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Does Homeopathy Work?

Conventional medicine is not good at allowing “natural healing” the latitude which it deserves. This is an hard nut to crack in the present mechanistic world. It could probably be done via the mass media in the guise of entertainment. Dr. Marcus Welby was one such program, fostered by the American Medical Association. Dr. Finlay’s Casebook another. All the other ER and Grey’s Anatomy types of progam have a contrary (and so undesirable) message. That message emphasise an immediate, “scientific” solution to all illness, provided by “physicians”.

But homeopathy does give the latitude, by legerdemain, for natural healing to have its chance

http://gu.com/p/46g99/sbl

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Piriformis Syndrome again

Originally published in Orthopaediciq, April 2013

The following  letter which demonstrates the difficulty some have in obtaining help from obdurate therapists.

 

Dear Doctor,

This is rather random, but I came across your contact details while trying
to find out where I could get the surgery to treat piriformis syndrome. I am
having great difficulty persuading my GP and spinal specialist that my
problem is piriformis syndrome as apparently it’s not seen as a legitimate
diagnosis in the UK. I am absolutely miserable with the daily pain and lack
of movement in my leg. I can’t enjoy life anymore and nobody will give me an
answer. I am supposed to be having an epidural in the spine which I know
will not work. I gave had the pain for nearly 2 years and its getting worse
as the range if movement decreases. I believe it is a result of falling on a
step wearing high heels on to me right buttock as that us when the sciatic
pain started and now I am in almost constant pain with ache and stiffness. I
guess I am just hoping you have an answer or more information. I just want
someone to release this muscle and give me my life back. I am only 26 and
feel like my life is over. I would be so grateful if you could reply. I
understand you are probably very busy.

 

Dear V,

I am sorry that you have received this rebuffing approach.
Further, could you tell me more about and where is your pain – does it extend down your leg? Is it aggravated by cough, sneeze and straining on the toilet? Do you have any difficulty in controlling your bladder or any sensation loss around the anus?

I find it curious that many qualified people “oppose” the diagnosis of the piriformis syndrome. What I find difficult to understand is that there is nothing “unconventional” about it. The anatomy is undeniable, and there are many ways of demonstrating its existence.

It might be that every sciatica is not attributable to the piriformis syndrome, but that is not invalidation.

The good news is that it can be conclusively diagnosed and equally conclusively treated. As is always the case diagnosis is the sine qua non. Therefore my current approach in establishing the diagnosis – if the clinical features support it – is to inject the muscle, under ultra-sound guidance, with local anaesthetic. This temporarily paralysis the muscle, reduces the spasm and as a sequel takes the constricting pressure off the underlying (and compressed) sciatic nerve. Some radiological skills are required and selection of a capable and interested radiologist (or orthopaedic surgeon) is advised

In your case there might be an accumulation of blood from the injury in the muscle which you sustained and CT scanning (or MRI) could be warranted. Once the local anaesthetic wears off, at the expected time, the pain would be expected to return. This is therefore a DIAGNOSTIC procedure. At times the benefit lasts, which is a great plus. But if it does not there are many other approaches to its management, sometimes by non-surgical methods.

It is ironic that you have been lined up for an epidural injection (of what?). Epidural injections for back and leg pain are “random walks”. A loosely empirical “therapeutic trial” with little basis regarding the mode of action, an absence of any diagnostic accuracy, no established certainty of its benefit and not inconsequential risks. Therefore your clinicians, in denying the concept of the piriformis syndrome are proposing a form of treatment which is, itself, totally lacking in “legitimacy”

A “lost” comment

I apologise for having lost a comment from a podiatrist. If he could repost I would be appreciate.

My comment was as follows:

Thank you for your interest, I admire your assiduous pursuit of the best for you patients.

Risk needs be assessed in terms of frequency, and one function of the surgeon is to know that and make his own.

