April 4th, 2008 by Dr. Val Jones in Humor
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Today I attended a lecture given by an orthopedic surgeon. He was in his early 40’s, tall, and athletic in appearance. He spoke about spinal injuries the way a young boy would talk about crashing his toys together – vertebrae were “smashed, crunched, or wrecked” in various ways. He showed the audience various CT scans and x-rays of the neck, and proudly described the hardware he used to fuse spinal segments. Here are some choice quotes from his lecture:
“I think I’m losing my voice. I don’t talk that much at home because I have all girls. Um… so the cement from a kyphoplasty can get into the veins and travel to the lungs, but it’s not like a big clump gets in them or anything. It’s more like little tiny microscopic pieces of cement. You know, they kind of cause bronchio… bronchiec… broncho… broncholectasis or something. I don’t remember. But if your vertebral body is smushed, what are you going to do? It’s just really awesome to stick that balloon in there and blow up the area. With kyphoplasty you get less… whatever that word is… spill of cement
…So with the thoracic spine I come at it from the back because otherwise the heart gets in the way. Also, I use a posterior approach because then I don’t need another surgeon in there with me, and it’s hard to find them on Saturday mornings.
…If you see lateral translation of the spine then you know you’ve torn everything up. I mean, that thing is going to be a disaster zone so you may as well just go in there with all you’ve got. Hey, if you need surgery, you need surgery. But if a high c-spine injury isn’t unstable then don’t immobilize it or it’ll freeze up like an elbow. You won’t be able to do much more than move your eyes.
…And here’s a case of a guy with Tuberculosis in his spine. We opened that sucker up and it just poured out all over the place. It was awesome. He’s totally fine now.”
I was trying so hard not to giggle throughout this “academic lecture.” It was actually kind of refreshing to get the straight scoop on spinal surgery from an orthopedist who obviously loves what he does. But at the same time, I felt strangely nervous…This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 23rd, 2008 by Dr. Val Jones in True Stories
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I just learned a valuable lesson.
A friend of mine described some fluid build up in her knee, made worse by exercise. She said she had seen an orthopedist who recommended surgery… and she wondered what I thought. Based on her description, I assumed that she had an acute knee effusion – potentially from some recent exercise-induced ligament or meniscal damage.
My friend said that she was concerned about having surgery, and that she was planning to have an MRI first. I must admit that I was a little bit confused as to why surgery was recommended so quickly, without having the MRI results to confirm the cause of the effusion (and that surgical correction was warranted). My knee jerk response was to question the clinical judgment of the orthopedist, and to wonder if he was too “surgery happy” and was leading my friend away from conservative measures (of which I am a great fan).
Several weeks passed, and I finally met my friend in person for a quick look at her knee (she was still waiting for the MRI). Guess what? She did NOT have a knee joint effusion at all. What she had was an almond-sized ganglion cyst on the side of her knee.
I felt pretty silly. Of course the orthopedist recommended surgery (a tiny procedure under local anesthetic) without the MRI. He was indeed offering the appropriate treatment.
Sometimes a picture’s worth 1000 words. And sometimes the physical exam can make the diagnosis – no other studies needed.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
December 17th, 2007 by Dr. Val Jones in True Stories
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For more than a decade, I successfully avoided a visit to the orthopedist for a chronic elbow problem. Today I reluctantly decided, on the advice of a friend and orthopod, to go to the hospital and find out once and for all what could be causing my elbows to lock during certain exercises.
The process took 4 hours, all told. I registered at the clinic, then proceeded to the radiology suite to wait for some X-rays. There was a long line of legitimate-appearing X-ray candidates before me – some in casts, others in slings, still others limping pitifully. I was just fine and pain free, feeling a bit guilty – as if I might be wasting resources.
I glanced at the films as I put them in a folder to take back upstairs to the clinic – they looked perfectly normal. “Oh, boy.” I thought, “young Caucasian female complaining of elbow locking for 15 years, now with normal X-rays.” I bet the orthopedist is going to roll his eyes at me. I was escorted to an examining room where I sat on a table across from my normal X-rays, clipped on a light box.
A trim and athletic gentleman in his mid 60’s introduced himself to me. He had crystal blue eyes and short white hair… and disproportionately large hands (kind of the way Michelangelo’s David does). I was sure that I was the healthiest person he’d see that day. He glanced at my totally uninteresting elbow X-rays, took a deep breath and raised a skeptical eyebrow as he asked me to describe my difficulty.
“Well, when I’m at the gym, my elbows lock at about 15 degrees from full extension during certain exercises. It’s always during the eccentric phase of muscle contraction, and usually during a lat pulldown or seated row. If I rotate my forearm there’s a snap and the discomfort disappears and I can resume the exercise.”
He was impressed by the specificity of my description, and asked me to demonstrate the problem. I felt a little bit silly, but attempted to keep a straight face. Seeing that we were not going to be able to reproduce the problem without counter weight, the good doctor jumped in to simulate the exercise by pulling on my arm. I pulled back, and we soon realized that he was unable to apply a force strong enough to trigger the problem. In fact, I pulled the poor man off balance and nearly dropped him on the floor.
