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Doctors articles on various injuries
Knee Replacement
Shoulder Impingement
Common injuries above the elbow in Children
Concussion - what you need to know
What is knee replacement surgery?
By Dr Francis Y. H.Wong
Specialist Orthopaedic Surgeon
MBBS (Singpore) FRCS (Edinburgh) FRCS (Glasgow) FAMS (Orth)
Adult Reconstruction & Joint Replacement. Peadiatric Orthopaedics and Trama
Knee replacement is a surgical procedure whereby the diseased knee surface is replaced with metal and plastic surfaces. The knee is a hinge joint which provides motion at the point where the thigh meets the lower leg. The thigh bone (or femur) abuts the large bone of the lower leg (tibia) at the knee joint. During a total knee replacement, the surfaces of the knee are replaced accurately with metal surfaces. A plastic insert is placed between the two metal surfaces for articulation. Depending on the condition of the kneecap portion of the knee joint, a plastic "button" may also be added under the kneecap surface. As a result of this surgery, the painful surfaces are replaced with artificial parts and the joint is no longer painful. In addition, any deformities to the joint are also corrected at the same time.
Other forms of knee replacement surgery can be performed. A unicondylar knee replacement is a partial replacement and replaces only half the joint. This can be considered for younger patients who suffer from disabling pain from localized damage to one side of the knee. Your doctor should be able to help you decide if you need a total knee replacement or a partial knee replacement.
What patients should consider a knee replacement?
Knee replacement surgery is considered for patients whose knee joints have been damaged by either progressive osteoarthritis, trauma, or other rare destructive diseases of the joint. The most common reason for knee replacement is severe osteoarthritis of the knees.
Regardless of the cause of the damage to the joint, the resulting progressively increasing pain and loss of function may lead the patient to consider knee replacement surgery. Decisions regarding whether or when to undergo knee replacement surgery are not easy. Patients should understand the risks as well as the benefits before making these decisions.
What are the risks of undergoing a total knee replacement?
Risks of knee replacement surgery can be divided into two groups. Risks associated with the surgery itself include wound infection, residual deformity and pain. These risks are minimized by prophylactic antibiotics, good surgical techniques and experience and early physiotherapy after surgery. More important are risks associated with pre-existing medical conditions of the patient. Diabetes, hypertension and ischemic heart disease are common ailments that elderly. They should be evaluated properly once the decision for surgery is undertaken.
What is involved with the preoperative evaluation for total knee replacement?
Before surgery, joints adjacent to the diseased knee are carefully evaluated. This is important to ensure optimal outcome from the surgery. Simple x-rays of the joints are sufficient. MRI may sometimes be needed in deciding what form of knee replacement surgery to undertake.
All medical conditions and current medications which the patient is taking are reviewed. Blood-thinning medications such as warfarin (Coumadin) and antiinflammatory medications such as aspirin or plavix may have to be adjusted or discontinued prior to surgery.
Routine blood tests of liver and kidney function and urine tests are evaluated for signs anaemia or infection, or abnormal metabolism. Chest radiographs and ECG are performed to exclude significant heart and lung disease. Further evaluation by a cardiologist or endocrinologist may be necessary. Excess body weight simply puts the replaced knee at an increased risk of loosening and/or dislocation.
A similar risk is encountered in younger patients who may tend to be more active, thereby adding trauma to the replaced joint.
What happens in the postoperative period?
Knee replacement surgery generally requires between one and a half to three hours of operative time. After surgery, patients are taken to a recovery room, where vital organs are frequently monitored. When stabilized, patients are returned to their hospital room.
Passage of urine can be difficult in the immediate postoperative period, and this condition can be aggravated by pain medications. A catheter inserted into the urethra (a Foley catheter) allows free passage of urine until the patient becomes more mobile.
Physical therapy is an extremely important part of rehabilitation and requires full participation by the patient for optimal outcome. Patients can begin physical therapy 48 hours after surgery. Some degree of pain, discomfort, and stiffness can be expected during the early days of physical therapy. These are supervised by the physiotherapist.
A unique device that can help speed recovery is the continuous passive knee mobiliser (CPM). The CPM machine is first attached to the operated leg. The machine then constantly moves the knee through various degrees of range of motion for hours while the patient relaxes.
Patients will start walking using a walker and crutches by 4 days after operation. Eventually, patients will learn to walk up and down stairs and grades. A number of home exercises are given to strengthen thigh and calf muscles. Patients can often be discharged by 5 days after surgery.
