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Interviewer: When should you consider University of Utah Health's Orthopaedic Injury Clinic over perhaps a visit to the ER or urgent care, or is it something you can handle on your own? That's what we want to find out today.

Dr. Julia Rawlings is a primary care sports medicine and also practices pediatric emergency medicine, but it's that sports medicine doctor that we really want to talk to today. So the first thing I want to find out is what are some of the common orthopedic injuries a person should consider using the Orthopaedic Clinic versus an ER or urgent care?

Dr. Rawlings: The Orthopaedic Injury Clinic is a great place to go if you have an acute injury, meaning that you have had an injury that you've sustained recently. We're actually willing to see people that have had an injury anytime in the last three months, but preferably not something that's chronic and going on. We'd rather you go ahead and make an appointment with a regular physician during regular hours, although it can be at the Orthopaedic Center.

Specifically, things that are good for the Injury Clinic. So we see a lot of injuries from the ski slopes. We see people that have been playing different sports, or running, biking. We see some football injuries. Anything that's kind of acute. Anything that could go to an urgent care can go to the Orthopaedic Injury Clinic if it's a musculoskeletal injury.

A couple of things we don't see at the Injury Clinic. We don't do stitches there. So if you're bleeding and you think you need stitches, an urgent care or the emergency department would be more appropriate. Also, if your bone is pretty crooked, it's probably a better idea to go to the emergency room. We can do some local numbing medicine to set some easy broken bones, fingers, and things like that, but larger fractures would need to be seen in the Emergency Department for sedation.

Interviewer: And what kind of diagnostic tools do you have there that kind of makes you the choice for some of these as opposed to perhaps an emergency room or an urgent care?

Dr. Rawlings: Yeah. So the Injury Clinic is fantastic because we have access to x-ray on-site, and we can see those images back as soon as they are done. And depending on the time of the day, we actually can often get the reads back from a musculoskeletal radiologist within a few hours. Sometimes those reads don't come back until the next day. We don't have the capability to do CT scans at the Injury Clinic. We do have access to scheduling MRIs in the building, but that's not done the same time as the visit.

So one great thing about the Injury Clinic is you get kind of a full package. So you get your x-rays. You could get an MRI set up. We have all of the braces and everything that you would need, crutches, things like that. And then, we can get you set up with a specialist, whether that's a sports medicine surgeon, foot and ankle surgeon, or one of our non-operative primary care sports medicine physicians. We will actually make that appointment for you while you're there for follow-up.

Interviewer: So the clinic, it sounds like a better option than perhaps making an appointment. It can be difficult to get in sometimes with an orthopedic doctor at times. So this clinic, it's primarily walk-in, is that how it works, or do you have to make an appointment?

Dr. Rawlings: It is walk-in. It's a little bit tricky right now with coronavirus going on, but, typically, it is walk-in. They are switching to appointments during this period of time, but that's going to be very temporary. Generally, it is walk-in, first come, first served.

Interviewer: How can a person decide if an injury is something that they can treat at home or they can just try to see if it's going to get better versus coming into the clinic or seeing a professional?

Dr. Rawlings: Yeah. So we're always happy to check anything out if you're not sure. A couple of tips that just come to my mind. One is if you have an injury that's bad enough you can't really walk on it or bear weight on it, that's something that should be seen, probably get an x-ray, make sure you haven't broken a bone. Or if you really can't move your shoulder or can't move your arm in some way. If you twist your ankle, and you're walking on it okay, and it gets a little bit swollen, that's something that you could probably wait on at home and see how you do. But, yeah, if you have a hard time moving a body part, that's a good time to go in.

Interviewer: All right. Are there some injuries that really you do want to have looked at, otherwise it could affect you and your mobility in the future?

Dr. Rawlings: Yeah. So there are definitely, particularly injuries that involve the joints. We often like to get a sooner look at what's going on rather than a later look, just because things can happen down the road that can lead to arthritis if they're not treated early. That being said, a lot of musculoskeletal injuries aren't emergencies. Meaning, even if you get something like a torn ACL, which is considered a pretty big injury in the sports world, if you're diagnosed several days after that happens, in general, that's okay. It's not something that absolutely needs to go to the emergency department or into the Injury Clinic even the same day you have it. You'd really be okay to get yourself a pair of crutches from the garage and come in a couple of days later.

Interviewer: For the particularly injury-prone that might have some crutches?

Dr. Rawlings: Exactly. There are a lot of people with crutches in their garage from siblings, so.

Interviewer: Any final thoughts that you have when it comes to the walk-in Orthopaedic Clinic? It's such a great resource. I was able to utilize it. I had a shoulder injury. I'm not even going to go into how that happened because it was not cool, it was not athletic. But it was great because I could go in, they were able to look at it, make sure that I didn't, you know, do any permanent damage, which I didn't, and then, you know, gave me a reference to go to a physical therapist to do some exercises to rehabilitate it, so.

Dr. Rawlings: I think it's a fantastic clinic. I mean, it's staffed by people that are trained in musculoskeletal medicine, so we have a little bit of an advantage over lots of the urgent cares that are more kind of general medicine, that we treat a lot of musculoskeletal injuries. We can get you set up with physical therapy pretty easily. And one or two days of the week, we actually have a physical therapist with us in-clinic. So if your injury is appropriate for that, we can even get you started on physical therapy the night that you come in. So I think it's a fantastic resource.