I think that I have posted a comment on the paper “Foot Ankle Surg. 2011 Sep;17(3):150-7. Epub 2010 Jul 9. Weil osteotomy: assessment of medium term results and predictive factors in recurrent metatarsalgia”

You use the analogy with the hip. In fact most hips survive until death even in nonagenarians. Only a fraction of human hips need replacement. Further, a hip arthritis might be unilateral and one must then ask why one went wrong and the other did not. The answer is unknown, but as illustrate it is clearly cannot be “age, wear and tear”.

If I extend that argument to a “long” metatarsal, it is not abstract to appreciate that such a metatarsal has worked well for the greater part of the patients life,  probably on both feet. Therefore there must be some other factor which has intervened and caused that ray to become painful, particularly if  one ray on only one foot is symptomatic. What is “abstract” is for surgeon to pick a long metatarsal, blame the pain on its length and shorten it. Indeed probable more often than not the deformed and painful ray could be one of the shorter metatarsals. The metatarsal shortening enthusiasts will then go ahead and shorten that “short” metatarsal.

Hallus rigidus and hallux valgus are very different pathologies, and the reason for the difference has been well assessed.

Weil osteotomy was born out of the failure of all other approaches. Remember that that before the Weil surgeons were convinced that they were doing the “right things”, and justified their conviction by a “rationale”. The rational currently used to justify the Weil is equally unconvincing to me.

The explanation and descriptions of the pathologic evolution of forefoot deformities (and flowing from that the treatment) has taken me some time, given that I have set myself a minimum (and large) number of patient in the study with a minimum follow up of 25 years. Hence the delay.

Best Wishes

Leatt-Brace and Similar Devices

 

The Leatt-Brace is promoted to protect the motorcyclist’s cervical vertebral column. However, this device may produce “dangers” of its own. Of course, a device cannot be considered “dangerous”: it is motorcycling which is dangerous. However this device could convert relatively innocuous or survivable injuries into injuries with greater morbidity and death.

Although claims are made that injuries to the vertebral column will be reduced if the Leatt-Brace is used, there is no possible way of substantiating this claim. Controlled trials are simply not possible. The tumult of a motorcycle accident and the multiple variables cannot be replicated.  It is certainly not possible to re- visit those injuries and introduce categories as controlled trials.

Motorcycle accidents on the road are difficult to reconstruct.  Race-track injuries are well documented, but these are usually slither-tumble injuries. On modern race tracks the impact against stationary objects is relatively infrequent. Rarely do these become projection or impact injuries and only occasionally “ride-over” injuries.

Motorcycle accidents on the road, however, are more likely to be collisions resulting in impact and projection injuries. Even in a slither event, the rider on the road often hits stationary or moving objects.

Therefore this claim by Leatt remains supposition,  based on a primitive, linear reasoning which is:

The neck is potentially vulnerable in that it is not protected by a strongly mechanical sheath, unlike the way that the lumbar, thoracic, and intra-cerebral spinal cord is protected. Let us then put a  brace about it, and so “protect” it.

Wish it were that easy.

This linear reasoning appears not to have fully comprehended the functional anatomy of the mechanisms of the cervical vertebral column, which makes it invalid.

If my head is fully protected by a helmet, is it not logical to extend that protection to my neck?

Firstly one must ask what protection the helmet offers.

There can be no debate that the crash-helmet reduces head injury and death in motorcyclists, a worthwhile but not universal protection.

The helmet prevents many penetrating, abrasive and direct contact facial injuries But it offers little protection against rotational injuries (which produced diffuse axonal and brainstem lesions) and these injuries might be increased  by the helmet’s inertia if body rotation decreases rapidly.

The helmet reduces deceleration injuries to some extent but concussive and contra-coup injuries will be reduced only by a margin when deceleration is from speeds of excess of 50 km an hour.

Direct blows on the top of the head (axial compression injuries) are a common cause of spinal injuries. These might be increased in some circumstances by the weight of the helmet

The Leatt-Brace will not prevent axial compression injuries: But it could promote or worsen that injury, because it interferes with evasive actions

There is some evidence that helmets reduce injuries to the cervical vertebral column, but this is poorly documented and the types of spinal injury which are reduced by the use of a protective headgear are not well analysed.

 

How do we protect ourselves from external forces?

