis. Technically known as lateral epicondylitis, Tennis Elbow affects the lateral (outside) portion of the elbow.  The same diagnostic tools and treatment for Tennis Elbow are used to treat Selfie Elbow.

Symptoms of Selfie Elbow

The symptoms of Selfie Elbow are also similar to those of Tennis Elbow and can include:

  • Pain on the outside of the elbow during activity.
  • Weakness with grabbing or gripping.
  • Dull ache while at rest/night.

Diagnosing Selfie Elbow

A physical examination and understanding of patient history and activities leading up to the pain will help determine the areas affected and the diagnosis.

Treating Selfie Elbow

Treatment for this and most types of tendonitis includes rest and refrain from the activity causing the stress and strain.  Other conservative treatment may include:

  • Physical therapy to stretch and build strength.
  • Behavior modification – a change in posture/position while taking Selfies.
  • An elbow brace to be worn during the daytime and a wrist brace at night – holding both in anatomically comfortable positions.
  • Steroid injections.
  • Ultrasound or heat therapy.
  • Platelet Rich Plasma (PRP) Injections.
  • Shockwave Therapy.

While rare, if conservative treatment fails to resolve the issue and pain becomes incapacitating, surgical intervention may be required to remove diseased, degenerated tendon tissue. This type of procedure is generally performed by minimally invasive surgery including arthroscopy, followed by rehabilitation therapy.

Preventing Selfie Elbow

While avoiding such overuse conditions is difficult for athletes and others inflexibly bound to their activity, those experiencing Selfie Elbow are encouraged to limit their Selfie activity and engage their upper extremity in other exercise during off time.  Also, frequently changing arm position, and possibly arms, while taking selfies can help reduce the strain on the elbow and the tendons and muscles which support it.

References

 

Cowboy Casualties and the Rigors of Rodeo Life

While the Houston Livestock Show and Rodeo has come and gone, the rodeo athletes who kept us captivated as they rode, roped and wrangled their way across the arena for the duration are on to a new city – and not even half way through their rodeo season.

The life of a rodeo athlete, many true cowboys at heart, is one of unyielding dedication and physicality.

Those who have participated since youth in rodeo events have built both strengths and vulnerabilities to the ongoing rigors of rodeo life. Proper mental and physical conditioning are key in avoiding serious injury.Rodeo Quote

While many of the injuries commonly associated with these athletes include concussions and fractures, others are the result of ongoing strain placed on the same limbs, ligaments and joints day in and day out for months at a time.

Many rodeo athletes begin in their teens, tie-down roping calves before progressing to adult wrangler, bull or bare back rider.  The years of hand and upper extremity strain predisposes this athlete to tendonitis in the hand, wrist, elbow and shoulder. Known as a repetitive stress or overuse condition, without proper treatment it can cause chronic inflammation, joint instability and eventually the early onset of arthritis.

Recognizing early signs of tendinopathic injuries and conditions and establishing an effective treatment program is key.

Tendonitis

Tendonitis (also spelled Tendinitis) is the inflammation of the tendons and other soft tissue connecting muscle to bone.  It is most often caused by repetitive movement, placing strain on the tendon and negatively impacting the affected area over time.  It may also occur following a sudden more serious injury such as a fracture or dislocation.

Tendonitis can affect different parts of the body.  Some of the commonly diagnosed upper extremity tendinopathies include Tennis Elbow, Golfer’s Elbow, deQuervain’s Tenosynovitis, Pitcher’s Shoulder and Swimmer’s Shoulder – named after the repetitive motion and sport implicated.  Though, many other activities and types of sports can result in one of these types of tendinopathies as well.

Among rodeo athletes, wrist tendonitis and tendon damage is particularly common, both as a result of the repetitive stress on the wrist and fractures and other trauma this athlearthritis_tendinitis_elbow_strainte sustains.

Symptoms

Symptoms of tendonitis may include;

  • Pain and swelling
  • A feeling of friction as the tendon moves
  • Warmth and redness about the affected area
  • A lump that develops along the tendon
  • Difficulty moving

A tendon rupture may result in a gap felt in the line of the tendon and would manifest with weakness or lack of function of that muscle.

