X-radiography pitfalls: some undisplaced Garden 1 & 2 Fxs may be missed d/t pre-existing DJD and osteophytes along the femoral head-neck junction that may overly the Fx line
Fx line is incomplete and too small/subtle especially if the study is read by non-radiologists
Incomplete Fxs if left untreated will not heal and likely to progress to complete Fxs
AP hip spot view: note valgus deformity of the head (above yellow arrow) with a small/subtle line of sclerosis in the sub-capital region representing Garden 1 Fx. MRI may help with Dx of subtle radiographic Fxs. If MRI contraindicated, Tc 99 radionuclide bone scan may help demonstrate high uptake of the radiopharmaceutical in Fx (below image)
Above – Tc99 Radionuclide Bone Scan Reveals Left Subcapital Femoral Neck Fx
Garden 2 complete undisplaced (above green arrows) Fx
AP hip: Garden 3 complete partially displaced Fx (above the first image)
AP pelvis: complete displaced Garden 4 Fx (above the second image)
Clinical pearls: in some cases of Garden 4 Fx, DDx may be difficult to differentiate from OSP vs. pathologic fx d/t to bone Mets of Multiple myeloma (MM)
Management: depends on patients age and activity level
Garden 3 & 4� require total hip arthroplasty in patients <85-y.o.
Garden 1 & 2 may be treated with closed reduction of fx and open capsule and 3-cannulated fixating screws
Pre-existing DJD may require total arthroplasty
Occasionally observation may be performed on patients who are not active and significant risks of surgery and depends on surgical centers
m/c Rx of Garden 1 & 2 undisplaced Fx with 3-screws. Screws proximity depends on the bone quality and Fx type
THA aka hip replacement: cemented THA with bone cement (above the first image) vs. non-cemented (biologic) that is used mostly in younger patients
2-types: metal on metal vs. metal on polyethylene
The femoral angle of the prosthesis should have slight valgus but never >140 degrees
The non-cemented component uses porous metal allowing the bone to integrate sometimes coating in bone cement from osteoconduction
THA has good outcome and prognosis
Occasionally cement failure, fractures, and infections may complicate this procedure
Grateful for the treatment they have received for their injuries and conditions, many patients highly recommend Dr. Alex Jimenez, doctor of chiropractic, for a variety of health issues. Chiropractic care is an alternative treatment option which focuses on the diagnosis, treatment, and prevention of injuries and conditions associated with the musculoskeletal and nervous system. Dr. Alex Jimenez’s patients describe how much chiropractic care has improved their overall health and wellness, changing their quality of life for the best. Dr. Alex Jimenez is the recommended non-surgical treatment choice for a variety of health issues, including neck and back pain, among others.
El Paso, TX Chiropractor�Recommended
We are blessed to present to you�El Paso�s Premier Wellness & Injury Care Clinic.
As El Paso�s Chiropractic Rehabilitation Clinic & Integrated Medicine Center,�we passionately are focused on treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.
If you have enjoyed this video and we have helped you in any way, please feel free to subscribe and recommend�us.
Back pain can be debilitating, causing immobility, inflexibility, and have a significant impact on a person�s quality of life. It can make even the most mundane daily activities extremely difficult � and even excruciating. Building the muscles that make up your core (abdominals and back) can help support your spine and reduce back pain. In many cases, strengthening these muscles can assist a patient to avoid medication with its unpleasant side effects and even avoid surgery. With just a few smart moves you can significantly decrease your back pain, increase your mobility, and take back your life.
The Role of Abs and Back Muscles
The spine is the supporting structure for the back, but it also is a vital infrastructure for the entire body. It houses the central nervous system, and neural impulses are transferred along what is�a spinal superhighway.
The arms, legs, neck, and head are all connected and stabilized by the spine through an intricate network of ligaments and muscles. The back muscles and abs, or abdominal muscles, are at the center, or core, of this muscle network. They keep the body upright and facilitate movement. When these core muscles are not in good condition, it puts stress on the spine, impacting its ability to support the body. This often results in back pain and even injury in some cases.
