Is it October yet? Part 3: Bob Baun

This is the third (and last) in a series of posts looking at historic hockey injuries, intended to keep me busy and you interested while we wait for October to get here.

The history was provided by Jen aka @NHLhistorygirl. Jen is a librarian and graduate student at the University of North Dakota in the last stage of her MA in history: writing her thesis on the 1972 Summit Series, media, and notions of national identity.

Badass Bobby Baun

The history…

Bob Baun is not afraid of pain. During Game 6 of the 1964 Stanley Cup Final, he was hit in the ankle by a Gordie Howe shot. He continued playing, but when he circled to clear the puck from the zone, he heard an audible pop and went down.

The trainers carried Baun off the ice on a stretcher, and an examination of the ankle in the dressing room revealed major swelling and a large welt. Baun insisted the trainer inject painkillers and tape the leg to keep the swelling down. With his leg wrapped from foot to nearly his knee, Baun squeezed back into the skate and finished the period.

For whatever reason though, the painkiller wore off quickly, and so Baun needed several more shots. When he returned to the bench in overtime after one of the shots, coach Punch Imlach was sending Carl Brewer and Kent Douglas onto the ice. Baun took Douglas’ place, caught the pass from Bob Pulford, and scored the game winner, tying the series with Detroit at 3-3.

On the train back to Toronto, Baun knew his leg was broken. Imlach knew it too, ordering Baun to see the team doctor at 9 am the next morning. Rather than see the doctor and sit out Game 7, Baun packed an overnight bag and went to a friend’s farm to hide out. He refused to even tell his wife where he was.

After almost two days of hiding, rest, and ice, Baun appeared at Maple Leaf Gardens 30 minutes before Game 7, because he knew that was “too late for them to check me out and stop me from playing.” He suited up and played a shift or two in the 4-0 victory over the Red Wings. He wasn’t allowed to celebrate much, as he was sent almost immediately to hospital, where x-rays revealed a jagged fracture immediately above the ankle, in the fibula.

The medicine…

As broken legs go, fibula fractures are among the most interesting, and yet they get the least attention. Poor fibula fractures. No respect.

Fibuwhat?

The fibula. It’s that other bone in your lower leg. The one you don’t think about. It’s not part of your shin, it doesn’t bear much weight, and when it breaks it doesn’t look anywhere near as spectacular as a broken tibia. It’s also fairly scrawny.

Tibiwho?

The tibia. It’s the bone in your lower leg that you know and love. It’s your shin. It’s the weight-bearer. It’s the one you whack on the coffee table in the dark. When it breaks, it’s generally pretty obvious, and pretty gross.

Anterior (front) view of the right leg

The question is how Bob Baun could last two days and a hockey game with a broken leg. The answer is because it was his fibula that was broken, and because he was an enormous badass. Generally when you break your lower leg, you break the tibia, or the tibia and fibula (which we call a tib-fib fracture because that sounds cooler). The tibia and fibula are attached together by a flat ligament (the interosseous membrane), which is why they’re frequently broken together. In Baun’s case, the isolated lateral force from Howe’s shot resulted in just a fibular fracture.

Treatment

Fibular fractures are fairly easy to treat assuming they’re not open (bone poking through skin), displaced (bone going somewhere it shouldn’t), or comminuted (bone broken into multiple pieces). The first order of business is pain control. Bones are covered by periosteum, a membrane that has the distinction of being lousy with pain receptors. That would be why broken bones hurt so much (SCIENCE!).

Since the fibula is non-weight-bearing (or minimally weight-bearing – a distinction we won’t get into, but that orthopods love to fight about), simple fractures are treated with a cast for the first two or three days, and a pair of crutches if needed. That gives you time to get into the ortho office, where they’ll put you in a walking cast or a cam walker, which you can buy on Amazon, but probably shouldn’t.  They’ll also take away your crutches if you’re still using them. After three to four weeks of immobilization, the cast comes off, and a splint is used on an as-needed basis for exercise. Athletes can generally return to light training after just a few weeks, but full recovery is a six- to eight-week process. Sports that consist of a lot of twisting and trauma to the leg (like hockey or soccer), however, can require a much longer healing period (as much as 18 to 24 weeks) in order to prevent refracture.

As with any injury, the healing process for fibula fractures is helped along by physical therapy, consisting of strengthening exercises and getting yelled at.

The Take-Home

Basically, Bob Baun was a complete animal. He had a fracture that you can walk on, but broken bones HURT. He sucked it up and hid out so he could play in game 7. Smart decision? No, probably not. Understandable? Yes, probably.

Oh, and in case you weren’t aware – hockey season starts again soon. I know, I know, I’m excited too. Many thanks to Jen for collaborating on this series!!!

Kesler: Terrible hip pun available on request.

The Vancouver Canucks announced today that interview-bombing center Ryan Kesler has had a successful repair on his hip labrum. Kesler is no stranger to hip injuries, having had a labrum repair once already in 2007. Frantic googling and help from @ArtemChubarov via @BotchonCanucks seems to indicate that the repair in 2007 was on the right hip, and today’s procedure was on the left.

 

What’s a hip labrum?

