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Monday, March 31, 2014

Painful Ankles...to X-Ray or NOT?

Image: http://www.bmj.com/content/326/7386/417

This month I am talking a bit about bone fractures and x-rays. As we try to "do no harm" in medicine, leading physician groups have been taking a closer look at procedures that have become automatic, and determine whether or not they are medically necessary- do they IMPROVE outcomes? One such procedure involves imaging ankle injuries. Both clinicians and patients often expect that a painful joint needs an x-ray as part of a thorough evaluation. When SHOULD we order an x-ray for a painful ankle? Current evidence suggests the answer to that question- at least for adults- lies in the "Ottawa Rules", a guideline to help clinicians decide whether or not a fracture is truly likely, and therefore, whether or not to order an x-ray.

First, questions for the patient:
When the injury happened- could you bear weight immediately? 
Could you bear weight when you reached the medical facility? 
                     If the answer to both of these is YES- you could definitely bear weight and walk on the ankle- it is less likely to be fractured.

Then, questions for the doctor as she examines your ankle: 
Is there pain at the bottom, back edge of your ankle bones, both on the inside and the outside? (in medical terms, the distal 6 cm, posterior edge or tip of the lateral or medial malleolus).
Is there tenderness at two different spots on your foot (the navicular and 5th metatarsal bones)? 

The majority of ankle injuries are sprains, not fractures, which involves the ligaments attaching the bones to each other- not the bones themselves. As such, x-rays will not "show" ankle sprains- they are diagnosed by clinical exam. Ankle sprains can be very serious injuries that require splinting or even casting, but they do NOT necessarily require imaging with x-rays.

BOTTOM LINE: Not all ankle injuries need to be x-rayed; an open conversation with your physician about utilizing the Ottawa Rules may save you some unnecessary radiation and expense. 

Monday, March 24, 2014

Do I Need An X-Ray?

Image: B. Rushing

When you hurt your back (or ankle, or wrist) and head to the doctor, should you expect an x-ray? In my last post, I mentioned that the only way to be certain whether or not a bone is broken is with imaging, and that is true. However, not every painful joint NEEDS to be x-rayed. I find that many patients are surprised or disappointed if I do not insist on an x-ray for an acute injury, but they are simply not always necessary, and radiation is not without harm.

XRAYS look at bones. They do not "see" cartilage, muscles, tendons or ligaments, though sometimes distance between bones suggests lack of cartilage. The vast majority of injuries that send patients to their doctors are not from broken bones, but strains and sprains and spasms of muscles and supporting tissue.  (As a quick aside,  a SPRAIN happens to ligaments, the tissue that attaches bone to bone. A STRAIN occurs in muscles or tendons (tissue connecting muscles to bones.)

As we try to limit both unnecessary radiation and expense, the world of medicine is taking a closer look at when interventions such as taking x-rays are really needed to improve patient outcomes. Medical centers are developing guidelines for different injuries that help physicians determine when an xray is truly needed, such as the Ottowa rules for ankle injuries. Stay tuned for more on those rules in my next post.)

RICE: Rest, Ice, Compression and Elevation (plus a bit of pain-reliever/anti-inflammatory medicine such as ibuprofen) go a long way towards treating injuries. Your doctor can show you the best way to compression wrap an extremity, plus possibly prescribe muscle relaxants or stronger anti-inflammatory medicine. Perhaps most importantly, your doctor may prescribe PHYSICAL THERAPY- where you will learn strengthening, flexibility and stability for your injury to fully rehab.

BOTTOM LINE: XRAYS are helpful diagnostic tools for bone injury, but don't assume your treatment of an injury isn't complete without one!

Monday, March 17, 2014

Wait, Is It Broken?

Image B. Rushing

"I can move it, so it's clearly not broken..." Maybe, maybe not! In primary care settings, the majority of fractures that we treat are diagnosed days after they occur (sometimes weeks), ignored because of this inaccurate belief. Wrist fractures are notorious for this presentation, because often there is not dramatic bruising or deformity, and swelling may not be impressive. Finger, foot, and ankle fractures tend to have much more impressive dark bruising and swelling, but even with these injuries, the affected area can most frequently still be moved voluntarily (albeit with significant discomfort).

Fractures come in many shapes and sizes. Fortunately, most fractures are not "open", meaning most have no break in the skin (no bones sticking out anywhere). Some fractures are simple a hairline crack or a small buckle in the bone, while others break all the way through the bone and may shift out of place under the skin. The only way to be certain whether or not there is a fracture is with imaging- most commonly an ordinary X-ray.

