Sunday, October 6, 2013

Is Ryan Nugent-Hopkins being rushed back from his torn labrum?

THE PLAYER

Ryan Nugent-Hopkins, 20, is expected to return to the Edmonton Oilers lineup for their game against the Devils on Monday. The former first-overall pick recently signed a seven-year, $42 million contract extension in September and has been sorely missed by the Oilers.

On April 21st, it was revealed that Nugent-Hopkins would have season-ending shoulder surgery, missing the final five regular season games. Nugent-Hopkins tore his shoulder labrum, just like another former Oilers first-overall pick, Taylor Hall, the previous season.

That flex.


At the time, Oilers fans were not happy because the issue/injury was not addressed sooner. It was quite obvious that Nugent-Hopkins was playing through his injury as evidenced by his affected and negative performances. The organization decided to monitor his condition and fans believe they didn't handle their young star more carefully by ending his season sooner. 

All in all, Nugent-Hopkins underwent surgery and was expected to be out for 6 months, putting him on track for a late October, more likely early November return. Surprisingly, Oilers coach Dallas Eakins announced last Friday that his young center was ready to go and would be in the lineup Monday evening. 

THE INJURY

To understand the injury, we must first take a look at the shoulder's anatomy (as shown below) and understand the function of the labrum. The shoulder is a highly-mobile, ball-and-socket joint that is made up of only three bones - the humerus (upper arm bone), the clavicle (collarbone), and the scapula (shoulder blade). The shoulder joint is formed by where the rounded end of the humerus meets the concave of the scapula (glenoid fossa). The humerus and the scapula are connected and stabilized by tough tissues known as ligaments that form tethers and hold the bones in their proper place. 


The labrum is a type of cartilage found in the shoulder joint. Cartilage is a flexible connective tissue that is not as hard as bone but less flexible than muscle. Cartilage does not contain blood vessels like other connective tissues and thus takes more time to grow and repair. There are two types of cartilage found in the shoulder joint. The first type of cartilage is found on the ends of bones and is called articular cartilage. Articular cartilage allows the bones to glide and move on each other, when this white cartilage begins to wear out (arthritis) it causes the joint to become stiff and this loss in flexibility is very painful. The labrum is the second type of cartilage in the shoulder joint and is quite different than articular cartilage in both function and form. The labrum is a ring of soft fibrous tissue that is found only around the socket where it is attached. The tissue surrounds the glenoid and helps stabilize the shoulder joint. 

The labrum is an important tissue in the shoulder joint that has two distinct functions. The first is to deepen the socket of the shoulder blade to ensure that the ball stays in place. The labrum is attached the the rim of the socket and essentially acts as a bumper which deepens the socket over time and keeps the humerus in place. The second function of the labrum is to act as an area of attachment for other structures and tissues of the joint. Essentially, the labrum creates more surface area to share the load on the joint in order to not create unnecessary stress. 

The labrum can be injured and torn in a variety of ways. The first type of tear is when the labrum is torn completely off of the bone and is usually associate with when the shoulder has subluxated or dislocated (check out my post on subluxation focusing on Nathan Horton here). This is known as a Bankart lesion and occurs in the lower part of the labrum. The second type of labrum tear is when the substance of the labrum is tearing itself. Over time, the edge of the labrum may get frayed and not longer be smooth. This tearing is quite common and doesn't have many symptoms. The third type of tear is when the upper part of the labrum is injured. The labrum can be injured in the area where the biceps tendon attached to the upper end of the socket, the superior end of the joint. This third type of tear is known as a SLAP lesion, which stands for Superior Labrum Anterior and Posterior. The SLAP lesions are divided into four types, classified on the severity of the injury. In a lesser injury, the labrum is only partially detached while in a more severe injury the labrum is pulled completely off the bone along with the biceps tendon. 


TREATMENT AND SURGERY

Diagnosing a labrum tear is not small feat. Since the cartilage is deep in the shoulder, it's difficult for a physician to diagnose based on physical examination and other tests. A physician may ask the patient for an MRI which can show a tear, but it may miss smaller tears and is not always reliable. The only sure way to make a diagnosis is view arthroscopy of the shoulder. A surgeon will make a small incision and view the joint via a tiny camera and make his diagnosis. Usually, the surgeon then proceeds to perform the procedure depending on the injury. 

