Low back pain is very common, and the majority of the patients get better with time. The ideal patient will get better with time and has no radiation below the knee, no history of trauma, no fever or chills or weight loss, no bladder or bowel dysfunction, no neurological deficits, and no pathological reflexes.
In order to optimize recovery, management of the patient should consist of early return to activity as tolerated, as the symptoms allow. You will give the patient reassurance with limited analgesia, early range of motion, and muscle relaxants. A healthy patient with an acute onset of non-traumatic low back pain, you do not need early diagnostic imaging before proceeding with the therapeutic treatment. Diagnostic imaging is not necessary unless the initial treatment is unsuccessful, and the symptoms are prolonged. X-rays may not be needed in the first six weeks unless there is a reason for it, such as red flags. In fact, the use of x-rays can lead to better patient satisfaction but doesn’t necessarily lead to better patient outcome. X-rays and MRIs may show changes in the intervertebral discs and may be associated with the patient’s pain, but these changes are also commonly seen in cross-sectional studies of asymptomatic people. There are a lot of false positive MRIs, and you need to correlate the MRI findings with the clinical findings. Don’t rely on the MRI alone! Just because you have MRI changes or disc protrusion, it does not mean that the patient needs surgery!
A nonspecific pain does not require surgery; therefore, it does not require further work-up. There are risk factors associated with low back pain that includes Poor physical fitness; Smoking; History of repetitive bending or stooping on the job and whole-body vibration exposure. If the patient has a simple low back pain, 50% of the patients resolve their pain in one week. Resolution of the acute back pain occurs in 90% of the patients within one month. If the patient has leg pain greater than back pain, then the patient has sciatica. Sciatica means nerve root irritation, probably due to a herniated disc.
Maisonneuve fracture involves fracture of the proximal fibula associated with an occult and unstable injury of the ankle. The problem in these patients occur when the ankle injury is presented without a fracture of the lateral malleolus, or the medial malleolus and the injury is mistakenly diagnosed as an ankle sprain and the proximal fibular fracture is missed. Examine the leg for tenderness in the proximal fibula to diagnose a proximal fibula fracture. The patient could be mistakenly treated for having an isolated proximal fibular fracture alone and the ankle injury is missed.
High index of suspicion is necessary to diagnose and treat this injury. Maisonneuve fracture equals syndesmotic injury. Syndesmotic Injury equals Syndesmotic Reduction and Fixation. If ankle x-rays show medial or posterior malleolus fracture, or a medial clear space widening with no fracture of the lateral malleolus, then you must obtain a long-leg films to assess possible proximal fibular fracture. Clinical examination of their entire leg for pain and tenderness in addition to long leg films of the entire leg that includes the ankle, and the knee is mandatory in case of the patient with approximate fibular fracture to exclude the presence of an additional ankle injury, or if the patient has an unexplained increase in the medial clear space of the ankle joint. You should be searching for the presence of a high fibular fracture. Look for signs of syndesmotic injury such as an unexplained increase in medial clear space or tibiofibular clear space is widened and it should be less than 5 millimeters.
So how do you explain this injury? It is explained by the presence of rotation force to the ankle with transmission of the force through the interosseous membrane, which exits through a proximal fibular fracture. Maisonneuve fracture occurs from external rotation of the foot, most often with pronation mechanism. This force has to go somewhere! If you don’t see a fracture of the fibula then do the squeeze test or the external rotation stress test (both will show syndesmotic). The injury can involve the deltoid ligament injury or medial malleolar fracture medially and a fibular fracture proximally. Additionally, the tibiofibular ligaments are also involved, which can be the anterior tibiofibular ligament, interosseous ligament, the posterior tibiofibular ligament or posterior malleolar fracture. This looks like a very unstable ankle injury that may not be very obvious at presentation and you have to look out for it.
So how do you treat an Maisonneuve Fracture? This treated by fixation of the tibiofibular syndesmotic injury (key of treatment) or syndesmotic screws. if you have a medial site injury and there is a tear of the deltoid ligament, leave it alone. if there’s a medial malleolus fracture you should fix that of the lateral side if there’s approximate fibular fracture leave it alone. If there is a medial malleolar fracture, it should be fixed. If there is a proximal fibular fracture on the lateral side, leave it alone. As for the Syndesmotic Injury, the fixation has to be stable and adequate. Because of the magnitude of the injury, the Maisonneuve fracture may require more syndesmotic screws than with a routine ankle fracture with syndesmotic injury. After the fixation you will give a short leg non-weight bearing splint for six to eight weeks. Here is a patient taste example: the proximal fibular fracture and you can see increase in the medial clear space and you can see that the syndesmosis is widened. You can see that in the posterior malleolar fracture the patient is fixed with syndesmotic screws.
