Snap and Pop: PL guide to ankle injuries

Icing a sprained ankleThis feels wrong. Like I’m about to do some shady insider trading with you , or something. Every industry has its secrets. Medicine is no different. But, that’s what this blog is about: sharing medicine’s little secrets so you know when you need us.

Ready? (speaking under my breath): Not every twisted ankle needs an x-ray. There. I said it. Glance over my shoulder, no medical information police around… I think we’re good.

Sprained ankles hurt. They swell. They bruise. They resist bearing the weight of our bodies. Most people who have participated in sports know the prescription for a sprained joint is R.I.C.E therapy, right? Rest. Ice. Compression. Elevation. But, doc, don’t I need an x-ray to make certain it’s not broken? As usual, the answer is not necessarily. I’ll explain.

Let me clarify one thing first. Broke and fractured are the same thing. One isn’t better than the other. To medical providers, the two have the same exact meaning.

Let’s start with a little anatomy lesson first. The long bones from the knee to the ankle are the tibia and fibula. The tibia is closer to the middle of the body, the fibula along the outside of the lower leg. The tibia is bigger and bears weight for us. These two bones bulge out around the ankle and form the medial (toward the inside of the body) malleolus, and the lateral (toward the outside of the body) malleolus. Lots of ligaments are around the ankle to hold it all together like duct tape.

How do I know from examining you whether you need an x-ray? Studies. There are these clinical decision tools called the Ottawa Ankle Rules. They were developed by our northern neighbors in Ottawa, Canada. The researchers originally looked at over 1000 patients with ankle injuries. Then they validated their findings with tens of thousands of patients. These rules don’t predict that there is absolutely no fracture. It’s looking for fractures that need to be treated differently than a sprain. This is good research. Trust me. I’m a doctor.

So, the Ottawa Ankle Rules help me see a patient with an injury and determine if he needs an x-ray. Just because the rules say you need an x-ray, doesn’t mean there is going to be a fracture. It just means I can’t rule out a fracture by examining you. I need some pics.

Who needs an x-ray?

Unable to bear weight. So, if you’re unable to bear weight (4 steps) BOTH at the time of the injury AND in the emergency department, you need an x-ray. It doesn’t say it won’t hurt to walk, it just asks if you’re able to. If you could walk initially, but later can’t, or vice versa, that doesn’t meet the criteria.

Tender over the back or bottom tip of the medial malleolus (inside of the ankle). So, feel that bump on the inside (medial malleolus). If you’re looking at your ankle standing up, go to the back part (we call that posterior). If the bottom 6 cm (2.5 inches) of the back part or the bottom tip is tender, you need an x-ray. Basically, if only the front (anterior) part is tender, no big deal. That’s a sprain.

Tender over the back or bottom tip of the lateral malleolus (outside of ankle). Same as above, only check out the outside bone. Still, we’re paying attention to the back (posterior) part, not the front.

You’ll notice there isn’t anything in here about swelling. Ankle sprains and fractures swell. Now, the doctor still has to use good judgment. If the patient is intoxicated, or there are other severe injuries (we call these distracting injuries), x-rays may be needed.

How do I use these when I see a patient? I usually explain why I don’t think an x-ray is necessary. If she still wants it, I usually oblige. Peace of mind is sometimes worthwhile. But, getting out of the ED an hour or two faster without an x-ray is also valuable.

I tend to get more x-rays in children, open growth plates and all, but there is data that says these rules can be applied to reduce the number of x-rays for kids as well.

Next time you twist your ankle, you may still need to see the doctor for pain control or a good splint, or just to make certain you are applying these rules properly (we’re the trained professionals). But, maybe this helps your openness to the idea that you may not need that x-ray you would have otherwise expected was necessary.

What ankle injuries have you suffered that, looking back, may not have needed an x-ray?

Smashing melons: a guide to head injuries

iStock_000008037242_SmallSummer is in full force now. And with summer comes trauma. Just ask any ER doc: people start crashing into and falling off things they wouldn’t otherwise starting with the first warm day of the year. With all these collisions, head injuries abound, as do all the misinformation that has been passed on from generation to generation. Before any more melons are bashed, let’s smash some myths and clarify some truths.