 

Tendinosis

Tendinosis is often referred to as “chronic tendonitis” and is damage to a tendon at a cellular level.  In fact, “osis” represents a pathology of “chronic degeneration” without inflammation.  Key identifiers include disrupted collagen fibers within the tendon, increased cellularity and neovascularization.  This condition is thought to develop from micro tears, repeated injury and increases the risk of tendon rupture. While pain associated with this condition may be addressed similarly to that of tendonitis, emphasis is on stimulating collagen synthesis and breaking the cycle of tendon injury.

Extensor Carpi Ulnaris (ECU) InstabilityWrist Tendonitis

The ECU tendon of the wrist attaches the ECU muscle to the bone and is responsible for straightening and rotating as well as gripping and pulling movement in the wrist and hand. While this tendon normally slides over the forearm (near the little finger), held in place by the retinaculum (ligament-like structure), damage to the area can cause it to slip in and out of place (sublux) or dislocate completely.

Treatment

Treatment for and recovery from a tendinopathic condition will depend on the type and severity.  While minimally invasive corticosteroid injections have proven effective in relieving pain, rest from the repetitive activity contributing to the condition is also indicated.  Stretching and strengthening exercises are also proving effective.

In severe cases, or when the tendon becomes displaced and nonsurgical treatment fails to resolve the problem, surgical intervention may be indicated.  Surgical intervention may include repair of the retinaculum, tendon lining (tendon sheath), or tendon – or to replace the tendon if it is torn.

Prevention

While many injuries in the life of a rodeo athlete cannot be avoided, damage can be reduced by staying fit and strong overall.  Strength and flexibility, combined with periods of rest and other activities involving different muscle groups will help reduce risk of injury and the impact of a tendinopathic condition.

According to long time rodeo professional and bareback rider Cody Goodwin, “every ride is like getting in a car wreck.”

“You have to be in pretty darn good shape, which is why I jog four miles every other day and lift weights every other day – to develop lean muscle mass,” said Goodwin.

“I take good care of my body, so that I can, at my age, continue to compete with 20 and 25-year-old riders,” added the 41-year-old rodeo veteran.

Dr. Korsh Jafarnia is the hand and upper extremity specialist at UT Physicians / Memorial Hermann IRONMAN Sports Medicine Institute (Memorial City and Texas Medical Center locations), 713.486.1700.

Hoverboard Hazards

The exciting new phenomena of “hoverboarding” has made hoverboards one of the most popular technological “toys” on the market today.  Intended for agile adolescents, its appeal has also drawn parents and other adults nostalgic for those days gone by.

The technology of the hoverboard, known as a smartboard or balance board as well, doesn’t actually create a hover but rather a forward and backward motion on a sideways skateboard of sorts, with either a large single center wheel or two smaller ones at each end.  It is automated, can reach a formidable speed of 16 mph and relies on body movement for navigation. It is basically a hands free, self-balancing electric scooter.

Concern over hoverboard safety grows amid increase in injuries.

Concern over hoverboard safety grows amid increase in injuries.

They have become the vehicle of choice for students travelling around campus and preteens maneuvering around the house and down the street to visit friends.  They light up, are stealth quiet, move as fast as one’s imagination …. and leave hands free for any other activity desired on the fly.

Unfortunately, while the mainstream hoverboard never actually leaves the ground, its ability to send riders airborne is causing increasing concern.

In fact, the Consumer Product Safety Commission has reported receiving dozens of hoverboard-related injuries from across the United States.  Houston hospitals have also reported in a recent Associated Press article seeing a sharp increase in the number of hoverboard accidents sending adult and young riders alike to the ER and urgent care clinics.

Colleges are not only restricting their use on campus, as a result of the injury risk (to the user and passers by) but also the fire hazard their electrical system poses.  The hoverboard fire hazard is covered extensively in other hoverboard reports.

Among the most common musculoskeletal injuries seen from hoverboard use include concussions, fractures, contusions and abrasions.