Back it up. First let’s look at how the hip is built. The hip joint is a ball-and-socket joint, which is exactly what it sounds like. There’s a socket on the side of the pelvis, and a ball on top of the femur (thigh bone) that fits in there. The femoral head (the ball) and the acetabulum (the socket) are both covered in cartilage. The cartilage provides cushioning as well as allowing the bones to articulate – bone on bone doesn’t slide too well (and hurts like a bitch). In addition to the articular cartilage of the bones that make up the hip joint, there’s a ring of fibrous cartilage around the outside of the acetabulum (that’s the labrum) that adds to the stability of the hip joint. The labrum deepens the socket, provides extra surface area to spread out the load the hip is carrying, and essentially provides a seal around the joint that keeps the femoral head in place (with help from a whole lot of ligaments).

 

The hip joint

 

So how do you tear your labrum?

Labral tears are common in sports with a lot of hip flexion (that’s the motion you get when you pull your leg up to your chest), external rotation (rotation of the leg so the toes point out) and twisting (duh). The usual culprits are hockey, soccer, dance (not a sport, I don’t care what the IOC says) and golf (the twistiest of the twisty sports).

 

Oh look, hip flexion.

 

How do I know if I’ve torn my labrum?

The most common symptom of a torn labrum is hip pain – most often in the front of the hip. There can also be limitation of range of motion of the joint, as well as joint weakness, clicking, catching and locking. Frequently labral tears go undiagnosed for a while (typically as much as two years), as the symptoms can be very non-specific and there’s usually not one particular incident that the patient can identify as the cause of the injury.

When Kesler had his hip problem in 2007, he was having issues with joint stiffness and locking, and was said to have been unable to walk up a flight of stairs prior to his repair. This time the Canucks revealed after the playoffs ended that he’d been playing with a hip injury sustained in game 5 of the series with the Sharks. Kesler had been trying to avoid surgery with therapy, but team management and medical staff decided that a repair now was better than compounding problems later.

The diagnosis is usually made with an MRI, although in 2007 Kesler’s hip was diagnosed with an MRI arthrogram – where dye is injected into the joint.

 

So how do you fix a labrum?

The definitive treatment is surgery, and there are several options. Depending on the extent of the damage, it could be as simple as an outpatient arthroscopy (little cameras poked through little holes) to trim off the torn cartilage. Other options would be a repair using sutures or other anchoring devices (similar to what we saw in Huselius’ pectoral repair). The worst case scenario involves damage to the articular cartilage, and not just the labrum. In that case, there could be a need for what’s called microfracture surgery – where small holes are drilled in the bone underlying the cartilage, stimulating the growth of new cartilage. Microfracture requires no weightbearing for 6 to 8 weeks after the procedure, and 4 to 6 months before a return to play can even be contemplated. The worst WORST case scenario would be a total hip replacement.

 

Torn labrum

 

In the picture above you can just see the smooth femoral head on the left, and the labrum hanging off the acetabulum (which the probe is hooked around). This is bad.

 

What’s ahead for Kesler?

It takes about 4 to 6 weeks for the repaired cartilage to really re-attach to acetabulum. Generally you’d be looking at anywhere from an 8 week to 6 month recovery time, but Kesler came back in only 10 weeks last time (only to break his finger 3 days later). The earliest you could reasonably expect him to be back would likely be mid to late October.

It’s also a safe assumption that Kesler’s injury and surgery won’t be keeping him from his finely-honed interview bombing techniques.

 

Torn pectoral? Gross, dude.

Want to know what it takes to gross me out? This:

Gross.

That’s Scott Howson, GM of the Columbus Blue Jackets. I could easily fill a post on the subject of how kickass it is that there’s a GM on Twitter (solid PR move, Columbus), but let’s talk about the pectoralis major and what happens when you tear it (other then me getting grossed out).

Pectoralis Major (aka the pec, pec major, moobs, etc.)

Pectoralis major

Pectoralis major is the muscle that makes up the bulk of what your personal trainer calls your pec. You’ve got one on each side, and if you’ve ever benched too much, then you know exactly where they are.

The pec originates at the sternum, clavicle and aponeurosis of the external abdominal oblique, and inserts on the bicipital groove of the humerus.

Huh?

The pec is connected to the sternum, collarbone, top of the abs, and the upper arm.

That’s better.

It has several jobs, mostly involving shoulder movement (and holding your arm on), and the NCAA guide to “Ice Hockey Officials’ Signals” will illustrate them nicely:

Arm flexion

Arm flexion: In order to get your hands up in front of you to signal cross-checking, you’d first have to raise them up in front of your body. That’s arm flexion.

Arm adduction

Arm adduction: To signal kneeing, you reach across your body and slap the opposite knee. To do this you have to adduct your arm (the opposite of raising it away from your body to the side).

Medial rotation of the humerus

Medial rotation: Delay of game? Well, actually this isn’t really close. Imagine your arm is bent at the elbow with your hand pointed straight in front of you. Rotate your arm so that it’s across your chest (like you’ve got it in a sling). That’s medial rotation.

Deep inspiration: The NCAA can’t help me here. If you take a really deep breath, the pectoralis helps expand your chest.

Assorted scapula (shoulder blade) jobs: Flex your pec and you’ll have a better idea of what it does to the shoulder blade than I could possibly explain.

Holding your arm on: Obviously your arm is connected to the rest of your body by a lot more than your pec, but it definitely contributes. The tendon that attaches the pec to the humerus (upper arm) is about 2 inches wide – that’s not insignificant where tendons are concerned.

The Injury

Pectoralis tears aren’t exactly common, which just as well because they’re painful and take a long time to heal. The tear generally happens during the bench press, and results in sudden pain, swelling, bruising, and a dimple above the armpit (from the missing muscle). This is a gross injury on a lot of levels – there’s horrible pain, your arm stops working properly, and many patients who’ve had this injury say they actually heard their muscle tearing when it happened.

