Batter and Egg Yolk Make a Good Mutta (Egg) Dosa . But Why Treat Fractures With Them?

Hello and Welcome to Orthopaedics Made Simple , Making No Bones About It! And I am Naveen , Your Bone and joint Guy.

Even the greatest bone and joint surgeon  in the world cannot say "I Heal Fractures". That would be one big lie . The healing of any fracture is Nature's work. Period!

What am I trying to say? To keep it simple

Fracture . Now any break in the continuity of the bone , however small or big , is called a fracture. And bones are not some dry , dead structures. they are like any living organ and supplied with blood and nerves. So once the bone breaks the nerves that supply the outer cover of the bone called periosteum , immediately send signals to the brain in the form of pain. And the blood vessels rupture and blood accumulates. This is called fracture haematoma formation and is the first stage of fracture healing. So you can see that the fracture healing process starts right away.

The fracture haematoma has a lot of healing properties that helps in the formation of the soft tissue (callus) that converts into a hard tissue (bony callus) which then becomes bone and over a period of time that bone models into a normal bone completing the healing process.

So you can see that no man or machine is needed for fracture healing. Then what is the role of an Orthopaedician?

Now remember I have only been saying Fracture Healing is Nobody's Business , but fracture healing isn't the only aspect of patient care right? Healing happens once the fracture is stabilised or splinted but there are many conditions where one has to involve the bone and joint specialist.

Role of An Orthopaedic Surgeon

First it is in the management of open fractures known as Compound fractures where the orthopaedician's role is very very critical. These are fractures that are exposed to the outside and are prone for infections and delayed healing. These fractures could include small punctures to fractures where the entire soft tissue cover from skin to muscle can be torn apart. Washing the wound , keeping it clean , giving cover to the bone and then stabilising the fracture are some of the things that the orthopaedician needs to do. Sometimes the vessels can be damaged requiring a vascular surgeon. The skin loss could be extensive requiring a plastic surgeon's expertise to achieve cover without which healing cannot happen.

I only said bones start healing but they heal in an "as is where is" condition meaning if there is displacement , that would not be corrected. This could lead to deformity , difference in limb length and if fractures are around the joint do not heal in the correct position it could lead to reduced movement in that joint. So the next function of the orthopaedician is to see to it that the fractures heal in the right position.

Fractures heal , but they do take a considerable amount of time to do so and ideally during this time the fracture has to be immobilised and weight bearing is not allowed in the affected joint. This could mean being bed ridden for a considerable amount of time , loss of livelihood , other health problems like diabetes going out of control , bed sores , blood clots (DVT) among others and stiffness of the joints is very common. So the duty or responsibility of the orthopaedician is to get the patient on his or her feet as soon as possible and get the joint moving but making sure the fracture is stabilised and the bone union is on course. And not to forget a bed ridden patient is a burden to self and the family.

Finally in some cases the healing process takes more time than normal (Delayed Union) , sometimes the fracture unites in the wrong position (Malunion) , sometimes the fracture does not unite (Non Union) , the orthopaedician has to be called in to check out and set things right.

What does the Orthopaedician do?

Once you go to the orthopaedician with a suspected fracture , the first thing to be done will be splinting of the fracture and a painkiller will be given. If your vitals like blood pressure and pulse are alright you will be asked to get an X Ray done which would confirm the diagnosis.

Then depending on the fracture you will be treated as an out patient or be asked to get admitted. Simple fractures of the shaft that are not too displaced , especially in younger individuals and do not need prolonged immobilisation or bed rest are given a Plaster Cast and sent home and asked to review after a few days. Then again this is generalisation and is not applicable to all.

If the patient needs to get some procedure done like Wound Wash and Repair for Open fractures , fixation of fractures with rods , plates or screws , if there are signs of blood vessel or nerve damage or patients that need nursing care , they could be asked to get admitted. Each one of these is a separate blog post ,which I will talk to you in detail later.