Announcer: "Health Hacks" with Dr. Troy Madsen on The Scope.

Dr. Madsen: Today's health hack is an easy to do, homemade splint. So all of us have cardboard boxes around the house. So let's say you have something where you fall or a child falls, you look at their arm, and it looks like it's broken. It's obviously deformed, it's swollen, they're having lots of pain. You want to get them in to get some x-rays and get this checked out. But every time they're moving that arm, it hurts.

So if you take a cardboard box, you break it down, do a couple layers the length of their arm, you can then put one piece of that cardboard box on each side of their arm, so you've got two pieces total. And then wrap it around with something that's not too tight, maybe just use like a shirt, a couple shirts to tie it around there. This can stabilize their arm and help them to feel a lot more comfortable while they get into the ER to get an x-ray.

So you're wondering, "Well, why cardboard?" Well, it's easy to use. And a lot of EMTs, so if you call an ambulance, a lot of them have cardboard splints. They're just using the same thing. It's really a great tool to have. The advantage of it is if this arm's moving around while they're in the car, they're just going to hurt a lot. There's potential that the fracture could move out of place even further. And again, it's something you probably have around. It's simple enough to do. You can grab it, quickly put this in place, get them in to get some treatment.

Announcer: For more health hacks, check out thescoperadio.com. Produced by University of Utah Health.

Interviewer: Today, another edition of ER or Not, with Dr. Troy Madsen. You swallowed a chicken bone. Emergency room or Not.

Dr. Madsen: So you probably don't need to go to the ER if you swallow a chicken bone. So if you happen to swallow a chicken bone, you're probably going to be fine. The things you worry about swallowing are things that are really sharp or things that are really long. If they're sharp, they can puncture the intestines as they're working their way down. If they're really long, they may not even make it past the stomach.

You got to figure most chicken bones you swallow are probably going to be splinters off a chicken bone. It's probably going to pass with no problem. But if somehow you happen to swallow a chicken bone that's longer than say three inches or a really big sharp piece, that's probably a reason to go to the ER and get a specialist there to remove it from your stomach.

updated: July 8, 2021
originally published: October 6, 2017

Announcer: Need reliable health and wellness information? Don't listen to the guy in the cube next to you, get it from a trusted source, straight from the doctor's mouth. Here's this week's listener question on The Scope.

Interviewer: This week's listener question is about fractures, and we've got an expert here to answer it, orthopedic surgeon Dr. Justin Haller. So the question is if this parent suspects that their child has a fracture, or if somebody suspects that they have a fracture, is that something that you need to have treated, or can that just heal on its own? I mean, because it's not like a broken bone.

Dr. Haller: Sure, that's a great question, and a fracture is a broken bone. And it's. . .

Interviewer: Okay.

Dr. Haller: And so it depends on the type of fracture and the severity of the fracture, whether it needs an operation or whether it can be treated with a cast. To really be evaluated, the patient needs to have an x-ray to determine the amount of displacement or the amount that the bone has moved, and the location of the fracture as to whether it needs an operation or not.

Interviewer: So I guess the question is, how would this person even know that they have a fracture? I mean, what are the symptoms of that? Because a broken bone is pretty obvious if you've got a malformed arm.

Dr. Haller: That's right. Yeah, so, a fairly displaced fracture is pretty obvious, where an arm or leg doesn't look right, as patients say, but a non-displaced fracture can be as simple as just pain in a wrist. And the only way to really know is to get an x-ray.

Interviewer: Yeah, and ultimately, it sounds like what you're saying is, if you have symptoms, you believe it's a fracture, realize that that is a broken bone.

Dr. Haller: Right, exactly, that's a broken bone.

Interviewer: That something might need to be manipulated to make sure that it heals properly.

Dr. Haller: Yes.

Interviewer: And you should seek treatment.

Dr. Haller: You should seek treatment to have it evaluated to see if it's something that needs a manipulation in a cast, or whether it's something that needs an operation.

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Dr. Miller: Thin bones and the risk of fracture and what to do about that. We're going to talk about that next on Scope Radio.

Announcer: Health tips, medical news, research, and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Dr. Nick Spina, and he's an orthopedic surgeon here at the University of Utah, in the Department of Orthopedics. He's an expert in spine care. Nick, how do you get a fracture when you have thin bones or osteoporosis? What happens? Where do they occur typically in the back? Tell me about that. It's a lot at risk.

Dr. Spina: Yeah. Osteoporotic compression fractures or what we call fragility fractures are probably the most common fracture we see in spine surgery. It tends to be on the more elderly side of the population.

Dr. Miller: At the time when we lose our bone mass.

Dr. Spina: Exactly, at the time when we lose our bone mass. So I'd like to describe them to people to imagine a soda can or a pop can. And each patient's vertebral body is like a pop can. So it has a hard rim on the top and a hard rim on the bottom, and the center part of the can is relatively empty. As we age and we get osteoporosis, the center of the can becomes even more empty. And so, as we stress the top, the can eventually cracks and crushes where our end plates become closer together or the ends of the can become closer together.

Dr. Miller: And so, what happens to precipitate that fracture? My understanding is they could just happen spontaneously if your bone density is so low.

