Hughston

Health 6262 Veterans Parkway P.O. Box 9517 ColumbusAler GA 31908-9517 t VOLUME 14, NUMBER 1 www.hughston.com WINTER, 2002

Cervical Spine Side view Bird's-eye view Injuries in Olympic Athletes Spinal cord Nerve roots Vertebral Vertebral facet facet Although Olympic athletes are ligament among the best trained and achieve the highest state of physical conditioning, they are still susceptible to sport-related injuries. When these well-conditioned athletes subject their musculoskeletal systems to the extreme physical requirements of Olympic competition, they increase the risk of injury to their cervical spine (Fig.1). Normal anatomy of a Approximately 10,000 severe cervical vertebra cervical spine (neck) injuries occur annually in the United States, with Fig. 1 about 1,000 of these injuries resulting from sport-related events. Olympic- level athletes share the rare but of severe cervical spine injury. For High-velocity events, such as potentially catastrophic risk example, in the fall of 2001, German downhill skiing, ski jumping, and ski coach Markus Anwanda toboggan racing, carry a greater risk underwent spinal surgery after he for cervical spine injury than lower- Inside This Issue: sustained spine and head injuries in a velocity events, such as ice hockey, collision with World Cup champion figure skating, or curling. Hand and Wrist Injuries Regine Cavagnoud. Tragically, Cavagnoud, a French Olympic Cervical sprain or strain Surviving SCA hopeful, died from her head injuries The most common cervical two days after the accident. condition occurring in the athletic Collagen Implants Many Winter Olympic sporting and nonathletic populations is the events have an increased risk of muscle sprain or ligament strain. Frostnip / Frostbite cervical spine injury because of the Symptoms from cervical sprains or strains include localized (restricted to Winter Hydration speed at which the athlete travels and the potential for contact with other one area) tightness on one side of the athletes or the surrounding terrain. neck that is associated with pain and Page 1 FOR A HEALTHIER LIFESTYLE limited motion in the neck. This condition often becomes noticeable 12 to 24 hours after an injury. This A. Cervical facet B. Cervical condition is known by many as a syndrome radiculopathy "crick" in the neck. It usually subsides with ice or moist heat, gentle Spinal cord stretching exercises, and anti- inflammatory medications, such as Vertebral aspirin or ibuprofen. Athletes with facet cervical sprains or strains are rarely limited from returning to their sport.

Cervical facet syndrome A more serious cervical sprain or strain affects the small facet joints that connect one cervical vertebra to another. Cervical facet injury occurs when the joint capsule and spinal ligaments are stretched and the small Vertebral facet ligament tear muscles that attach to the vertebra are strained (Fig. 2A). Symptoms include localized neck pain; pain that extends to the shoulder, arm, or upper back; Herniated disc limited movement; and, sometimes, Fig. 2 headaches. The symptoms often occur immediately after a traumatic injury, occurs because the nerves that patients with cervical radiculopathy. such as a sudden neck rotation in a extend from between the cervical Surgery is reserved for those patients whiplash injury or sideways bending vertebrae provide sensation and whose symptoms persist beyond this that can occur from a fall. Physical trigger movement in these areas. An point. Return to sport is possible when therapy or chiropractic treatments and injury near the root of the nerve can the athlete’s symptoms resolve and anti-inflammatory medication or cause pain at the end of the nerve, nerve function returns to normal. muscle relaxants will usually resolve where the sensation is felt. Patients the symptoms of cervical facet often feel relief by holding the Transient quadriplegia syndrome. affected extremity over their head, Transient quadriplegia results from a taking pressure off the irritated nerve more serious but temporary injury to Cervical radiculopathy root. X-rays of the cervical spine the cervical spinal cord. Nerve Cervical nerve root impingement rarely show the source of the pain; dysfunction can occur in one or both (pinching of the cervical nerve) results however, the magnetic resonance arms, one or both legs, all four from a disc herniation (a protruding imaging (MRI) scan, a test that extremities, or an arm and leg on the disc) or from a nerve entrapped shows soft tissue, can easily confirm same side of the body. Patients can between bony structures (Fig. 2B). the diagnosis. Cervical traction and a have numbness or pain, with or Forced hyperextension (extension brief dose of oral corticosteroids to without weakness, or complete beyond normal limits) of the cervical reduce inflammation and analgesics paralysis. The typical episode of spine or axial (rotation around a to relieve pain are usually