What is Whiplash?

 

For those who have been in a rear-end auto collision, the word whiplash may mean a lot. It’s a common injury that has become a household name. Each year there are about 2.5 million rear end auto collisions. So what exactly is whiplash?

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Figure 1

Whiplash is a non-medical term that implies injury to the soft tissues of the neck, specifically ligaments, tendons and muscles.

It is characterized by a collection of symptoms that occur following damage to the neck, usually because of sudden extension or flexion from extreme motions pushing neck muscles and ligaments beyond their normal range of motion.

 

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Figure 2

Injuries can range from minor tears of the sternocleidomastoid Muscle ( Figure 1) to partial avulsions of the longus coli (Figure 2) and  retropharyngeal hematomas.

Other common findings include:

  • Invertebral disc failures
  • Tears of one or both of the anterior longitudinal ligaments
  • Soft tissue injury of the facet joints
  • Dorsal root ganglia contusions
  • Damage to the vertebral arteries.

 

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Figure 3

Whiplash is most commonly caused or associated with motor vehicle accidents (Figure 3). However, contact sport injuries, blows to the head, repetitive stress injuries, and chronic strain are also common whiplash causes.

Whiplash Child abuse, particularly the shaking of a child, can also result in this injury as well as in more serious injuries to the child’s brain or spinal cord.

Whiplash may be difficult to diagnose as it may occur immediately or minutes to hours after the initial injury. Patients may experience:

  • Diffuse neck pain, tenderness and stiffness
  • Muscle spasms as a result of injuries to the muscles or ligaments
  • Headache, dizziness, nausea and blurred vision (symptoms of a concussion)
  • Difficulty swallowing and chewing and hoarseness (could include injury to the esophagus and larynx)
  • Abnormal sensations such as burning or prickling (this is called paresthesias)
  • Shoulder and/or arm pain
  • Back pain

 

Examination of the patient begins with a detailed patient history which should include:

  • Mechanism and velocity of the injury;
  • Delay between the injury and onset of symptoms;
  • Additional related symptoms; and
  • Review of previous neck injury

Radiographs or other imaging may also be utilized to determine if a fracture exists and to assess the condition of the cervical spine’s soft tissue. The physical examination should include palpation for areas of tenderness, cervical spinous processes, cervical paraspinal muscles, cervical nerve roots, and anterior cervical soft tissues. Lastly, the examiner should provide a neurologic examination to access cranial nerves, cervical nerve-root, upper extremity function and reflex evaluation of the upper extremity.

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Figure 4

To manage these injuries, doctors will usually immobilize the neck with a soft cervical collar (Figure 4) which may need to be worn for two to three weeks. Other ways to manage whiplash include ice therapy, pain medications, muscle relaxants and possible surgical intervention.

 

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What is Rheumatoid Arthritis?

Rheumatoid arthritis involves the synovium of the joints. The condition of rheumatoid arthritis will result in deformities. Rheumatoid arthritis occurs in females more than males.

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There may be a hereditary component with rheumatoid arthritis. Rheumatoid arthritis has spontaneous remissions and exacerbations. The disease can have a systemic nature. Pain and stiffness of joints especially in the morning (morning stiffness). Rheumatoid arthritis is typically poly-articular, bilateral, and symmetrical and most commonly affects the hands and feet.

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X-rays show periarticular erosions at the time of diagnosis. Osteopenia and minimal osteophyte formation favors the diagnosis of rheumatoid arthritis.

Pathogenesis

Rheumatoid is an auto immune disease. The disease has two important components: immunological reactions and increased degradative enzymes. The IgM (rheumatoid factor) is produced by the plasma cell as an antibody to the native IgG, which is altered in RA. 70% of the patients with RA have rheumatoid factor positive. Leukocytes are attracted to the immune complex forming deposits over the inflammatory surface of the synovium. These leukocytes ingest fibrin and immune complex and is called the rheumatoid cells. The leukocytes release lysosomal enzymes that causes acute inflammatory response and tissue necrosis as well as inflammatory mediators (IL-1, IL-6, and TNFα). The chondrocytes respond to stimulation by TNFα, IL-1 and other inflammatory mediators causing cells to become activated and secrete more metalloproteinases which lead to cartilage damage. The synovium becomes hypertrophied (Pannus), showing intimal hyperplasis and infiltration by plasma cells and lymphocytes.

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Stages of Rheumatoid Arthritis

Early stages (acute) include hot, swollen, tender joints (synovitis), wrist swelling, MCP swelling and Flexor Sheath Synovitis. Complicated rheumatoid arthritis include digital vasculitis, ecchymosis, skin atrophy and nodules. Advanced rheumatoid arthritis includes swelling of the MCP joints, lateral slippage of extensor tendons and tendon ruptures and ulnar deviation of fingers. X-rays show destruction of MCP with subluxation, ulnar deviation and wrist destruction.

Finger deformities include mallet, boutonniere, and swan neck.

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The thumb is also involved. These changes occur due to proliferation, inflammation and hypertrophy of the synovium. Involvement of the distal radioulnar joint is usually associated with rupture of the extensor digiti minimi.