Dr. Spina: Right. Depending on the degree of your osteoporosis or the degree of the strength of your bone, it can happen with just minimal activities such as waking up from sleep, standing, walking. They are commonly precipitated from falls, so patients often come in after a fall from standing or a fall during gardening, or routine activity around the house where they develop an acute onset of back pain.

Dr. Miller: Or one of the favorites from my patients would be shoveling snow.

Dr. Spina: Exactly. It seems no one should shovel snow anymore. That's pretty much a general rule.

Dr. Miller: So what happens? Do they have pain typically after that?

Dr. Spina: So the most common presenting symptom is acute back pain. Some of the worst pain you've had in the center of your back. It tends to be localized to the midline or right in the middle. Our muscles also become very inflamed, so it can radiate out towards our rib cage. It tends to be in the mid portion of the back. For women, right around their bra strap, and for men, kind of in-between the shoulder blades.

Dr. Miller: Now, you would find more osteoporotic fractures in women, I would think, right?

Dr. Spina: It does.

Dr. Miller: Osteoporosis is more common in women.

Dr. Spina: It's more common in women. So we do tend to see more osteoporotic fractures in elderly women versus men.

Dr. Miller: So, aside from analgesics, pain killers, that type of thing, what can you do to alleviate the pain or help with the pain?

Dr. Spina: So we sort of take a two-tier approach. One is a reduction in activities and modification of daily living, to avoid those activities such as heavy lifting, bending over at the waist, stressing the spine by bending forward or twisting. And the second would be we occasionally use a brace to provide an external support, kind of external crutch you can think of to keep the spine upright or support it while a bone tends to heal in that compressed manner.

Dr. Miller: What's this brace look like? Is it corset?

Dr. Spina: Yes. It tends to be a corset. It kind of looks like a turtle shell, hard in the front and hard in the back, and it wraps around your torso.

Dr. Miller: And usually, how long would a person have to wear that for that to work?

Dr. Spina: We tend to use them for about two months. And then, we tend to wean out of it because as we put people in braces, their muscles, obviously, become weaker. And having good muscular strength is one of the ways we compensate for having fractures. And so we don't cut them cold turkey. We often ask people to slowly come out of them and wear them when they're upright or up for long periods of time, and then remove them when they're sleeping or sitting.

Dr. Miller: Now, tell me a little bit about what's call kyphoplasty. I understand there's a little bit of controversy about the use of this technique and has been for a number of years.

Dr. Spina: So kyphoplasty and vertebroplasty were very common about 10 to 15 years ago. They sort of exploded in the world of spine surgery. And the procedure itself is directed at restoring the height of that pop can. So what we do is . . .

Dr. Miller: So this maintains height in the patient. So the concept, I guess, was if you increase the height of the crushed pop can, then the person wouldn't lose height.

Dr. Spina: Exactly. And so we insert a probe from the back of the spine into the front, the vertebral body. And there are two different means. One, we use a balloon to try to restore the height of the body. And the second is we just inject a material to try to restore the height. And the bottom line is that we take the empty space in the vertebral body, that space that's crushed down, and we try to stabilize it and if not, restore it by putting cement in the front of the vertebral body.

Dr. Miller: So what is the controversy surrounding this technique?

Dr. Spina: So there have been a couple large studies that have been done, that have looked at patients who have not had vertebroplasty or kyphoplasty and who have, and they haven't shown much of a difference as far as long term outcomes. So, in my practice, we tend to reserve them for those patients with intractable pain after about six weeks of non-operative care.

Dr. Miller: So they have some role in alleviating pain if it's not treated with the standard sort of non-interventional means that you just spoke about a few minutes ago?

Dr. Spina: Exactly. In those patients out of refractory which are very, very few in my practice, tend to see a little bit of benefit from doing a kyphoplasty. But again, we tend to reserve that to those people that fail all the non-operative means which we start with in the beginning.

Dr. Miller: The other point would be that if a patient has osteoporosis, they should also be treated for that with one of the newer medications. I should say newer. The medications have been around now for 10 years, and there's new medicines coming out all the time.

Dr. Spina: Exactly. One of the biggest risk factors for vertebral body compression fracture or fragility fracture is having a previous fracture. So it's our routine practice when we identify these patients to make sure that they have a pipeline of care through either us as treating providers or their primary care physicians to check their bone quality through a DEXA scan and address the degree of osteoporosis that they have.

Dr. Miller: Screening becomes very important in this age group, especially women over 65 years of age.

Dr. Spina: Exactly. Screening is probably the best form of prevention for these fractures that we have.

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Interviewer: You think you may have broken a bone but you're not sure. Is there a way you can tell? We'll find out next on The Scope.

Announcer: This is From the Front Lines with emergency room physician Dr. Troy Madsen on The Scope.

Interviewer: Dr. Troy Madsen is an emergency room physician at University of Utah Health. And I know it seems like a silly question because one would think if I broke a bone I would know for sure that I broke a bone. But personal experience, when I was a kid, I broke a bone in my leg, I didn't know, my dad didn't know. He told me to walk it off, you know, as fathers back in that day did, and it turned out the next day I went to the ER and sure enough it was broken. So how can you tell if you broke a bone if you're not sure?