Humans, like most other mammals, have exceedingly good “energy dissipating devices”. What this means is that there are highly sophisticated neuromuscular circuits designed to protect the individual from that universal enemy, the force of gravity. It is therefore possible for the human to fall, sometimes heavily, and sustain little or no damage. This is well illustrated in contact sports, notably rugby and professional wrestling.  The sophistication of the martial arts has allowed specific techniques of energy dissipation to be trained into participants early in their martial arts career.

In American and rugby football, energy dissipation or “break fall” is not usually trained: Instead the players rely on intuitive and inherent capacities to protect themselves from injury when their balance is perturbed. Some fondly imaginings this is a “conscious” mechanism: it is not. It is not possible in the time available to rationalise which strategies should be employed. With very few exceptions, there is no time to anticipate the vectors of destructive forces. Humans survive by the blessings of ”hardwired” and intuitive mechanisms [1]

That these mechanisms of energy dissipation exist is easily demonstrated. Most individuals could jump from a table to the floor and suffer no injury. There would be no outward expression of the kinetic forces, such as loud sounds, generation of heat or light or damage. On the other hand, if a 75 kg facsimile of that individual in granite was pushed from the table the forces of falling would convert to  sound, heat, light and damage. Another example: Robots can do much, even mimic running. But robots do not have the energy dissipating mechanisms of humans. A robot on a rugby field would not survive the first tackle or even, perhaps, the first nudge, without damage. Watch a cat fall.

 

How is this done?

The human frame, in its vertical axis is designed as a complex zigzag from the toes to the skull. Each of the angles of these zigzags is controlled by muscle allowing these zigzags to be compressed, concertina-like. During this compression, muscles response near instantly by tensioning, and by using their inherent energy allow the external energy to be slowly and safely dissipated.

Rotational movements are also used to dissipate energy, and allow the limbs to flex, reducing their lever-arm length, or tucking the limbs beside or behind the trunk.

There seem to be priorities in the methods of protecting the body. The head brain and eyes seem to have a priority re. protection. The hands and mouth are next in this triage and the feet follow.

Why a high head and a thin neck?

It is no coincidence that the head is placed high on the body. Better surveillance is an obvious benefit. Perhaps more important, by its height the brain is maximally protected from injury. Whilst accepting that the phrasing which I use is teleological, the “purpose” of the mobile and relatively thin neck is that it allows the head a great freedom of movement and consequently the maximum capacity to protect the brain from jarring or other forces (including rotation) which could damage the enclosed brain. It is well-recognised that, when people fall, the head is rapidly moved away from a potential point of contact.

Consider the tumult such as occurs in motorcycle accidents. This freedom to move the head will likely be the critical component to the broader “energy dissipating mechanisms” and its contribution to protecting the head from impact.

Where the body is thrown towards an impacting surface, even a few centimeters of intuitive movement of the head away from the potential point of impact (perhaps transferring impact to the shoulder or the upper limbs) could prevent severe injury to the head. If this flexibility is lost and the ability to move the head is prevented (as it would be with the Leatt-Brace) that latitude is lost.  . Even distances of one or 2 cm might be critical in preventing severe brain damage. Immobilisation by a neck brace might therefore result in severe injury

Whilst the Leatt-Brace could protect the neck from flexion injuries, by imposing immobility it is equally likely to make damage to the brain more common and more serious than any neck injury would have been.

Other functions of the head.

Inasmuch as movement of the head plays an important role in protecting the brain, the head also plays a vital role in the overall posture of movement, particularly movement during falling. The head weighs the equivalent of two bricks and functions as a counterbalance. The capacity to move the head rapidly and induce “coupling” dynamics in the physics of equilibrium is immensely important. If the head is restrained, for example by the Leatt- Brace, it becomes impossible to posture the body in space. This use of the head as a counter balance is well illustrated by springboard divers  to control backwards and forward somersaults. Without a free range of neck movement it would be impossible for the diver to obtain a posture safe for entry into water, or the gymnast to land. Try jumping from a step wearing a Leatt-Brace! Make sure that it is not more than a step, since jumping from a height of even half a meter, wearing the Leatt-Brace, could produce a severe injury including a fracture of the base of the skull.