Postural Alignment
Postural alignment is a frequent contributor to back pain. This is often due to weak core muscles.
As the muscles fail to do their job to stabilize the spine, the body adjusts structurally to accommodate the weakness. This can result in postures that cause joint pain as well as muscular pain and even headaches.
For instance, stooped or hunched shoulders can cause back pain, but it can also create tension in the shoulders and neck. This, in turn, can cause tension headaches and migraines in patients.
A sway back, where the lower back bows, causing the pelvis to tilt up, can cause severe lower back pain, especially after standing for long periods of time. Swayback can be the result of weakened core muscles or a combination of a weak core, combined with obesity or pregnancy.
The weight in the abdominal area pulls the spine forward so that it curves. A pregnancy sling can sometimes help with the pain, but it is just a band-aid. The real cure is to strengthen the core muscles so that they are better able to support the spine and body adequately.
Foundation Training
Eric Goodman, a chiropractor, developed Foundation Training as a way to help his patients who suffer from lower back pain but are not physically able to do Pilates or yoga. It is also designed to help those who sit for long periods of time to counteract the associated adverse health effects.
Foundation training incorporates powerful yet straightforward movements that work to integrate the body�s muscular chains, increasing strength and realigning the core and spine. It does not require any equipment so the actions can be performed anywhere. The muscles are trained how to move correctly and work together so that you the body learns to move how it is designed to move. The critical, essential exercise can be viewed in this video.
Creating a strong core can help relieve back pain but also have added benefits such as increasing energy, better mobility, and an improved mood. By allowing the body to support itself, it can naturally relieve pain and heal certain conditions without invasive surgery or medication which can have unpleasant or even harmful side effects. When you take good care of your body, it will take good care of you.
Unstable Fx: a result of high energy trauma with >50% d/t MVA
20% closed Fx and 50% of open Fx result in mortality
Mortality is associated with vascular and internal organs injuries
Vascular injury: 20% arterial 80% venous
Chronic morbidity/disability and prolonged pain
Unstable Fx are rarely seen in the outpatient setting and typically and present to the ED
Stable pelvic Fx are usually caused by muscles/tendons avulsions and more often seen in pediatric cases
Understanding Pelvic Anatomy Is The Key To Successful Imaging Dx
The bony pelvis is a continuous ring of bone held by strong ligaments
During significant impact, pelvic fractures may occur in more than one location because forces applied to one region of the ring will also correspond to injury on the other, usually the opposite side of the ring (above image)
Thus the majority of unstable pelvic Fx will typically demonstrate more than one break
Pelvic is seen as a ring of� bone connected by some of the strongest ligaments in the body
The pelvic ring comprises 2-semirings: anterior to the acetabulum and posterior to the acetabulum
The bony pelvis is in close proximity to major vessels carrying a greater chance of vascular injury
Anatomical Differences of The Female and Male Pelvis
Post-Traumatic Pelvic Views May Vary and Include:
Standard AP Pelvis (above images)
Judet views evaluating the acetabulo-pelvic region
Inlet/Outlet views helping with the symphysis and SIJ regions
Rad survey of the pelvis should include evaluation of the continuity of pelvic rings:
Inlet/outlet, obturator rings (above the first image)
Symphysis pubis and SIJ for diastasis and post-trauma separation (above the second image)
Lumbosacral spine and hips should also be carefully examined
Pelvic inlet (above top left) and Outlet (above bottom left)
Judet views: left and right posterior oblique views
Additional Survey:
Iliopectineal, ilioischial, Shenton and Sacral arcuate lines will help detection of sacral, acetabular and hip fracture/dislocations
Stable Pelvic Fractures aka Avulsion Injury
Appreciating anatomical sites of pelvic origin/insertion of different muscles will help Dx of pelvic avulsion Fx
Avulsion Fx of the AllS (origin of the direct head of Rectus femoris M)
Pelvic avulsions occur by sudden eccentric contraction especially during kicking or jumping
Imaging: x-radiography will suffice
Clinically: sudden snap or pop followed by local pain. Pt can weight bear
Care: non-operative with rest for 4-weeks. Non-union is rare. No major complications
DDx: key rad DDx feature is not to mistake an avulsion from an aggressive pediatric bone tumor-like osteosarcoma that may show some exuberant new bone formation d/t healing and bone callus
Commonly Encountered Unstable Pelvic Fractures
Malgaigne Fx: d/t vertical shear injury to the ipsilateral pelvis
Rad Dx: ipsilateral superior and inferior pubic rami Fx (anterior ring) with ipsilateral SIJ separation/Fx of the sacrum and adjacent ilium (posterior ring). Symphysis pubis diastasis can be seen. An additional clue is an avulsion of L4 and/or L5 TP that often signifies serious pelvic injury
Clinically: marked leg shortening, shock, inability to weight bear.