What should you do if you think you may have broken a bone? Is it an emergency? If it is "open" (bone sticking out), of course this is an emergency, and this most likely would have occurred in a very traumatic situation such as a car wreck or other high speed injury. Call 911. If the limb is obviously distorted, or there is new and persistent numbness, tingling or decreased circulation (area turning cold, pale and/or blue), you need immediate medical help.  In less traumatic situations- you smash your toe against a door walking to the bathroom at night, you step off a curb funny, you fall on an outstretched hand- your injury may be urgent, but not emergent. Follow the RICE pneumonic- Rest, Ice, Compression (ace wrap) and Elevation while you are waiting for medical care.

BOTTOM LINE: Voluntary movement of a finger, toe, hand, foot or leg does NOT mean a bone is definitely not broken- head to your doctor if you are having persistent pain, swelling or bruising, and find out for sure.

Thursday, March 6, 2014

Spring Break: Alcohol 411

Spring Break is nearly here, and students everywhere are gearing up for a week-long party. Alcohol is often a large part of these festivities, so I think this is a great time to review some facts about alcohol dangers. In recent years, studies show that about a third of college students admit to binge drinking (consuming 5 or more drinks in a row.) The good news is that this number is down over 15% from over the last two decades, and actually, drinking trends in ALL categories are decreasing- whether the measurement is annual consumption, monthly, weekly or number of binging episodes. A great website to educate yourself (or your favorite college student) is  http://www.b4udrink.org/statistics - complete with a virtual bar where you can enter in your gender, age and weight, and then "pour" yourself drinks and watch your blood alcohol levels rise...

Another wonderfully informative program/website is Aware Awake Alive. Check out their table with drinks/blood alcohol concentrations, and SHARE THIS WITH YOUR FRIENDS. Ultimately, know that if you have a THIRD drink, you are most likely legally drunk. AND, please note, this is a third drink measured by the book (not a "college pour" of alcohol into a plastic red cup- those cups hold several servings in just one glass). The biggest mistake friends make is leaving their intoxicated friends alone to "sleep it off".  If someone has "passed out," they NEED supervision. The alcohol level in their bloodstream will continue to rise, which can cause them to either vomit (and potentially choke, because their gag reflex is dulled by the alcohol) or to stop breathing. If their breathing is less than 8 breaths/minute, CALL 911 immediately.

Pain killers often find their way to spring break as well, whether that is courtesy of a knee injury skiing, or simply part of someone's personal medicine cabinet. Please take note: Pain Killers (narcotics- think codeine or vicodin) + ALCOHOL= DEATH. This combination accounts for far too many accidental suicides per year- don't do it.

BOTTOM LINE: Enjoy spring break, but if your festivities include alcohol, make sure you know your limit AND know exactly what to do if one of your friends drinks too much. 

Thursday, February 20, 2014

"Don't Let the Frostbite BITE"

Who doesn't love FROZEN? Our family can't stop singing the award-winning songs from Disney's latest musical hit, so I couldn't resist borrowing a line for my blog title today...However, frostbite is no laughing matter, and with the record low temperatures we have had this year, I thought I should say a few words about this cold weather danger.

What is frostbite?
Frostbite occurs when ice crystals literally form within the tissue in our fingers and toes and noses, damaging and often completely destroying the cells in the skin. Frostbite shows up when it the thermometer reads in the negative in Celcius or below minus 17 in Fahrenheit. Remember, though, that wind chill can push the "real" temperature below the numbers you see on your favorite weather app!

Risk factors besides the extremely low temperatures include alcohol use, smoking, diabetes, previous cold injury, low calorie intake, lean body mass and history of Raynaud's phenomenon (where the blood supply to the hands gets restricted and your hands turn red/purple and ache terribly.)

What are the signs and symptoms?
Frostbite manifests as very painful, severely cold, and initial white and numb areas that progress to blotchy, swollen redness in the tip of your nose or the ends of your fingers and toes. While the affected areas hurt, they are also typically numbed (you can't feel someone touching the end of your finger/toe, but you have pain in that area). With second and third degree frostbite, blisters and "blood blisters" appear, and in fourth degree frostbite there is actual gangrene (rotten, dead tissue).

Dress your core in LAYERS, cover all exposed areas, avoid alcohol (or any drugs that can alter mental status), and stay inside if the temperature is below negative 10*. HOWEVER, be aware that if you try to layer socks or gloves, you may end up with excessively tight, constrictive layers that can actually make you MORE likely to get frostbite. Also, remember to remove rings (fingers and toes) before skiing or other cold weather activities.