Dr. Madsen: Well, you know, it's really not a stupid question at all because there have been lots of studies done to answer that question for us. How can I know as a physician if someone possibly broke a bone, in their knee, their ankle, their foot?

Interviewer: And you're talking without doing imaging?

Dr. Madsen: Yeah, exactly.

Interviewer: Okay.

Dr. Madsen: To say, okay, are there cases where I can avoid getting an X-ray, or every time someone comes in and says it hurts here on this bone do I need to get an X-ray? So it's actually a great question. And in terms of ankles, knees, and feet, if you can't walk on it, you need an X-ray. That's kind of what these studies showed. But then they also show there are certain parts where if you push on a part of the knee or the ankle or the foot that are more prone to fractures, then those are people who need X-rays as well. So it's a little bit tough to kind of go through and say, "Well, if it hurts on this spot, you need an X-ray, or this spot you don't, this spot you do, this spot you don't."

That's what it comes down to for me as a physician, I know there are certain areas that are more prone to fractures but, you know, typically with fractures you're going to see a lot of swelling, you're going to have trouble moving that joint around or you push on the bone, it hurts there. Again, it's going to be kind of a judgment call. I would say if you're able to walk on it or you're able to use that joint okay, you might be able to get by. But if after a couple of days you're still having a lot of pain there, I think in my mind that increases the likelihood of a fracture in that bone.

Interviewer: And when you say fracture, that's used interchangeably with broken?

Dr. Madsen: Exactly. And that's a great question because sometimes, you know, if you say to someone, "Oh, you've got a fracture in the bone." They'll say, "Well, is it broken?" But, yeah, that's a great question because those are terms that are used interchangeably. You know, the other things we always think about are sprains, strains, you know, where you're pulling on muscles, you're bruising the bone, these are all possibilities as well, things that can look like fractures or like broken bones but, you know, the biggest thing in my mind in the ER is, is it broken, and do we need to do something about that fracture?

Interviewer: Yeah, on that next question sometimes if it is fractured there is nothing that really needs to be done?

Dr. Madsen: That's right. Yeah. Sometimes if something is broken its maybe in a place where there's really not a concern there. Maybe you need a splint on it, but it's all aligned, you don't need to push things back in place. There may be some fractures that are just little chip fractures, little chips off the bone where there's really nothing at all you're going to do for it. So there are certainly cases where, you know, you may have broken something but it's not a big deal. But in my experience, most cases of broken bones, they at least need a splint or a sling or something to keep that from moving around a lot and making it a lot worse.

Interviewer: So with this information that you have, the studies that have been done and knowing where to press and what to expect, how often do you not have to use imaging now? Can you just tell through a physical examination if the bone is broken?

Dr. Madsen: In terms of what I do in the ER, one of the challenges I face is that I think most people come there and if they're ankle hurts they came there to get an X-ray. So sometimes I do spend time trying to talk them out of getting an X-ray, I would say with the knowledge I have of where it hurts and where it hurts and where it doesn't hurt, and maybe 20% of the time people don't need an X-ray. The other 80% of the time people sort of self-triage, they say, "Hey, I can't walk on my foot. I need an X-ray." And I say, "You're exactly right, you need one."

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Interviewer: If you break bone, do you still get a plaster of Paris cast that your friends can sign? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists" with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi. I'm Dr. Tom Miller and I'm here with Dr. Bruce Thomas. He's an orthopedic surgeon here at the Department of Orthopedics at the University of Utah and also practices at our Farmington facility in Farmington, Utah.

Bruce, do we still use plaster of Paris? I mean, when I was training, we'd go into the cast room and they had this big, goopy bin full of plaster of Paris. And they wrapped you up and put all the plaster of Paris on there. It dried and then your friends wrote all over the cast. Times change a little bit or not?

Dr. Thomas: For most things, times have changed.

Dr. Miller: I would suspect.

Dr. Thomas: Plaster is . . . It's been good. It's traditional. It's heavy. It's dirty. And for a long time, orthopedic surgeons felt like it held the molds better. There are studies that show that fiberglass will hold the mold that we put on the cast as well as fiberglass. And when we mold the cast, we put pressure on the bones in the right place to hold the fracture in place. The orthopedic axiom is crooked cast, straight bone.

Dr. Miller: So you can mold the fiberglass right around the arm or leg in the same way that you did with the plaster of Paris?

Dr. Thomas: You can. And when they've looked at it scientifically, the results were very similar.

Dr. Miller: So I suspect it's a lot lighter than that big, clubby plaster of Paris cast that people wore around for eight weeks.

Dr. Thomas: Significantly lighter, much cleaner, and your friends can still write on it.

Dr. Miller: That's great. How about the cast itself? These fiberglass casts, can it be removed so that you can shower or put back on? Does that just depend on the type of fracture?

Dr. Thomas: It does. It depends on the fracture and how stable it is. Once the fiberglass is on, it's not easy for the patient to take it off, but we can cut the cast and make it removable, if there is a fracture that is stable and we're not worried about a lot of displacement.

Dr. Miller: So casts are lighter. You can still write on them. And sometimes you can even take them off to take a shower.

Dr. Thomas: True.

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Dr. Miller: Break a bone, where should you go? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists," with Dr. Tom Miller, is on The Scope.