How does the patient continue to improve as an outpatient after discharge from the hospital?
It is important for patients to continue in an outpatient physical-therapy program along with home exercises for optimal outcome of total knee replacement surgery. Patients will be asked to continue exercising the muscles around the replaced joint to prevent scarring (contracture) and maintain muscle strength for the purposes of joint stability.
Future activities are generally limited to those that do not risk injuring the replaced joint. Sports that involve running or contact are avoided, in favor of leisure sports, such as golf, and swimming. Swimming is the ideal form of exercise, since the sport improves muscle strength and endurance without exerting any pressure or stress on the replaced joint.
Patients with joint replacements should alert their doctors and dentists that they have an artificial joint. These joints are at risk for infection by bacteria introduced by any invasive procedures such as surgery, dental or gum work, urological and endoscopic procedures, as well as from infections elsewhere in the body.
Patients are recommended to take antibiotics before, during, and immediately after any elective procedures in order to prevent infection of the replaced joint.
Shoulder Impingement
By Dr Chan Beng Kuen
Specialist Orthopaedic Surgeon
MBBS (Singpore) FRCS (Edinburgh) FRCS (Glasgow) FAMS (Orth)
Sports Surgery, Shoulder and Upper Limb Surgery
Many of us take our shoulder function for granted until simple tasks such as lifting overhead, scratching your back or wearing your favorite tight T shirt becomes a painful chore. There are many causes of shoulder pain such as the common frozen shoulder, tendonitis or even arthritis of the shoulder joint. In this article, I would like to share with you the most common cause of shoulder pain I see in my sports practice.
Shoulder impingement is one of the most common causes of pain in the adult shoulder. It results from pressure on the rotator cuff on the acromion as the arm is lifted. The acromion is the front edge of the shoulder blade. It sits over and in front of the humeral head. As the arm is lifted, the acromion rubs or "impinges" on the surface of the rotator cuff. This causes pain and limits movement.
The pain may be due to
a. "bursitis" or inflammation of the bursa overlying the rotator cuff tendon
b. "tendonitis" or inflammation of the cuff tendon
c. a tear of the rotator cuff tendon
Risk Factors/Prevention
Impingement is more common in people aged 30 and above. Those who do repetitive lifting or overhead activities using the arm such as lifting or racquet games are especially at risk.
Symptoms
Pain may also develop as the result of minor trauma or spontaneously with no apparent cause.
The pain is usually in the front of the shoulder but many patients feel that the pain also "travels" down the side of the affected shoulder. It is worse when lifting the affected arm. There may be a clicking sensation when moving the shoulder.
Ladies would complain of difficulty buckling their undergarments and gentlemen find putting on and taking off their T shirts painful.
There may be pain and night and patients will not be able to sleep on their affected shoulder. Occasionally, they are woken up by the sharp pain when they turn in bed at night
Diagnosis
X-ray may show a bone spur/ hook on the front edge of the acromion. Further imaging studies, such as an ultrasound or MRI (magnetic resonance imaging) may be required to confirm a tear in the cuff tendon.
An impingement test, injection of local anesthetic into the bursa, can help to confirm the diagnosis.
Treatment Options
Initial treatment is conservative and includes rest, avoidance of overhead activities and stretching exercises. A short course of oral non-steroidal anti-inflammatory medication may be necessary. Some patients may benefit from injection of local anesthetic and steroid into the affected area.
Surgical Treatment
If conservative treatment does not relieve the pain, surgery may be required. The goal of surgery is to remove the part of the acromion (subacromial decompression) and create more space for the rotator cuff. This allows the humeral head to move freely without impingement against the acromion. This may be performed by either arthroscopic or open techniques:
In an arthroscopic procedure, two or three small puncture wounds are made. The joint is examined through a fiberoptic scope connected to a television camera. Small instruments are used to remove bone and soft tissue. This method is more commonly used as the incisions are small and the post-operative pain is minimal. A short video of this procedure can be seen at our website at www.iog.com.sg
The other advantage is that the surgeon can confirm and treat other conditions present in the shoulder at the time of impingement surgery e.g. rotator cuff tear.
Rehabilitation
After surgery, the arm may be placed in a sling for a short period of time. As soon as the patient is comfortable, he/she may remove the sling and begin exercise and use of the arm. A rehabilitation program based on your needs and the findings at surgery will begin and it will include exercises to regain range of motion of the shoulder and strength of the arm. It may take two to four months to achieve complete relief of pain.
