Don’t Get ‘Bitten’ by the Frost!

With Mother Nature’s most recent gift of ice and snow, it seems fitting that we talk about a cold related emergency: frostbite! Historically, frostbite was known to be a problem suffered only by military personal and hunters, who spent hours in sub-freezing temperatures due to the nature of their profession; however times have changed and civilians are now included in those at risk.

Frostbite occurs when tissues freeze after being exposed to temperatures below the skins ‘freezing mark,’ which is 2 degrees Celsius. Those individuals most susceptible still include military personal and hunters, but also include those of us who spend large amounts of time outdoors; whether that be all-terrain hikers, sanitation workers or recreational skiers. Other individuals most susceptible include those who are dehydrated, malnourished, intoxicated or elderly. Parts of the body that are most affected include areas that protrude from the body, meaning ones fingers, toes, ears, nose and cheeks!

There are two mechanisms by which tissues can freeze resulting in frostbite:

1. Directly: As the tissues are exposed to colder and colder temperatures ice crystals form within the tissues causing the surrounding cells to lose some of their water content (dehydrate). The state of dehydration leads to breakdown of the cell structure and results in frostbite.

1. Indirectly: Known as the “hunter’s frostbite,” this mechanism occurs when there is increased blood flow to the freezing tissues followed by decreased blood flow, and increased blood flow again. The alternating blood flow leads to inflammation and damage to the small vessels within the affected tissue, which in its most advance stages leads to inability for blood to reach those sites indefinitely, i.e. frostbite!

Whichever mechanism of ‘freeze’ causes the frostbite, symptoms typically present in the same fashion. Initially burning, numbness, tingling and/or itchiness in the affected area occurs, warning of impending freeze. When these sensations are experienced it’s best to get inside and warm up for a bit before heading back out into the cold temperatures. However, if you don’t notice these symptoms, or fail to heed their warning, progression of your ‘tissue freeze’ will continue. The affected areas will begin to turn white, there will be an absence of sensation and swelling will occur. In severe cases, blistering of the affected area occurs with purplish/blue color changes and hardening of the tissue or a “wooden” feeling to the skin. It is at this end-point that the danger of losing the affected part becomes reality.

Classically, four stages of frostbite have been described from 1^st degree being the most benign and resulting in no permanent injury or tissue damage to 4^th degree frostbite being the most harmful with complete tissue death and loss of the affected part. There are also categories of frostbite such as Chilblain’s and Frostnip that don’t fall into one of the four stages, and are characterized as milder forms of the typical frostbite. In any situation, if you are even the tiniest bit suspicious of frostbite, it is important to seek medical attention immediately. Treatment, including controlled/monitored rapid re-warming of the affected area will help save as much tissue as possible.

Frostbite is not an injury you want to suffer from so prevention is key, but if you find yourself in a situation where frostbite seems probably remove yourself from the cold temperatures immediately and seek medical attention for evaluation and appropriate treatment.

Protect those areas most at risk by bundling up with gloves or mittens, hats, earmuffs, wool socks and water proof shoes next time you head out to shovel your sidewalk or make snow angels in some fresh powder!

DVT: Take Two!

Last week we discussed risk factors associated with the development of a Deep Venous Thrombosis (DVT). A DVT, to reiterate, is a clot in the deep venous system of the leg; the vessels responsible for carrying blood from the extremities back up to the heart for re-oxygenation and recirculation. We mentioned that a DVT can occur in anyone, but that certain risk factors such as stasis, tobacco use, estrogen use and heart conditions in addition to a history of DVT can predispose patients to development of a blockage. For a full list, including information about each risk factor, please refer back to the Blog entitled: What are My Risk Factors for a DVT?

This week, as promised we will focus on diagnostic testing that can rule-out or confirm a DVT, and if confirmed, the course of treatment that can be expected to follow.

Symptoms associated with a DVT typically present as a painful, red, swollen and hot leg. These symptoms, with or without the presence of risk factors should raise your index of suspicion for a DVT and medical attention should be sought immediately. As mentioned, should you present to your Podiatrist’s office with such symptoms you would be immediately referred to the nearest Emergency Department, therefore, starting at the Emergency Department is a wise choice!

When you arrive, it is important to explain to the admitting nurse all symptoms that you are experiencing as well as mentioning any risk factors associated with the development of a DVT. Although the process may be scary, it is important to convey all information and your suspicion of a DVT so that the Emergency Department staff takes you seriously and prompt evaluation can take place.