Dr. Miller: This is Tom Miller from Scope Radio and I'm here with Justin Haller. He's an orthopedic surgeon here at the University of Utah. We're going to talk a little bit about level one trauma centers. Now, you know that if you have a very severe injury, you're likely to end up at a level one trauma center, whether you're referred or end up there initially. But if you've fallen and you hurt your wrist or break your wrist, being at a level one trauma center might not even be a better place to get cure than some of the other type trauma centers, such as level two and three.

And we're going to talk about that a little bit with Justin. Justin, tell me a little bit about what trauma one means or trauma one center. And then we're going to get into how patients who have a fracture or some other musculoskeletal injury would be treated.

Dr. Haller: Sure, Tom. So the level of trauma center designation, there's a level one, level two, and level three designations for hospital trauma centers. And it's based on the number of resources that are available.

Dr. Miller: So you generally have more specialists at a level one center?

Dr. Haller: So level one has the most services available and the most services available acutely. So they have a neurosurgeon, general surgeon, orthopedic surgeon in-house, ready to see patients, depending on their acuity. Level two and level three centers have some of those resources available, but they're just not within the hospital at the time when a patient might arrive.

Dr. Miller: Now, just briefly, what kinds of injuries would a level one trauma center see?

Dr. Haller: So level one trauma centers are best at treating patients with multiple injuries that span general surgery issues, such as chest injuries, head injuries, as well as orthopedic or neurosurgery injuries because they have all the medical subspecialties available. And again, they're available acutely.

Dr. Miller: Now, you're an orthopedic surgeon. So would you say that a level one center handles all kinds of fractures and musculoskeletal injuries that happen during accidents or other strange things?

Dr. Haller: Yes. So level one centers tend to deal with the whole spectrum of orthopedic injuries that a patient could have. And they tend to see anything from referrals from level two and level three centers that are transferred and are complex enough that they do not have the resources available, as well as they see patients from a motor vehicle accident, motorcycle accident from the scene, brought in by the emergency providers.

Dr. Miller: Now, the University of Utah has a level one trauma center, as I understand it. And there are a couple in the state. So we end up getting a lot of referrals, I would guess, from outlying hospitals for severe injuries.

Dr. Haller: Yes, that's accurate. We get referrals from not only within the state but also from surrounding states, including Montana, Idaho, Nevada, Wyoming.

Dr. Miller: Well, let me ask you this, let's say you have a less severe injury. Let's say that you fall and you hurt your ankle or you break your leg or you think it's broken. I mean, would you come to a level one trauma center or should you go to another trauma center, like a level two or a level three because there are more of those?

Dr. Haller: There absolutely are more of those and some might view the access there as being a little bit better. However, the benefit of a level one trauma center is that they have all of the resources available to actually evaluate what's going on with your leg. Because when you first injure it, it can be tough to know whether it's broken or not. And they have the resources available to figure that out and treat you appropriately. And sometimes, even though the access is easier at the level two or level three centers, if it's a complex problem, you'll ultimately get referred anyway. And so it might actually turn out to be easier in the long run just to go to level one.

Dr. Miller: Well, the way that the emergency rooms work, as you know, is they triage patients. And if you have a serious injury, even if that's a fracture, you're going to go ahead of a lot of people to get treatment. You're not going to sit in the waiting room very long with a fracture, I wouldn't think.

Dr. Haller: That's accurate, yeah. Normally, patients with obvious fractures are moved along the emergency room triage board.

Dr. Miller: So before the show, we started talking a little bit about some studies that had been done to show that level one trauma centers actually provide better outcomes, even for simpler injuries. Is that something that you can talk about?

Dr. Haller: Yeah, so there have been a few studies that have looked at level one trauma centers and if they're necessary because they do have a lot of resources available, and if they're cost-effective. And they've demonstrated that level one trauma centers with specialized orthopedic trauma surgeons are cost-effective at treating patients, especially patients with complex injuries.

Dr. Miller: So to wrap it up, if you're a person that has some type of an injury and you have access to a level one trauma center, whether it's something that you think is fairly simple or maybe even more complex, you should maybe come to a trauma . . . you would recommend coming to a level one trauma center. Is that right?

Dr. Haller: I would recommend it if it's reasonably accessible, in terms of geographic location.

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Dr. Miller: Strains, sprains and fractures. How do you tell which is which? We're going to talk about that next on Scope Radio.

Hi, I'm Dr. Tom Miller and I'm here with Dr. Emily Harold. Emily is a Professor of Sports Medicine here at the University of Utah in the department of Orthopaedics. Emily, tell me the difference between . . . well, what do we do? What do we start with? Is there a difference between strains and sprains and . . .

Dr. Harold: Yeah, there is a difference. So, typically, when we talk about a sprain, we're talking about an injury to a ligament. A ligament is a structure that connects one bone to another bone. When we talk about a strain, we're talking about an injury to a muscle. So they vary in terms of what we're describing and they also vary a little bit in terms of treatment.

Dr. Miller: So ligaments are the tough, fibrous tissues that connect joints together? Would that be fair?

Dr. Harold: Yes, that's fair.

Dr. Miller: So you have them in your ankles, your knees, your hips, any major joint?

Dr. Harold: Any major joint. It's a tough, fibrous tissue that connects the two bones together.