I am not aware that this concept is discussed in standard textbooks of medicine, and for most medically and biologically trained people this is not considered.

Is the neck especially vulnerable?

The cervical vertebral column could be mistakenly considered a “vulnerable” area region. This might be because spinal cord injuries invoke highly emotive responses because they are potentially so incapacitating and incurable. However, taken overall injuries to the cervical vertebral column are less common than injuries to the brain. There are also specific situations where the vertebral column is at higher risk One is the diving into shallow water which has produced this devastating injury many thousands of times. The reason is that the diver does not expect to strike the head, and none of the “head / neck protection” mechanisms are recruited. Injuries to this vital part of the vertebral column also occur in road traffic accidents generally. These are far less specific and the victims range from pedestrians through to individuals who have survived motor vehicle accidents, and finding themselves inverted and held by seatbelts, then suffers catastrophic injury when a “helpful” individual releases the seatbelt: the victim then falls onto the (inverted) roof of the vehicle, and suffers cervical spinal cord injury.

How can we find out more?

Because it is so difficult to get sufficient information from road traffic accidents a possible model could be rodeo injuries, which are well documented. A number of rodeo injuries are caused by falls from height, such as would happen to a projected motorcyclist after hitting a stationary object.

In order to illustrate the effects on the neck of these types of falls, illustrations of Gauchos can be used to analyse the mechanics of the injury. Even more important is the analysis of the fail safe mechanisms which are spontaneously recruited by the rider. It is improbable that any rodeo rider would allow himself to be restricted by a Leatt-Brace – and it would be highly unethical to even suggest this.

 

illustration. It is apparent that this rider is already laterally flexing his head and rotated the left, whilst rotating the trunk to the right to allow his right hand to block the possible point of head impact. The probabilities are that he will strike his shoulder or shoulders and it is likely that he might escape injury free. However, had he been wearing a restrictive neck brace, he would not be able to posture his head in this protective way and the chances of him having a head injury would be considerably increased if not inevitable.

Is there a way to protect this vulnerability of the cervical vertebral column, and perhaps the brain as well? This seems possible and the author has researched this, including the compounded locus of movement of the neck and the neck-on-head, in much detail. That research has included a detailed investigation into the (complex) locus of movement and angular velocities of the cervical vertebral column. A later paper will consider an appropriate design for a protective neck brace.

Mini-tightrope surgery for bunions

I have been asked to comment on ‘mini-tightrope bunion surgery’

This is currently promoted as ‘the latest technique’. For that you should read ‘new and therefore unproven’. The outcome of any foot surgery is to be measured over many years – perhaps a minimum of twenty – since these feet need to serve their owner for those years ahead.

The concept is not new. I contemplated this approach many years ago and have done cadaveric studies to try and establish its merits. However there were a number of significant complications to be anticipated. For that reason I have never done this surgery and would not endanger my patients in this way. Many variants of this have been attempted in the past, including using screws to force together the metatarsals of the great and second toes, and the smaller and thinner second metatarsal. That did not work, as the screw rapidly pulled out of the bone, leaving a weak second metatarsal, which then often broke. So it is not as new as these authors would have you believe. What is relatively new is the ‘tight-rope’ originally designed for other purposes, and characterized by the ‘toggle’ which allows this band to be tightened (and over-tightened) relatively easily and the material ‘fibrewire’.

The loads on the foot are very high. These are multiplied during walking be various leverages, and the loads on the mini-tightroap wire are likely to be sufficient to cause the wire, or toggle to cause pressure atrophy of the bone, where this is attached.  This could cause the implant to cut free of bone, damaging the bone in the process.

A number of surgeons/podiatrists have felt sufficiently confident to place their procedure on U-tube. Therefore they must expect a commentary (although I notice that the comment facility on some has been disabled) and I will use their claims to answer my reader.

Let us take their demonstrations one at a time to point out criticism.

Firstly there does not seem to be a single procedure, but a number of not so closely related variants.