Two thirds of pec tears involve pulling the tendon off the humerus. The rest are scattered amongst pulling off one of the other attachments, or rupture of the pectoral muscle itself (which is thankfully uncommon).  Since rupture of the tendon that holds the pec to the arm is the most common, that’s what we’ll be looking at.

The Repair

The best results are achieved with a quick repair. Older or sedentary patients can be managed conservatively and non-operatively, but since the majority of these injuries occur in athletes, they’re almost always repaired surgically. The repair involves opening the shoulder, scraping what’s left of the tendon off the bone, and re-attaching the severed end of the pectoralis tendon. Traditionally the repair was done by drilling holes through the humerus and threading suture through the holes and the end of the tendon.  Recent research has shown that you can get as good a result using absorbable sutures threaded onto an anchor that’s screwed into the bone (which is a far easier surgical technique).

Anchor suture

The suture takes years to be absorbed, and maintains full strength for 5 months – plenty of time for the tendon to heal to the bone.

The Recovery

The ugly part of this injury (other than hearing your own muscle ripping) is the recovery. After surgical repair, it can take four (more likely six) months to get back to pre-injury activity:

  • The first four weeks: The patient has to stay in a sling and isn’t allowed to bear weight or move their arm in any of the ways the NCAA refs are showing us above.
  • Weeks four to six:  Simple range of motion exercises start – they’re allowed to move the arm, but not to lift it up or twist it away from the body, as these movements put too much stress on the tendon.
  • Six weeks post-op: The sling comes off and all range of motion is permitted.
  • Eight weeks post-op: Isometric training begins – no weights, just contraction of the muscles by pushing or pulling a fixed object. I’m bored just thinking about it.
  • Three months post-op: Light resistance training begins.
  • Four months: Heavy training begins.
  • Six months: Full activity resumes.

As with any major injury, it can take a long time to feel good again. The same study that looked at absorbable sutures found that at fourteen months post-op all patients were happy with their result.

What this means for Kristian Huselius

He’s in for a long, long rehab. He could be back mid-November at the earliest, more likely early January. He may not feel right or play to his fullest for a year. On the other hand, he could heal quickly and be fine. This is one of those injuries that would be a bad idea to rush back with (honestly, there’s no good injury to rush).

Things I didn’t mention, and will spend very little time discussing

Steroids: Yes, steroids can weaken tendons. No, this is no way means Huselius was using them. Tendon rupture with steroid use is frequently seen in older patients taking steroids for other reasons (like respiratory problems), and the rupture is usually atraumatic (i.e. it just happens out of nowhere). Jumping right to a steroid conclusion here would be stupid. Don’t do it.

Pectoralis minor: Pec minor is a tiny version of pec major that lives directly underneath it. It attaches to the underside of the scapula (shoulder blade) and the top few ribs. Its job is to hunch the shoulders forward. Boooooooring. That’s why I didn’t bother discussing it.

Many thanks to the NCAA refs for beautifully demonstrating the actions of pec major.

- Jo

Mason Raymond: So you’re an expert?

After Mason Raymond’s hit from Johnny Boychuk in game 6 of the Stanley Cup final, nobody could have been more surprised than I when he left the ice on his feet after what seemed like several minutes of face-down on-ice discussion with a Vancouver trainer. When a player goes down (and stays down) for that long, we’re used to seeing them stretchered off in full spinal immobilization.

The purpose of full spinal is to keep the spine still (amazing, I know). It involves being strapped to a hard plastic spine board with your head held completely still looking straight ahead (or straight up, as is the case once you’re laying flat on your back). There’s an algorithm used to decide who needs full spinal precautions – at its simplest it’s a question of whether there’s potential for a head, neck, or back injury. Is there neck pain? Spine board. Head injury? Spine board. Penetrating injury that could compromise the spine? Spine board. Too drunk to stand up and fell off the porch/bicycle/moped/roof of your brah’s SUV? Spine board.

So the question is why Raymond left the ice on his feet. There are actually several reasons this could have been completely appropriate, despite what Twitter’s many, many experts seem to believe. I kicked off a Twitter explosion the likes of which I hadn’t previously seen with two simple tweets:

Lots of criticism for skating Raymond off. Trainers aren’t stupid, guys. Guarantee they tried to get him on a spineboard and he refused.

And as if that weren’t enough expert-bait, I followed it up with:

So let’s give up the “Skating him off is malpractice!”. Were you there? Are you an expert? Cue Andy Sutton.

Now let’s back it up just a bit and take a look at the hit:

 

The first thing worth noticing is that Raymond doesn’t seem to lose consciousness. He’s also moving his arms and legs. Next, he and Canucks head trainer Mike Burnstein actually spend a full minute in discussion before Kesler and Higgins help Raymond up and off the ice. In an injury situation a minute is a really, really long time. Usually the way it goes is you get the equipment you need, get the patient on it, and get the patient out. You know what situation usually gets in the way of keeping things moving? Arguing. My suspicion is that Burnstein was doing his best to convince Raymond to get on a board, and ultimately couldn’t do it. That wasn’t malpractice, Vancouver’s trainers are experts, and I’ll gladly explain why.

The Algorithm

To be clear, there are two types of spinal clearance algorithms. The kind that determines if an injured person needs to be on a spine board at all (used in the field by EMS, athletic trainers, and other first responders) and the kind emergency physicians use to determine if someone with a spinal injury can come off of the spine board, and if they need imaging (x-rays). I’m talking about the first algorithm. Let’s walk through it.