With suspicion of a DVT you will immediately be set up with an IV and medications given that can help break up a clot, should one be present or medications that can thin the blood to decrease the risk of additional clotting and migration of an existing clot. It should also be expected that you have blood drawn for evaluation of your base-line status in addition to looking for any imbalances in your electrolytes or blood counts. There is a specific blood test that can be conducted called a D-Dimer Test. This test looks for a specific chemical in the blood that if present can indicate the presence of a clot. It is not specific or diagnostic of a DVT but can help lead the Physicians in the right direction.

Additional tests such as a Venous Duplex Ultrasound can be conducted to look specifically at the deep veins of the lower extremity for direct visualization of a clot. The Ultrasound is completely non-invasive and consists of an Ultrasound Technician using a camera with ultrasound gel on your legs to locate a clot. Should they find one, the Technician is usually able to tell if the clot is new or if it has been present for sometime (noted by how hard the clot appears), which will help guide your treatment.

If a Deep Venous Thrombosis is detected, immediate treatment is indicated, as progression to a Pulmonary Embolism (PE) is the largest complication of a missed or under treated DVT. A PE is defined as the progression of clot from the deep veins of the leg to the lung, blocking off a section of the lung. It often becomes difficult to breath and in worst case scenarios, can be fatal!

Anticoagulation therapy is a treatment modality most of us have heard of in some form or another, usually referred to as “blood thinning.” It is the best and most effective treatment for DVT’s and helps reduce the risk of progression of your DVT to a PE. Medications that can be used in both the short and long-term include Heparin and Warfarin (Coumadin). In the hospital you will likely be started on Heparin and transitioned to Warfarin prior to being discharged home. The indication for blood thinning in patients with an acute DVT includes 3 months of therapy and in patients with recurrent episodes of DVT’s or a multitude of associated risk factors, longer.

Anticoagulation therapy requires weekly monitoring to ensure that your blood levels are thin enough, but not too thin, thus prior to any long-term treatment, you should discuss all options with your Physician. There are other options that can be explored in patients that are not candidates for anticoagulation and those should be discussed with your doctor as well.

Just remember, that if you suspect a DVT prompt recognition and treatment are a necessity, so seek medical attention immediately!

What are My Risk Factors for a DVT?

When you hear someone talking about a DVT or Deep Venous Thrombosis, even if you don’t fully understand the process of the condition, it makes you a little nervous! DVT’s, in the eyes of the general public, and in the eyes of medical professionals, are not something to “mess around with.” The seriousness of the condition, if caught early can quickly be diluted, but if a DVT is not detected or progresses beyond its initial stages, complications become real threats!

To take a step back for a minute, lets talk specifically about what a DVT is, and what it means in terms of presenting symptoms. The vasculature in the leg, and in the remainder of the body for that matter has two main systems. There is an arterial system that is responsible for brining blood from the heart out to the body providing oxygen and nutrients to the tissues allowing them to thrive. There is also a venous system, which is responsible for carrying deoxygenated blood from the body’s tissues back up to the heart and lungs for re-oxygenation and recirculation. For all you engineers out there, it’s a closed-circuit system!

Specifically in the lower extremities, the venous system, that which is responsible for carrying blood back up to the heart, is divided into a superficial (meaning close to the skin’s surface) and a deep (meaning hiding within the musculature of the leg) system. All blood within the superficial system is funneled into the deep system before it can be returned to the heart. A Deep Venous Thrombosis is a clot or a blockage in the deep venous system of the leg, meaning blood from both the superficial and deep systems of the affected leg can not properly return to the heart, as all blood must return through the deep veins.

When a blockage occurs (DVT), the patient may feel no symptoms at all, but more than likely the patient will notice pain, redness, increased temperature to touch, and swelling all within the affected leg. These symptoms, in addition to some of the associated risk factors for a DVT should raise immediate suspicion and requires immediate medical attention.

Speaking of risk factors, there are categories of patients who are more likely to suffer a DVT than others, and although it is rare to develop a DVT in the absence of such risk factors it is possible.

Here are a few common risk factors for the development of a DVT:

1. Stasis – periods of immobilization of the lower extremities such as casting after an injury or surgery, or long periods where the legs are stationary such as long airplane rides.

2. Hypercoagulability – some individuals are more prone to clotting than others secondary to genetically inherited disorders called thrombophilias.

3. Damage to vessel walls – injury to the venous system directly from any traumatic injury or recent surgery can be a predisposing factor

4. Heart Conditions – such as atrial fibrillation, congestive heart failure and past history of a myocardial infarction (heart attack).