Dr. Miller: And yet a sprain is a problem between the tendon and the muscle?

Dr. Harold: Exactly. So, typically, sprains can either be located at where the tendon and the muscle connect, or sometimes they'll be within the muscle themselves.

Dr. Miller: Which is more common, sprain or strain? And also, why is it important to know the difference between the two? Is that something that the general audience should be familiar with or is that more something that a physician needs to know?

Dr. Harold: I think that it's important to know the difference because when we talk about an ankle sprain we're talking about injury to a ligament that connects the two bones. And therefore, the recovery and the treatment for that injury is going to be a little bit different than when we're talking about a hamstring sprain, which is an injury to the muscle itself.

Dr. Miller: Treatments are different?

Dr. Harold: Treatments are different. When we talk about an ankle sprain or ligament sprain, we grade those one through three, with one being just a very mild injury to the ligament and three being a complete tear in the ligament.

Dr. Miller: So, obviously, a complete tear would result in a lack of function or a severe impairment of function.

Dr. Harold: Exactly, and depending on the joint, the treatment is a little bit different. So when you hear of an ACL sprain, a complete tear of the ACL, which would be a grade three sprain, typically results in a surgical intervention.

Dr. Miller: How about the minor stage one and stage two? Are those treated with physical therapy, typically?

Dr. Harold: Typically, those are treated more with physical therapy to help get the joint moving again. Ice, anti-inflammatories. And they take about two to four weeks to recover, whereas a grade three sprain can take up to six weeks to recover.

Dr. Miller: So you're a sports medicine physician. You treat a lot of athletes and also weekend warriors, I imagine. Tell me a little bit about what are the major sprains that you see, and then later on the major strains.

Dr. Harold: So the major sprains I see would be an ankle sprain, as well as, a lot of times, knee sprain. So MCL, different ligaments in the knee that can get sprained. The major strains I see are rotator cuff, which are the muscles in the shoulder, and then I also see a lot of calf and hamstring.

Dr. Miller: So let's take a sprained ankle. That's a fairly common injury, I would think, among athletes and just people who are exercising on a day-to-day basis, and step off a curb incorrectly. Do you always need an x-ray of that? I mean, how does one proceed? Let's say they have swelling, they have pain, does that need to be evaluated by a physician? And how would they know?

Dr. Harold: That's a good question. So there is a set of rules called the Ottawa Ankle Rules, that came out of Canada, where they looked at a lot of patients who had an ankle sprain and they tried to determine which ones were at risk for a fracture and which ones were at risk just for a ligament injury. And so there are some rules you can follow. One is if you can walk on your ankle right after the injury, that's a good sign.

Dr. Miller: Bear weight and walk.

Dr. Harold: Bear weight, exactly. The other is we look for tenderness on either side of the ankle on the bony prominences, both on the inside and the outside of the ankle, as well as if anyone has tenderness on the outside or the lateral part of their foot.

Dr. Miller: And if you have either of those debilities, what next?

Dr. Harold: Then you should come in and get an x-ray, just to make sure that you don't have a fracture with the injury.

Dr. Miller: So you could go to an urgent care clinic, you could go to your primary care physician or even a sports medicine physician?

Dr. Harold: Yeah, all three would be able to handle that with an x-ray and let you know if it's a fracture or just a sprain.

Dr. Miller: So sometimes, there's this difficulty in distinguishing whether it's a fracture or whether it's actually just a sprain?

Dr. Harold: Yes.

Dr. Miller: Okay. Other joints that are concerning for either fracture or strain? I think of ankle, most commonly, and then knee is one where . . .

Dr. Harold: Ankle, knee, I think wrist.

Dr. Miller: Wrist?

Dr. Harold: I'll see some people who fall on their wrist and there's concern whether it's a fracture, or whether it's a sprain or a strain. And that doesn't have a set of rules to guide x-ray so, typically I'd say if it's really swollen and if you have limited movement, those are the times that I would get an x-ray.

Dr. Miller: So if you're lacking function in that hand because of swelling and pain, that needs to be checked out, especially if it goes on any longer than maybe a day. Or if it just hurts incredibly, it needs to be checked out. Okay. So let's talk about strains. You've mentioned hamstring.

Dr. Harold: Yes.

Dr. Miller: And is that the most common that you're familiar with or that you deal with on a day-to-day basis?

Dr. Harold: Because I treat a lot of the younger athletes, I see that probably most commonly.

Dr. Miller: And what do you do to rehabilitate that? What's the main treatment there?

Dr. Harold: The main treatment there is to keep from over-stressing it when it's still injured. So usually, we start with some gentle stretching, usually some physical therapy. Avoid any kind of sprinting or any kind of activity that really stresses it until it slowly heals with time, and that can take up to a month.

Dr. Miller: I imagine you work very closely with physical therapists?

Dr. Harold: Yes.

Dr. Miller: And so a person with either a sprain or strain would end up maybe going to a physical therapist if it was a non-operative injury?

Dr. Harold: Yeah, absolutely, and I would say at least 90 to 95% of all of them are non-operative.

Dr. Miller: That's great to know.

Dr. Harold: So most injuries require physical therapy, some time off from the activity that really bothers it, but very few ever go on to require surgery.