Tears of the labrum due to subluxation/dislocation require that the labrum be reattached to the rim of the socket. This surgery can be done with arthroscopic techniques but some institutions prefer to perform an open operation with an incision on the front of the shoulder. SLAP lesions or tears of the labrum near the biceps tendon attachment are fixed using arthroscopic surgery since the area is too difficult to reach with an open operation. The surgeon uses an arthroscope and makes small incisions to re-attach the labrum to the rim of the socket using either sutures or tacks. A video example of the procedure is show below.  


RECOVERY 

Once the cartilage is anchored back to the bone, it has to grow back and reattach itself. The suture helps hold the cartilage in place but it can't withstand the normal pressure the joint sustains on its own. Thus, for four to six weeks the patient's arm is in a sling. During the four to six weeks it takes for the labrum to heal itself, it's important that the arm remains in the sling to sustain as little stress as possible so the injury does not become aggravated. Physical therapy is a must in order to recover your full range of motion and strength. 

After the four to six weeks waiting for the labrum to re-attach itself to the rim of the bone, it takes another four to six weeks to regain your strength gradually and carefully. Most doctors recommend a six month timetable to return to sports after your surgery. 

IS RYAN NUGENT-HOPKINS BEING RUSHED BACK? 

It has been less than six months since Ryan Nugent-Hopkins decided to undergo surgery to repair his torn labrum. Dallas Eakins says he is ready to return to the lineup on Monday, a few weeks ahead of schedule (previously Oilers GM Craig MacTavish stated that November 1st was the earliest expectation for his return). 

Labrum repair is a safe and reliable procedure in athletes. Recovery from the repair is not the same for each patient, especially a professional athlete. After the initial sling period of four to six weeks, the patient dictates their recovery with improving physical therapy. Shoulder strengthening and range of motion exercises must be done consistently. 

Is RNH being rushed back? The best bet is no, he's not. Nugent-Hopkins visited his doctors to get an okay on his shoulder and if he feels comfortable and confident enough to play, it is ultimately his decision after he received an OK from his doctors. 

The proper to question to ask is does returning before six months post operation put you at an increased risk for recurrent injury versus returning after six months. Although there are no studies that look to answer this specific question/comparison, several studies do show athletes returning at time points such as 5 months post-operation and sometimes as quick as 4 months. Here is a great resource describing instability of the shoulder: http://www.netorthodoc.org/sport/Shoulder%20Instab.pdf 

Owens et al. describes the sentiment regarding the uncertainty of when to return after surgery. The article states the "Surgical management....reduces the rate of recurrence...." and that recovery and management is up to the physician, stating "the clinician must consider the natural history of shoulder instability, pathologic changes noted on examination and imaging, sport and position-specific demands, duration of treatment, and the athlete's motivation." Essentially, once the physician reviews RNH's shoulder history (this is good since it was his first occurrence) and how his shoulder is functioning via testing he can determine if it's safe to return. RNH has demonstrated that he is motivated by his quick recovery which is a good sign for Oilers fans. They just have to hope that his injury does not get aggravated and that he is careful with his play (no fighting obviously, probably no checking with that side of the body) and protective of his shoulder. Oilers fans should also hope he returns to form, since only around 75% of athletes return to their previous skill level post shoulder surgery (Ide et al.)

Friday, October 4, 2013

The Scary Case of Tomas Vokoun

BACKGROUND

On Saturday, September 21st, Penguins goaltender Tomas Vokoun was taken to the emergency room after leaving practice. Vokoun, 37, noticed swelling in his thigh and was diagnosed with a pelvic thrombus, or a blood clot in the pelvis. Vokoun underwent a procedure after his diagnosis to dissolve the blood clot.

In fact, this is not Vokoun's first experience with blood clots. In April of 2006, Vokoun had back pain and visited a doctor where was immediately diagnosed with pelvic thrombophlebitis. In this post, I will discuss Vokoun's injury in depth, starting with his 2006 pelvic thrombophlebitis and recovery and ending with his current condition and treatment.

THE INJURY

When Vokoun was 10 months old, he grabbed a tablecloth causing hot coffee to spill all over himself. During his treatment, doctors inserted a femoral catheter in his right groin. Presumably, this catheter is thought to have damaged the endothelium (inside lining) of one of his veins. Catheter-related thrombosis is not uncommon, but they usually don't take place 30 and 37 years after the initial damage. Essentially, blood coagulates (clots) at a wound site in order to 'plug up the hole' or fix the wound. Vokoun's old blood clot turned into scar tissue which grew into the side of his veins which explains why his clots did not break apart or get bigger when he was prescribed blood-thinning medication 7 years ago.

