Magnetic Resonance Imaging (MRI) – Accredited Facility

Seattle Orthopedic Center has been awarded a three-year term of accreditation in magnetic resonance imaging (MRI) as the result of a recent review by the American College of Radiology (ACR).

The ACR gold seal of accreditation represents the highest level of image quality and patient safety.  It is awarded only to facilities meeting ACR Practice Parameters and Technical Standards after a peer-review evaluation by board-certified physicians and medical physicists who are experts in the field. Image quality, personnel qualifications, adequacy of facility equipment, quality control procedures and quality assurance programs are assessed.

Broken Foot: Common Symptoms and Treatments

foot injuries

There are several medium and small bones that make up the three sections of the foot. The forefoot includes the slender bones that make up the 5 toes (phalanges) and the anterior portion of the arch of the foot (metatarsals).

The mid-foot is made up of more compact bones (navicular, cuboids, and cuneiforms) that make up the top of the arch of the foot. The hind-foot is made up of two bones, the talus that connects the foot to the lower leg and the calcaneus (the heel).

Foot injuries are common and can arise from a multitude of different mechanisms. Each of the bones of the foot are subject to fracture from externally applied forces. Fractures to the talus and calcaneus (hind foot) are typically caused by crushing forces, such as landing from a great height.

Fractures to the forefoot can be caused by crush, flexing, and twisting forces. In addition to trauma directly to the bone, there are ligaments and tendons attached to the bones of the foot. If enough force is applied to these ligaments and tendons, they can separate and take a small piece of bone with it.

In addition to fractures from a single traumatic blow, some fractures can result from repetitive impacts to a bone. This is called a stress fracture and commonly occurs in the metatarsals of the foot.

Common Symptoms

It can often be difficult to distinguish fractures from other types of injuries of the foot, such as sprains of the ligaments or bruises of the soft tissue. If a bone is fractured, there is typically pain localized to the fracture. There will also likely be soft tissue swelling around the affected area.

Treatment Options

To determine if there is a fracture radiology studies such as x-ray and CT may be necessary. Careful physical exam performed by an experienced surgeon can also help to elucidate whether or not a bone is fractured. Depending on the fracture type and location, there are multiple types of repair. These range from simple alignment and casting to surgical repair with hardware placement. Dr. Mark Reed of OSS is well versed in all of these repair techniques.

A New Treatment Option for Big Toe Arthritis?

Hallux Rigidus

Big toe arthritis, also called 1st metatarsophalangeal (MTP) arthritis or hallux rigidus, is a common condition affecting the foot and ankle. It is the most common site for arthritis in the foot. Patients typically develop symptoms between age 30 and 60, and females are more commonly affected than men.

Presentation
Patients typically develop stiffness and decreased range of motion at the big toe, which affects walking, running, and other athletic activities. Some patients develop large bone spurs on the top of the foot, which can cause pain with shoe wear and discomfort when going up on the toes.

Causes
Sometimes trauma (a fracture or crush injury) can lead to this condition, but for most patients there is no specific inciting event. Some patients are more likely than others to develop big toe arthritis, either because of some anatomic abnormality or because of genetic predisposition.

Diagnosis
A clinical exam and x-rays can confirm the diagnosis. Generally, advanced imaging like MRI or CT scan is not required.

Treatment
Non-surgical options include anti-inflammatories, shoe wear modifications, and over-the-counter or custom inserts (orthotics). Physical therapy can be helpful to maintain range of motion. Occasionally cortisone injections into the joint can decrease inflammation for a period of time.

Surgery can be used to treat cases that fail non-operative treatment. Traditionally, a procedure called a cheilectomy can be used to remove bone spurs from the top of the big toe joint. This is recommended for mild to moderate cases of hallux rigidus. This is a joint-sparing procedure. Recovery involves walking in a surgical sandal for about 3-4 weeks after the surgery.

For moderate to severe arthritis, a fusion has until recently been the only proven surgical option. This is a joint-sacrificing procedure, in which the bones on either side of the joint are fused together with screws and possibly a plate.

This reliably addresses pain symptoms but eliminates all motion at the joint. Recovery involves a period of non- or heel- weight bearing followed by fully weight bearing in a surgical sandal for 8 weeks or more after the surgery.

Cartiva

A New Surgical Treatment Option

A new option is Cartiva, which can be an alternative to the aforementioned procedures. Cartiva is an organic polymer engineered to match the properties of human cartilage, which is what wears out as arthritis progresses. Your surgeon implants the polymer into the head of the 1st metatarsal, to act as a new joint surface. This is a joint-sparing procedure which retains, and in many cases increases, range of motion.

Recent literature shows greater than 90% patient satisfaction after 5 years of implantation. Recovery is similar to that of cheilectomy, and involves fully weight bearing in a surgical sandal for about 3-4 weeks after the surgery. If the procedure does not resolve pain, a fusion is still a surgical option for you.