Damage to Superior Gluteal Artery can occur
Imaging: x-radiography followed by CT scanning w/o and with IV contrast esp. if visceral injury present
Care: surgical in most cases d/t significant instability. ORIF. Hemostasis, Pelvic stabilization
Prognosis: depends on the complexity, rate of visceral complications and stability. 10% Superior glut artery bleed requiring rapid hemostasis
Open Book Pelvis (major instability)
Mechanism: AP compression of different force magnitude (picture depiction)
Rad Dx: diastasis of symphysis pubis with diastasis of SIJ with and w/o adjacent Fx of the ala
Imaging steps: x-radiographic, CT scanning with and w/o contrast for vascular injury, cystography for acute urinary bladder rupture
Immediate and delayed complications may occur: vascular injury, urethral/bladder injury
Straddle Injury: Unstable Fx
Mechanism: direct impact/collision
High risk of urinary bladder/urethral injury
Imaging: bilateral superior and inferior pubic rami Fx with or w/o diastasis and Fx of SIJ
CT with and w/o contrast for vascular injury
Cystourethrogram additionally evaluates a urogenital injury
2) Osteoporotic patients with low impact, trivial or no trauma (i.e., insufficiency Fx)
X-radiography is crucial to early Dx and prevention of complications which include:
Dx: intra-capsular vs. extra-capsular Fx
Ischemic osteonecrosis aka avascular necrosis (AVN) of the femoral head and rapid disabling DJD
Epidemiology: USA has some of the highest rates of OSP hip Fx worldwide. Highest healthcare cost Fx to treat overall
Women>men, Caucasians>African-Americans
25-30% mortality within the 1st year. Mortality depends on co-morbidities and stat of activity prior Fx
Pathophys: the femoral neck is intra-capsular and transmits arterial flow to the head. The neck is uncovered by the periosteum and unable to develop a good callus. The neck transmits maximum tensile forces through the proximal femur and prone to Fx and non-union
If you�ve ever had a rib slip out of place, you know well the extreme pain it can cause. Every breath can be excruciating. Movement and laughing can also be very painful. It can be located in the back, side, or front on of the ribcage. It is often confused with other conditions such as gastroesophageal reflux disease, a heart condition, pleurisy, or heartburn. The area is usually very tender, and sometimes the area will swell, and a lump will form over the joint. Chiropractic care has been proven to be a very effective treatment for this painful condition.
Structure of the Rib cage
Many people believe that the ribcage is a fixed skeletal structure that houses and protects the heart, lungs, and other internal organs. That is only partly true.
The ribcage is somewhat flexible. Note how the chest expands when inhaling. This is because each rib is attached to the spine by three joints in the back, and to the breastbone by one joint in the front. These joints are small but do allow some movement or flexing so that the ribs do not impair breathing. Instead, they rise and fall with each breath.