1. The patient gets injured. The ambulance gets called.

2. Spinal exam: Do they have neck and/or back pain? This can be on movement or palpation.

3. Neuro exam: Are there any focal neurological deficits? Examples would be numbness, tingling, weakness/inability to move.

4. Mechanism of injury: Is it significant? “Significant” is different just about everywhere. Several state EMS formularies define it as such (and yes, most of these relate to motor vehicle crashes):

  • Ejection from the vehicle
  • Death in the same passenger compartment
  • Fall greater than 15-20 feet (or some places use twice the patient’s height)
  • Vehicle rollover
  • Vehicle vs pedestrian
  • High-speed collision
  • Motorcycle crash
  • Unconscious or altered level of consciousness following injury
  • Penetrating injury to head, neck, torso

Common sense (and the more clever formularies) add axial loading to this list. An axial load is a force applied to the head that causes spinal compression (or loading). Think of someone jumping into a pool and hitting their head on the bottom. The Canadian Journal of Emergency Medicine did a nifty little study wherein they found that in non-car-crash incidents, you’re at greatest risk for a spinal fracture with axial loads, falls, diving accidents, and motorized non-car vehicles (ATVs, snowmobiles, etc – If anyone’s interested I have a great rant about why you should stay the hell away from those evil, evil, contraptions).

5. Impairment: Is the patient impaired (ie. by drugs/alcohol)?

6. Distracting injuries: Does the patient have any painful injuries that might distract from their spinal issue? For example, if your leg is hanging off, we’re probably not going to spend time discussing whether you need a spine board.

If you answered yes to any of those questions, the patient needs to be immobilized. Problematically, some people still refuse. Even more problematically, those people are often sober and intelligent.

Okay, so what do you do if someone needs to be put on a spine board and they refuse?

Well, contrary to what the Twitter experts believe, you don’t force them. You explain to them the consequences of their actions. You beg. You plead. You might bully a little bit. You might even threaten just a touch. Have I ever told someone that by refusing treatment they could die? You bet. Have I had a patient actually die as a result of refusing treatment? Almost. It’s hard to understand just how completely useless you feel trying to explain to an unwilling patient that you’re trying to help them. So let’s spend a moment in Mike Burnstein’s shoes, and in Mason Raymond’s skates.

In Raymond’s case, he’s just hit the boards ass-first in one of the most important hockey games he’ll ever be a part of. Maybe he’s in pain, maybe he isn’t. Spinal compression fractures are tricky little beasts – usually they’ll present with midline back pain, but they can also present with pain in a completely unrelated area (the lateral back, buttocks, hip, etc.) or no pain at all.  Since none of us are Mason Raymond, none of us know where or if he was hurting. There’s no way of knowing what his neuro exam was, but he was definitely moving his extremities after he went down. As far as mechanism goes, the video of the hit makes it look like there was probably an axial load from Boychuck driving him into the boards. Did Burnstein know that? Probably not. Did Raymond know that? If you’ve ever taken a hit (or been in a car wreck, or had any kind of sudden trauma) you know that even if you aren’t knocked out, you’re usually not able to immediately describe the mechanics of what happened. And let’s be honest – Raymond probably didn’t care what the mechanics were. More than likely he just wanted to get back up and keep playing.

Given Burnstein’s extensive training and experience, you have to assume he was trying to get Raymond on a board. Any assertion that he doesn’t know what he’s doing or committed malpractice makes about as much sense as trading Chara for Daigle (which is actually kind of a dumb example since that actually happened). To soothe the Twitter experts, why don’t we go ahead and define medical malpractice, just so it’s clear why Burnstein’s actions don’t qualify.

Malpractice: There’s more to it than you think.

Medical malpractice may vary from state to state, province to province, and country to country. I’m not a lawyer, so don’t expect any complex legalese here. This is just an overview of what’s involved. There are four requirements for a charge of medical malpractice:

  • Duty to act: This is the care provider’s responsibilities within his job/training. In Burnstein’s case, as the head trainer he has a duty to respond to and treat injuries to players. His level of training allows him to recognize Raymond’s injury and then to direct that he be immobilized and transported to the hospital. That’s assuming Raymond consents to the indicated treatment (we’ll look at consent in a second – that’s significant in this case).
  • Breach of duty: A breach occurs when the provider fails to provide the care that’s indicated (and permitted by his level of training). If you want to argue that Raymond needed immobilization (which it’s safe to say he probably did), then you may also want to argue that Burnstein committed a breach of duty. I’ll argue that he didn’t, under the assumption that Raymond wouldn’t consent to immobilization.
  • Injury resulting from the breach: Failure to provide the indicated treatment causes injury to the patient. This is hard to argue either way in this case. Raymond broke his back when he hit the wall. There’s no way to say if skating off the ice made it worse.
  • Damages: This refers to emotional distress or monetary loss – i.e. if someone didn’t receive the indicated treatment and as a result was unable to work. The damages must be as a direct result of the breach of duty. In this case you’d be hard-pressed to argue that there were any damages. Yes, Raymond will miss ice time, but his injury was from hitting the wall, not from skating off the ice. And as I just said, it’s impossible to know if skating off made it worse. Most significantly, damages don’t exist unless there’s a plaintiff to claim them. There can’t be malpractice unless Raymond makes a claim for it.

So is Burnstein guilty of medical malpractice? No. Clearly not. If you’re not convinced, then maybe a quick discussion of consent will help.