In 2006, after some back pain, Vokoun underwent an MRI and several blood clots were found in both his abdomen and pelvis. He was diagnosed with pelvic thrombophlebitis, a blood condition that created a multitude of blood clots presumably due to his past vein injury. After three days in the hospital and three months on blood-thinners, Vokoun returned to hockey when he was deemed to be stable.

On September 21st during a Penguins practice, Vokoun noticed swelling in one of his legs and was immediately sent to the hospital. Vokoun's foot was swollen and doctors found several blood clots ranging from his mid-thigh all the way to almost where his heart is located. This means Vokoun's clot was iliofermoral (very high and in his pelvis) which is quite unusual and the most troubling part of Vokoun's injury/condition. Most deep vein thromboses (DVTs) are usually in the lower leg and and can be treated with anti-coagulates alone.


DVTs are when a large thrombus forms in one of the deep veins of your body. The risk associated with DVTs are that the clots in your veins can break loose (embolus), travel through your blood stream and lodge into your lungs , blocking blood flow and killing you in an event known as pulmonary embolism.

THE TREATMENT

Vokoun was released from the hospital on Wednesday, September 25th.There are two options to treat Vokoun and it is undisclosed which he was treated with.

One option is called percutaneous mechanical thromectomy (PMT). During the surgery, doctors make a small incision and insert a catheter into the affected vein to break up and suck out out the clot. These catheters vary in method and range from using rotating wires, to jets of saline, and ultrasound.

A second option is a minimally-invasive procedure known as catheter-directed thrombolysis. Doctors make a small incision and insert a catheter into the vein, maneuver it to the thrombus (clot) and deliver thrombolytics, or medicines that can quickly dissolve a blood clot.

After his procedure, Vokoun is expected to be on a 3 or 6 month course of anti-coagulant therapy. Anti-coagulants are drugs that inhibit the blood's ability to coagulate, or clot. Considering this is Vokoun's second episode, it is highly likely that he undergoes a long treatment routine recommended by his hematologist. Vokoun will most like receive the best treatment that money can buy, for example, a more expensive or effective therapy than traditional anti-coagulants such as warfarin or heparin.

HOW SOON WILL VOKOUN BE BACK? 

This is completely unknown. It all depends on how Vokoun is feeling and how his doctors and hematologists evaluate him. One of the main issues is that Vokoun can not undergo and physical/sport activity while on his anti-coagulant medication. These medicines increases the risk for bleeding as your blood is not able to clot at a wound and heal. If Vokoun stopped a shot causing a severe bruise or god-forbid was accidentally cut by a skate, he could die.

For now, let's all be thankful that Vokoun is okay and is successfully undergoing treatment. I wish him a speedy recovery and hope he's on the ice at some point in the future.

UPDATE:

Redditor Ravenspike asked: "Just a quick question, couldn't the DVT also cause ishemia in other parts of the body including other organs and not just a pulmonary embolism?" 

My answer: Pulmonary Embolism is the most serious complication of proximal DVT so that's why I chose to highlight it. Also, the risk of PE is higher when clots are present in the thigh and pelvis (which were present in Vokoun's case)
As with any blood clots, ischemia is possible. This certainly occurred wkth Vokoun. As I said, his foot and leg were extremely swollen, meaning he definitely suffered from some ischemia in the tissues of his lower body.
Pelvic DVTs have also been found to cause brain ischemia in some cases, but I don't think that was present here.
Thanks for the great question!

Updated: James Neal's 'Upper Body Injury'

Penguins forward James Neal has sustained the infamously vague 'upper-body' injury.


According to Penguins coach Dan Bylsma, James Neal is now "more week-to-week than day-to-day" meaning the injury must be a little serious.


James Neal left the Penguins game vs the New Jersey Devils on October 3rd in the first period. Neal was a game-time decision for the game after missing Wednesday's practice and the Penguins game-day skate on Thursday. After leaving the game in the first period, Bylsma said it was an aggravation of the same issue.

Neal's only upper-body injury history includes a concussion sustained last April which caused him to miss 8 games. The Penguins are being cautious and vague, so it's hard to figure what Neal's issue is. It sounds like either he re-aggravated a hush shoulder issue or sustained a concussion relapse. Hopefully we'll know more soon.