effective transient quadriplegia lasts less than 15 straight line) loads can contribute to treatment. Athletes with signs and minutes but can take up to 48 hours this condition. Symptoms include symptoms of cervical radiculopathy to gradually resolve. There is localized pain or pain that extends (sensory or motor abnormality), such complete return of motor function from the neck into an extremity. For as numbness or weakness of a limb, and sensation and full, pain-free range example, an injury to a vertebra or are closely monitored by their of motion of the spine. When this disc in your neck could cause pain, athletic trainer and physician. dramatic condition occurs, the athlete numbness, or weakness in your Improvement usually occurs within 2 should be treated with all the shoulder, arm, or hand. This condition to 3 months in 65% to 70% of precautions for a cervical spine injury, Page 2 FOR A HEALTHIER LIFESTYLE including immobilization of the head are able to return to competitive Hand and Wrist and neck and transport to an sports once their symptoms improve. emergency facility. X-rays and MRI However, patients with cervical spine Injuries in Winter can reveal the presence of a fracture, fracture with resulting instability, disc herniation, or congenital (present those with congenital narrowing of Sports at birth) narrowing of the central the cervical spinal canal, and those spinal canal. However, the imaging who have had surgical fusion rarely Snow and ice can be hazardous studies are usually normal in transient return to competitive sports because enough, but add speed to the quadriplegia. Once an athlete has of the risks of reinjury to the cervical equation, and the chance of injury experienced an episode of transient spine. increases considerably. With or quadriplegia, there is a 40% chance without speed, most hand and wrist of a second episode. As long as there Thomas M. Bernard, Jr., M.D. injuries occurring in winter sports are is no evidence of abnormal motion Columbus, Georgia caused by falls. It’s not surprising that between the vertebrae or spinal cord we injure our hands, thumbs, fingers, compression, athletes are allowed to Further Reading: and wrists because when we begin to return to sporting activities without Vaccaro AR, Watkins B, Albert TJ, Pfaff WL, totter or stumble, we automatically try Klein GR, Silber JS. Cervical spine injuries in increased risk of permanent nerve athletes: current return-to-play criteria. to break the fall with our hands. injury. Orthopedics. 2001;24:699-703. Unfortunately, breaking a fall with an outstretched hand can lead to Cervical spine fracture Corcoran T, Cantu R. Transient quadriplegia. strained or torn ligaments (tissue Spineline. 2000;Nov/Dec:11-12. Athletes with high-energy trauma to connecting bone), fractures, and the head or neck must be assumed to Max J. Prehospital care of the spine-injured contusions. have a cervical spine injury until athlete. A document from the Inter-Association proven otherwise. Proper Task Force for Appropriate Care of the Spine- Skier’s thumb management begins on the scene Injured Athlete. National Athletic Trainers’ Injury to the thumb ligament has with examination and treatment of Association, 1998. become one of the more common these patients by emergency skiing injuries over the past 20 years. personnel, such as athletic trainers. Although they are rare, catastrophic cervical spine injuries during athletic Skier's thumb events require prompt treatment to prevent further nerve injury and to Metacarpus improve the chances for recovery. Nearly 50% of patients with acute Metacarpophalangeal spinal cord injury have other joint significant skeletal or organ injuries. The radiographic evaluation of these patients includes x-rays, computed tomography (sectional x-rays), and MRI to confirm the presence of a cervical spine fracture or other injuries and to determine fracture Phalanx stability. Many cervical spinal fractures are treated with a neck brace, while some patients with unstable injuries and persistent symptoms require surgery. Ulnar collateral Return to sport ligament Most athletes who sustain a minor cervical strain, cervical facet syndrome, or cervical radiculopathy Fig. 1