Now coming to the core purpose of this blog . 

Where do the Traditional Bone Setters come in?

In India ,and also in other parts of the world traditional bone setters are very famous in dealing with fractures. In spite of the increase in number of hospitals , doctors and improvements in the medical field people still go to them. The reasons could be one or many of the following.

1) Fear of implants and foreign objects.
2) Faith in the spiritual powers of the bone setter.
3) Flexibility of traditional care setting. 
4) Financial cost of orthopaedic care in a hospital setting.
5) Familiarity with bone setter culture and lack of familiarity with orthopedic centers. 
6) Fear Mongering that doctors are bad.

What lets the bone setters survive?

They have to thank Nature and the Body's Own Healing Powers. Most fractures are simple ones that heal on their own. They would have healed if nothing was done to them also. So these bonesetters go tom tomming that it is because of their secret herbs and "recipes" that the bone healed.

The second reason is the ignorance of the fact that better results are possible if treated by modern orthopaedic methods . The patients going to these centres see the healing of the bone as the only goal , which would happen anyway. But they seem oblivious to the loss of time , loss of motion , loss of livelihood and loss of health.

The third reason is lack of legislative control and monitoring. The medical fraternity is hauled up even for a small minor expected complication and expected to give explanations or compensations but these bone setters are answerable to none. You do not even get a piece of paper from them and there is no proof of treatment also. Nearly impossible to question them for any complication or even get an explanation. And these people do not come under medical council or government regulation.

What Has to be Done:

The doctor community has to learn from these people. We have to question ourselves and introspect if we spend enough time with the patient , explain the condition , the various treatment options , the pro and cons of it and then let the patient make an informed decision. It is this lack of effort to communicate to the patient clearly and not giving the confidence to the patient that most of the times the patients land up there.

We all know what the traditional bone setters do ,especially the Puttur Kattu practionners , for undisplaced fractures. Some magic secret herb is rubbed on to the fracture site , some setting is done and the fracture is splinted with cloth which is strengthened using Dosa/Idly Batter and Egg. None of these items have been proven to be of any benefit in bone healing. So as doctors we should not insist on surgical fixation trying to convince the patients of the benefits of surgery. The patient need not be forced in to surgery and the doctor need be disappointed with the patient's decision. Instead the doctor should come forward and tell the patient that in case he or she doesn't want surgery , conservative methods like plaster or splinting can be done by the orthopaedician itself. There is no need to go to a bone setter. At least it would be done in accordance to modern scientific guidelines.

As a society there should be more awareness that the goal of orthopaedic treatment is to get the patient moving as fast as possible and ensuring bone healing at the same time. The benefits of this are tremendous medically and also financially. For instance a person being treated for a fracture by bone setters has to be away from work for at least two months. Now please calculate the loss of livelihood , the cost of frequent visits to the bone setter (sometimes as many as 8) and the cost of care taker. This will far exceed the cost of treatment by an orthopaedician in direct terms and I am not even calculating the indirect benefits of better and faster recovery.

Moreover , the bone setters sometimes ignore conditions like open injuries , nerve and blood vessel damage. These could lead to disastrous complications that could even result in the loss of either life or limb. Please please be aware and spread the message.

So my dear friends I would like to finish off by saying that Dosa Batter and Egg Yolk are needed to make Mutta Dosa , my favourite tiffen item and have no role in Bone Healing.  But trust the Orthopaedician to decide if Plaster of Paris or Performing Surgery is good for you. We at SCOT explain the condition in detail to the patient and leave the ultimate decision making to the patient.

Please visit www.Scot.com for more details.

And no other topic can emphasis my signing off slogan better. Keep Moving Always....Without Pain!

Problems Of The Disc - And Is it a Big Risk?

Hello and welcome to Orthopaedics Made Simple , Making No Bones About It. And this is Naveen , Your Bone and Joint Guy.