Dr. Sadriech http://www.youtube.com/watch?v=dX6WKjsPpVc.places  inserts the wire a fair way down the great metatarsal and it penetrates the base of the second metatarsal in such a way as to interfere with the joint between the second and third metatarsal bases – potentially damaging that joint – a potent source of future pain.

He says that the ‘bunion’ is an ‘outgrowth’- which it is not – and promptly cuts off a perfectly normal part of the great metatarsal head, damaging that joint with the potential for a future osteoarthritis He describes this a ‘removal of the actual (mumble)’.  

Dr. George Homes http://www.youtube.com/watch?v=dX6WKjsPpVc

(An orthopaedic surgeon this time) also cuts away the normal metatarsal head, calling it a ‘medial exostosis’ presumably on the basis that if something is given a nasty sounding name surgical removal is approved. However he puts the wire through quite a different part of the great metatarsal from the previous surgeon, and also through the phalanx (the toe itself). Therefore there are now two drill holes through great metatarsal, with a not insignificant weakening of a bone which has to accept great loads. A subsequent ‘fatigue fracture’ would not come as a surprise. He says ‘cuneiform bone’ when the structure is actually the metatarsal.

The large incision on the inside (medial) is placed exactly over the medial digital nerve. If this is damaged it will produce chronic numbness and/or pain, particularly if the shoe make abrasive contact with this area, as is usual.

Dr. Allen Selner http://www.youtube.com/watch?v=9ibAY0f5MyE&feature=related treats someone who does not have a bunion, and does not have a crooked toe (as he claims). This patient has an entirely different problem (not a bunion), a ‘hallux rigidus‘ with a dorsal cheilosis. This is an outgrowth, but related to an entirely different entity, and the lump is not placed on the inside of the great toe, but on top of the metatarsal.

Dr Selner draws on the x-ray, claiming that he is demonstrating  ‘arthritic bone’. It is not (and neither is it the dorsal cheilosis). Once again this is normal anatomy which does not deserve to be deformed in the way we saw on the u-tube.

One more point, forcing the great metatarsal towards the second ray (toe) must damage and adversely realign the great metatarsal-cuneiform joint. This is well demonstrated in the skeletal models in the u-tube presentations but ignored in the commentary.

I notice that many of these people have general anaesthesia, when a regional (local anaesthetic) block would have many advantages.

I may not have answered my reader’s query entirely, but I hope that I have demonstrated that caution is due when a medical procedure is claimed to be a ‘major advance’ the ‘newest’ and similar hyperbole.

Any similar or specific queries will be welcomed, and I invite responses from the three surgeons mentioned, or any other people professionally involved in foot problems. Perhaps these same patients might also like to comment as time passes.

Why the Leatt-Brace might be dangerous

 

The Leatt-Brace is promoted to protect the motorcyclist’s cervical vertebral column. However, this device may produce “dangers” of its own. Of course, a device cannot be considered “dangerous”: it is motorcycling which is dangerous. However this device could convert relatively innocuous or survivable injuries into injuries with greater morbidity and death.

Although claims are made that injuries to the vertebral column will be reduced if the Leatt-Brace is used, there is no possible way of substantiating this claim. Controlled trials are simply not possible. The tumult of a motorcycle accident and the multiple variables cannot be replicated.  It is certainly not possible to re- visit those injuries and introduce categories as controlled trials.

Motorcycle accidents on the road are difficult to reconstruct.  Race-track injuries are well documented, but these are usually slither-tumble injuries. On the modern race tracks the impact against stationary objects is relatively infrequent. Rarely do these become projection or impact injuries and occasionally “ride-over” injuries.

Motorcycle accidents on the road, however, are more likely to be collisions resulting in impact and projection injuries. Even in a slither event, the rider on the road often hits stationary or moving objects.

Therefore this claim remains a supposition, which is based on rather primitive, linear reasoning which is:

The neck is potentially vulnerable in that it is not protected by a strongl mechanical sheath, the way that the lumbar, thoracic, and intra-cerebral spinal cord is protected. Let us then put a mimicing brace about it, and so “protect” it.

Wish it were that easy.