Myth 1: if someone has a head injury, you can’t let him sleep afterwards. False. It’s perfectly fine to sleep after a good whack to the noggin. But, someone has to check on the injured person, preferably waking him up every 2 hours or so. The reason? Sleep and coma look the same, until you try to wake the person. Sleep is fine. Coma is, well, you know. As long as the person wakes up and knows what’s going on, home neuro check is done.

Myth 2: If an injured head isn’t swelling on the outside, it must be swelling on the inside. False. Whoever started that rumor must have owned stock in CT scans. There is no correlation between lack of external swelling and serious head injury. On the other hand, a ton of swelling might mean there is a fracture, which can signify a more serious injury below. I have never been worried because a patient did not have swelling to the scalp.

Myth 3: A head injury where a person was knocked out (unconscious) should have a CT scan. Maybe. But maybe not. While I think it’s prudent for a person with a head injury who gets knocked out be seen by a doctor for an evaluation, he may not need a scan of the brain. Don’t get me wrong: prolonged loss of consciousness, change in behavior, repeated episodes of vomiting, a large area of swelling (hematoma) that could cover up a fracture, or a new weakness on one side of the body are all reasons to get a CT scan. Elderly patients and people taking blood thinners or who have abnormal blood clotting (like hemophilia) are at higher risk than the average Joe. These patients are more likely to need imaging of their heads.

So, a person wrecks his bike, hits his head, is unconscious for a couple of seconds, has no neck pain, and is fairly quickly back to normal. He may need to be evaluated by a doctor, but may not need to have any imaging of his brain. That same person not acting right 30 minutes later with repeated vomiting probably just earned a CT scan.

A couple of other things. Riding a bike or skateboard? Wear a helmet. It’s the one part of your body we’re not great at fixing. Also, if there is a head injury, make certain the cervical (neck) spine, located in the midline back of the neck, is not painful. The head and the cervical spine are often injured together.

In conclusion, most people who hit their heads are fine. Perhaps by knowing exactly what to look for, and learning what wives tales not to believe, you can know what to watch for, which might save you a trip to the hospital (and the accompanying bill)for a clearly minor injury.

What experiences have you had with emergency department visits for minor head injuries?

Everything you wanted to know about fevers…

Mother: My baby had a fever
Me: How high was the fever?sick kid
Mother: I don’t know. So hot he would burn you if you touched him.

Everyone has had a fever. Maybe not quite that high, but they’re common. They make us feel crummy. And, they’re the source of a lot of angst among patients. Especially parents. The fever talk is one that I give frequently to moms and dads. Hopefully I can put you at ease that next time you or someone you love develops this hyperpyrexia (fever).

First, fevers themselves are not dangerous. They don’t fry your brain. Yes, a fever usually means there is an infection (rarely, fever is related to something different going on, like a reaction to a drug, or something that has triggered inflammation in the body). Fevers don’t tell us whether an infection is serious or not. Just, that there is an infection present. Even how high the fever is doesn’t go very far with predicting how bad an illness is. Doctors look at other things as we try to determine if there is something to be worried about. We’ll get to that below.

We treat fevers with acetaminophen (Tylenol) and ibuprofen (after 6 months of age). Ready for the big shocker with these two drugs? Whispered voice: you can give them both at the same time. Gasp! Yes, these two drugs are in different classes. Their side effects don’t add to one another. So, you can give them together. You don’t have to alternate them back and forth every 2 hours. You CAN alternate them. But, you don’t have to. Don’t give either one more frequently than every 4 – 6 hours.

Here’s another pearl. Whether or not a fever goes away when you give Tylenol and/or ibuprofen doesn’t tell us whether the infection is serious. You can have meningitis (a serious brain infection), give Tylenol, and the fever may go away. Some fevers from just a simple virus may not get better with just a dose of medicine. We have to look at other things to determine whether or not to be worried.

It takes a lot of experience to identify really sick patients. But, here is some stuff I look at to help determine if I need to start testing.

Age – the younger the child, the closer I have to look at him. Children less than 2-3 months age usually require testing by the doctor. With newborns, they don’t show as many external signs of serious illness as older children and adults. Elderly patients, also, warrant a closer look when they have a fever.