Concussions

While most frequently seen in sports such as football and soccer, concussions are increasingly reported in hoverboard accidents.  With no recommended safety wear, the speed and maneuverability of the device is resulting in high impact falls and collisions – resulting in concussions. The primary symptoms of a concussion include:

  • Headache
  • Trouble concentrating, feeling “foggy”
  • Nausea
  • Delayed reaction times
  • Dizziness, lightheadedness
  • Sensitivity with bright lights or loud sounds
  • Irritability

 If a concussion is suspected, an evaluation should be conducted by a physician and hoverboard and other balancing activities should be avoided.

Fractures

Wrist fractures are among the most common types of fractures seen in hoverboard accidents – distal radius fractures among the most common type of wrist fracture.  This is often the result of breaking a fall or harsh impact with an outstretched arm. Other hoverboard fractures and dislocations have been seen in the fingers. Symptoms of a fracture or dislocation can be evident with extreme pain, swelling and slight disfigurement or subtle with only slight swelling and pain.

Most wrist fractures and finger fractures and dislocations can be treated nonsurgically, depending on the severity of the fracture or dislocation.  A splint or other bracing may be indicated, along with anti-inflammatory medication and rest/refrain from extracurricular activity.

Contusions and Abrasions

Collisions causing contusions and abrasions are frequently reported on hoverboards in the absence of safety gear. While most are minor cuts and scraps, some may result in open wounds requiring stiches, while potentially damaging nerves and other soft tissue.  Swollen, discolored injuries lasting more than a month should be further evaluated by a physician.

Preventing Hoverboard Injuries

The lack of safety standards and recommended safety gear/wear is a concern among hoverboard retailers and healthcare providers alike.  But, parents do not have to wait until such recommendations are established.  If a hoverboard is in your family’s future, take the proper precautions. As with any sport, safety gear recommended or not, will provide a bit of assurance.

Cyclists travelling at much less speeds not only have both hands and legs navigating a two-wheeled structure designed for the road, but also helmets, gloves, shoes and other gear designed for safety and the sport. This is also true of rollerbladers and skateboarders. Invest in the safety of your hoverboard rider and purchase protective safety gear.

Help young riders understand the potential risks for injury and encourage that they err on the side of caution to avoid the ER.

Have fun and be safe!

Read a hoverboard article from a young contributing writer.

 

Hoverboards

Link

By:  Jackie Jafarnia, 10

 

Hoverboards might be fun, but they can also be dangerous.  For instance, I know so many people who have hurt themselves.  My friend, Ana, broke her wrist because hers wouldn’t stop.  Also if you over charge them, some of the brands catch fire or explode.  If you have one or plan on getting one, I’m telling you to be cautious.  From what I know Harvard has already banned them.  That is what I think about hoverboards.

 

Colleges now restricting hoverboard use on campus.

Colleges now restricting hoverboard use on campus.

 

Defending Against Turf Trauma

Football is now more than half way through the season, and we’ve seen our share of sprains, fractures, and concussions.  Many of these injuries have been discussed at length, so we thought we would talk about a growing concern; injuries occurring from or made worse as a result of the synthetic turf our kids are playing on today. Turf Concerns in Sports

Synthetic Turf Concerns

At the professional level, there is concern that the difference in buoyancy and other  attributes of synthetic infilled turf may contribute to increased risk of ligament injuries and overall musculoskeletal wear, resulting in prolonged fatigue and recovery between games. While studies continue to assess these concerns without conclusion, debates grow in women’s soccer and are capturing the attention of parents of young athletes playing on artificial turf across the United States [1,2].

There have also been a number of studies assessing increased risk of infection in football associated with playing on synthetic turf.  While studies are ongoing, there are currently no scientific findings to conclude that synthetic turf results in a higher number of infections than natural turf.  The abrasive nature of this artificial turf, though, has certainly resulted in an increased number of severe abrasions and lacerations of the skin, leaving players more vulnerable to infection.

The surface temperatures of synthetic turf are also significantly higher than that of natural grass turf when exposed to sunlight (Buskirk et al., 1971; Koon et al., 1971; and Kandelin et al. 1976, Devitt et al., 2007, McNitt et al., 2007).  This may contribute to increased bacteria growth.