Page 3 FOR A HEALTHIER LIFESTYLE It ranks second only to knee sprains. Ice-skating falls injury. By then, the healing process Skier’s thumb is a strain or tear to Ice-skating injuries usually are the causes the fracture line to widen, the thumb's major stabilizing result of a fall, rather than a collision, making it more visible. If left ligament—the ulnar collateral and beginners are much more likely untreated, a scaphoid fracture can ligament of the metacarpophalangeal to be injured than experienced lead to chronic pain in the wrist and joint of the thumb (Fig. 1, pg. 3). The skaters. As for skiers, a lesson on how the inability to extend the wrist ulnar collateral ligament assists us in to fall will greatly decrease the risk of backward. grasping, pinching, and stabilizing items in our hands. Injury to the thumb while skiing usually results Ulna Scaphoid fracture from a fall on an outstretched hand Radius that continues to hold the ski pole. At impact, the thumb is driven directly into the snow and is bent back or to the side, away from the palm and index finger, straining or tearing the ligament. When injured, the ulnar collateral ligament and other ligaments cannot support the thumb bone, making grasping or pinching with the thumb difficult. Thumb injuries require evaluation to establish the correct diagnosis and initiate proper treatment. Physical signs include pain, swelling, and tenderness on the inner side of the metacarpophalangeal joint and loss of Scaphoid fracture strength in the thumb. X-rays should be taken to rule out damage to the bone. Sometimes, a small piece of Fig. 2 the bone is torn off with the ligament. Treatment for a torn ligament usually injury. A common injury that occurs Prevention is the best protection consists of a brief period of wearing a while ice skating is a wrist fracture. against winter injuries. Being in splint or cast for immobilization. The wrist is often fractured during a shape and having the proper Occasionally, however, with complete fall on an outstretched arm. In this equipment can help to reduce tears or displacement of the ligament, position, the arm remains straight and injuries, but learning how to fall surgery is required to repair the the wrist takes the full force of the fall. correctly and safely can be your best injured ligament. Long-term problems A physician should examine a bet for preventing injury. can result from instability of the person with severe wrist pain after a thumb. With proper treatment, fall, and x-rays should be taken to rule David C. Rehak, M.D. however, the patient can regain full out a fracture. While the two bones Columbus, Georgia function and return to activity. in the forearm, the radius and the To avoid injury, skiers can use ulna, are the most likely to fracture, it various types of safety devices that is also possible that the small bone in Further Reading: include strapless poles with a hand the wrist just behind the base of the Morgan WJ, Lowman LS. Acute hand and wrist protection device, or an already thumb, the scaphoid bone, can injuries in athletes: evaluation and injured thumb can be protected with fracture. A scaphoid fracture is management. J Am Acad Orthop Surg. gloves that have built-in splints. The difficult to find even with x-rays 2001;9:389-400. best protection, however, is skiing because the fracture line is very fine American Society for Surgery of the Hand. The lessons that help you learn to fall (Fig. 2). If wrist pain persists after a Hand: Primary Care of Common Problems. properly. negative x-ray, then the wrist should 2nd ed. St. Louis, MO: Harcourt:2000. be x-rayed again about 10 days after Page 4 FOR A HEALTHIER LIFESTYLE Surviving Sudden (AED) can restore the chaotic heartbeat as police, firefighters, flight attendants, caused by ventricular fibrillation if it is security guards, and other lay rescuers, Cardiac Arrest used early enough. A bystander who who have been properly trained. witnesses the onset of SCA can save a Having more people in the community Approximately 1,000 Americans die life if an AED is available and if the each day from sudden cardiac arrest chain of survival is followed. (SCA). The condition is caused by life- What is the chain of survival? threatening arrhythmias, which are The critical difference between life abnormalities in the heart’s electrical and death for a victim of SCA can be system. SCA occurs when the heart’s measured in minutes. Each minute of electric signals are disrupted, causing delay in returning the heart to its the heart to stop beating or to quiver normal pattern decreases the victim’s Automated (ventricular fibrillation). During cardiac chance of survival by 7% to 10%. The External arrest, the heart is unable to pump chain of survival is a 4-step process Defibrillator blood through the body to the brain that effectively directs at-the-scene (AED) and other vital organs. Usually, an SCA emergency care in the first moments of victim loses his or her pulse, then SCA to increase the patient's chances of trained to use an AED in response to a consciousness, and finally the ability to survival. breathe. Without immediate treatment, medical emergency will greatly the victim almost always dies. 1. Early activation increase SCA survival rates. The SCA is not the same as a heart attack. The first step in the chain of survival is American Heart Association and the Although a person suffering from a to recognize the emergency and call Red Cross recommend that AEDs be heart attack often develops an 911. Anyone who is unresponsive made available to nontraditional abnormal heart rhythm and SCA, there should receive emergency care, and rescuers and placed in public areas is a difference. A heart attack occurs regardless of the condition causing it, such as airports, malls, businesses, and when blood flow to the heart is will benefit from activation of the chain government buildings. blocked, causing damage to the heart of survival. 