5. Obesity – carrying extra weight tends to induce an increase in pressure on the deep venous system predisposing the vessel walls to damage, and thus increasing the risk of DVT

6. Tobacco Use – smoking can also induce damage on the vessel walls in addition to affecting the bloods ability to remain fluid and free-flowing.

7. Estrogen Use – a side effect of virtually any oral contraceptive available for women is development of a DVT.

8. Past history of a DVT – those patients with a previous DVT history have a much higher predilection to developing a DVT again.

To reiterate, if you suspect a DVT with or without associated risk factors, you should seek immediate medical attention. If you had presented to your Podiatrist office and a DVT was suspected during your visit, you would immediately be referred to the emergency room, so if you are at home, start with the emergency room first.

Next week we will discuss what to expect upon your arrival to the emergency room with suspicion of a DVT so that a diagnosis can be made or excluded. In addition we will discuss treatment options so as to prevent progression of a DVT into a more serious complication: Pulmonary Embolism.

Compartment Syndrome: A Rare but Serious Sequelae

Over the last several weeks we’ve talked about some injuries to the lower extremities that are suffered under high-energy mechanisms (calcaneal fractures and 5^th met base fractures), meaning a large force on the body has created the injury. We’ve talked about what to do when you suspect an injury, including early evaluation by your Podiatrist. Aside from an improved outcome through receiving early treatment and immobilization with either casting or surgical means, as Foot and Ankle specialists we are always on the lookout for Compartment Syndrome.

Well, what is that? Compartment syndrome, also known as neurovascular compromise (neuro = nerves; vascular = blood supply) needs to be ruled out every time an injury to the lower extremity occurs. When swelling occurs post-injury, pressure can build-up within the compartments of the leg or foot and can inhibit the function of both the nerve structures and the blood vessels within that same area. If function of those structures is inhibited for too long of a time period, permanent damage and impaired function can result, with possible loss of portions of the foot that have been compromised.

First and foremost, it is important that you be evaluated as soon as possible when you’ve suffered a lower extremity injury, especially those suffered via high-energy mechanisms. Prompt evaluation by a Podiatrist can recognize early indicators of compartment syndrome in addition to early intervention for relief of compartment pressure to free up those impinged structures.

When you present to the Emergency Room, you should expect the area of injury to be examined, but there are a few specific signs/symptoms we will be looking for to help us rule out compartment syndrome. Palpating your foot for pulses, the temperature of the foot and how quickly your toes “pink up” after pressure (capillary refill time) will give us a lot of information about compromise of blood vessels. Next, evaluation of the nerves to your foot and leg will be conducted where feeling on the injured foot will be compared with feeling on the non-injured foot. Several tools, such as a cotton-swab or a small piece of fishing-line will help with the comparison.

If all points of the examination are within normal limits compartment syndrome can be ruled out and standard evaluation and treatment of your injury will ensue. If there are several red flags in the examination, there is an additional evaluation with a Wick’s Catheter that can be conducted. The Wick’s can take a measurement of the pressure within the compartments of the leg and foot to determine if increased pressures are present and thus confirming a diagnosis of compartment syndrome. If the diagnosis is confirmed, immediate relief of the compartment pressure must take place to prevent long-term complications to the nerves and blood vessels significantly decreasing the risk of loss of portions of the foot secondary to compromise.

The “Gold Standard” for treatment of compartment syndrome is fasciotomy. Basically, what that means is that several small incisions will be made over the areas of concern for increased pressures, essentially relieving the pressure within the compartments of the foot and decreasing the risk of “neurovascular compromise.”

Compartment syndrome as a sequelae of high-energy injuries is rare, but can occur, thus early evaluation of your lower extremity injury is imperative to early recognition and prevention of long-term complications. Most often, evaluation will rule out compartment syndrome and early treatment of your injury can begin. In those rare instances where compartment syndrome is a real threat, you’ll be happy that prompt intervention took place, because even though the road to recovery will be long, function, sensation and blood flow to your leg and foot will be restored preventing the risk of long term disability!

Ankle Fracture Season is Among Us!

With the snow and ice fast approaching the number of patients heading to the emergency room with suspected ankle fractures is quickly rising! In previous Blogs we’ve talked about ankle fractures, but this week I want to talk about a different type of fracture associated with ankle injuries: the 5^th metatarsal base fracture!

The 5^th metatarsal bone is a long bone in the foot that connects the rearfoot to the 5^th toe. It is one of five metatarsal bones in the foot, each corresponding to a digit. Fractures of the 5^th metatarsal base (the end of the bone closest to the ankle) are commonly associated with classic ankle injuries where the foot turns inward.