Summary

Hallux rigidus is a common condition that involves pain, swelling, stiffness and decreased range of motion of the big toe. Diagnosis is often straightforward and involves a clinical examination and x-ray. Several non-operative treatments exist, including NSAIDs, shoe wear modifications, shoe inserts, and injections.

When non-operative treatment fails, surgery is an appropriate option. Cartiva may be an appropriate treatment option to avoid fusion of the big toe. Please see a qualified foot and ankle orthopedic surgeon if you believe you may be a candidate.

Mark Reed, MD is a fellowship-trained foot and ankle orthopedic surgeon who has undergone training on the Cartiva procedure and has incorporated it in his practice. Please contact OSS to schedule an appointment for an in-depth evaluation.

Shin Splints – What are They & How to Treat

Shin Splints

If you are a runner, you have likely experienced at some point that pulling pain along your lower legs. Most people report symptoms as a dull ache along the front part of the lower leg, pain along the inner part of the lower leg, pain on either side of the shin bone, muscle pain, or swelling of the lower leg.

In some rarer cases, people will also experience numbness and weakness of the feet. This is generally known as “shin splints”, or medial tibial stress syndrome (MTSS). Typically it coincides with exercise and may be associated with changes to training level, intensity, duration, running surface, or footwear. It is a common condition said to affect anywhere between four to thirty five percent of athletes.

shin splints

Medial Tibial Stress Syndrome

MTSS is an overuse injury that is most commonly caused by excessive pronation and repetitive impact activities. Pronation, or the way that the foot rolls inward upon impact with the ground, is the body’s natural mechanism for shock absorption. During this process, the lower leg, knee, and thigh also rotate internally.

In cases of excessive pronation however, the arch of the foot flattens and inward rotation of the foot is exaggerated. This increases stress on the muscles, tendons, and ligaments of the foot and lower leg, causing lower leg pain. With repetitive high impact activities such as running, the frequent strain will often cause inflammation and swelling about the lower leg, exacerbating the pain.

In most cases, MTSS is easily managed with rest, ice, and the use of nonsteroidal anti-inflammatory medications. Sports massage and calf stretching exercises may also be used to reduce tension in the muscles of the lower leg. Once the acute symptoms have resolved, it is important to identify and correct the triggers of MTSS.

Physical therapy is a wonderful option for those seeking professional assistance with learning proper stretching techniques, creating a proper training program focused on gradual conditioning, and addressing biomechanical issues. There are also many orthotists in the area who can create customized shoe inserts that help correct any alignment issues, such as over-pronation of the feet. It is generally treated non-surgically with great success.

While MTSS is a relatively benign condition, lower leg pain, swelling, numbness, and weakness can also indicate more serious conditions such as: stress fracture, exertional compartment syndrome, popliteal artery entrapment syndrome, various nerve entrapment syndromes, or gastrocnemius-soleus muscle strain. These can often be confused with MTSS given the similarities in their symptoms and cannot be identified without advanced imaging studies such as x-ray, CT, MRI, MRA, or Doppler ultrasound.

If you a runner with leg pain and have not responded to standard therapies, it is important to seek out a qualified foot and ankle orthopedic surgeon.

Dislocated Elbow

What is a Dislocated Elbow?

When the joint surfaces of an elbow are separated, the elbow is dislocated. Elbow dislocations can be complete or partial. In a complete dislocation, the joint surfaces are completely separated (Figure 1a). In a partial dislocation, the joint surfaces are only partly separated. A partial dislocation is also called a subluxation (Figure 2).

Complete Elbow Dislocation
After Reduction of the Dislocated Elbow
Partial Elbow Dislocation

The elbow is stable due to bone surfaces, ligaments (which connect bones) and muscles. When an elbow dislocates, all of these can be injured to different degrees. A simple dislocation does not have any major bone injury. A complex dislocation can have severe bone and ligament injuries (Figure 3). In the most severe dislocations, there is injury to the blood vessels and nerves that travel across the elbow. If this happens, there is a risk of losing the arm.

Fractures and Complex Dislocation of Elbow

Three bones come together to make up the elbow joint (Figure 4). The humerus bone is in the upper part of the arm and attaches to the two bones of the forearm (ulna and radius). Each of these bones has a very distinct shape. Ligaments connect all three bones together. As muscles contract and relax, two unique motions can occur at the elbow:

  • Bending occurs through a hinge joint that allows you to bend and straighten the elbow.
  • Rotation occurs though a ball and socket joint that allows the hand to be rotated palm up and palm down.

Injuries and elbow dislocations can affect either of these motions.

Normal Anatomy of Elbow

Elbow dislocations are uncommon. The most common age for an elbow dislocation is 30 years old.