4. Early advanced care muscle. Before and during a heart 2. Early CPR The final step in the chain is early attack, most victims complain of chest, advanced care. Emergency arm, abdominal, or jaw pain. In The next step is to begin cardiopulmonary resuscitation (CPR) management service personnel addition, a heart attack victim usually continue basic life support and further remains conscious, whereas an SCA immediately. CPR circulates oxygen- rich blood to the victim’s brain and defibrillation, if necessary. They can also victim always loses consciousness. SCA administer medications to help the has no warnings, and is unpredictable, other vital organs. Whenever possible, one person should stay on the phone heart maintain a normal rhythm while and although preexisting heart disease the patient is transported to a hospital. is a common cause, many victims have with 911, while one or two others perform CPR. SCA can happen to anyone at any never had previous heart problems. time. To increase the survival rate in Coronary artery disease is often the 3. Early defibrillation the victims, AEDs should be readily source of SCA. In an athlete 35 years In step 3, an AED is used to accessible in public areas. Having an old or younger, the most common administer an electric shock through AED in one’s home and workplace cause of SCA is an unknown cardiac the chest wall to the heart. Its built-in would also drastically increase the abnormality. A rare cause of cardiac computers can assess the patient’s heart survival rate in those who are at a arrest that often attracts media attention rhythm, judge whether defibrillation is higher risk for SCA. is commotio cordis, or cardiac needed, and then administer the shock. To learn more about AEDs and how concussion. Commotio cordis is caused Audible or visual prompts guide the you can be trained to carry out the by a blunt trauma to the chest that user through the process. chain of survival, visit the website of the interrupts the heartbeat, such as when An AED strengthens the chain of American Heart Association at an athlete is hit in the chest with a survival because it can restore a www.americanheart.org or the Red baseball. The most common cause of person’s normal heart rhythm. The new Cross at www.redcross.org. SCA, however, is ventricular fibrillation. portable defibrillators are designed to An automated external defibrillator Glenn C. Terry, M.D. be used by nonmedical personnel, such Columbus, Georgia Page 5 FOR A HEALTHIER LIFESTYLE Collagen Implants swelling, and occasional giving way manufactured by ReGen Biologics, and locking of the knee. The blood Inc. (Franklin Lakes, NJ), and is only For Meniscal supply aids in healing these injuries. available to patients participating in The blood supply is good around the the study. The CMI is made of bovine Regeneration outside rim of the meniscus, which (cow) collagen and is a biocompatible aids the healing process; however, (compatible with living tissue), the interior portion of the meniscus resorbable (absorbed by living tissue) Each year, nearly one million has a minimal blood supply. Because material that is arthroscopically Americans injure a meniscus in their of its poor blood supply and inability (surgery through small incisions in the knee. The menisci (plural of to repair itself, an injury to the inner skin) sewn into the area where the meniscus) are crescent-shaped portion of the meniscus usually meniscus tissue is missing. Once in wedges of tough, fibrous tissue that requires a meniscectomy, or removal place, the CMI provides a scaffold or of the damaged bridge onto which the body’s own or torn part of meniscus cells can begin to migrate Femur the meniscus. and form new meniscus tissue. Over Menisci Without the time, as the regeneration takes place, protection of the body naturally absorbs the CMI, the meniscus, leaving the new meniscus tissue. The Bird's-eye view the knee joint CMI provides an alternative to the of knee joint can become removal and permanent loss of unstable, and meniscus tissue that occurs during a the articular meniscectomy. Menisci Collagen cartilage To be eligible to participate in the Tibia implant covering the CMI research study you must be Back of knee femur and tibia between 18 and 60 years of age and may begin to have had at least one but no more deteriorate, than three previous surgeries resulting in involving the meniscus in your knee. degenerative Candidates will be examined and Ligaments osteoarthritis evaluated by participating physicians (“wear-and- before entering the study group. tear” arthritis). You can find more information If a torn about the CMI research study on the meniscus