There is a muscle that passes along the outside of the ankle and inserts into the 5^th metatarsal bone at its base called the peroneus brevis (PB). With an ankle sprain or injury where the foot turns inward, the PB contracts and pulls on the 5^th metatarsal base, sometimes so strong that it avulses, or pulls a piece of bone away from the rest of the metatarsal bone. Therefore, when you twist your ankle and have not suffered an ankle fracture, you may not be completely ‘home-free;’

You should be suspicious of a 5^th metatarsal base fracture any time that you are suspicious of an ankle injury. However, residual pain along the outside of the foot along the 5^th metatarsal bone is a good indicator of injury to that area. Try sliding your finger along the outside border of your foot from your 5^th toe back towards your heel. Along the way you should feel a “bump” which is the landmark of your 5^th metatarsal base. Pain in that are can be indicative of a fracture, as that is the most likely place where the PB would have pulled off a piece of bone. Be particularly suspicious if the pain in that area has not improved several days after your ‘ankle twisting incident.’

Fractures of the 5^th metatarsal base are particularly tricky to treat because the blood supply to that area of the bone is delicate. In the area of such fractures, two blood supplies are coming together, and disruption of their connection via fracture can permanently hinder the healing process, as blood supply is imperative to bone healing. Keeping that in mind, early detection of a 5^th metatarsal base fracture is important so that immobilization can be initiated as soon as possible. The goal of immobilization is to decrease motion at the site of the fracture to encourage healing making the delicate blood supply less of a factor!

There are several ways in which immobilization of the fracture site can be initiated and the choice depends on the severity of the fracture. If the fracture is well aligned and shows no gapping between fragments, conservative treatment with immobilization in a short leg cast is indicated. If the fracture is displaced and there is significant gapping between the fragments, the fracture is unlikely to heel unless the fragments are brought back closer together. In this case, surgery may be indicated to place a pin or screw across the fracture site and immobilize the fragment with the “hardware.” A short leg case is still indicated to ensure that the patient remains non-weightbearing and minimizes the risk on non-healing.

In either scenario, 4-6 weeks in a cast should be expected so that the bone has time to heal. Once healing is noted and pain in the area of the fracture is severely decreased or absent, transition into a walking cast and eventually back into a comfortable supportive sneaker can be allowed.

Next time you twist your ankle, don’t be fooled into thinking is just an ankle injury, unless you’ve been cleared by your Podiatrist and no 5^th metatarsal base fracture has been suffered!

Getting Ready to String Up Some Holiday Lights?

You Might Just be Making Your Heel a Little Nervous!

Believe it or not, the number of heel bone (calcaneal) fractures that Foot and Ankle specialist see in their office tends to increase around this time of year. Certainly we get an increase in ankle fractures when the snow starts to arrive, but often people wonder about why heel fracture numbers go up. I’ll tell you a little secret: people start climbing ladders to hang holiday lights, and if they fall off the ladder and manage to land on their feet, they might just fracture their heel bone!

Calcaneal fractures are high-energy injuries, meaning that there needs to be a large force to create a fracture. If you think about it, falling off a ladder and landing on your heels creates a large force, as the entire weight of your body crashes into the concrete! Another common mechanism of injury for calcaneal fractures are motor vehicle accidents; another high-energy pattern. Therefore, patients who suffer from a calcaneal fracture must be evaluated fully for other injuries and fractures created during this force. The most commonly associated injury (although not common at all) is a lumbar spine (lower back) fracture. The force into the calcaneus tends to travel up the body and compacts the lower back making it more susceptible to injury.

If you have fallen from a ladder recently and suspect any kind of lower extremity injury, it is important to see you Podiatrist! They can evaluate you, take x-rays and rule out a fracture if you’re suspecting one. If there is a fracture present, they can initiate treatment as soon as possible to get you on the road to recovery! Symptoms that one might notice include severe pain! In addition there may be a distinct “black-and-blue” mark extending from the heel into the arch of the foot. As you know, we Podiatrist’s have names for everything, and call that “black-and-blue” a Mondor’s sign. In addition you will have difficulty moving the foot up and down at the ankle joint and pain with moving your foot inwards and outwards. A comparison of your feet from behind will reveal a slightly wider heel/foot on the affected side when compared to the non-affected foot.

Once you have been evaluated, any other injuries to the body have been ruled out, and x-rays confirm the diagnosis of a calcaneal fracture, the decision then becomes whether surgery is indicated or not, in order to repair the calcaneus. The answer to this question and the recommendation that your Podiatrist will make will be largely based on the location of the fracture, how far the pieces of the fracture are away from where they belong and if the Subtalar joint (the one that sits underneath the ankle) is disrupted.