The bones that form the back (spine) are called vertebrae. And between these vertebrae , there are soft gel filled  like structures called intervertebral discs. There are 23 in number . 6 in the neck , 12 in the upper back and 5 in the lower back. These  basically act like shock absorbers for the spine.

And today we will be discussing about the problems caused by the discs and the ways to deal with it.

The Disc is actually like a jelly doughnut like structure that exactly fits the size of the vertebral body ,both above and below it, It has an outer tough layer that holds the jelly like substance inside.

As one ages the fluid content in the inner jelly reduces and the outer tough layer too becomes dry and susceptible to cracks and this leads to most of the problems in the disc.

The Degenerated disk is the one that loses the water content , becomes brittle and can get cracked , look at the picture above. And once that happens the bones lose the cushioning and can rub against each other and undergo wear and tear. 

The other type of disc problem is the jelly like inside can make it's way out of a tear in the outer layer and press up on the structures that are close by. Depending on the level of leakage and compression it can be called a bulging disc or herniated disc. The structure that is commonly compressed upon is the nerve that comes from the spinal cord and it can cause pain or symptoms due to nerve function loss like loss of power or loss of sensation to the area that the nerve supplies.

Complaints:

The most common complaint of a patient due to disc problems is Pain. This pain is of two types. One is the direct pain of damaged or degenerated disc. This is localised and also a pressure on the corresponding area elicits tenderness. Movements of the spine like bending can cause pain The other pain is the radiating pain due to the nerve compression. This pain is along the area that the nerve supplies and can be confirmed by aggravating the nerve compression. For instance lifting the patients leg can aggravate the pain along the buttocks , a sign of compression to the nerves supplying that area. This pain is what is called Sciatica.

The other complaints are all due to nerve compression and are the ones that have to be monitored closely and acted upon aggressively if needed. They include loss of sensation to specific areas supplied by the nerves. The other is loss of power or weakness in the muscles supplied by the nerves that are compressed. Sometimes Urinary problems like loss of bladder control or loss of sensation of fullness bladder can happen if the disc prolapse happens in the areas from where those nerves are.

Causes:

Now why does this happen. Firstly the degenerated disc is a part of the general ageing process. But nobody can say for sure why bulging or herniation happens. As a matter of a fact less than 10% of the patients who have disc problem will exhibit symptoms. In other words a significant percentage of the "normal" population has a disc bulge visible on imaging studies. Obesity is a contributor. The type of work which involves straining the spine like bending or lifting loads can be a contributor. And trauma also is a reason that can cause this.

When to visit a doctor:

If localised pain or discomfort are the only complaints then some over the counter pain medication for about 5 days and some rest refraining from physically hard work could settle the issue. But if the pain is severe , especially of the radiating variety and it persists beyond a week please visit the doctor.

And you have to visit the doctor immediately if there is significant loss of sensation or loss of power in the muscles. And it's a real emergency if there is bladder dysfunction and loss of emergency around the buttock area (saddle type) . This condition is called Cauda Equina syndrome which happens when the compression is slightly higher up in the lower back.

Management:

Pain medication is the starting point to handle the discomfort. And some patients get away with it. The pain killers can include ones that reduce the swelling and fluid collection (inflammation) or ones that act on the brain , opiod like drugs. Your physician is the best person to take a call. Muscle relaxants are also prescribed and in rare cases drugs that reduce anxiety and depression form a part of the prescription.

Lifestyle advice is also important and helps many people. Weight reduction , especially weight around the abdomen , has been proven to help people back issues. How to sit , how to stand , how to walk , how to lie down , how to get up , how to lift objects and what activities to avoid are all explained in great detail to the patient after evaluating their daily routine and work life.

The physiotherapist steps in various modalities like localised heat treatment to provide relief and also manipulation and massages. But the most significant thing that a physio can do is core strengthening exercises that help people overcome back pain related to disc issues.

