The Quiet Room: The Week of Weird Injuries

 

Hey, look! More stuff on the Backhand Shelf! This week I’m looking at some injury weirdness around the league – Chris Higgins’ infected foot, Marty St. Louis’ broken face, and Patty Wiercioch’s throat-puck.

Aaaaaand Rick DiPietro is hurt. Again. Poor Rick.

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.

 

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

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