In the best-case scenario, the fracture will be minimally displaced and the Subtalar joint will be unaffected, sparing you from surgical correction. In this instance, you will need to be casted for 6-8 weeks with crutches to avoid that any weight is put onto the affected foot. After those 6-8 weeks, when healing can be confirmed via x-ray, you will slowly be transitioned into a walking cast and finally back to a supportive sneaker.

In the worst-case scenario, the fracture will be largely displaced and the Subtalar joint will be severely affected, indicating surgical correction for realignment. The goal of surgical intervention is to repair the Subtalar joint with the hope that the height of the calcaneus can be regained and normal function of that joint can be restored. In order to accomplish this, a metal plate with several screws will be inserted against the heel bone to bridge the area and allow for healing in the corrected positioning. The length of time that you will be casted and non-weight bearing with crutches is closer to 12 weeks, again with transition to a walking cast and finally backs to a sneaker over the next several weeks. The treatment course for a severe fracture like this is about 6 months until you are able to return to normal activity, while the long-term effects last a lifetime.

Patients who suffer calcaneal fractures where the joint is involved, typically require an additional surgery down the line. The indication for this surgery is post-traumatic osteoarthritis, which we discussed over the last several weeks. PTOA is virtually impossible to avoid with this type of fracture pattern, but the initial surgery is important in managing PTOA in the long-term. It has been reported that patients who have initial reduction of their calcaneal fracture as indicated, do better down the line with managing their PTOA and although they end up having a joint fusion (a joint that will no longer move) they are more pain-free than their counterparts!

Scope it out!

Last week we reviewed the topic of Post-Traumatic Osteoarthritis. We defined the condition of PTOA as an arthritic condition that occurs within a joint sometime after the joint has been injured. Proper realignment of the initially injured joint helps to cut down on the occurrence and progression of PTOA, but sometimes it is inevitable!

There are several injuries, specific to the lower extremity that are infamous for causing PTOA, and they are as follows:

- Ankle fractures: PTOA in the ankle joint

- Heel bone fractures: PTOA in the Subtalar joint (the joint just below the ankle)

- Midfoot fractures: PTOA within the joints across the middle of the foot

This week, I wanted to focus on Arthroscopy as a treatment modality for PTOA in the ankle joint, following an ankle joint fracture. Arthroscopy is a procedure that utilizes a small camera to access and view the joint on a larger monitor, while allowing the surgeon to “scope” the joint and remove debris from the joint space. The end result and goal of Arthroscopy is to decrease the patient’s joint pain secondary to PTOA and to allow the joint to glide more easily through its typical range of motion.

When you suffer from PTOA, the joint becomes clouded with debris coming in the form of lose cartilage pieces, or in the form of synovitis. Synovitis describes inflammation of the “joint synovium;” a.k.a. the joint fluid that helps with easy gliding of the joint surfaces. Each of these components leads to painful range of motion in patients, thus eliminating or decreasing their presence within the joint space, through Arthroscopy, can be very beneficial!

The joint will be prepared with a distraction device, meaning an external device will be applied to both your leg and foot, with a gentle pull placed on each side, to increase the ankle joint space. This allows for easier insertion of instruments and for better visualization of the joint damage, so that debris is not missed during the procedure.

Local anesthetic will be injected into the ankle joint, with continual sterile saline flushing through the joint space during the procedure. The saline is important to create a “fishbowl-like” appearance of the joint, essentially floating the pieces of debris inside the joint that might otherwise adhere to the joint surfaces making it difficult to remove them.

The typical approach to Ankle Arthroscopy is from the front of the leg through two small incisions, measuring about 1cm in length. A camera will be inserted into one of the incisions entering the ankle joint capsule. In the other incision, a small cannula (hallow tube) will be inserted, which can be used to feed surgical instruments into the joint, helping to clear debris. A small ‘burr’ is the typical instrument of choice used by surgeons performing these procedures. The burr rotates back and forth eating debris as it is moved around the joint. Envision Pac-Man!

Post-operatively you will have two sutures in place, one over each of the small incision sites. Depending on surgeon preference, you will be placed in am immobilization device and will be required to remain non-weight bearing until your first follow-up appointment. Physical therapy is often initiated in patients who undergo Ankle Arthroscopy to help strengthen the muscles surrounding the ankle joint while improving joint function and getting you back on your feet, with range of motion to the ankle joint that is much less painful than prior to your “scope!”

There are risks to any procedure, although the risks of arthroscopy are minimal and rare. However, you should discuss all options for treating your Ankle Joint PTOA with your Podiatrist prior to any surgical intervention.