UPDATE: @DavidMTodd on Twitter (ESPN Pittsburgh Radio Host) tweeted on October 8th:

          "Was told by source #Penguins James Neal's injury is something similar to strained oblique. Suffered it            when Pens played whiffle ball on ice."

So it is an "upper-body injury" but not where many thought (head/shoulder) but rather in the chest/abdomen. Also, it wasn't suffered during hockey so the Pens have to be disappointed in losing their 40-goal scorer this way.


Thursday, October 3, 2013

Sam Gagner's Broken Jaw

THE INCIDENT

On September 21st, Oilers Center Sam Gagner sustained a broken jaw after being hit in the face from a reckless swinging stick by Canucks forward Zach Kassian. After making a pass, Gagner dodged Kassian's attempted check,  which resulted in Kassian coming to a spinning stop with his arms and stick elevated, causing it to connect with Gagner's face.


Although Kassian asserted that he did not intend to hit Gagner in the face, the department of player safety determined that he is responsible for the consequences of swinging his stick. Since the play resulted in a significant injury, Kassian was suspended for the remainder of the preseason (3 games), as well as 5 regular season games.

THE INJURY

Sam Gagner tweeted out this gruesome picture of himself showing the severity of his jaw injury:


Jaw fractures are frustrating, difficult injuries to deal with. The lower jaw/jawbone - the mandible - is an important but complex bone.

The mandible holds and supports all of your bottom teeth in place. Not only that, the mandible holds important cranial nerves.  The trigeminal nerve, the fifth and largest cranial nerve, is responsible for sensation in the face and motor functions such as biting and chewing. The trigeminal nerve has three major branches, one of them being the mandibular nerve. The mandibular nerve then branches off itself, innervating several important muscles, the inside of the cheek, the teeth, the skin, the lower lip, and chin. The branches of the mandibular nerve including the inferior aleveolar nerve, provide sensation to the teeth and bottom lip.

Importantly, the mandibular division of the trigeminal nerve, innervates muscles such as the masseter, one of the muscles of mastication (chewing).

Trigeminal nerve, shown in yellow (http://en.wikipedia.org/wiki/Trigeminal_nerve)

TREATMENT

The first step after a mandibular fracture would be to give start the patient/player on an antibiotic regimen to prevent infection. Pain medication would also be prescribed. After examination of the fracture and physician evaluation, the next treatment path would depend on the severity of the break. There are three common treatments for broken jaws:

1. No treatment, no surgery: If the fracture is minor, bones haven't been displaced, and important muscles and nerves haven't been damaged or misaligned, no treatment is necessary. Of course, the jaw needs to be protected in some fashion, so the doctor would determine a plan for recovery including which foods to eat, jaw stretches without straining the muscles, and first and foremost; rest.

2. Mandibulomaxillary fixation (MMF) or Closed Reduction: Quite possibly the most miserable forms of treatment, as the jaw is wired shut for four to six weeks. You can't eat solids, brush your teeth, you have difficulty breathing and it's incredibly uncomfortable. MMF remains a choice for non-displaced fractures (bones aren't displaced/shifted) and severe fractures where the bone is shattered and needs to be held together/in place. There are several techniques to providing mandibulomaxillary fixation (MMF), but the most common is the use of arch bars. Arch bars are metal bars that follow the regular contour of the jaw and are held on by wires anchored to the teeth. Example shown below:


3. Open reduction and internal fixation (ORIF): Open reduction involves surgery at the fracture site in order to place internal fixation to prevent movement of the fracture site. ORIF is often used in displaced fractures and when the patient wants a quicker recovery.

The surgery involves placing  placing titanium plates to repair the fracture. Incisions are either inside the mouth or outside the jaw on the skin. During the surgery, the surgeon cleans the fracture line and meticulously places plates and screws in optimal positions so as not to damage the teeth or the jaw's sensory nerves. The wound is then closed and the patient's jaw will usually be able to function either immediately or within a week. The surgery is complicated because the surgeon must be precise in the configuration of the titanium plates and screws. 

RECOVERY

The recovery period usually lasts about 4 to 6 weeks. Patients are encouraged to stay on soft foods. This can be particularly troubling for athletes because you lose a significant amount of weight when you're only eating a liquid diet. Strong mouthwash, antibiotics and pain medication are also often prescribed. 

Athletes are limited to light workouts. So while the jaw may heal in 4 to 6 weeks, expect Gagner to be out six to eight weeks in order to regain his overall strength.