Non-Steroidal Anti-Inflammatory Medication (NSAIDS) have become one of the most popular medications in the world. There are many different NSAIDS, at least twenty in the U.S., but they are all related to each other. Unlike corticosteroids, these medications block inflammation by a different pathway. They are effective in reducing the pain and swelling associated with many orthopaedic conditions.
Aspirin was the first NSAID. Ibuprofen (Motrin, Advil, Nuprin) is by far the most popular. Other NSAIDS have become available for over the counter use (Aleve, Orudis) recently, and you can expect many more to be available soon. Generally, the over-the-counter medication is identical to the prescribed medication, but is a smaller dose. There are once a day NSAIDS (Relafen, Daypro, Orudis and others) that are more convenient to take.
All medications have side effects, and the most common side effect from NSAIDS is stomach or gastrointestinal upset. Therefore, NSAIDS should be taken with food, and discontinued if abdominal pain persists. Another side effect of NSAIDS is interfering in the normal blood clotting mechanism. Patients on chronic NSAID use may notice easy bruisability, bleeding gums, or other signs of 'thinned blood'.
Recently, a new type of NSAID has been developed. All of the previous NSAIDS have worked by interfering with the 'COX1' enzyme. Unfortunately, COX1 is also involved is protecting the stomach, the blood coagulation process, and many other important bodily functions. The COX2 enzyme is specific for inflammation, and COX2 inhibitors (Celebrex, Vioxx) were recently approved by the FDA. Other COX2 inhibitors are expected soon. The advantage of these new medications is that they do not bother the stomach, can be taken without food, and do not interfere in the clotting process.
Every person responds differently to NSAIDS. Some people respond to most of them, and for other people only a few different NSAIDS may work. If an NSAID is ineffective, have your doctor change you to one in a different class.
The arthroscope is a fiberoptic camera that allows the Orthopedic Surgeon to see inside many of the joints in the body, without having to cut those joints open with a large incision. The Arthroscope is a long thin tube, shaped like a straw. They come in various sizes, depending on the size of the joint that is being examined. A camera is attached to the end of the Arthroscope that is outside the body, and this is connected to a television monitor. Thus, one can see the inside of a joint clearly, and magnified many times, on the television monitor in the Operating Room. Often, irrigating fluid is pumped into the joint through the arthroscope cannula, to distend the joint, control any mild bleeding, and improve visualization. Frequently the interested patient can watch along with the rest of us in the Operating Room (only if they want to!)
With the arthroscope, we can now visualize the shoulder, elbow, wrist, hip, knee, and ankle joints. In most cases, the arthroscope gives us an even better picture than if we had to cut open the joint, and is often the only way to visualize certain structures in the body.
During the initial development of the arthroscope, its value was primarily in diagnosis. Now however, many procedures have been developed with arthroscopic techniques, and new arthroscopic instruments have been designed. Often the arthroscopic procedure is superior to the open technique, as there is no need to open a joint and cause additional trauma and scarring. Damaged tissue can be removed or repaired, and many highly sophisticated reconstuctive procedures are performed using the arthroscope.
There are many potential advantages to arthroscopic surgery. In addition to superior visualization, the avoidance of a large incision means less pain, less scarring, and faster healing. Usually only a few tiny puncture wounds are required, and these heal in a few days. This allows earlier motion (when appropriate), and better results.
There are some limitations to arthroscopic surgery, and certainly not every procedure is appropriate for this technique. A well-performed open procedure is always superior to a poorly performed arthroscopic one, and the operating surgeon needs to know his abilities and limitations. There are usually advantages and disadvantages with regards to arthroscopy, and these need to be discussed in detail with your doctor.
Arthroscopic Surgery requires extensive training for the Orthopedic Surgeon. Many courses exist to help surgeons learn new techniques. The Arthroscopy Association of North America is an organization devoted to advancing the arthroscopic knowledge and abilities of its members.