However, these joints can become inflamed, and that is where the problems start. Because breathing is an involuntary response � and necessary for life � it is impossible to avoid movement in these joints. When there is inflammation in one or several, it can be unbearable.
Causes of a Rib Subluxation
There is any number of reasons for a dislocated rib. Some experience it by doing simple, everyday things like putting dishes in the dishwasher or putting the milk in the refrigerator. Some of the more common causes include:
Extreme sneezing or coughing � Excessive or severe coughing such as is associated with bronchitis or pneumonia puts a great deal of strain on the ribcage. However, even coughing due to a common cold can add enough stress to cause the rib to dislocate. Sneezing very hard can also cause it. Often the illness associated with coughing and sneezing can make a person more susceptible to rib dislocation due to the weakened state of the muscles.
Excessive vomiting � Much like sneezing or coughing, vomiting can also cause this condition. While it does not necessarily involve the lungs, the convulsive action of vomiting can cause a rib to �pop.�
Exercise � Working out can cause the ribs to move out of position, particularly if the person has poor or improper form, or if they do a lot of work with their arms extended in front of them. This is especially true when weights are involved. The muscles involved in the movement may not be strong enough to handle the added weight and movement combination, causing the rib to move out of place.
Improper Posture � Poor posture puts stress on the body, including the spine which, in turn, puts pressure on the posterior portion of the ribcage. Over time, this can cause ribs to dislocate.
Pregnancy � As a woman�s body changes toward the end of her pregnancy, her weight shifts to the front. This can create a continual downward pull on her rib cage, increasing her risk of rib dislocation.
Pain or discomfort in the area of the chest or back.
Swelling and bruising in the affected area.
The formation of a lump over the injured rib.
Extreme pain and difficulty when breathing, trying to sit up, or while straining.
Painful sneezing and coughing.
Pain when moving or walking.
Difficulty breathing.
Numbness or paralysis in nearby or surrounding ribs.
Tenderness in the affected area.
Treatments for a Dislocated Rib
Chiropractic care is considered one of the best, most effective treatments for dislocated or subluxated ribs. Once the chiropractor has determined that the rib is out of place, he or she will often begin by using various techniques that will �loosen� the area, making the muscles more pliable.
They may do this by using stretching, massage, or a vibration tool. They will then apply gentle but firm pressure to �pop� the rib back into place. In some cases stabilization may be used after to keep the area protected, allowing it to heal. The treatment is usually far less painful than the condition, and some patients report not experiencing any pain at all.
Ankylosing Spondylitis is a type of arthritis that typically begins during adolescence or in a person�s early twenties and occurs more often in men than in women. However, once experiences onset, they are affected for the rest of their lives. It is estimated that between 0.2% and 0.5% of individuals in the United States suffers from ankylosing spondylitis. �It can cause significant pain, discomfort, and immobility. While there is no cure for the condition, the symptoms can be treated, bringing some degree of comfort and mobility.
What is Ankylosing Spondylitis?
Ankylosing Spondylitis, or AS, is a type of arthritis that causes inflammation in the spine. While the vertebrae are primarily involved, it can also affect other joints as well, including the hips, shoulders, heels, ribs, and the small joints of the feet and hands.
In some cases, the heart, lungs, and even eyes can be involved. If left untreated, the condition can progress, causing chronic pain that can be severe as the spinal inflammation increases. More advanced cases can cause the spine to grow new bone formations so that it is immobile, or fixed, sometimes resulting in kyphosis, which is a bowed or forward-stooped posture.
What Causes Ankylosing Spondylitis?
While genetics is believed to be a key player in the development of Ankylosing Spondylitis, the exact cause has not yet been determined. The majority of people who have AS also carry a specific gene that has been linked to the condition.
This gene produces HLA-B27, a protein or genetic marker, that more than 95% of Caucasians with ankylosing spondylitis have. However, some people don�t have this protein who develop AS and many people do carry this marker yet never develop the condition.
