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case of the week Sept 23
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case of the week Sept 23 - September 24, 2007 8:18:35 AM
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Dr.Wagner
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45 year old white male involved in mixed martial arts arrives complains of severe swelling and pain at his elbow after being submitted with a "kimura" lock. He notes decreased range of motion at the elbow and wrist. He also notes burning in his entire forearm. He initially thought it was "no big deal" when it first happened 2 days ago.
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RE: case of the week Sept 23 - September 24, 2007 11:13:13 AM
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bonez
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With the lock in question being applied forcefully in terminal extension combined with the subsequent swelling and loss of rom we need some work up.
Evaulation of osseus structures with an elbow series of radiographs paying particular attention to fat pad signs. further physical exam of the wrist to determine if local loss of rom is here or referred from the elbow should also be done. Remember that the wrist is also the distal of the lock in question so we need to be mindful of osseus and ligamentous structures here too.
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RE: case of the week Sept 23 - September 24, 2007 11:53:59 AM
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FLAOrthoPT
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i am thinking maybe a nerve traction type injury. Why not rule out some of the bad stuff as noted above.
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RE: case of the week Sept 23 - September 24, 2007 1:41:40 PM
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Tom Reeves DPT ATC
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Burning in "the entire forearm" makes me think vascular. No nerve covers the entire forearm. Is there a ton of swelling, distended veins, good pulses, cap refil etc . . . Is the forearm, especially the flexor compartment turgid as in a compartment syndrome?
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RE: case of the week Sept 23 - September 24, 2007 1:47:41 PM
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Tom Reeves DPT ATC
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I just looked at a video of the kimura lock. It is a big hammerlock with the wrist stabilized, max internal rotation of the lockee. could be a radial nerve stretch, could be rupture of the lateral ligaments or wrist extensors.
Where in the elbow is the swelling, and when he says the "entire forearm" is it really the entire forearm or is it only part of the forearm.
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RE: case of the week Sept 23 - September 24, 2007 9:02:32 PM
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bonez
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The concern for me is the severe swelling combined with loss of rom. If the rom loss has that "hard" end feel then we should likely hed the boney structures first. The lock brings the jonts to the maximal closed pack position and the force of the other combatant could easily disrupt the joint through fracture or ligament tear to leave a luxation here.
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RE: case of the week Sept 23 - September 25, 2007 12:23:31 AM
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steve
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Bonez,
Being a big fan of MMA (Seriously, its great to watch, particularly the submission guys) the Kimura is hold that attempts to forcefully internally rotate your opponents shoulder until they tap out. From what I have seen, it is done with the elbow in a flexed position and not a close packed position. You may be thinking of an arm bar, where the victim is put into forceful extension at the elbow until he submits or fractures.
This all being stated, sometimes the elbow is injured during a kimura and based on the swelling and lack of ROM I would want to r/o fracture/significant ligament rupture. Wags, can we get observation and any pertinent medical history before we proceed to examination?
Steve
PS Wags, what do you think of all the recent upsets?
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RE: case of the week Sept 23 - September 25, 2007 1:16:43 AM
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bonez
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Being a big fan of MMA (Seriously, its great to watch, particularly the submission guys) the Kimura is hold that attempts to forcefully internally rotate your opponents shoulder until they tap out. From what I have seen, it is done with the elbow in a flexed position and not a close packed position. You may be thinking of an arm bar, where the victim is put into forceful extension at the elbow until he submits or fractures
Steve you are right I was assuming that it was the extension hold. That being said then we be watchful for the rotational stress and the ligaments affected
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RE: case of the week Sept 23 - September 25, 2007 10:25:08 AM
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Dr.Wagner
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quote:
Wags, can we get observation and any pertinent medical history before we proceed to examination?
A: You observe a swollen elbow and forearm, particularly the flexor forearm.
Past Medical history significant for I&D for pinna hematoma, boxers fracture, rib fracture...no medications. Patient admittedly takes Nandrolone and is on the down cycle.
How do I feel about the upsets: I hate them, a few I could handle, but Shogun Rua disappointed me and Cro Cop needs a year off to settle down.
Kimura from side mount
 Attachment (1)
< Message edited by Dr.Wagner -- September 25, 2007 10:29:23 AM >
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Dr. Wagner DO
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RE: case of the week Sept 23 - September 25, 2007 2:35:20 PM
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bonez
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Well the lateral elbow shows a fairly positive fat pad sign. The AP shows a significant radial head fracture on the ulnar side which may be comminuted and extends to the radial neck. The wrist could not have been taken at the same time/machine as the pic quality is way inferior but all osseus structures appear in place and intact. The grainyness of the radiograph does not let us comment on bone density.
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RE: case of the week Sept 23 - September 26, 2007 10:09:50 AM
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Dr.Wagner
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I am assuming people want a physical exam?
Extensor strength of the wrist is intact, but pain on passive stretch. Flexor strength of the wrist is far decreased vs unaffected side.
The patient reports pain with movement of the elbow.