Consent: Wherein medical providers would rather not assault people.

In order to administer treatment to a patient, a health care provider must first obtain that patient’s informed consent (unless the patient is unable to provide consent and the treatment is absolutely required, in which case consent is implied). Informed consent consists of informing the patient of:

  • Their diagnosis (to the best of the provider’s knowledge at that time) – In Raymond’s case, it would be as simple as Burnstein telling him that he could have a back injury.
  • The treatment or procedure that’s indicated and its risks/benefits (spinal immobilization to prevent any movement in the spinal column).
  • Any alternative treatments and its risks/benefits (not really applicable here).
  • The risks/benefits of refusing the treatment (Risk: making it worse. Benefit: full spinal is uncomfortable).

If your patient doesn’t consent to the treatment and is in possession of their faculties (not drunk, not high, not a minor, not head injured, etc), and you treat them anyway, then you’ve just committed medical battery. That’s a real thing, and people get sued for it. It’s defined as violating a patient’s rights to direct their medical treatment, and involves the unauthorized touching of a patient. Health care providers are acutely aware of what they can and cannot do, and assessing a patient’s ability to make an informed decision is a skill that comes with time and experience. Any Twitter expert assertion that “They should have just made him get on the spine board!” is frankly ignorant. It’s never that simple. You can’t just make someone do something.

Trying to paint the Raymond incident in black and white strokes isn’t possible. There are a lot of factors involved, and screaming malpractice doesn’t make sense. Yes, Raymond broke his back. Yes, he should have been immobilized. The long and the short of it is that Burnstein knew that, and more than likely tried to make it happen. In the end he had to get Raymond off the ice and into treatment, and when he was transported to the hospital it was reportedly in full spinal immobilization.

Still not happy? The Globe and Mail had a few experts of their own opine on the incident, among them a spinal surgeon and a physiotherapist. You’ll notice that one of the physicians in the article states that “…the team should err on the side of caution and insist he be taken off on a stretcher” – didn’t I say something about this not being black and white? Again this comes down to one’s ability to convince/cajole/bully the patient into doing what’s appropriate. In Raymond’s case, it seems like it just didn’t work.

Raymond’s Injury

Raymond suffered a compression fracture of the L5 (lumbar aka lower back) vertebrae. Per Vancouver GM the fracture is through the belly of the vertebrae, which is to say the big fat round part in the front.

Here’s what’s broken.

These fractures can be managed through injection of special cement into the vertebrae, or surgery to immobilize the bone from the inside through the placement of plates or rods, although this is generally a last resort.  Most often this is treated with a back brace to immobilize the spine, pain medication, time, rest, and physical therapy. The brace generally used in injuries like Raymond’s is the TLSO (thoracic-lumbar-sacral orthosis) brace, which you can conveniently buy on Amazon (although you probably shouldn’t).  Raymond is expected to miss 3 to 4 months.

In case you have no idea what the Andy Sutton reference is all about, here you go. I will never, ever tire of this.  Ever.

- Jo

It’s just a numb leg. I can skate it off.

Time heals all wounds.  Actually, it’s time, physical therapy, medication, possibly surgery, and not pushing yourself for no reason.

In a show of truly spectacular self-defeatism, talented hockey players will often push themselves to come back before their body is ready.  How often do we hear about someone “Playing through it”?  And why are some injuries somehow more acceptable to play through than others?  Nobody would expect a player to suit up after an eye injury or a giant laceration (helloooooo Malarchuk), but this year we saw player after player limping through the playoffs on injuries that should have had them out for the duration.  Was Dany Heatley really contributing more by playing with a broken hand and a high ankle sprain than he would have by packing it in for the season?  Was that one point in the Western Conference finals worth the pain?  If you asked him he’d probably say yes.  How about Steven Stamkos – he hurt his shoulder in the Pittsburgh series, and played through to the Eastern Conference finals where he tallied seven points.  So absent of my sneaking suspicion that Stamkos is basically infinitely better than Heatley (sorry, Sharks fans), for him it probably was worth it.

Stamkos: He is tougher than you.

Daniel Alfredsson was the perfect example this year (and last) of playing with injuries that should have put him in the press box.  Ottawa Senators fans scratched their heads and wondered what was wrong as their captain’s point production dropped off towards the end of the 2009-10 season.  After the Sens were eliminated in the first round of the playoffs (as usual) by the Pens, Alfie admitted he’d been playing with a sports hernia since February (which isn’t really a hernia, but groin pain caused by any number of different injuries in the…  ahem…  area).  He still finished the season with 71 points, more or less on par with his usual production.

This year Alfie only played 54 games, and finished with 31 points – the fewest games and points he’s put up since he started with the Sens in 1995-96.  The problem this time was a back injury that he tried to fight through, and to which he finally conceded defeat in early February.  He admitted he’d been having weakness in his right leg, and today Ottawa GM Bryan Murray made the following statement:

“Daniel will have surgery on Friday.  He’s done a lot of rehab.  He felt to continue his career at the level he wants to, it’s the right thing to do.  It’s just to relieve a little pressure on the nerve that has taken away some of the strength in his leg and affected his skating and overall game, obviously…  It was a decision that he, during the latter part of the year and the off-season now, was hoping that he wouldn’t have to have.  I guess the fact the nerve is touching and being affected … in particular on the left side of his body … that he felt it was the right thing after much thought.”

Let’s go ahead and overlook the fact that all the interviews earlier this year said the problems were in the right leg, and discuss this injury, and the surgery that will (hopefully) fix it.

