Pudendal Nerve Palsy

Damage to the pudendal nerve can occur suddenly as a result of trauma to the pelvic region, prolonged bicycling, fractures, or from falls. The pudendal nerve re-enters the pelvis under the sacrotuberous ligament and gives three branches.

usepudendalThe first branch, the inferior rectal nerve, provides rectal tone and perianal sensation. The second branch, the Perineal Nerve, gives scrotal sensation. The third branch, the dorsal nerve of the penis, give branches to the corpus callosum.

The pudendal nerve arises from S2, S3, and S4. The pudendal nerve carries sensations to the external genitals, the lower rectum, and the perineum.

The symptoms of pudendal nerve palsy can start suddenly or develop over time. Symptoms include the loss of sensation or numbness, burning or stabbing pain, difficulty with bladder and bowel functions, and sexual dysfunction.

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Causes of pudendal nerve palsy include prolonged sitting exercises such as bicycling or following fracture table traction—the nerve is compressed between the ischium and the hard object.

Treatment options are typically conservative, as the condition is usually transient and will improve over time. Treatment includes:

  • Restbike
  • Physical therapy
  • Stretches and exercises
  • Anti-inflammatory medications
  • Injections/nerve blocks
  • Surgery (as a last resort)

 

Prevention options for bicyclists consists of changing the sitting position while riding the bicycle and changing the seat from a narrow seat to a wider seat.

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Unbelievable Bacteria

One of the ways bacteria enters the body is through an open wound. When an open wound goes straight down to a fractured bone it is called and open fracture. When bacteria gains access to the deeper tissue beneath the open wound, the tissues become contaminated. Preoperative and prophylactic antibiotics are given to the patient to help decrease the infection rate with the hope of killing the bacteria in the contaminated field.

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Additionally, a special treatment is done during an open fracture to further help prevent infection. This treatment consists of irrigating and washing the wound, as well as debridement of the dead tissue. Once the tissue has been adequately cleaned, the fracture needs to be reduced and stabilized. Three different ways to stabilize the fracture is with a plate, a rod, or an external fixator. The open wound is either left open for a variable amount of time and it is closed later on. At the time of wound closure, a skin graft will be needed. To promote healing of the fracture a bone graft will be needed usually four to six weeks after the injury.

skin graft

A bone graft is obtained from the pelvis as the pelvis has a large reserve of bone that can be utilized. The bone that is harvested is cut into pieces and then added to the fracture where needed. Despite the best care, a certain percentage of open fracture injuries will become infected. When the tissues become infected by bacteria, white blood cells are attracted to the infected site where the bacteria are multiplying and causing inflammation.

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Bacteria multiply by replicating their DNA and then dividing into two identical bacterial cells. Due to the doubling of bacterial cells, the population of the bacteria grows rapidly. Once at the site of infection, the white blood cells begin to ingest the bacteria. These bacteria however, may survive and multiply within the white blood cells, causing the cells the burst. When this occurs, the bacteria is then released back into the tissues.

Other types of bacteria can also produce a thick capsule that prevents them from being engulfed. Engulfed bacteria may also produce toxins used to destroy cells that try to attack them. Bacteria can also hide in dead bone or bone cells. When this happens, antibiotics and white blood cells are unable to reach the bacteria, since the dead bone has no blood supply. In addition to the bacteria hiding in the bone, the bacteria grow rapidly.

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During this growth period, the bacteria communicate with one another through a process known as quorum sensing. Quorum sensing is the use of a chemical signals from one bacteria to another. As the bacterial population grows, the concentration of the chemical signal. Once the concentration of the chemical signal reaches a certain threshold, the bacteria then begin their attack. The bacteria will attack the tissues causing it to break down and die which can lead to an abscess formation. The abscess must be drained and evacuated, followed by antibiotic treatment.

bacteria communuity

Antibiotics can kill bacteria in several different ways. One way is by disrupting the cell wall which ruptures the bacteria. Another way, is by preventing DNA replication by blocking the unwinding of the DNA. A third way is by inhibiting the ribosomes from making proteins needed for the cellular structure and function. The last way is by blocking the enzymes that produce folate. Folate is needed for DNA synthesis, and without it the cell will die.