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Key words: cortisone, corticosteroid, Medrol
Corticosteroids are a family of medication. There are many different corticosteroids that naturally occur in the body, and are also available as oral or injectable medication. The most famous, 'cortisone', is actually not in use anymore, and has been replaced by more effective medications.
Corticosteroids have significant value in the treatment of many Orthopaedic conditions. Corticosteroids are potent anti-inflammatory medicines. They reduce the bodies 'inflammatory response' to injury. Signs of inflammation may be swelling, pain, warmth, and stiffness. While these are normal responses by the body to injury, and are essential in the normal healing process, the inflammation itself can, at times, slow down the recovery process. By giving a patient a corticosteroid, the body's own inflammatory response to an injury is decreased.
This means that corticosteroids can reduce some of the symptoms following an injury, especially swelling and pain. This can be helpful if the swelling and pain are interfering with recovery. The corticosteroid mediation itself usually doesn't heal an injury; it just allows the body to do it with fewer symptoms. One must be careful about using corticosteroids to simply mask symptoms. This may be appropriate is the diagnosis is known, and there are no other good options. If masking symptoms will make a condition worse, or harder to treat later on, then their use is inappropriate. It's as if your car was making a loud noise from the engine. Corticosteroids are like turning up the radio and rolling up the window: you just don't hear it. Now if you know what's wrong, and there's not much to do, then that is appropriate. If you don't know what's wrong, you might be making things worse.
Corticosteroids, like all medication, have side effects. Injections may be painful for a day or two. In dark skinned individuals, a corticosteroid injection can rarely cause a small area of skin lightening, or depigmentation. Corticosteroid injections are contraindicated in certain areas of the body, like the Achilles tendon, where it can actually cause rupture of the tendon. Regardless of location, repeated multiple corticosteroid injections are probably not a good idea. Nevertheless, used appropriately, corticosteroids can be extremely effective in treating certain conditions.
Key words: electrodiagnostic, NCV, EMG, nerve conduction, electromyography
Electrodiagnostic studies refer to two different tests that examine the health of muscles and nerves.
Nerve Conduction Velocities (NCV) test how well a nerve can conduct an electrical signal, much like a wire conducts electricity. By giving a nerve a small stimulation, and then measuring how long it takes to conduct that signal to another point, the physician can calculate the speed of nerve conduction. If a nerve is injured or compressed, the speed of conduction may be impaired. NCVs can also help localize where a nerve is injured or compressed.
Electromyography (EMG) involves testing the health of individual muscles. By giving a specific muscle a small electrical stimulation, the physician can measure how the muscle behaves electrically. This is useful to detect any damage to a muscle, or to determine if there is long-term nerve damage to that muscle.
Both of these types of studies are generally performed by a specialist, either a Neurologist or Physiatrist. There is occasionally some discomfort with these tests, although they are not excruciating! As with any test, there are several limitations with these studies; they often give helpful information, but need to be interpreted only with a good clinical examination.
Key words: X-ray, fluoroscopy, MR, MRI, CT, Arthrogram, Bone Scan
Imaging studies are special studies that your doctor may order to help diagnose your injury or condition. Here is a list of commonly used imaging studies.
X-rays are the most common study used in Orthopaedic Surgery. Different tissues in the body, especially bone, will block the x-rays from passing through the body onto a sheet of film. Thus x-rays are an excellent way to visualize the bones in the body. This is useful for diagnosing fractures, dislocation, arthritis, tumors, growth injuries, and many other conditions. While X-rays are a form of radiation, they are generally extremely safe to the body in doses and quantities typically obtained by your doctor.
Fluoroscopy is a form of x-ray. It is like an x-ray movie, where the body's bones can be visualized in real time. It is very valuable when looking for abnormalities that show up only during activity or motion, or when a joint is stressed. Flouroscans use extremely low doses of radiation, and are quite safe.