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Rheumatoid Nodules

25% of patients with RA will have subcutaneous nodules on extensor surfaces of elbow and forearm. Nodules are often multiple and seen along the ulnar margin of the forearm or pulp of the digits. Vasculitis is more common in patients with SC nodules, it is a strongly seropositive disease (aggressive) with a less than favorable prognosis.

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Treatment

If the patient has synovitis, it should be treated by a splint and medical treatment. If the patient has joint space narrowing, bone erosions and osteopenia the patient will need a synovectomy. If the patient has joint destruction/fixed deformity or loss of hand function, surgery is based on the conditions.

Before operating on RA patients, x-ray of the cervical spine is needed because the patient may have subluxation of C1-C2. Metacarpophalangeal joint arthroplasty of the fingers usually results in decreased extensor lag and improvement of the ulnar drift.

How to Tell If Your Orthopaedic Surgeon Is Board Certified

Responsible for setting standards in orthopaedic surgery, the ABOS certifies the physicians who meet those standards. Attained by passing a rigorous examination, certification must be maintained through specific, peer-reviewed processes, and re-examination every 10 years, unless the initial certification was attained prior to 1986.

Many patients place a great deal of importance on their surgeon’s board certifications. To help patients verify the quality of their surgeon, the ABOS allows the public to search its index of certified physicians. Orthopaedic surgeons will not appear on the list if they are uncertified or their certification has lapsed or been revoked, but they may also be omitted if their certification was very recent or if they are now retired.

To search the list for your orthopaedic surgeon, click the VERIFY CERTIFICATION link at ABOS.org.

About the author:

Nabil Ebraheim

A professor, department chairman, and residency program director at the University of Toledo, Dr. Nabil Ebraheim is a leader in orthopaedic surgery. Certified by the American Board of Orthopaedic Surgery (ABOS), Dr. Nabil Ebraheim ranked in the 100th percentile when he renewed his credentials in 2015.

Posterior Tibial Tendon Dysfunction

A tendon is a band of fibrous tissue that connects muscle to bone allowing the joint to bend. Tendons enable participation in physical activities such as running, jumping and other movements. The posterior tibial tendon starts in the calf and descends down the leg behind the inside of the ankle and attaches to the foot’s arch. Its function is to support the medial arch and sub-talar joint as the body passes over the foot. When the posterior tibial tendon becomes inflamed or is overstretched, the ability to support the arch is impaired resulting in flattening of the foot.

Posterior tibial tendon (Figure 1) dysfunction, as this phenomenon is called, can be attributed to several factors:

  • Tendon overuse.
  • exposing the foot to a significant load
  • Obesity
  • Hypertension
  • Trauma
  • Diabetes
  • Inflammatory diseases such as rheumatoid arthritis.

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    Figure 1

Patients with posterior tibial tendon dysfunction will often present with pain and swelling on the inside of the ankle, loss of the foot’s arch (flatfoot), tenderness over the mid-foot and an inability to stand on the toes.

To diagnose posterior tibial tendon dysfunction, physicians will likely use the “too many toes” test (Figure 2). Here, the physician measures abduction of the forefoot. If the

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Figure 2

posterior tibial tendon is damaged, the forefoot will deviate outwards in relation to the rest of the foot and will appear to have too many toes when viewed from behind. In addition to the “too many toes” test, the physician may ask patients to do a single heel rise. Here, patients are asked to stand with their hands on the wall and lift the unaffected foot off the ground and raise the toes on the affected foot. If the heel does not rotate inward, there is posterior tibial tendon dysfunction.

 

 

Posterior tibial tendon dysfunction can be classified in four stages:

 STAGE I – characterized by an inflamed posterior tibial tendon with normal strength. Upon examination, the patient will be tender to palpation but may show little or no change in the arch of the foot. While X-rays will most likely show no changes, an MRI will likely reveal mild to moderate tenosynovitis.

 STAGE II – characterized by a partially torn tendon or degenerative changes. Here, the physician will note considerable flattening of the arch without arthritic changes and will have a positive too many toes sign. X-rays will reveal abduction of the forefoot while an MRI will reveal a partial tear.

 STAGE III – characterized by severe tendon degeneration with a rupture likely. Patients with stage III posterior tibial tendon dysfunction will present with rigid flatfoot. X-rays will likely reveal abduction of the forefoot and collapse of the talo-navicular joint while an MRI will show a tear in the tendon.

 STAGE IV – is similar to stage III with the addition of an arthritic ankle joint.

Treatment for posterior tibial tendon dysfunction can range from conservative to surgical depending on how far the condition has progressed. In its early stages, physicians will often utilize rest, anti-inflammatory medications, and immobilization. If the foot fails to respond to conservative treatment or the condition has progressed too far, there are several surgical procedures that can be utilized. First, physicians may perform a tenosynovectomy. Here, the surgeon will debride and excise inflamed tissue surrounding the tendon. A second option is an osteotomy. Here, the surgeon changes the alignment of the calcaneus and may remove a portion of the bone. A third option is a tendon transfer where fibers from another tendon are used to repair the posterior tibial tendon. Finally, surgeons may fuse one or more bone together, eliminating movement in the joint through a process called arthrodesis. During this procedure, the forefoot is stabilized.