When hardware is used to stabilize the fracture, the story can become much more complex.

 

Sever’s Disease

Sever’s disease is a common cause of heel pain in children between the ages of 9 and 12 years. The pain is due to calcaneal apophysitis occurring due to repetitive and continuous traction on the calcaneus from the Achilles tendon. The apophysis is not part of a joint and has muscle or tendon attachments. This traction apophysitis may lead to stress fractures, pain and tenderness over the heel.

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Sever’s disease is similar to Osgood-schlatter disease of the tibial tubercle.

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Patients are usually young athletes presenting with heel pain that increases with activities. Upon examination there could be swelling, tenderness, warmth and/or redness on the back of the heel where the Achilles tendon inserts.

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Plain lateral X-rays may show sclerosis or fragmentation of the calcaneal tuberosity. Sclerosis is not specific for this condition.

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Fragmentation of the calcaneal tuberosity on the other hand, is more common in patients with Sever’s disease relative to the general population.

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Remember that Sever’s disease is a clinical diagnosis. X-rays may show other causes of pain such as tumors, fractures, infections or cysts. MRI is not commonly used, but can help rule out calcaneal stress fractures or osteomyelitis.

Sever’s disease is a self-limiting condition that usually resolves with time. Treatment usually consists of NSAID, Achilles tendon stretching exercises, and activity modifications and in severe condition a short leg walking cast can be used.

Heat Illness in Athletes

As summer approaches, athletes, coaches and other individuals will need to be aware of heat-related illnesses. Heat illnesses include a spectrum of conditions ranging from heat syncope, heat cramps and heat exhaustion to the more severe heat stroke.

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Heat Syncope (fainting) is a form of orthostatic hypotension that is related to dehydration. It occurs due to inadequate cardiac output and hypotension. It also occurs with standing quickly after sitting or lying down for prolonged durations in the heat. Symptoms include fainting, dizziness and light-headedness. Treatment includes oral rehydration (water, juice or sports drinks) and placing the patient flat on the ground in a cool area with slight elevation of the legs to push the blood back to the vital organs such as the brain.

Heat Cramps are painful muscle cramps that occur due to decreased sodium heat2.pngconcentration in the blood. The patient’s core temperature is usually not elevated. Sodium may decrease when salts are lost in sweat or with excessive water intake that does not include electrolytes leading to a situation called dilutional hyponatremia. Symptoms include painful muscle cramps occurring commonly in the abdominal muscles, arms, legs and thighs. Treatment includes rest, cooling and IV fluids or oral rehydration with fluids rich in electrolytes (sports drinks and juices) to replenish the sodium stores. Prevention could be achieved by consumption of fluids high in electrolytes before strenuous activities.

heat3Heat Exhaustion is the most common heat illness. The body temperature becomes elevated but is less than 40°C. The core body temperature is best measured rectally. The signs and symptoms of heat exhaustion include profuse sweating, core body temperature lower than 40°C, weakness and fatigue, cramping, headaches, nausea and vomiting,  fainting, hypotension, increased heart rate, and fast shallow breathing. Treatment includes rest, IV fluids or oral rehydration and rapid cooling by whole-body immersion in an ice bath.

Heat Stroke is the most severe form of heat illness. It is a medical emergency that needs immediate attention. The patient should be transported to the hospital as soon as possible. Heat strokes occur due to failure of the body’s normal thermoregulatory mechanism. If treatment is not started promptly, end-organ failure and ultimately death may occur. Heat strokes have a high mortality rate and require quick reduction of the patient’s temperature. The three characteristic features of this condition are a lack of sweating, core body temperature above 40°C (best measured rectally) and an altered mental status. Additional signs and symptoms include hot, dry skin, disorientation, confusion and hallucinations, headache and slurred speech. This is a serious medical emergency that requires rapid core body temperature reduction. The patient should have close monitoring of airway, breathing and circulation. The physician should implement basic life support and ACLS protocols. Rapid cooling by whole-body immersion in an ice bath will be utilized as well as IV fluids.

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