This linear reasoning appears not to have fully comprehended the functional anatomy of the mechanisms of the cervical vertebral column, which makes it invalid.

If my head is fully protected by a helmet, is it not logical to extend that protection to my neck?

Firstly one must ask what protection the helmet offers.

There can be no debate that the crash-helmet reduces head injury and death in motorcyclists, a worthwhile but not universal protection.

The helmet prevents many penetrating, abrasive and direct contact facial injuries But it offers little protection against rotational injuries (which produced diffuse axonal and brainstem lesions) and may increase these injuries by its inertia if body rotation decreases rapidly.

The helmet reduces deceleration injuries to some extent but concussive and contra-coup injuries will be reduced only by a margin when deceleration is from speeds of excess of 50 km an hour.

Direct blows on the top of the head (axial compression injuries) are a common cause of spinal injuries. These might be increased in some circumstances by the weight of the helmet

The Leatt-Brace will not prevent axial compression injuries and could promote or worsen that injury, because it interferes with evasive actions

There is some evidence that helmets reduce injuries to the cervical vertebral column, but this is poorly documented and the types of spinal injury which are reduced by the use of a protective headgear are not well analysed.

 

How do we protect ourselves from external forces?

Humans, like most other mammals, have exceedingly good “energy dissipating devices”. What this means is that there are highly sophisticated neuromuscular circuits which are designed to protect the individual from that universal enemy, the force of gravity. It is therefore possible for the human to fall, sometimes heavily, and sustain little or no damage. This is well illustrated in contact sports, notably rugby and professional wrestling.  The sophistication of the martial arts have allowed specific techniques of energy dissipation to be trained into participants early in their martial arts career.

In American and rugby football, energy dissipation or “break fall” is not usually trained: Instead the players rely on intuitive and inherent capacities to protect themselves from injury when their balance is perturbed. Some fondly imaginings this is a “conscious” mechanism: it is not. It is not possible in the time available to rationalise which strategies should be employed. With very few exceptions, there is no time to anticipate the vectors of destructive forces. Humans survive by the blessings of  “hardwired” and intuitive mechanisms [1]

That these mechanisms of energy dissipation exist is easily demonstrated. Most individuals could jump from a table to the floor and suffer no injury. There would be no outward expression of the kinetic forces, such as loud sounds, generation of heat or light or  damage. On the other hand, if a 75 kg facsimile of that individual in granite was pushed from the table the forces of falling would convert to  sound, heat, light and damage. Another example: Robots can do much, even mimic running. But robots do not have the energy dissipating mechanisms of humans. A robot on a rugby field would not survive the first tackle or even, perhaps, the first nudge, without damage.

 

How is this done?

The human frame, in its vertical axis is designed as a complex zigzag from the toes to the skull. Each of the angles of these zigzags is controlled by muscle allowing these zigzags to be compressed, concertina-like. During this compression, muscles response near instantly by tensioning, and by using their inherent energy allow the external energy to be slowly and safely dissipated.

Rotational movements are also used to dissipate energy, and allow the limbs to flex, reducing their lever-arm length, or tucking the limbs beside or behind the trunk.

There seem to be priorities in the methods of protecting the body. The head brain and eyes seem to have a priority re. protection. The hands and mouth are next in this triage and the feet follow.

Why a high head and a thin neck?

It is no coincidence that the head is placed high on the body. Better surveillance is an obvious benefit. Perhaps more important, by its height the brain high is maximally protected from injury. Whilst accepting that the phrasing which I use is teleological, the “purpose” of the mobile and relatively thin neck is that it allows the head a great freedom of movement and consequently the maximum capacity to protect the brain from jarring or other forces (including rotation) which could damage the enclosed brain. It is well-recognised how, when people fall, the head is “lifted” away from a potential point of contact with alacrity.

Now that is considering the tumult such as occurs in motorcycle accidents. This freedom to move the head will likely be the critical component to the broader “energy dissipating mechanisms” and its contribution to protecting the head from impact.