Theory: The stress of carrying around so much hair destroyed his spine.

The Injury

Although the interviews disagree on which leg was affected, the common thread is that Alfredsson has a lower back injury that’s causing one of his legs to be weak, tingly, and “heavy”.  Murray said today that there was pressure on a nerve that needed to be relieved.  The best way to understand why an injury in the back is affecting the leg is to learn a little something about the spine and dermatomes.

Whatatomes?

The nerves that make up the spinal cord exit the vertebrae through little canals called intervertebral foramina and proceed on to whatever part of the body they’re responsible for.  Those parts are very specific, and beautifully demonstrated by this fellow:

Best Halloween costume ever: A guy dressed up like dermatomes.

Each zone on the dermatome map represents the area that the specific listed nerve innervates.  So if you hurt L4 or L5, the top of your foot will suffer for it.

Your spine isn't this pretty. Sorry.

You have 24 vertebrae, plus 9 more that are fused to form the sacrum and coccyx (which make up the back wall of your pelvis).  The vertebrae are lettered and numbered according to where they are.  From the top, you’ve got

  • Cervical (neck) C1-C7
  • Thoracic (midback) T1-T12
  • Lumbar (lower back) L1-L5
  • Sacral (S1-S5 – fused) and coccygeal (also fused, don’t have a fancy letter, but have the distinction of being the oft-whacked tailbone).

The spinal nerves are named for the associated vertebra.  Those among you who are clever (or smartasses) have probably already noticed that although you have seven cervical vertebrae, there are eight cervical spinal nerves.  Feel free to impress girls at (nerdy) parties with the following bit of spine trivia: The spinal nerves exit the vertebral column above the associated vertebral bone until nerve C8 – the first one to exit below the bone (specifically vetebra C7) – cleverly paving the way for an extra nerve.

Bored yet?

The vertebrae are cushioned by discs, which are tough cartilage rings around a jelly-like center.  It’s a great design – they’re shock absorbers, allow for movement, and hold things together.  Unfortunately, they can also get badly out of place and cause awful symptoms.

When good discs go bad…

Injury or aging can cause discs to go to new and exciting places (that you’d rather they didn’t visit).  You can have a disc bulge – where the outer cartilage ring sticks out (usually posteriorly) from between the vertebrae and can put pressure on spinal nerves (or the spine itself).  A bulge can become a herniation, where the outer cartilage ring loses integrity completely and the jelly-like inside protrudes.  These injuries are best seen on MRI, like so:

Spot the disc bulges!

 

These are disc bulges at L3 and L5 – very common places for this type of injury.  This particular injury was the result of lifting a fat drunk kid out of a deep ditch in the rain after he drove mommy’s Lexus off the road.  But I’m totally over it.  Obviously.  I actually got lucky – I’ve been able to stay functional with exercise, responsible NSAID use, and being smart about lifting – let the fire department do it!  Kidding.  Sort of.  Not really.

If you look at the information available, it should be clear to you at this point that Alfredsson most likely has a disc bulge or herniation that’s pressing on one of his lumbar nerve roots.  He tried rehabbing the injury for a long time, and in fact there’s good data to show that non-surgical treatments are usually very effective for this sort of injury.  Pain control, steroids to relieve inflammation and physical therapy can bring relief in the majority of patients.  The exception is patients who have symptoms exceeding 6 weeks despite appropriate treatments, specifically those with neurologic deficits – Weakness, sensory deficit (numbness), and tingling.  This is Alfredsson’s picture.  Obviously he tried far longer than 6 weeks to avoid surgery, which was smart.  He also made loud noises after the all-star break about wanting to come back and play out the end of a dismal season, which was dumb.  There was no point, and there would have been a risk of worsening the injury.

FYI…

According to the World Health Organization, spinal manipulation (chiropractics) in the setting of a disc herniation is contraindicated.

The Surgical Fix

If Alfie does indeed have a herniation that’s pressing on a spinal nerve root, the likelihood is that he’ll be having a discectomy of some sort.  The operation is exactly what it sounds like – part of the disc is removed.  First a laminectomy is performed, where a tiny portion of the lamina (part of the vertebra) is removed to allow access to the disc and nerves.  The actual disc surgery can be done as an open procedure (cut the back open, remove part of the disc), percutaneously (through a small incision in the skin – less effective than open), or as microdiscectomy – where the surgeon operates using a special microscope allowing for more precise cuts and thus less damage to surrounding tissues.    A retractor holds the nerve roots out of the way while a device called a rongeur (what’s labeled here as ‘grasping device’ removes the offending disc tissue.  This should relieve the pressure on the nerve, allowing a return of strength and relief of pain.  The material that’s removed in surgery will eventually fill itself in with new disc material.

 

Discectomy Overview
A study out of Dartmouth cleverly called SPORT (Spine Patient Outcomes Research Trial) showed that patients with lumbar herniations showed significantly more improvement in pain and functionality with discectomy than patients who used non-surgical interventions.  Remember – these are the people with symptoms that persisted longer than six weeks with neurological problems and failure of non-surgical treatment.

After the surgery patients are encouraged to get up and walk as soon as possible, and physical therapy is started two weeks post-op.  It consists of stretching, strength training, and all the usual torture PTs put patients through (I love PTs, but they’re giant bullies – just ask one).