The other modality that a physiotherapist may use is Traction. This basically is trying to pull the vertebrae apart using weights in the hope that it decompresses the pressure on the disc and helps to reduce the pain. No other treatment in orthopaedics produces as much debate as traction as some studies suggest very good results and the others say it is just a placebo (mental satisfaction) that people experience relief from as a natural subsiding of symptoms or due to pain medication and exercises.

These are all out patient procedures and most of the patients respond to this. They may have a repetition of symptoms in the future but they will respond to this and can get away from the next level of treatment that include minimally invasive and surgical procedures.

Who needs surgery?

As I have already mentioned above that a significant number of the normal population has some disc problem or the other that are visible on imaging , especially MRI. But they won't have any symptom. So this itself should be a clear indication that all discs do not cause problems and can be treated conservatively. And if at all you decide to operate , you must be absolutely sure that it is the disc which is causing the problem.

So the doctor will perform extensive clinical examinations and ask you to undergo investigations to confirm the diagnosis. The clinical examination has to be thorough so as to rule out other causes of back pain which can include kidney issues , uterus issues , infections , trauma and even Herpes in old people.

The investigations among others will include 

X Rays. - Even though the X rays would not reveal the disc , the spine alignment and other problems can like wear and tear be made out. In India TB is a cause of a lot of back pain.

CT Scan - A more detailed study on the vertebrae and joints.

Blood tests - to rule out other causes like infections and arthritis.

Nerve conduction studies - To see which nerves are affected and at which level and to what extent.

MRI - This is the confirmatory diagnostic modality and is usually prescribed when the surgeon more or less has decided to operate on the disc.

But please remember only a very few people need invasive procedures and that too only after exhausting all the conservative treatments as listed above. The only exception is the cauda equina syndrome that needs to be operated upon as soon as possible.

Epidural Steroids

This is injecting some Steroid and Local Anaesthetic in to the area of the nerve affected by the disc bulge. The logic being the symptoms of nerve compression are due to inflammation ( fluid collection  , pain , swelling ) response due to irritation and steroids are drugs that reduce the inflammation. So under X ray guidance usually in the operation room an injection is inserted in to affected area and these drugs are infiltrated. They take about 3 days to a week to act and some may need a repeat dose. How long will they provide relief is a big question. Some experience relief for a few days whereas others never have the symptoms again. If you are on blood thinners you may be asked to wait for a fw days and if there is an active infection this procedure is better avoided.

Surgery:

There are three methods of surgery that are in practise now. The most common is the Micro- Discectomy where the a small opening is made and the herniated part of the disc is removed and the compression removed. This is a near magical surgery if done on an indicated patient. They will have tremendous relief as they are wheeled out of the Operating room itself.

The next type of surgery is where the entire disc may have to be removed and is replaced by an artificial disc. Finally comes the surgery where a significant portion of the disc or multiple discs have to be removed and the spine appears unstable. In these conditions the two vertebrae are fused together and stabilised using rods and screws.

Caution:

We at SCOT believe that Disc bulge / herniation is a very common problem. Very few people with disc bulges experience symptoms. And even among those who experience symptoms very few need treatment. Among those who need treatment only a very few need surgery. To put it lightly , often it is joked the the most common indication for operating on a disc is "Surgeon needs to fund his vacation". Hope I am clear.

But remember that the patient needs to be patient as sometimes a surgeon will be forced to operate to safeguard his reputation. Any compression pain will go away immediately with surgery and the surgeon will be made to operate on a patient who is in a hurry , as he fears that the patient might go to another surgeon who will operate and provide immediate relief , making him look bad. But it could be a case where a major surgery could have been avoided , if the patient showed some patience.

That's it folks , I think I have covered nearly all aspects of Disc problems. In case you need more info please leave a comment or email to ScotBoneAndJoint@gmail.com. And you can also catch the podcast version of this topic on Anchor at www.anchor.fm/OrthoMadeSimple . At Anchor you will also find the list of other podcast channels where OrthoMadeSimple is available

www.Scotortho.com for more details.