Common Injuries about the elbow in children
By Dr Francis Y. H.Wong
Specialist Orthopaedic Surgeon
MBBS (Singpore) FRCS (Edinburgh) FRCS (Glasgow) FAMS (Orth)
Adult Reconstruction & Joint Replacement. Peadiatric Orthopaedics and Trama
Children's fractures are often very different from adults. This is because their bones are more plastic and would bend and crack rather than shatter. In addition, the growth plates are open and are weak points in the bone itself. They are generally weaker and break with less force. Injuries sustained by children also tend to be of the low velocity type. Compared with adults, children injure their upper limbs more often. One of the most common injuries encountered by the paediatric orthopaedic surgeon is the pulled elbow in a child. Of all the fractures in the upper limb the supracondylar fracture of the humerus (elbow) is not only the most common injury. It can result in serious complications if not treated appropriately. Other important injuries at the elbow include the lateral condylar fracture and the epiphyseal fracture of the radial neck.
In general, fractures in children are often treated conservatively. Children?s bones heal faster and have the special ability to remodel with time. This ability is more pronounced in the youngest and is gradually lost as they approached skeletal maturity in the teens. Surgical treatment is reserved for some physeal injuries, fractures associated with neurovascular compromise, open fractures and certain special circumstances such as fractures around the hip.
The Pulled Elbow
The pulled elbow is often encountered in children from as young as 2 years to as old as 10 years of age. As its named suggests, the injury is sustained when the forearm of the child is pulled with minimal force to prevent the child from falling. This results in a mild subluxation of the radial head at the elbow resulting in pain. Sometimes the injury is sustained by child losing its balance whilst seated or whilst turning in bed. The injury results in pain and loss of use of the affected limb. Clinical examination shows no swelling and the child is often comfortable except he does not want to use the arm. On closer examination, supination and pronation of the forearm is limited by pain.
The injury is resolved, almost miraculously, by a quick twist of the forearm to reduce the subluxed joint. There are no known long-term problems associated with the injury. Recurrence is possible but it is not known to be a long-term problem.
Supracondylar fractures of the Humerus
The management of supracondylar fractures of the humerus has changed from a more conservative approach to a more aggressive approach. The fracture has no problem healing but it is difficult to achieve adequate and stable reduction until union took place. Previously treated by cumbersome skin traction to achieve reduction of the fracture and required expensive and painful prolonged hospital stays. Unfortunately, this still often resulted in less than adequate fracture reduction and the common ?gun stock? deformity of the elbow. This deformity is often cosmetically unacceptable and may require corrective surgery later on.
Very often the child is mistakenly treated by massage and manipulation by traditional methods. This contributes to more soft tissue injury and may further injure the nerves or compromise the circulation. Excessive massage also causes a condition called myositis ossificans, characterized by excessive new bone formation about the elbow and severe stiffness of the joint. Should this occur, treatment can be protracted and unsatisfactory.
The management of the displaced supracondylar fracture requires a better understanding of this unique fracture and its potential for complications. This fracture is sometimes associated with injury to the 3 major nerves about the elbow as well as compression of the brachial artery at the elbow. If the child is seen within the first few hours of the injury it is easier to do a closed reduction and immobilization under general anaesthesia. Percutaneous pinning under image intensifier will allow the reduction to be maintained with the elbow immobilized in a less flexed position. Increased flexion of the elbow was often taught as an important step to achieve stability of the fracture. This however, contributed to vascular compromise resulting in a condition known as Volkmann's ischaemia of the limb.
Open reduction and internal fixation with K-wires is usually unnecessary as most of the fractures can be reduced closed. In cases where closed reduction is not possible or where there is vascular compromise open reduction and internal fixation will then become necessary. If there is severe swelling of the limb it may be prudent to admit these children and put the arm in traction until the swelling subsides before further treatment is instituted. In all cases of displaced fractures it is important to monitor these children closely post- operatively for signs of compartment syndrome and vascular compromise (Volkmann's ischaemia).
Crossed percutaneous pinning is shown to be the most stable configuration for fixing these fractures. However, the ulna nerve may be damaged by the inexperienced surgeon when placing the medial pin. Studies have also shown a significant re-displacement of the fracture even after pinning was done. This is due to failure of adequate reduction of the fracture fragments and wrong placement of pins resulting in an unstable fixation.