 

What we learned…

 

Alfredsson took from February until June to decide that he needed back surgery.  Although I admire his attempts to keep from being operated on, the research shows that if he was still having symptoms after 6 weeks he would have been better off just having the discectomy.  Did his hesitation stem in large part from his clear (and often-stated) desire to come back and play at the end of the season?  Probably.  With any luck, he’ll be looking at about a 6-week recovery, which puts him back in action at the end of July.  This should have him good to go for training camp on what is widely seen as likely his last season with the Sens.

 

- Jo

 

Eye injuries: From “No big deal” to “HOLY S*%T” Part 2

After years of scraping accidents off highways, there’s not much that skeeves me out any more.  There are a few exceptions: Beer vomit, stringy snot, snaggleteeth, and eye injuries.  Just in case you’re of a like mind, here’s your warning:  Gross pictures ahead.

What better time to explore the “HOLY S*%T” side of eye injuries than with the news that Manny Malhotra has been cleared to play just in time for the Stanley Cup finals.  The exact nature of his eye injury was never made clear, but he’s undergone two eye surgeries since the injury on March 16th, and may require a third in the offseason.  He’s also made it clear that he’s changed his view on the subject of vision protection:

“I realize the importance of it now,” he said. “I’ll wear the full face shield for the rest of this year and see what my comfort level is with different pieces of equipment.”

Manny Malhotra, eye surgery expert.

Having already looked at injuries to the surface of the eye, it’s time to look at their more serious, grosser cousins – blunt and penetrating eye injuries.

What’s in there?

There's a lot crammed into a little space

First, the contents of the eye.  At the front is the cornea, the clear covering that gets scratched when you don’t take care of your contacts properly (and you can get eye fungus, so don’t do that, okay?).  The iris is the coloured part of your eye, the pupil is the black bit in the middle (and isn’t really a thing per se – more like a hole), and the lens is the lens (duh) which focuses light (and thus images) on your retina.  The retina lines the inside of the eye and translates what you’re seeing into information your optic nerve takes to your brain.  The macula is a little spot near the center of the retina that’s responsible for central high-definition vision.

The largest part of the eye (the posterior chamber)  is filled with vitreous humour, a thick jelly-like material that helps the eye maintain its shape.  The front of the eye (the anterior chamber) – the space between the cornea and the lens – is filled with aqueous humour, a less viscous liquid that also serves in a shape-maintaining capacity.  Aqueous humour is constantly being produced in the eye and draining out via the vasculature.  Vitreous humour is a little more boring, pretty much just sitting there.

How much blood can the eye hold, anyway?

Like most things in your head, the eye is plenty vascular.  Also like the head, it’s basically a closed system.  The upshot?  If something in your eye is bleeding, there’s not really much of anywhere for the blood to go.  Let’s assume you’ve taken a puck in the eye, and the impact has torn a blood vessel in the anterior chamber.  You’re likely to end up with a hyphema – the fancy word for an anterior chamber full of blood.

Hyphema - Blood in the anterior chamber.

Hyphema can cause pain, light sensitivity, and vision disturbances.  The treatment depends on how severe it is.  A mild injury may heal on its own with rest, an eye patch (to protect the eye and make you look like a cool pirate), sleeping with your head elevated, and painkillers.  A serious injury can cause a rise in the intraocular pressure either by occupying space with blood, or through inflammation to the area where the aqueous humour drains.  Either way this is an emergency, and may require surgery to drain the blood out of the eye.

Careful, you’ll detach your retina!

Since the retina’s job is to receive the input from the lens and pass it along to the optic nerve, it stands to reason that it’s absolutely packed with nerve tissue.  Nerve tissue needs a blood supply to stay alive, and the blood supply comes from the back of the eye.  So it’s not hard to understand why a detached retina is an emergency – if the retina isn’t attached to the back of the eye, it’s not getting the blood supply it needs, and nerves will die (translation: vision loss).

A blow to the eye will briefly change its shape.  Remember the eye is filled with vitreous humour, which is attached to the retina at the optic disc (the area where the optic nerve enters and exits the eye).  If you change the shape of the eye, you’ll move the vitreous around, and this can result in traction on the retina.  The retina is thin and delicate, and traction will tear it.  It can also tear at sites of direct impact on the surface of the eye.  A retinal tear is bad enough, but when you add the fact that the vitreous takes advantage and starts seeping in between the retina and the back of the eye, you’ve got a serious problem.

This is bad news.

 

Retinal detachment comes with a scary set of symptoms – floaters, flashers (those are self-explanatory), shadows in the peripheral vision, and sudden vision loss.  Treatment is surgical – draining the fluid out from behind the retina, and attaching it back to the inside of the eye.  This can be done by laser (scarring the retina in place), freezing (same idea), instilling a gas bubble that sits over the tear (but the patient has to stay in a certain position – usually face down – for up to two weeks), or a vitrectomy – where the vitreous is actually removed from the eye and replaced by gas or silicone oil.  Gas will eventually be replaced by new vitreous, but oil must be removed with a later surgery.  Retinal detachment surgery has very high success rates – some sources quote numbers as high as 90%, although often requiring more than one procedure.

 

It’s all fun and games until…  You know.

One of the most obvious and impressive eye injuries is a ruptured globe.  That’s exactly what you think it is – a popped eyeball.  It’s not hard to figure out the mechanics between blunt or penetrating trauma and a ruptured eye.