Turf concerns have been noted as early as 2003 when Connecticut’s Department of Public Health launched an investigation into infections in a Connecticut college football team [3]. Of the 100 players studied, those with turf burns had an infection risk seven times higher than their scraped teammates. Cornerbacks and wide receivers, who frequently come into contact with other players, accounted for most cases. Improperly treated whirlpools could also have helped spread the bacteria.

When these bacteria become resistant to antibiotics they can spread and cause pneumonia, bone infections, or life-threatening infections of the bloodstream that are difficult to treat.

Reducing Risk for Turf Related Skin Infections

Each football season, we see a growing number of skin infections related to synthetic turf burns, abrasions and lacerations.  While many of these infections can be treated with antibiotics, those more resistant require special attention.  Parents and coaches are encouraged to educate their athletes on preventive practices to avoid the dangers of a serious skin infection.

Signs of a Turf-Related Skin Infection

Two of the most common skin infections associated with turf, both natural and synthetic, are Staph (staphylococcus bacteria) and MRSA (resistant staph).

Staph is one of the most common forms of infections that can develop from a turf wound.  This type of skin infection, also referred to as cellulitis, may or may not result from an open sore/wound.

Possible Symptoms of a Skin Staph Infection include: 

  • An area of tenderness, swelling, and redness
  • Inflammation — redness, warmth, swelling, and pain
  • Fever and sweats, as well as swelling in the area (if the infection has spread)

MRSA is a more serious type of staph infection resistant to many of the antibiotics used to treat staph and other common infections.  These types of infections require special antibiotic therapy.

Possible Symptoms of a MRSA Infection include:

  • General feeling of poor health (malaise)
  • Skin rash
  • Headaches
  • Muscle aches
  • Chills / Fever
  • Fatigue
  • Cough
  • Shortness of breath
  • Chest pains

Treatment of Staph and MRSA Infections

Treatment for Staph infection generally entails a course of antibiotics.  Treatment for MRSA requires a special class of antibiotics or a combination of multiple antibiotics – depending on the patient’s response and the severity of the infection.

Reducing Risks of Skin Infections

The Center for Disease Control (CDC) has outlined the five primary conditions for contracting and spreading MRSA and Staph infection.  Referred to as the Five “C’s”:

  1. Crowding
  2. Contact – frequent skin to skin
  3. Compromised Skin (cuts, scrapes, abrasions)
  4. Contaminated Items (sweaty towels, clothes, mats, synthetic turf)
  5. Cleanliness

For the prevention of skin infections, it is important that athletes:

  • Keep wounds covered and contained
  • Shower immediately after participation
  • Shower before using whirlpools
  • Wash and dry uniforms after each use
  • Report possible infections to coach, athletic trainer, school nurse, other healthcare providers, or parents

Other CDC recommendations addressing MRSA and Staph infection in sports can be found on their website: http://www.cdc.gov/mrsa/community/team-hc-providers/index.html .

References

1.) Meyers MC, Barnhill BS.  Incidence, causes and severity of high school football injuries on FieldTurf versus natural grass:  a 5-year prospective study. Am J Sports Med. 2004 Oct-Nov;32(7):1626-38.

2.) http://www.usatoday.com/story/sports/soccer/2014/10/15/alex-morgan-us-women-artificial-turf-world-cup/17295011/

3.) Begier et al. 2004. A High-Morbidity Outbreak of Methicillin-Resistant Staphylococcus aureus among Players on a College Football Team, Facilitated by Cosmetic Body Shaving and Turf Burns. Clin Inf Dis. 2004;39:1446-53.

(Keywords:  synthetic turf, artificial turf injuries, lacerations, Staph infection, MRSA, sports injuries, skin infections)

Top Hand & Upper Extremity Injuries Prompting ER / Urgent Care Visits

Hand and upper extremity injuries account for over half of the orthopedic injuries seen in an ER or Urgent care center.