Dr. Miller: Emily, you mentioned something earlier, talking about non-steroidals. Could you talk about that and what a non-steroidal is?

Dr. Harold: Yeah, a non-steroidal is a drug that helps with inflammation. If you get them over the counter, brand names like ibuprofen, Aleve, or naproxen, Advil, those are medicines that people take to help with inflammation. Now, I think it's worth noting that it hasn't been shown to heal anything quicker, it's more of a pain alleviator.

Dr. Miller: Should they go to the drug store and pick up ibuprofen or Naprosyn, common non-steroidals that are available without a prescription? Or do you have a certain way that you prescribe them or tell them how to use them so that they don't overuse those types of medicines? Because they do have side effects.

Dr. Harold: Yeah. I typically tell my patients that if they have a lot of pain, they should take the dose that is written on the over-the-counter bottle and take that for pain only. And once their pain starts to get better, they should stop the medication as they tolerate it. There are some doctors who will tell people to take it constantly for one or two weeks. Again, I don't think there's any data behind either option. I think it's more of a physician and patient preference.

Dr. Miller: So, Emily, we just talked about sprains, strains and fractures. Could you just summarize what we said? And we said quite a bit but I think, for the audience, a little bit of a recap would be good.

Dr. Harold: Absolutely. So a sprain is an injury to a ligament, which is a piece of tissue that connects a bone to a bone. A strain is an injury to where the muscle and tendon are connected. And a fracture is any break in the bone, regardless of how many pieces it is in or how big it is. All of these are treated a little bit differently, and . . .

Dr. Miller: I think, as you said, 90% of them . . .

Dr. Harold: . . . most of them are non-operative.

Dr. Miller: . . . that don't require procedure and operation to heal.

updated: December 21, 2022
originally published: October 4, 2016

Dr. Miller: Could you have a pelvic fracture? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. David Rothberg. He's an orthopedic surgeon and specializes in trauma care. David, how would one know if they had a pelvic fracture? Now I know that these are fractures that don't just occur spontaneously. Generally, people will have some type of trauma. Tell us a little bit about how that happens. How does one suffer a traumatic pelvic fracture?

Dr. Rothberg: There really are two separate patient populations that will have a pelvic fracture. One is the patient with a devastating life-threatening injury. These are not ones where you're questioning. These are patients that come in as a Level 1 trauma activation, but really a lot of these come in in an older patient population who have had a ground-level fall. They've tripped on the carpet, or over a dog, or something like this, and they can have pain anywhere from there groin, their abdomen, or low back, and that's when the work-up starts.

Dr. Miller: Is it sometimes confused with a hip fracture?

Dr. Rothberg: Commonly. The type of pain that you have with those two fractures is extremely similar, and we typically will figure out which one it is by taking x-rays.

Dr. Rothberg: Now a pelvic fracture, I guess depending on the type of patient, generally those are surgically repaired. They're fixed and treated, and then there's a recovery period. What about a pelvic fracture? How do you treat those? It seems like it would be kind of hard to cast a pelvic fracture.

Dr. Rothberg: Yeah, that's true.

Dr. Miller: It's like a rib. You can't cast ribs.

Dr. Rothberg: We don't cast pelvic fractures. What we're trying to figure out when we're working up some of the pelvic fractures is is the pelvis stable or unstable? And what that means is how much motion is in the pelvis when someone would walk.

Dr. Miller: And how do you determine that?

Dr. Rothberg: It's based on physical exam, the x-rays, and oftentimes a CT scan really looking at the pattern of the fracture, or how the bones are broken, and trying to determine the best course.

Dr. Miller: So in a pelvic fracture, would you operate on them from time to time?

Dr. Rothberg: Yeah, it's a very common operation for us. We do them almost daily, if not weekly. It really depends on the age and patient health status and mobility, and a lot to do with what they've broken.

Dr. Miller: Is the recovery time similar to a repaired hip fracture, or is it longer? Is there a difference in the type of recovery?

Dr. Rothberg: It's pretty much in the same ball park depending on the pattern of fracture they had. The surgery is a little easier to recover from. The surgery is not as invasive, but the ability to get back walking is about the same. It's tough in the early period, but we do expect that most people will get back to their daily life.

Dr. Miller: So the real key is if someone falls at home, especially an older person, and they have persistent pain they ought to be checked out and receive some type of radiologic study in order to determine at least initially if there's a fracture.

Dr. Rothberg: That's exactly right.

Announcer: TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

Interviewer: All right, it's time to play the game ER or Not, where you get to play along and decide whether or not something that has happened is worth going to the emergency room. We're here with Dr. Troy Madsen, emergency room physician at University of Utah Hospital.

ER or Not? You're eating a chicken wing and you accidentally swallow a bone.

Dr. Madsen: This is tough one, Scot, so I want to know, what do you think?

Interviewer: All right, so I'm going to say that we did one on toothpicks before . . .

Dr. Madsen: Yes.

Interviewer: . . . that if you swallow a toothpick and it goes into your abdominal area it could puncture through.

Dr. Madsen: Sure.

Interviewer: I'm going to guess based on the kind of chicken wing or the chicken bone, that could be a problem here.

Dr. Madsen: Yes.