After a few more maneuvers he concluded that he had no idea whatsoever what the problem might be. He told me that since the X-rays were normal there was probably nothing to worry about, and that I might consider avoiding lifting weights in “clanky gyms filled with smelly, sweaty people.”
He dictated his note in front of me, highlighting my excellent health, unusual strength, and completely benign X-rays. He seemed to relish the whimsy of the fact that he was no physical match for me (a smallish blond woman) and added that I was unlikely to be damaging my elbows at the gym.
His advice, as I had anticipated, was to “stop doing the things that trigger the locking” and to consult him if I developed any neuropathic pain or effusions. He added that I reminded him of his daughter.
Well, it was an amusing interaction – but somewhat unsatisfying. It made me think of all the times that I wasn’t sure what was wrong with my patients, and how disappointed they were when I had to tell them this. Medicine is an inexact science at times – and the best that we can do is rule out the really bad stuff, and shrug when the rest remains unclear.
Have you had a problem but couldn’t find a diagnosis? Do tell…This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
August 31st, 2007 by Dr. Val Jones in Health Tips
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Have you ever had a strange cramp in your foot (between your big toe and the next one or in the ball of your foot) after wearing flip flops all day? Do you get sore calves or pain in the bottom of your feet?
Flip flops seem comfortable and easy to wear (I like them because they don’t pinch wide feet) but they actually create more work for your foot and leg muscles than regular shoes. You may not realize it, but when you wear flip flops your toes must grip them extra firmly to keep them from sliding off or sideways. So you actually contract many extra toe muscles (like the adductor hallucis and the flexor hallucis brevis) with each step you take. Wearing flip flops for long hours can give you actual cramps in these muscles and others.
In addition to muscle cramps, flip flops have no arch support so your calf muscles and Achilles tendon have to work extra hard and can become sore. And finally, the lack of support can strain your plantar fascia (a thin rubbery band on the bottom of your foot), causing pain at its point of origin on the heel bone.
So if you’re having foot pain or muscle cramps – it may be caused by too much flip flopping. Of course, the cure is simple: wear comfortable shoes with good arch support and sturdy straps. Luckily for you, summer is almost over and your feet may recover naturally as you pack up the flip flops and pull out the work shoes.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
April 2nd, 2007 by Dr. Val Jones in True Stories
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Continuing on with the car accident theme… A patient came to see me in the clinic. She had been run down by a bike messenger (could it have been my friend with the bleeding leg?) when attempting to step out of a bus onto a cement curb. She had a lot of pain in her shoulder and side, and was taken to the ER where a chest XRay was unremarkable. She was released with a prescription for extra strength Tylenol.
Still in pain, she made an appointment at the hospital’s orthopedic clinic for the next available time slot (she was covered by Medicaid) where she met with a young resident who suspected that she was a drug seeker and sent her away with “reassurance” and more Tylenol.
The woman, knowing that if she came back to the clinic again, she’d probably see a different physician (and could therefore get a second opinion) – made another appointment. The next orthopedic resident read her chart (where the previous resident had written that the patient exhibited drug seeking behavior) and barely listened to the woman’s story. But after the patient insisted he do something, the orthopedist did what most do with “chronic pain patients” – send them to the rehab doc.
And so, nearly 6 weeks after the accident, I met the woman in the rehab clinic. I had read the ortho notes prior to seeing the patients and was nearly convinced from their descriptions that she was a belligerent, drug-seeking nightmare.
The woman was thin and irritable. I asked her why she had come to see me, and she said she thought I was going to do some physical therapy with her. I asked if she could recount the events in her own words, and explain what exactly was troubling her. As the story unfolded, I was saddened by what she described – the endless frustration of being in pain, of being bounced around from one young physician to another in clinics overflowing with patients, and of being labeled as a drug seeker. And all this after a very painful encounter with a hit-and-run bike messenger.
I asked her to describe her pain and point to it exactly. She said it had been slowly improving, but that it hurt most when she breathed in and there was some point tenderness over her 8th, 9th, and 10th ribs. I asked her if she had had a rib series… nope just a chest XRay.
I told the woman I thought it was likely that she had fractured her ribs, and that rib fractures are often hard to see on XRays, especially chest XRays. I also told her that there wasn’t any real treatment for rib fractures, except pain management and time to heal. Her face lit up.
“So you believe me? I’m not crazy?”
“Sure I believe you,” I said. “I’ve fractured ribs in the past and I know how painful it is. When it happened to me no one believed me either. My chest XRay was normal.”
“So what did you do about it,” the patient asked, looking at me compassionately.
“The truth is, I had to sleep sitting up for a week or so, and I breathed very shallowly for a while. Eventually, though, the pain went away on its own.”
“Thank you for listening to me, doc,” she said, tears welling up in her eyes. “Even though there’s nothing I can do about the ribs, I’m glad to know what the pain is from, and that I’m not crazy.”
I wrote a short note in the chart, documenting my impressions. I did not recommend physical therapy for the patient, but to follow up if needed.
Apparently, the woman had one more clinic appointment with the orthopedic team. They read my note and ordered a rib series to confirm the diagnosis. The rib series showed healing fractures of ribs 8, 9, and 10.
I never saw the patient again, but I’m quite sure that explaining her diagnosis was the most therapeutic thing that we did for her.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