is ReGen website at causing www.regenbio.com, or call Cynthia symptoms, it Wolfe, clinical coordinator for the should be Hughston Sports Medicine treated. In Foundation, for more details at (706) years past, 576-3333. act as cushions between the ends of surgeons often removed the entire the femur (thighbone) and the tibia meniscus. We now know that this Ashley Holloway, M.S. and fibula (lower leg bones). Each practice can also result in Columbus, Georgia meniscus acts as a shock absorber and osteoarthritis, so today, only the torn helps to protect the articular cartilage portion is removed. Further Reading: that covers the ends of the femur and Currently, physicians at 13 sites in Rodkey WG, Steadman JR, Li ST. A clinical tibia. The meniscus also assists in the U.S., including the Hughston study of collagen meniscus implants to restore lubricating the joint and stabilizing the injured meniscus. Clin Orthop. Clinic, are involved in a study to the knee during rotation. 1999;365S:S281-S292. determine the safety and The meniscus can tear during effectiveness of the collagen meniscus Stone KR, Steadman JR, Rodkey WG, Li ST. sudden twisting of the knee or from implant (CMI) as an alternative to Regeneration of meniscal cartilage with use of a blunt or repetitive forces. Injury to collagen scaffold. Analysis of preliminary data. J removing the meniscus. The CMI is the meniscus can result in pain, Bone Joint Surg Am. 1997;79:1770-1777. an investigational device Page 6 FOR A HEALTHIER LIFESTYLE seldom causes permanent tissue Rapid rewarming, similar to what Be Aware of the Cold! damage. should be done for frostnip, is Treatment of frostnip focuses on important, as well as getting indoors If you are not careful, cold weather rewarming. Apply steady, firm as soon as possible. If available, a can be dangerous to your face, ears, pressure with a warm hand or blow warm (not hot) water bath can thaw fingers, and feet. Whether you are on the affected area with warm the affected area quickly and outside exercising or hunting or a breath. If the fingers are affected, thoroughly. Try to maintain body spectator at a sporting event, you hold them in the armpits. DO NOT temperature with warm, nonalcoholic need to consider not only the air RUB! Rubbing the skin can cause drinks. temperature, but the wind chill factor friction, which can lead to additional Deep frostbite is very serious and as well. The wind chill factor is the injury to the tissue. After the skin affects the skin and deeper tissues combined effect of the air thaws, it may turn red and tingle, and and sometimes bone. The hands and temperature and wind speed on the peeling may occur. If the tissue has feet are most commonly involved. body's heat loss. For example, a 40°F been damaged, it may be sensitive to The skin is pale, cold, solid, and day with 15-mph wind translates into re-exposure to the cold and require numb. As the skin begins to thaw, it a wind chill temperature of 22°F more protection than before. turns purplish-blue and can be very (Table). In the cold, you are in painful. Large blisters may appear. jeopardy because your skin and the Frostbite Depending on how long the skin tissues below the skin’s surface are Frostbite is a more serious cold remains frozen, there is a chance of made up of cells that contain water. injury than frostnip. It can occur in permanent tissue damage and In freezing temperatures, the water temperatures of less than 44°F. Think gangrene (tissue death). Emergency in the cells can freeze and the cells of it as similar to a burn, in that cold treatment with immediate transport can die. Frostnip and frostbite are two can kill skin tissue in the same way to a hospital is vital. problems that can result from that heat does. Protect your skin from the cold and prolonged exposure to the cold. Superficial frostbite affects the skin wind. Pay particular attention to the and tissue just below the skin’s ears, nose, cheeks, chin, fingers and Frostnip surface. The skin is pale, waxy, cold, toes—areas that are vulnerable to Frostnip is a whitening of the tips of and firm to touch. There may be extreme cold. Dress warmly in loose the ears, nose, cheeks, chin, swelling, and blisters may form. The layers. Wear a hat pulled down over fingertips and toes—parts of the body skin may throb and burn for a long the ears, and consider a hat with a that are often left unprotected. It is time. It may remain red and facemask. Wear gloves or mittens and slow to develop, usually painless, and permanently sensitive to the cold. socks made of wool or down. Choose fabrics that are good insulators and that do not lose their ability to insulate when wet. Wear loose-fitting socks and shoes to avoid cutting off the circulation to your feet. Be mindful of the dangers with exposure to cold temperatures and wind. Be smart, and take the necessary precautions for protection and prevention. When in doubt, seek prompt medical attention.