Mechanism of Injury

Elbow dislocations typically occur when a person falls onto an outstretched hand. When the hand hits the ground, the force is sent to the elbow. Usually there is a turning motion in this force. This can drive and rotate the elbow out of its socket. Elbow dislocations can also happen in car accidents.

When the crash happens, the passengers often reach forward to cushion the impact. The force sent through the arm can dislocate the elbow, just as in a fall.

Diagnosis

When the elbow is dislocated, the deformity of the arm is obvious. X-rays are the best way to confirm that the elbow is dislocated. If the bone detail is difficult to evaluate on an X-ray, sometimes a computer tomography (CT) scan will be done. If it is important to evaluate the ligaments, a magnetic resonance imaging (MRI) can be helpful.

However, the doctor will set the elbow first, without waiting for the CT scan or MRI. These studies are usually taken after the dislocated elbow has been put back in place.

Risk Factors and Prevention

Some people are born with greater laxity or looseness in their ligaments. These people are at greater risk for dislocating their elbows. Some people are born with an ulna bone that has a shallow groove for the elbow hinge joint. They have a slightly higher risk for dislocation. Nothing can be done to alter these risk factors.

Symptoms of a Dislocated Elbow

A complete elbow dislocation is extremely painful and very obvious. The arm will look deformed and may have an odd twist at the elbow. Get emergency treatment. It is important to evaluate the circulation of the arm and to check pulses at the wrist after an elbow dislocation.

If the artery is injured at the time of dislocation, the hand will be cool to touch and may have a white or purple hue. This is due to the lack of warm blood getting to the hand. It is also important to check the nerve supply to the hand.

If nerves have been injured during the dislocation, some or all of the hand may be numb and not able to move. Further testing such as an X-ray is necessary to determine if there is a bone injury. X-rays can also help show the direction of the dislocation.

A partial elbow dislocation or subluxation can be harder to detect. Typically it happens after an accident, but because the elbow is only partially dislocated, the bones can spontaneously relocate and the joint may appear fairly normal. There may be pain, however. The elbow will usually move fairly well.

There may be bruising on the inside and outside of the elbow where ligaments may have been stretched or torn. Partial dislocations can recur on a chronic basis if the ligaments never heal.

Treatment Options: Nonsurgical

The goal of immediate treatment of a dislocated elbow is to put the elbow back in joint. The long term goal is to restore function to the arm. First the alignment of the elbow must be restored. This can usually be done in an emergency department. The patient will receive sedation and pain medications. The act of restoring alignment at the elbow is called a reduction maneuver (Figure 1b). This should be done gently and slowly and usually takes two people to perform.

Simple elbow dislocations are treated with early motion after a short period in a splint or sling. Keeping the elbow immobile for a long time usually results in poor range of motion for the recovered elbow. Physical therapy can be helpful during this period of recovery. Some people will never recover full elbow extension even after a course of therapy.

Fortunately the elbow can work very well even without full motion. Once the elbow’s range of motion improves, the doctor or physical therapist may add a strengthening program. Interval X-rays may be necessary while the elbow recovers. This helps to ensure that the elbow joint remains well aligned.

Treatment Options: Surgical

In a complex elbow dislocation, surgery may be necessary to restore bone alignment and repair ligaments. It can be difficult to reduce the joint and to keep it in line. There is an increased risk for arthritis in the joint if:

  • The alignment of the bones is not good.
  • The elbow does not track well.
  • The elbow continues to dislocate.

After the surgery, the elbow may be protected with an external hinge. This device guards against re-dislocation. If there are associated blood vessel or nerve injuries with the elbow dislocation, multiple surgeries may be necessary. These surgeries repair the blood vessels and nerves in addition to reducing the joint. They also fix the bone and ligament injuries.

Research on the Horizon/What’s New?

Treatment for simple dislocations is usually straightforward and the results are usually good. However, many people with complex dislocations still end up with permanent disability at the elbow. Treatment is evolving to improve results for these people.

The best time to schedule surgery is being evaluated for treatment of complex dislocations. For some patients with complex dislocations, it seems that a slight delay for definitive surgery may improve results by allowing swelling to decrease.

The dislocation still needs to be reduced right away, but then a brace, splint or external fixation frame may rest the elbow for about a week before a specialist surgeon attempts major reconstructive surgery.

Moving the elbow early appears to be good for recovery for both kinds of dislocations. However, early movement with complex dislocations can be difficult. Pain management techniques encourage early movement. Improved therapy and rehabilitation techniques such as continuous motion machines, dynamic splinting (spring-loaded assist devices) and progressive static splinting can improve results.

Late reconstructive surgery can successfully restore motion to some stiff elbows. This surgery removes scar tissue and extra bone growth. It also removes obstacles to movement.

Severe arthritis can develop in the elbow. For this condition, newly designed elbow replacement prosthesis can be implanted. The arthritic elbow joint can be replaced with an artificial elbow, similar to joint replacements in the hip or knee. This decreases pain and improves motion.