Fractures among most common ER/Urgent Care injuries

Fractures among most common ER/Urgent Care injuries

According to a 2012 study published in the Hand journal, the most common region injured is the finger (38.4%), and the most common upper extremity injury was a fracture (29.2%). Specific injuries with high incidence rates (all per 100,000 per year) included finger lacerations (221), wrist fractures (72), finger fractures (68), and lower arm fractures (64). [1]

While home is cited as the most common setting for an upper extremity injury, sports injuries in the field run a close second.

A few of the most common hand and upper extremity injuries include:

  • Contusions and Lacerations
  • Fractures
  • Sprains and Dislocations

Hand and Upper Extremity Contusions and Lacerations

Contusions and lacerations can result from an accident, fall or sports injury.  Both should be carefully assessed, as damage to nerves, tendons and bone may exist.

Contusions

Contusions occur when a direct blow strikes part of the body, crushing underlying muscle fibers and connective tissue without breaking the skin.

Contusions cause swelling and pain, and limit joint range of motion near the injury. Torn blood vessels may cause bluish discoloration (bruising). The injured muscle may feel weak and stiff.

Sometimes a pool of blood collects within damaged tissue, forming a lump over the injury known as a hematoma. Swelling and bleeding beneath the skin in severe cases may cause shock. If tissue damage is extensive, there may also be a broken bone, dislocated joint, sprain, torn muscle, or other injury.

Diagnostic tools used to assess the extent of the damage may include ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT) scans.  For some injuries, testing for nerve injury may also be indicated.  Treatment will depend on the extent of the injury, though RICE (Rest, Ice, Compression, Elevation) is encouraged for contusions until a physician can be seen.

Follow up is important to thoroughly assess the scope of soft tissue damage.  Complications that can occur from contusions include compartment syndrome and myositis ossificans.

Lacerations

Lacerations often result from a cut with a knife, piece of glass or other sharp object. It can be difficult for patients to determine how deep and how damaging a laceration may be.

Concerns include:

  • Length and depth of cut (more than 1/4” deep with visible deep tissue)
  • Visible bone
  • Width of cut and inability to squeeze skin closed
  • Severe bleeding
  • Cleanliness of cut (item causing cut) and possible debris in the wound

An ER or Urgent Care clinic can address these types of injuries, properly cleaning the wound and bandaging and/or suturing (stitching).  Lacerations of the hand and upper extremity should be further evaluated by a specialist to determine if there is damage to surrounding nerves, tendons or other soft tissue.  If unaddressed permanent loss of sensation or range of motion can result.

Hand and Upper Extremity Sprains and Dislocations

Unlike a fracture, sprains and dislocations do not cause a break in the bone.  These types of injuries are usually the result of extreme stretching of the limb, occurring from a twist, hit or fall.  A sprain is a tear (minor or severe) in a ligament, which connects bones.  Symptoms may include pain, swelling, and bruising.

A dislocation occurs when the bones meeting at a joint are disrupted and moved out of their natural alignment.  This is a common injury to the fingers.  Symptoms may include severe pain during movement and an obvious deformity.

While initial treatment will depend on the severity of the injury, most sprains will resolve on their own with RICE (rest, ice, compression and possibly elevation).  A dislocation may require reduction (placing the joint back into proper alignment) and a brief period of immobilization with a splint.  Injuries should be assessed more thoroughly by a specialist to ensure that there is no further damage to surrounding nerves, ligaments or tendons.

 

Hand and Upper Extremity Fractures

Fractures are among the most commonly seen injuries in the ER or Urgent Care setting.

Fracture type can vary and are treated differently in the adolescent child and adult.

Fracture type can vary and are treated differently in the adolescent child and adult.

These types of injuries most commonly occur to the shoulder, elbow, wrist, and hand/finger as a result of a fall onto an outstretched arm or block from a harsh impact.  This is particularly true of sports injuries.

With both the frequency and intensity of youth sports participation higher than ever, understanding the significant anatomical differences between the skeletally immature patient and the skeletally mature patient is also key in properly identifying and treating the variety of musculoskeletal injuries that occur to the hand and upper extremity.