Where the body thrown towards an impacting surface, even a few centimeters of intuitive movement of the head away from the potential point of impact (perhaps transferring impact to the shoulder or the upper limbs) could prevent severe injury to the head. If this flexibility is lost and the ability to move the head is prevented (as it would be with the Leatt-Brace) that latitude is lost.  . Even distances of one or 2 cm might be critical in preventing severe brain damage. Immobilisation by a neck brace might therefor result in severe injury

Whilst the Leatt-Brace could protect the neck from flexion injuries, by imposing immobility it is equally likely to make damage to the brain more common and more serious than any neck injury would have been.

Other functions of the head.

Inasmuch as movement of the head plays an important role in protecting the brain, the head also plays a vital role in the overall posture of movement, particularly movement during falling. The head weighs the equivalent of two bricks and functions as a counterbalance. The capacity to move the head rapidly and induce “coupling” dynamics in the physics of equilibrium is immensely important. If the head is restrained, for example by the Leatt- Brace, it becomes impossible to posture the body in space. This use of the head as a counter balance is well illustrated by springboard divers  to control backwards and forward somersaults. Without a free range of neck movement it would be impossible for the diver to obtain a posture safe for entry into water, or the gymnast to land on a surface. Try jumping from a step wearing a Leatt-Brace! Make sure that it is not more than a step, since jumping from a height of even half a meter, wearing the Leatt-Brace, could produce a sever injury including a fracture of the base of the skull.

I am not aware that this concept is discussed in standard textbooks of medicine, and for most medically and biologically trained people this is not considered.

Is the neck especially vulnerable?

The cervical vertebral column could be mistakenly considered a “vulnerable” area region. This might be because spinal cord injuries invoke highly emotive responses because they are potentially so incapacitating and incurable. However, taken overall injuries to the cervical vertebral column are less common than injuries to the brain. There are also specific situations where the vertebral column is at higher risk One is the diving into shallow water which has produced this devastating injury many thousands of times. The reason is that the diver does not expect to strike the head, and none of the “head / neck protection” mechanisms are recruited. Injuries to this vital part of the vertebral column also occur in road traffic accidents generally. These are far less specific and the victims range from pedestrians through to individuals who have survived motor vehicle accidents, and finding themselves inverted and held by seatbelts, then suffer catastrophic injury when a “helpful” individual releases the seatbelt: the victim then falls onto the (inverted) roof of the vehicle, and suffers cervical spinal cord injury.

How can we find out more?

Because it is so difficult to get sufficient information from road traffic accidents a possible model could be rodeo injuries, which are well documented. A number of rodeo injuries are caused by falls from height, such as would happen to a projected motorcyclist after hitting a stationary object.

In order to illustrate the effects on the neck of these types of falls, illustrations of Gauchos can be used to analyse the mechanics of the injury. Even more important is the analysis of the fail safe mechanisms which are spontaneously recruited by the rider. It is improbable that any rodeo rider would allow himself to be restricted by a Leatt-Brace – and it would be highly unethical to even suggest this.

 

 

Is there a way to protect this vulnerability of the cervical vertebral column, and perhaps the brain as well? This seems possible and the author has researched this in much detail. That research has included a detailed investigation into the (complex) locus of movement and angular velocities of the cervical anatomy.

Mallet Finger

Rupture of a digital extensor tendon at the level of the terminal phalanx is common and can cause significant disability.

It causes difficulty in making the finger “flat” with the hand, and the passively flexed distal phalanx catches whilst tucking sheets or reaching into a pocket. Catching a ball difficult and it is regarded as an important aesthetic loss in a woman. Because adaptive strategies are difficult it may merit surgical correction.

Conventional management is not always simple or effective.
In addition the “scientific” documentation of this injury is often poor,  illustrating an incomplete understanding of the surgical biology.

Below are extracts from the most frequently consulted web sites.