Teri LaSalle, MS, PT, ATC Jackson, Mississippi

References: Arnheim D, Prentice WE. Principles of Athletic Training. 8th ed. St Louis, MO: Mosby Inc;1993. Schenck RC, ed. Athletic Training and Sports Medicine. 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1999. Page 7 FOR A HEALTHIER LIFESTYLE Editor A Fluid Winter David C. Rehak, M.D. Managing Editor Dennise Brogdon In the crisp dry air of winter, our skin often becomes dry and cracked. The Art Director evidence of winter’s harshness is clearly visible on the outside, but imagine Rick Sargent, M.S.M.I. what happens to us on the inside. Fluid intake is always an important health Editorial Board issue during the summer heat, but it is actually just as important during the Thomas N. Bernard, Jr., M.D. Carol M. Capers, M. S. M. I., C. M. I. cold, dry winter months. Clark H. Cobb, M.D. We need just as much fluid in the winter as we do in the summer. When William C. Etchison, M.S. our bodies are exposed to extreme temperatures–hot or cold–fluids help us Bruce A. Getz, ATC Steve Haywood to maintain a normal body temperature. During winter activities, we often Ashley S. Holloway, M.S. wear layers of clothing that heat up our bodies, causing water loss through Charles H. Keaton, FACHE, CEO Teri LaSalle, M.S., P.T., ATC perspiration. Even when we don’t exercise, our bodies use fluids to digest James Mullennax, P.T. food, absorb nutrients, lubricate joints, and process waste. We need to regularly replace the fluids our bodies consume. These fluids Suggested readings and classic can come from a variety of sources. Of course, drinking water will do the references for articles contained trick, but we can also enjoy a nice warm bowl of soup before a meal, drink a in this issue can be found at cup of hot chocolate or warm apple cider, or dine on an assortment of fresh www.hughston.com fruits and vegetables. Beware of highly caffeinated beverages and alcohol because they are diuretics, which promote urination. Instead, enjoy a hot Health Hint cup of caffeine-free tea or coffee. This winter, as you reach for the hand lotion to soothe your dry skin, Washing your hands is the single remember that your inside needs moisture too! healthiest thing you can do. You should wash your hands after using the bathroom, before eating and drinking, after petting an animal, The Hughston Health Alert is a quarterly publication of the Hughston Sports Medicine Founda- and anytime you handle raw tion, Inc. The Foundation’s mission is to help people of all ages attain the highest possible standards of musculoskeletal health, fitness, and athletic prowess. Information in the Hughston Health Alert meat.To wash away germs, use reflects the experience and training of physicians at The Hughston Clinic, P.C., of physical therapists warm water, apply soap and lather and athletic trainers at Rehabilitation Services of Columbus, Inc., of physicians who trained as well for 15 to 20 seconds, rinse residents and fellows under the auspices of the Hughston Sports Medicine Foundation, Inc., and of research scientists and other professional staff at the Foundation. The information in the Hughston hands thoroughly, then dry, and Health Alert is intended to supplement the advice of your personal physician and should not be turn off the water with your arm. If relied on for the treatment of an individual’s specific medical problems. you are in a public restroom, turn Special written permission is required to reproduce, by any manner, in whole or in part, the material herein contained. Send inquiries to Medical Writing, Hughston Sports Medicine Founda- off the water with a paper towel tion, Inc., P.O. Box 9517, 6262 Veterans Parkway, Columbus GA 31908-9517 USA. and then use the paper towel to Copyright 2002, Hughston Sports Medicine Foundation, Inc. ISSN# 1070-7778 open the door.

Hughston Health Alert P.O. Box 9517 Columbus GA 31908-9517

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