Fracture Type

There are many different types of fractures, all of which fall into one of two categories – displaced and non displaced.  A displaced fracture means that the parts of the bone at the break are not in alignment and require realignment before healing can begin.  A non displaced fracture means that the break did not disrupt the alignment of the bone.

A displaced fracture can sometimes cause the bone to pierce through the skin, which is known as an open or compound fracture.

Because the lining of the bone is thicker in children, diminishing with age, the most common fractures seen in adolescents are non displaced buckle and greenstick fractures (affecting the wrist and forearm bones).  In adults, fractures tend to be more severe – often displaced and comminuted (multiple bone fragments requiring more complicated reassembly). Common fractures seen in adults are wrist fractures (distal radius fractures and scaphoid fractures).

An x-ray will help determine the type of fracture and best treatment.  Initially, most fractures can  be safely splinted and supported with a sling, until an orthopedic specialist is seen.  Prompt followup with an orthopedic physician is important, particularly for displaced fractures.  Most ER and Urgent Care centers will provide patients with a digital copy of their x-ray for followup with a specialist.

Fracture Care

Most non displaced fractures heal well with a period of casting followed by rehabilitation exercises.  Displaced fractures first require realignment, which is known as either closed reduction (non surgical) or open reduction (surgical).  Surgical repair will also include internal fixation with plates and screws to ensure the bone pieces remain aligned while healing.

Close followup with a hand and upper extremity specialist is key for proper healing of fractures and reduced risk of future problems affecting the injured bone and nearby joints.

References

1.) Daan Ootes, Kaj T Lambers, David C Ring. The epidemiology of upper extremity injuries presenting to the emergency department in the United States. Hand (NY). 2012;7(1):18-22.  Published online 2011 Dec 14. doi:  10.1007/s11552-011-9383-z

Ring Avulsion, a Traumatic Finger Injury

Recently talk show host Jimmy Fallon explained to his audience how a seemingly minor fall nearly cost him a finger – shedding light on a rare yet serious finger trauma known as a Ring Avulsion injury.

Ring avulsion results from the mechanism of crushing, shearing and avulsion, inducing severe macroscopic and microscopic damage. This type of injury often occurs when a ring that an individual is wearing is caught on an object, usually during a fall or jump.  It can also occur when caught on fast moving equipment or just simply in a “freak” accident.

Damage from the abrupt and often harsh tug of the caught ring can range from a simple contusion to “degloving” of soft tissue – pulling the skin off circumferentially and stripping away the nerves, tendons and bone. Severe accidents may result in traumatic amputation of the finger.

Ring avulsion can be among one of the most devastating traumatic finger injuries, as often replantation following severe soft tissue damage is not possible – requiring revision amputation.

Fortunately, advances in microsurgery and interposition graft techniques have improved results with ring avulsion replantation.  Patients should see a hand specialist immediately after the injury is identified.

Symptoms of Ring Avulsion

While Fallon knew he had severely injured his finger in his fall, the extent of the damage and seriousness of the injury was not completely revealed until his examination and x-ray.  Prompt attention and surgical care from a specialized hand team fortunately saved his finger.

The severe damage that can occur in a ring avulsion case is not always evident to a patient. Immediate examination and x-ray assessment are necessary.

Symptoms may include:

  • Pain
  • Bleeding
  • Lack of sensation at the tip
  • Disfigurement
  • Finger discoloration or whitening

In severe cases, part of the finger is removed from the bone or completely severed (traumatic amputation).

Diagnosing and Treating Ring Avulsion

When a patient presents with this type of finger trauma, the wound is cleaned and inspected for visible avulsed vessel, nerve, and tendon.  Damaged skin edges are also assessed.  An x-ray may also be indicated before determining the type of avulsion a patient has incurred.  If a portion of the finger is separated, an x-ray is performed on both the amputated part and the remaining digit to fully asses damage and likelihood of replantation.

If there is a separated part, it is wrapped in a saline gauze and placed in a bag with ice water.  The patient is given antibiotics and tetanus prophylaxis.

The injury is then classified using one of several ring avulsion classification systems that exist.  Most commonly used is the Urbaniak Classification system.  The class of ring avulsion (Class 1, 2, or 3) will help determine treatment.