WIKIPEDIA: http://en.wikipedia.org/wiki/Mallet_finger
It results from hyper-flexion of the extensor digitorum tendon (1), and usually occurs when a ball (such as a softball, basketball, or volleyball), while being caught, hits an outstretched finger and jams it – creating a ruptured or stretched (2) extensor digitorum tendon.
The splint allows the tendon to return to normal length (3), if the finger is bent during these weeks the healing process must start all over again. Surgery is used to reattach the tendon and is usually performed within a week of the injury
It should be determined via radiograph if the Extensor Digitorum tendon has avulsed from the phalange, which will require surgical intervention to reattach the tendon and should be done within 10 days of the injury. Surgical treatment is used when the mallet finger presents as an open injury or if the bony mallet involves more than 30% of the articular surface of the joint. If passive extension cannot be achieved, surgery will put the finger in a neutral position and drill a wire through the DIP to the PIP, forcing immobilization and eliminating patient compliance for re-injury(4).
There are errors here:
1. Not so. It is hyper-flexion of the distal inter-phalangeal joint. The extensor tendon cannot hyper-flex.
2. Incorrect. Breakage (rupture) occurs. The tendon cannot “stretch”.
3. Fanciful. The tendon is unlikely to return to “normal length”, because the natural tendency of muscle is to retract the tendon. No splint provides the forces essential to pull the tendon back distally and so draw the tendon ends anatomically together.
4. It is assumed that the author means ”non-compliance which will perpetuate the injury or increase the deformity”

AMERICAN ACADEMY OF ORTHOPEDIC SURGEONS:

http://orthoinfo.aaos.org/topic.cfm?topic=A00018

AMERICAN SOCIETY FOR SURGERY OF THE HAND  has good illustrations and valid comments: http://www.eatonhand.com/hw/hw015.htm
How Successful is the Treatment?

Although this may seem like a trivial or simple injury, a cosmetically perfect correction is not likely with any form of treatment. However, with proper therapy and effort on the part of the patient, this problem can usually be improved to a tolerable level most – that is, the end joint of the finger may not fully straighten, but it will work well enough to be used for normal activities.
• Unless the injury is due to a cut on the back of the finger or there is some other associated problem, many hand surgeons believe that the final outcome and complication rate are at least as good with splinting alone compared to surgical repair. This may change as new techniques are developed to improve the results of surgery.
• Surgery is a reasonable consideration if the finger remains unacceptably bent after a full trial of splinting or if splinting is not possible – for example, if a skin reaction develops beneath the splint. Surgery is only considered if the outcome of surgery is expected to be better than the outcome of treatment without surgery.
What Happens if you have no treatment?

• Without any treatment, the appearance and ability to straighten the end joint of the finger will not improve. Additionally, if the injury is less than a month old, the problem may be worsened by using the finger without a protective splint of some sort.
• If the injury is more than three months old and has not been treated, it is unlikely that it will get better or worse on its own. Injuries more than three months old are not likely to be improved with anything short of surgery.

My Summary.
Conventional, non-intrusive management of mallet finger by splinting will not correct deformities (but might prevent worsening).

If the deformity is minimal, or otherwise acceptable, non interference is the way to go. However, if leaving the finger “as is” is not acceptable, then surgical treatment is frequently attempted:

Surgical treatment, as currently practiced,  falls into two types,
1. Attempts at repair. This has been attempted by suturing with wire and other materials where there is no fragment of bone attached to the tendon. If there is a fragment of bone then attempts to fix the fragment (by screws or wire) are usual. However the tiny fragment of bone often splits and surgical failure is common. Whilst this repair is healing the position of the finger must be retained (immobilized) by :
• Splinting for several weeks, or
• Pushing a steel pin through the fingertip, then down the marrow cavity of the finger bones. This causes an awkward projection of the pin which has to be kept dry and requires repeated bandaging for several weeks. This penetration of the fingertip can cause small portions of the skin to become “implanted” more deeply with a painful pseudo-tumor resulting. Infection is not rare
2. “Fusion” of the joint leaving it permanently stiff. This prevents some fine movements (such as playing some musical instruments), and leaving the hand as a whole marginally weaker. Fusion also requires immobilization, as above, for several weeks.

Surely there has to be a more certain, safer and quicker solution? A description of my long established technique for managing mallet finger is available in the Store.

The benefits of this technique are that predictable and accurate results can be obtained, and the procedure can be performed electively long after the injury.

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