Appearance – a child who is truly lethargic is worrisome. But, that’s doctor lethargic, not parent lethargic. Lethargic to doctors doesn’t just mean lying around. If I started an i.v. on your child, would he get upset and fight? If he doesn’t have the energy, I’m definitely worried. Difficulty breathing, severe headache, stiff neck, and really pale color warrant an evaluation.

Duration – when fevers are lasting 5-7 days, I start thinking about doing some testing. Fevers lasting a week or longer can be from something other than infection.

Other factors – someone getting chemotherapy, which suppresses the immune system, should be evaluated at the first sign of fever. Also, recent surgeries to go along with that fever would make an evaluation more important. Some other common conditions that warrant a closer evaluation: children not immunized, diabetics, elderly, dialysis patients, i.v. drug users, and anyone with multiple serious medical conditions.

This list is not complete. Any time you are worried about someone with a fever, get checked out. If you have a child who seems to be getting worse instead of better over time, see the doctor. But, don’t hesitate to treat the fever before you go. We will believe you that your child had a fever. Honestly, it helps me more to see how the child looks when the fever goes away. Everybody looks bad when they have a fever. But, if the child’s fever is gone, and she still looks quite puny, I might need to do some tests.

Most fevers don’t need antibiotics, but we can cover that in the future. Meanwhile, the next time someone at home gets sick, treat it with Tylenol and ibuprofen, sit back, and watch the magic. A little extra TLC doesn’t hurt either.

When doctors do harm: understanding pre-test probability

What doctors don’t tell you: we’re scared. More than just scared of being sued, most of us are scared we’re going to miss something that will harm you. Scared this is going to be the one time out of a thousand that we miss something bad. We miss things all the time, but it’s usually things that don’t cause any damage. So, we test.

We over-order tests because the systems tells us to. You, our patients, tell us to. To over test, but not miss something bad, is rewarded. No one says, “good job not getting a CT scan on that person. By the way, she had appendicitis, which you missed, but at least you tried to not give her a big dose of radiation.” So we test.

Overlooked by patients, the best “test” your doctor has available is talking to you and examining you. Let’s introduce a medical term. Pre-test probability. Let’s say you see your doctor for chest pain. After she talks to you and examines you, but before she orders a test, she determines how likely it is that you are actually having a heart attack. We call that pre-test probability. After doing her assessment, maybe she decides that there is at most a 1% chance this is your heart. That means that you have a LOW pre-test probability. Then, she gets an EKG, which is normal.

Now, after examining you and doing an EKG, your doctor thinks you really are not having a heart attack. A low pre-test probability. This is where this concept becomes important: if she orders more tests, and one of those is positive, it is more likely that positive test represents a false positive. Tests are like doctors. They’re not perfect. Nearly every test can be falsely positive, or falsely negative. If you test a bunch of people for a disease they don’t have, some of them will test positive. But this is false. That’s just the nature of testing.

In the above example, if your doctor orders further testing, she is ordering it on someone who was very unlikely to have the disease to begin with. If you test positive, you may have tested positive for a condition you don’t really have. The test is positive, but it’s WRONG. It should be negative. The test is out to get us.  What’s the solution? Stop doing a bunch of tests on people who are very unlikely to have the condition you’re testing them for.

The problem with false-positive tests? They cause the ordering of more tests and the prescribing of more medications. Sometimes false positive tests result in referrals to specialists who have their own tool bag full of goodies for you. Talk about escalating health care expense! This whole series of unfortunate events could have been curbed by the doctor understanding, in the right setting, you’re ok with not testing. A little dialogue that says, “If you don’t think I need the test at this time, I’m fine with that.”

I have had patients basically demand tests. Like I said, I don’t want to miss anything. So, if pushed, I find myself obliging, to a degree. If I really think a test is harmful, I won’t do it. But, the art of medicine is splattered with gray. Most of the time, the best test I had was talking to my patient. The extra testing a patient requests, that I thought was unnecessary to begin with, rarely contributes to the care. It does, however, contribute to the patient’s bill.

Save some exposure to testing and hard-earned dough. Try having a discussion with your doctor about pre-test probability and such. That might just floor her. It might just save you some agony and money.

What unnecessary trips have you taken down the road of follow-up tests?