MR scans (MRI, Magnetic Resonance Imaging) are a valuable way to visualize the soft tissues in the body, such as tendons, ligaments, muscles, and other organs. The MR scan uses a magnetic field, not radiation. Basically, you lie still on a flat table, with the MR tube over the body part, in a magnetic field. A computer is able to analyze the data (how fast hydrogen atoms change their spin direction!) and provide exquisitely detailed pictures of slices of your body. It is painless and safe, but people with significant claustrophobia may require some sedation. It is not cheap: about a thousand dollars per scan. It is also not perfect, and one must be careful not to rely too heavily on the MR scan. It does a poor job with bones and cartilage.
CT scans (CAT scans, Computed Axial Tomography) are another form of specialized x-rays. They look a lot like a MR scan, and you also have to lie still on a table with the CT scanner over you. The CT scan will also provide detailed pictures of slices of your body, but it works best on bones, and works relatively poorly for soft tissues. The CT scan is useful to look for fractures or other bony injuries, when the plain x-ray is difficult to interpret.
Arthrogram: An arthrogram is a study where a special dye is injected into a joint. This dye shows up on x-ray, and an x-ray of the joint while the dye is being injected can reveal information about soft tissues such as muscles and ligaments, even if they aren't seen directly. Typically, an arthrogram is positive when dye is seen traveling into an area it shouldn't normally go to, implying a tear of another structure. Arthrograms have generally been replaced by MR. Although they are a lot cheaper that MR scans they are invasive and fairly uncomfortable. There are other limitations with Arthrograms: just because the dye doesn't cross into an area, doesn't mean its not torn anyway. Think of the one-way valve on an inflatable pool toy.
Bone Scan. A bone scan is a study that looks at relative blood flow to parts of the body. A small amount of a patient's blood is withdrawn, and a short acting radioactive isotope is attached to the red blood cells. The 'radioactive' blood is then reinjected back into the body. The patient lays on a table, which is really a big geiger counter. Wherever the blood flows in the body will show up on the scan. It just so happens that the skeleton has a tremendous amount of blood flow through it, compared to the rest of the body. Therefore, a bone scan will provide a picture of blood flow through the skeleton. Certain conditions cause a relative increase in local blood flow, such as a fracture, infection, or tumor. A bone scan is very sensitive at detecting this. By the way, the radioactive isotope is very weak, short-acting, and not very dangerous. It is expensive, however.
The most important reason for ordering any test or study is only if the results of that test will aid in making a diagnosis, or change the decisions regarding treatment. One should not order a test simply for the sake of ordering it. Many of these tests are expensive, and uncomfortable. Care should be taken regarding the relative risk and benefit before any study is ordered.
Ligaments are the strong tissues that connect a bone to another bone. Ligaments are very important in joint stability, by holding the bones in a joint together.
Excessive tension on a ligament will cause injury, also known as a sprain: A grade 1 sprain is a stretch injury to the ligament, without damage to its structure. These injuries typically heal rather quickly, with little long-term problems. A grade 2 sprain involves microscopic damage to the ligament, but the ligament remains structurally intact. These painful injuries will usually heal well, but often the joint needs to be supported while the ligament heals, up to 6 or 8 weeks. A grade 3 sprain involves actual disruption of the ligament, and may render a joint unstable. Depending on the location of the injury, the ligament may or may not heal on its own, and surgery to repair the ligament may be necessary for these injuries.
Tendons are the strong whitish tissues that attach muscles to bones. All muscles cross a joint, and when the muscle contracts, the joint moves. If the muscle is overloaded beyond its normal strength, the tendon may begin to tear, causing a strain. These may range from a mild strain, which heals quickly, to a complete tendon rupture. Since the normal elasticity of the muscle causes the torn tendon to pull away from the bone, the tendon end does not remain near its normal attachment. This means that most complete tendon ruptures will not heal normally, and thus many complete tendon ruptures require surgical repair.