My practice is to routinely manipulate and reduce all displaced supracondylar fractures under general anesthesia as an outpatient setting. Crossed percutaneous pins are inserted under image intensifier guidance and the elbow further protected in a backslab or a full cast. The pins are left sticking out of the skin and are removed about 2 weeks later in the clinic, when the fracture is thought to be more stable on x-rays. Full mobilization of the elbow is allowed usually after a further 2 weeks of protection. Children seldom require physiotherapy postoperatively.
I must emphasize that such a protocol of treatment should only be carried out by the more experienced surgeon. Clinical assessment of the injured limb is paramount in deciding the management protocol, as complications can be disastrous.
It is important to recognize the injury, as the epiphysis is often not ossified in the very young child and cannot be seen on routine x-rays. Once diagnosed, it must be reduced adequately either closed or open techniques. Fixation with implants is usually unnecessary and fortunately the prognosis is good.
The elbow must be immobilized in a full cast at 90 degrees flexion and with the forearm in supination. This is probably the most stable position for the bone to heal in about 4 weeks. Bi-weekly x-ray checks are advised to monitor the position of the fragments until healing takes place.
Concussion – what you need to know
By Dr Tan Siah Heng James
Specialist Neurosurgeon
MBBS (Singpore) FRCS (Edinburgh) FRCS (Glasgow) FRCS (Neurosurgery)
Brain and Spine Surgery
Introduction
Concussion is also known as minor head injury or mild traumatic brain injury (TBI). It occurs as a result of trauma to the head, with sufficient force to affect brain function.
What happens when you bang your head?
The brain is a soft organ that 'floats' in the skull, surrounded by water (cerebral spinal fluid). The interior of the skull consists of ridges and sharp corners. Any sudden, quick movement of the head can cause the brain to move and come in contact with the skull. If the impact is hard, it will cause bruising of the brain, leading to a concussion. Examples of these are when the head hits an object or when a moving object hits the head. It can happen with a fall, sports activities and car accidents.
Upon impact, the brain is temporarily 'stunned' and its function is disrupted for several seconds - enough to result in a loss of consciousness. The forces involved affect cellular processes in the brain for days or weeks.
Signs and Symptoms
Depending on the severity of the impact and the resultant concussion, the signs and symptoms may vary.
In a concussion,
- There may or may not be a loss of consciousness (varying from several seconds to several minutes)
- There is temporary confusion (disorientated to time, location, person)
- Inability to recall details of the incident
- Inability to retain information (after being told where the patient is, he keeps asking the same question)
- Headache
- Nausea and/or vomiting
- Ringing sound in the ears
- Dizziness
Some of these symptoms above will last only a few hours and others may last up to a week or more. Patients with concussion may develop new symptoms after a few hours. Some have complained of increasing headaches, dizziness, difficult falling or staying asleep. Rarely, they report difficulties with concentration (for example, when reading).
About 2% of patients with concussion have a seizure immediately after the impact. These are known as immediate post-traumatic seizures and are the result of temporary loss of brain function. As there is no structural damage to the brain, it is very rare for this to proceed to repeated epileptic seizures and the outcome is good.
They may also develop post-traumatic amnesia where the person cannot remember events leading up the injury or after it, or both.
Some patients actually lose their sense of smell (anosmia) after a fall. The olfactory nerves (responsible for our sense of smell) are sensitive to horizontal translational forces that may tear and permanently damage these nerves fibres. Losing one's sense of smell will affect the sensation of taste as well.
Management of Concussion
It is important that the concussed patient be examined by qualified personnel. This is especially true if there has been a period of unconsciousness. It is important not to move the unconscious patient as there may be an underlying spinal injury as well. The medical team will need to perform physical examination including examining the conscious levels, pupils and neurological examinations. It is of the upmost importance that more severe injuries (spine, chest and abdominal) be excluded.
A CT scan of the brain is very helpful in diagnosing the presence of life threatening bleeding in the brain. There are some clots (extradural hematomas) that take several hours to develop and if left undiagnosed and untreated, will result in permanent brain damage and death.
Treatment
The treatment of concussion is symptomatic. This means that the appropriate medications are given to treat the headache, nausea, vomiting or dizziness. Complete rest is recommended for a few days to a week depending on the severity of the concussion. Exertion during this time may result in increased headaches and vomiting as the brain is vulnerable to raised intracranial pressure.
Conclusions
Head injury, especially when it occurs in high impact accidents like road traffic accidents and sports injuries need to be assessed carefully to exclude any potentially dangerous extradural hematomas that can kill a patient within several hours. Fortunately, most concussions are benign and complete recovery occurs in a matter of weeks