 

Ruptured globe

 

Ruptured globes cause pain (obviously), vision disturbance (obviously), and may result in permanent vision loss (again, obviously).  The treatment is immediate surgery, assuming the eye can be saved.  The surgery is pretty straightforward – the patient gets a crapload of antibiotics, is anesthetized, and the holes in the eye are sewn shut after any foreign bodies are removed.  That’s a pretty heinous oversimplification, but the details of suture size and how you close each layer aren’t very exciting.  An injection of salt solution into the eye both restores the shape of the eye and tests whether the repair is waterproof.  More antibiotics are injected under the conjunctiva (the white of the eye), and the patient gets yet more antibiotics (topical and IV) as well as topical steroids.  Globe ruptures often go hand-in-hand with retinal detachment – either when the injury occurs or later on as vitreous sneaks under the retina.

 

The moral of the story…

It’s certainly possible to regain full vision after an injury like these, but of course it’s entirely dependent on the nature of the injury, how quickly it was repaired, and plenty of other factors.

Wouldn’t you rather get a Stamkos-esque nose laceration than a Malhotra or Berard-esque eye injury?  As we learned in an earlier post, visor use may result in facial lacerations of greater severity, but overall results in decreased injury to the face.  The simple truth is that while I’m pretty fantastic at sewing up your face, I’m not very good at fixing your eye.  You can guarantee that any NHL game will have a doctor on site who can stitch up your face.  There may or may not be an opthalmologist on staff, but the odds of a fully functional opthalmologically-outfitted OR are firmly parked at zero.  Your face can be repaired.  Your eyes?  Maybe.  Maybe not.  Hell of a chance to take.

 

- Jo

 

 

 

Phaneuf v Moser, aka What Not To Do With An Unconscious Guy

Video of Dion Phaneuf’s hit on Simon Moser at a Canada/Switzerland match at the IIHF worlds is making the rounds today. Phaneuf delivers a solid hit, Moser gets up. Once on the bench, Moser passes out, and Hockey Expressen says it was because he “swallowed his tongue”.

STOP.

That doesn’t exist. Some freaky people can do freaky things that involve freaky tongue gymnastics. Granted. In this case, however, what the video shows is poor management of an unconscious patient. Let’s watch, shall we?

What do you notice there? An unconscious guy that some dude is holding upright while his head flops back. That makes my inner paramedic cringe in horror. While you can’t technically swallow your tongue, it can block the hell out of your airway. Especially if some Swiss dude is holding you upright while you’re unconscious. The thing about unconscious people is they can’t do a little thing we like to call “protecting your own airway”. ie. keeping things out of there – your tongue, vomit, etc. In fact, the most common cause of airway obstruction in unconscious patients is the tongue. And here’s why:

Throat Anatomy

Your tongue is huge. When you’re unconscious, you’re not in control of voluntary muscles like the ones in your tongue and lower jaw. So if you’re upright, on your back – or in any position that lets gravity take over – your tongue is going to slide back and occlude your airway. You don’t swallow it. To wit:

Sneaky bugger.

So how do you keep this from happening? Well, if there’s no chance of a spinal injury, you’d roll them onto their side into something called the recovery position:

The right thing to do with an unconscious dude/dudette

The patient needs to be on their side, head extended, limbs positioned to keep them stable. The point of this is that the tongue won’t slide back, and vomit will drain out, not down. If there is a question of spinal injury, then someone will hold c-spine (a hand on either side of the head to maintain the head, neck and spine in a straight line) until the patient can be secured in full spinal precautions (which the Slovakian paramedics in the video have on their stretcher), and you can still roll them onto their side. Carefully.

So what should the Swiss trainer have done? Get Moser on the ground. You can pass out from trauma, or you can pass out from things that deprive your brain of adequate oxygen – things like hyperventilating, vagal nerve stimulation (remember Bush choking on a pretzel?), low blood pressure, and standing up too fast (ask any skinny girl about this). Moser was not immediately knocked out by the hit, so it’s possible one of these things took him out. Best way to get blood (and thus oxygen) to the brain? Get the brain on the same level as the heart and it won’t have to pump so hard. If the loss of consciousness was due to some kind of head pathology (like bleeding or concussion), lying him down is about 500% better than trying to haul him upright and letting his head flop around.

Take home points:

- Your tongue will block your airway given half a chance.

- Unconscious people can’t protect their airway.

- The recovery position is good.

- Protect the c-spine if there’s any question of injury.

- Slovakian paramedics have jazzy red jumpsuits and it takes four of them to run a call.

- Everyone should take CPR. Stat.

Jo

ps – the recovery position is also ideal for people who’ve passed out drunk. Nobody wants barf in their lungs. Scientific fact. Nobody.

What makes YOU so smart?

I never claimed to be smart. Okay, I actually probably have. Okay, honestly I know for a fact I’ve made that claim. Modesty, however, I probably wouldn’t own up to.

After nearly a decade of schlepping stretchers and scraping mistakes off of interstates as a paramedic, going to medical school seemed like a good idea. I traded my time dealing with the Friday night urban gun and knife club for time in the anatomy lab and the OR. I also decided my 30s was a great time to learn how to play hockey, a direct contradiction to my claims of being at all intelligent.

Now here I am almost a doctor, a completely terrible right winger, and I find myself very interested in the place where medicine and hockey meet. What the hell is a lower body injury, anyway? Why does one guy take a hit from behind and come back in the same game, where another is gone for months? Where do all those teeth go?

Injuries during play, hockey health policies and equipment issues are always at the forefront of discussion by the media and its fans. If you’ve been looking for a blog that discusses all of these topics and more, you’ve come to the right place.  Stick around, there’s plenty more to come.

- Jo

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