The best way to prevent surgical site infection, is optimizing the patient prior to surgery. The physician will want to make sure that the patient is nutritionally fit. Specific protocols will need to be followed for patients with conditions such as diabetes, are overweight, or who smoke. It is also important to improve the skin and soft tissue condition (area where the incision will be). The physician should try to reduce the bacterial burden that the patient is carrying. Immediately before surgery, the patient should be given prophylactic preoperative antibiotics and try to decrease the contamination in the operating room. The patient may bring organisms on themselves into the operating room (about 80% of these organisms are brought in by the patient). A screening for Methicillin-Sensitive Staphylococcus Aureus (MSSA) or Methicillin Resistant Staphylococcus Aureus (MRSA) and decolonization. Identifying the patients carrying diseases and treating the condition prior to going into the hospital will reduce the infection rate. Once patients are in the hospital, it is possible for them to spread bacteria to other patients. The best way to prevent the spread of bacteria is with PROPER HAND WASHING PRACTICES!
How can we decrease the bacterial burden of the patient bringing these organisms to the operating room? What are the tests that we should do? How can we help the situation when the patient is in the clinic or in the office?
The patient should be screened for MSSA or MRSA and then a decolonization should be done. Some patients have large reservoirs of bacteria (carriers) and these are the patients who will have an increased risk of surgical site infection. These reservoirs are located in the nose, axilla, groin, and perianal area. These patients will need to be identified so the bacteria can be eradicated and the risk of surgical site infection can decrease. Being a MRSA carrier will increase the chances of infection (about 10x more risk for surgical site infection). You wouldn’t know that the patient is a MRSA carrier unless you test them. It is important to identify these MRSA carriers so that proper antibiotics can be given. A MRSA “carrier” is an individual who can carry the bacteria without necessarily becoming ill. About 2% of the population are MRSA carriers.
MRSA is a contagious bacteria that is difficult to treat because it is resistant to most commonly used antibiotics. In the bacteria cell wall, there is a penicillin binding protein. When penicillin is able to bind to the binding protein of the cell wall, disruption of the cell wall and destruction of the bacteria is possible. However, if the staph aureus acquires the mecA gene, then it can alter the penicillin binding protein, making the bacteria resistant to all penicillin. The primary way of transmitting MRSA is through direct contact from another person, an object that has it, or from sneeze droplets of an infected person. 30% of staph bacteria lives in the nose. About 25-30% of the population is colonized with S. aureus.
This means that the bacteria is present; however, it is not causing an infection with S. aureus. Ironically, if you are a carrier, you are only 6 times as likely to receive an infection, while non-carriers are 10 times as likely. MRSA carriers are diagnosed by examining a swab or culture of the nose. The physician will want to identify these patients before bringing them to the hospital, and eradicate or decolonize the organisms by using a 2-4% chlorhexidine bath for 5 days. The patient should leave the chlorhexidine on the surface of the skin (it works better if kept on for a longer time), so it is better not to wash it off. A 2% nasal mupirocin for five days may also be used. By the screening and eradication program, you can drop the infection rate by about 40-60% or more depending on the compliance of the patient. Our institution showed that empiric treatment is less costly than S. aureus screening and decolonization in total joint arthroplasty patients. They find that the cost is much less than the cost of the standard screening and decolonization of the S. aureus. They found that the empiric treatment allows for more efficient workflow without compromising the patient.
The biceps muscle is attached to the bone at the elbow. The biceps muscle is inserted into the radial tuberosity by the distal biceps tendon. The biceps muscle is responsible for some elbow flexion and is the primary supinator of the forearm. Supination is the function used when turning a key or a door knob. The biceps muscle is responsible for over 50% of forearm supination. Rupture of the distal biceps tendon involves flexion of the elbow against resistance with eccentric loading and sudden tearing of the tendon. The muscle may retract into the upper arm causing a bump or “Popeye” sign. If the ruptured tendon is not repaired, the patient will lose the ability to supinate the forearm adequately. Injury to the lateral antebrachial cutaneous nerve may occur when treating a distal biceps tendon rupture. The lateral antebrachial cutaneous nerve lies between the brachialis and biceps muscles. The nerve can become injured from aggressive retraction. The lateral antebrachial cutaneous nerve originates cutaneous nerve originates from the musculocutaneous nerve. Injury to the nerve results in loss of sensation along the radial aspect of the forearm.
Treatment of a distal biceps tendon injury usually requires surgery due to the important supination function of the biceps muscle. Surgery may be done in the form of a single anterior incision or a two incision technique. Both of these techniques have their advantages and disadvantages. The anterior approach is easier with minimal risk of synostosis; however, there is a risk of injury to the posterior interosseous nerve. The two incision approach has less risk of injury to the posterior interosseous nerve, however there is a risk of synostosis. The lateral antebrachial nerve is the nerve most commonly injured during repair of a distal biceps tendon rupture regardless of the technique that is used. When treating the distal biceps tendon rupture, identify and protect the lateral antebrachial cutaneous nerve. Diffuse pain and paresthesia in the forearm after distal biceps tendon repair should be investigated for lateral antebrachial cutaneous nerve injury. In this situation, the nerve may need to be explored.