What is the Treatment? 
Remove any jewelry if present. Immerse the affected areas in warm water and take NSAIDS (ibuprofen) and quickly SEEK MEDICAL CARE. Do NOT rub affected areas, as this may actually increase tissue damage.

BOTTOM LINE: Watch the temperatures, especially if you are traveling to an area that is much colder than you are used to experiencing, and make sure you have gloves, socks, and face gear that is made for sub-zero weather challenges if you plan to be outdoors in below zero weather!

Tuesday, February 11, 2014

What's Hookah?

What's Hookah?? In the past few years, instead of asking my patients "Do you smoke?" I have learned to ask  "Do you smoke? (pregnant pause)...ANYTHING?" I found that asking in that manner greatly increases my yield. Couple that with Colorado's legalization of marijuana, and more people are freely sharing the full extent of their substance use with their doctors. Which left me asking the question, "what's hookah?" (I could add here that I was also asking "what's shisha" and "what's snus"?)

Hookahs are water pipes used to smoke flavored tobacco. The flavors are often sweet- chocolate, cherry, licorice or fruit flavored. The heat source is charcoal, and the vapor/smoke goes through a water basin before being inhaled. A common misperception is that this "purifies" the tobacco, so that the smoke is no longer harmful. Hookahs can have multiple tubes allowing several people to inhale at one time, or users can pass around the mouthpiece and take turns inhaling (obviously sharing germs as well as the hookah vapor).  Hookah bars seem to be multiplying across the United States, especially in college towns. Austin, Texas, is no exception. A 2013 study of 7 large universities showed that 1 in 10 college students used hookah.

Although hookahs has been around for centuries, we certainly do not have a plethora of double-blind, placebo-controlled meta-analysis studies to clarify exactly the specific health risks of long term use of hookah. What do we know?

  • Hookah smoke is "at least as toxic as cigarette smoke" (CDC, 2013)
  • Hookah tobacco and vapor contain the same poisons that cause mouth, lung and bladder cancer
  • Hookah sessions are usually much longer than cigarette breaks- often up to an hour, increasing the toxin exposure up to ten times higher than traditional smoking
  • The nicotine in hookah tobacco and vapor is very addictive (just as in cigarettes)
  • Smoke from the heat source, charcoal, can cause carbon monoxide poisoning
  • Gum disease is 5 times more common in hookah users than cigarette smokers
BOTTOM LINE: Hookah (water pipe) smoking is NOT a "safe" alternative to cigarette smoking- don't take up this habit! 

Thursday, February 6, 2014

CVS Quits Smoking!

Congrats to CVS pharmacy for taking a stand for HEALTH and announcing that they will completely quit selling tobacco products by October 1st of this year! While, yes, consumers can choose to walk across the street and head into another store to purchase their cigarettes, I am hopeful that other major pharmacies and grocery stores will consider this same step. As people have heard me say repeatedly, there is NO amount of tobacco that we believe to be actually GOOD for your health.

Every single day in the United States, there are over 1300 deaths attributed to smoking. How can you picture what that means in terms of human tragedy? Imagine two enormous jumbo jets colliding- which would mean approximately 1200 people dying...and think about how many times we would see that ghastly image on our computers and televisions. I want young people starting to smoke to have THAT image printed on their brains, rather than associating smoking with fun, alcohol and parties.  Did you know that the vast majority of long-term smokers began the habit before the age of 21? I cannot tell you how many soccer moms my age, as well as professionals of all sorts, are still closet smokers- hating their addiction and wanting to quit. Many picked up "social smoking" in college fraternities and sororities, thinking it was no big deal...and that they would stop that habit after they graduated. Now it is ten or twenty years later, and they are hiding this addiction from their peers and especially their children. I believe it may be easier for people who smoke openly to quit, because at least they can enlist the support of their friends and family!

If you are still smoking, please talk to your family doctor about all the medical options to help you quit, and think about setting a quit date in 2014. Your habit didn't form over night, and the average serious smoker takes 7 tries to quit for good. Nicotine replacement medications (gum, patch, nasal sprays, inhalers and lozenges)  have been shown to increase your chance of successful smoking cessation by 50-70%. Other medications such as Chantix & Zyban double or triple the success rate as well.

BOTTOM LINE: Smoking doesn't "just" cause lung cancer (and many other cancers), it causes heart attacks, strokes, and really crummy quality of life with chronic bronchitis and COPD (Chronic Obstructive Pulmonary Disease). If you still smoke, please make an appointment to talk to your family doctor about quitting. You CAN do it!