Researchers theorize that there may be other genes that may be involved, as well as environmental factors that trigger the gene activation, such as a bacterial infection, causing people who are susceptible to AS to activate it. Scientists have identified more than 60 genes that are believed to be associated with AS with only about 30% that are linked to HLA-B27 regarding overall risk. Other genes that have been identified as key to AS include IL-23, IL-17, IL-12, and ERAP.
It is also believed that AS can be triggered when the intestinal defenses break down, allowing certain bacteria into the bloodstream. This can, in turn, cause an immune response.
How is Ankylosing Spondylitis Treated?
AS cannot be cured, but the symptoms can be treated to relieve stiffness and pain as well as delay or prevent spinal deformity and other complications. The damage that it does to the joints is irreversible, so it is best if treatment is started before that occurs. There are several ways that AS is treated:
Medication � Nonsteroidal anti-inflammatory drugs (NSAIDs) like indomethacin (Indocin) and naproxen (Naprosyn) are commonly used to treat the symptoms of AS. They can be useful in relieving pain, inflammation, and stiffness but may cause some side effects, including gastrointestinal bleeding. This makes long-term use impractical and even unsafe. If NSAIDs do not help, other medications may be prescribed, including:
Golimumab (Simponi; Simponi Aria)
Certolizumab pegol (Cimzia)
Adalimumab (Humira)
Etanercept (Enbrel)
Infliximab (Remicade)
Physical therapy – PT is often recommended to help with flexibility, strength, and pain relief. It can help with posture and prevent some of the more debilitating symptoms.
Surgery � Most people with AS do not require surgery, but it may be recommended if there is severe joint damage or pain. In some cases, it can cause significant damage to hip joints, and they will need to be replaced.
Chiropractic � Many patients with AS have with outstanding results with chiropractic treatment. It is non-invasive and does not have the unpleasant side effects that many medications have.
Chiropractic Treatment for Ankylosing Spondylitis
Chiropractors strongly recommend chiropractic treatment for the non-acute inflammatory stage of AS. Once the condition has progressed to acute joint disease, there is a very high risk of injury or damage to the connective tissue. Adjustments and exercise are used to relieve symptoms, but some of the traditional spinal manipulation treatments are not performed.
A chiropractor will also make recommendations to the patient regarding lifestyle changes that can help with symptoms, such as stopping smoking. Tobacco use can increase inflammation and damage connective tissue. They may also advise increasing their intake of omega three fatty acids in their diet. Regular chiropractic care can help patients manage symptoms and prevent disease progression, improving their quality of life.
Roberto Varela was always actively involved with chores at home before he started to experience neck, shoulder and leg pain. Due to his symptoms, Mr. Varela had difficulties engaging in regular physical activities, such as driving. However, after being recommended by his wife, he first received chiropractic care with Dr. Alex Jimenez, and Roberto Varela experienced tremendous relief from his neck, shoulder and leg pain, regaining his quality of life. Mr. Varela highly recommends Dr. Alex Jimenez and his staff for their services.
Shoulder Pain Treatment
Shoulder pain or leg pain is common; however, sometimes these problems don’t originate in the location of the symptoms. Shoulder and leg pain may also occur due to health issues in the neck or cervical spine. A variety of injuries and conditions can have their roots in improper posture, sports injuries or automobile accident injuries, causing misalignments, or subluxations, in the cervical spine or neck. Many healthcare professionals will discuss how damage to the cervical spine can be an underlying cause for shoulder pain and leg pain, among other symptoms.
We are blessed to present to you�El Paso�s Premier Wellness & Injury Care Clinic.
As El Paso�s Chiropractic Rehabilitation Clinic & Integrated Medicine Center,�we passionately are focused on treating patients after frustrating injuries and chronic pain syndromes. We focus on improving your ability through flexibility, mobility and agility programs tailored for all age groups and disabilities.
If you have enjoyed this video and we have helped you in any way, please feel free to subscribe and recommend�us.
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