Sensation is intact, though there is the noted "burning" in the flexor forearm. Two point descrimination is somewhat decreased.
< Message edited by Dr.Wagner -- September 26, 2007 12:34:01 PM >
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RE: case of the week Sept 23 - September 26, 2007 2:41:19 PM
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bonez
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Based on the fracture I saw at the radial head and these exam findings , tere is a nice fit for a lesion of the median nerve as it crosses deep in the cubital fossa. There is a nice overlap for the musculo cutaneous nerve for the forearm distribution. The burning is consistent with a nerve injury the pain on passive extension would traction the median nerve as well. There is likely weakness of the small muscles of the hand especially ab pollicis brevis and sparing of flexor carpi ulnaris if it is the median nerve.
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RE: case of the week Sept 23 - September 27, 2007 6:17:13 PM
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Dr.Wagner
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The answer will be given tomorrow.
I will answer any questions regarding this patient up until tomorrow.
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Dr. Wagner DO
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RE: case of the week Sept 23 - September 28, 2007 9:36:03 AM
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Dr.Wagner
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Radial head fracture with delayed compartment syndrome of the flexor forearm
Pathophysiology
Elevated intracompartmental pressure within the forearm is most common in the volar compartment or the combined volar and dorsal compartments. Although rare, CS may occur in the dorsal compartment alone.
CS may be the result of externally applied or internally expanding forces. It is most frequently associated with supracondylar fractures of the humerus and has been reported in conjunction with fractures of the radial or ulnar diaphysis and with surgical neck fractures of the humerus and following Colles fractures. In this case, the kimura, and the lack of care after the fracture, caused additional swelling and a cycle of injury.
The patient afflicted by CS may experience crescendo pain that is out of proportion to the original injury. The pain is deep and aching in nature and is worsened by passive stretching of the fingers. The patient may also describe a tense feeling in the extremity. Pain, however, should not be a sine qua non of CS. The forearm is often tender and tense, and the sensibility/sensitivity of the fingertips may be diminished.
Paraesthesia, or numbness, is an unreliable early complaint of CS5; however, decreased 2-point discrimination is a more reliable early test and can be helpful to make the diagnosis. Botte and Gelberman reported that 4 of 9 awake patients with compartment pressures higher than 30 mm Hg had median nerve 2-point discrimination of more than 1 cm.18 Correlation has also been reported between diminished vibration sense (256 cycles/s) and increasing compartment pressure.
On physical examination, evidence of trauma and gross deformity should alert the physician to the possibility of an evolving CS. Comparison of the affected limb to the unaffected limb is useful. Pulselessness is a late and unreliable finding, and the presence of a radial pulse does not exclude the possibility of a CS. The most important diagnostic physical finding is a firm, wooden feeling on deep palpation. Bullae may also be seen; however, so-called fracture blisters are common in the absence of CS. As the pressure increases, pallor and loss of pulses are late findings. If objective evidence of a motor deficit is found, the CS is far advanced. Laboratory testing that reveals a creatine kinase (CK) of 1000-5000 U/mL or greater or the presence of myoglobinuria can suggest CS.
CS in the hand most often occurs following iatrogenic injury in a patient who is obtunded in an intensive care unit. Symptoms may be nonspecific compared with those in other CS cases. Early recognition of this complication is based on physical examination and a high index of suspicion. Unlike elsewhere, CS in the hand lacks abnormalities in the sensory nerves, as no nerves are found within the compartments.
Consider the diagnosis when nonspecific aching of the hand, increased pain, loss of digital motion, and continued swelling are present. A tight, swollen hand in an intrinsic minus position—with the digits in metacarpophalangeal (MCP) extension and proximal interphalangeal (PIP) flexion—is highly indicative. Intrinsic tightness becomes evident on examination because motion of the PIP joint becomes dependent on the position of the MCP joint (more PIP motion is possible with MCP flexion than with MCP extension).
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Dr. Wagner DO
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RE: case of the week Sept 23 - September 28, 2007 9:38:37 AM
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FLAOrthoPT
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good case, thanks...
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RE: case of the week Sept 23 - September 28, 2007 2:03:17 PM
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steve
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I agree, excellent case. Not only were you able to present an interesting and relevant orthopaedic case for us physios but you were able to combine it with MMA. Well done.
PS I personally have enjoyed seeing how difficult it has been for most of the guys to hold on to their belts and being upset by so called lesser fighters. I think as the sport is evolving the fighters have needed to become increasingly more well rounded and if they aern't their opponents find their proverbial chink in the armour.
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RE: case of the week Sept 23 - September 29, 2007 8:10:24 AM
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Dr.Wagner
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I think I will make as many cases as possible relevent to MMA...may be funny, in a nerdy way.
Yeah this has been a turbulent year. Perosonally I am one of the "pride" followers, much less of a UFC guy. So I have seen Rampage, Wanderlei, Shogun, Fedor, Henderson, Minotauro, Saku fight multiple multiple times. The general American audience knows little of the history of Pride, especially the epic Sakuraba fights.
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Dr. Wagner DO
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