The goal of the hand surgeon is to salvage, maintain function and, if possible, provide an esthetic appearance.

Commonly used classification chart for Ring Avulsion injuries.

Commonly used classification charts for Ring Avulsion injuries.

Avoiding Risk of Ring Avulsion

It is difficult for patients to understand how otherwise inconsequential stumbles or movements can result in the damage or loss of a digit when a ring is involved.  We often forget that the bones and joints of the hand and wrist are small and capable of sustaining just so much force. Skin is the finger’s strongest part.  Once the skin tears, the remaining tissue quickly degloves. Though rare, the potential harm that a ring can pose should be considered – particularly when performing certain extracurricular or sports activities, or when working with machinery. Unfortunately many accidents resulting in a ring avulsion are not anticipated nor could be imagined.  Prompt attention is key to a successful outcome.

References

Flagg SV, Finseth FJ, Krizek TJ. Ring avulsion injury. Plast Reconstr Surg. 1977;59:241–8.

Brooks D, et al. Ring avulsion: injury pattern, treatment, and outcome. Clinics in Plastic Surgery April 2007 ;34(2):187-95, viii.

Fejjal N, Belmir R, Mazouz S El, Gharib NE, et al. Finger avulsion injuries:  A report of four cases.  Indian J Orthop. 2008 Apr-Jun; 42(2): 208–211.

Sears ED, Chung KC.  Replantation of finger avulsion injuries:  A systematic review of survival and functional outcomes.  J Hand Surg Am. 2011;36(4):686-94.

 

Don’t Let Injuries Dampen Your Family’s Fourth of July Fun!

Coast to coast, the Fourth of the July is one of the most celebrated holidays of summer and an opportunity to enjoy every bit of what the outdoor has to offer.  Unfortunately there are thousands of injuries incurred across the United States every year at this time, as a result of firework accidents.

Ensuring family fun this Fourth of July.

Ensuring family fun this Fourth of July.

Unofficially, those at highest risk for firework injuries are teenaged boys.  Adult men closely follow in the second highest risk group, according to reports of ER physicians and orthopedic hand specialists….

It is estimated that over 40 percent of firework injuries occur to the hand and upper extremity.

Injuries most commonly occur when an ignited firework seemingly fails to go off, though explodes when checked – often in a hand.  Other injuries occur from the unexpected heat many fireworks omit.  Even an unassuming “sparkler” can heat to over 2000 degrees, capable of causing 2nd and 3rd degree burns.

The fireworks most implicated in causing injury include small firecrackers, bottle rockets and sparklers, because they are the least feared.

Among the most common hand and upper extremity traumatic injuries caused by fireworks include:

  • Burns
  • Contusions and lacerations
  • Damage to bones, muscle, ligaments and nerves 

Medical Attention for a Traumatic Firework Injury

To avoid permanent damage to the hand and wrist, it is important to seek immediate attention for a traumatic firework injury.

With approximately 50 nerves in the hand, 34 muscles moving the fingers and thumb, over 120 known ligaments, 30 major joints, 30 bones and a myriad of connective tendons, it is imperative that you follow up with a hand specialist following an ER or urgent care visit should such an accident happen.

Hand function and quality of life is dependent on not only immediate care but proper follow up to a hand injury.  If such injuries are not adequately addressed, irreversible nerve and tendon damage can impair hand feeling and movement, and the early onset of osteoarthritis from post traumatic bone and joint damage can further hinder hand function.

Reducing Risks of Traumatic Firework Injury

While many of the tips for reducing risk of hand injury trauma from fireworks seem common sense, they are often lost during the festivities surrounding such holidays and warrant repeating.

  • Ignite all fireworks with extended lighters.
  • Remain a safe distance from ignited fireworks.
  • Allow sufficient time for fireworks to go off / explode before approaching (and handle previously ignited fireworks with an extended apparatus such as BBQ tongs).
  • Supervise young children holding sparklers, advise teens of the heat hazard of these and other small, seemingly harmless fireworks.

Have a happy and safe Fourth of the July!