Interviewer: A bigger, duller bone, I don't know. It could be painful coming out, but it probably could pass through. I don't know. I don't know. I don't know.

Dr. Madsen: See? I'm going to put you to work in the ER. Look how much you've learned and how much you know. I'm so impressed. Those are the exact processes that are going on in my mind. I'm imagining myself having a family member call me and say, "I'm having chicken wings tonight. I was watching a game and I don't know what I did, but I swallowed a chicken bone."

My first question for them is, "Are you sure you swallowed it? Are you sure it's not in your airway?" If it's in the airway, that's an entirely different issue. Absolutely, you need to get to the ER if it feels like it's stuck in there, you're having a hard time breathing, maybe there's like a high-pitch wheezing sound, that's ER, absolutely.

Interviewer: Anytime there's an airway issue, ER.

Dr. Madsen: Yes, ABC; A stands for airway. If it affects the airway, get to the ER.

Then the next question is, let's say, okay, it's not in the airway, what are we talking about in terms of a chicken bone here? I'm thinking number one, is it something that's going to somehow puncture their intestines as it's passing through? Was this a piece of a chicken bone that splintered, and then they swallowed it down? Or is it a really big chicken bone? And by a big chicken bone, I'm talking about something usually longer than about three inches.

Interviewer: Okay, so it would've been really hard to swallow something like that.

Dr. Madsen: It would have been, exactly. If you're talking about something three inches or longer, that's really tough to swallow, and a chicken wing isn't the sort of thing that's going to do that. If they tell me, you know, I don't know why they would do this but if somehow they were chewing on this chicken wing while watching a game and swallowed a big sharp piece down there, that would be a reason to go the ER because there you do worry about possibly causing some sort of a puncture wound in the stomach or in the intestines.

Or if they said, "This was not a chicken wing. This was a chicken thigh and this was a big bone," and again, I don't know why they would have done that or swallowed it, but that's another reason to go to the ER.

Interviewer: All right, so the grey area is a dull kind of bone that's not that big.

Dr. Madsen: Exactly.

Interviewer: Maybe a half-inch long, not very big around, is that going to pass through?

Dr. Madsen: It should, yeah.

Interviewer: Do you take the chance?

Dr. Madsen: If you're concerned you can always go to the ER. We can get an X-ray, we can look at it. It's a bone; we're going to see it on an x-ray. We can call the GI doctors and ask them to look at it. My suspicion is they would not go in and put you through anesthesia to go down and fish that out and pull it out. If it's a small chicken bone, maybe half an inch long, an inch long, it should pass through okay.

Interviewer: Okay. I'm nervous now. I mean, this is one of those things where in a couple of instances, you know absolutely what the answer is, but then there's that grey area.

Dr. Madsen: It is definitely a grey area.

Interviewer: Is there a chicken wing hotline I could call, like poison control that can give me some advice?

Dr. Madsen: It's funny, if you call poison control they probably would give you advice.

Interviewer: You think so?

Dr. Madsen: Yeah, they would. And then they would get people on the phone if they needed to. So of it is a grey area and you're not sure, and it's something you've ingested like that, they would probably be able to help you out there.

Interviewer: If it's the grey area, is there a period of time or something that would make you more concerned that this might be an issue?

Dr. Madsen: That's a tough one because some things, you swallow it and it's just going to sit there or it's going to work its way into your intestines. Once it gets in there, you may have no symptoms but it may be too far down to really fish it out. If it is a concern and you're just saying to yourself, "Hey, what do I do about this?" it's worth at least talking to someone, calling your doctor, and you can always go to the ER. It's not a big deal, but certainly talk to someone if you're just wondering, "What do I need to do about this?"

Interviewer: One of those nurse hotlines or something of that nature, perhaps.

Dr. Madsen: Exactly.

updated: July 22, 2020
originally published: April 3, 2016

Dr. Miller: You sprained your ankle, could you have a fracture and what to do about it? I'm Dr. Tom Miller in here with Scope Radio.

Difference Between an Ankle Fracture and a Sprained Ankle

Dr. Miller: I'm here today with Dr. Alexej Barg and he is an orthopedic surgeon here at the University of Utah. He specializes in foot and ankle problems. Alexej, ankle sprains are very common and occur frequently among adolescents and kids who are playing sports. Under what circumstances should one go receive additional attention after spraining an ankle to make sure that they haven't fractured the ankle?

I think this is a typical concern that I see in my practice. People come in, they sprain their ankles and they want to know, "Well, could I have fractured the ankle?"

Most Common Sports Injuries

Dr. Barg: The ankle sprain is for sure the most common injury in the United States. This is actually also the most common sports injury. More than every 10th patient who is showing up in the emergency room is coming to the clinic because of the ankle sprain. Of course, you cannot just do in every patient without seeing this patient, just the routine radiograph assessment.

In the last case, there are some clinical studies addressing the efficacy or whether the radiograph need to be done or not. I don't think those guidelines are good. However, it's still in the hands of the treating surgeon or orthopedic surgeon whether the patient does need the radiographs or not. In my experience, if it's just a mild sprain, especially in the younger kids or teenager, there's definitely no need to do immediately radiographs.

Dr. Miller: What does a mild sprain look like to you?

What Is a Mild Ankle Sprain?

Dr. Barg: A mild sprain looks like for me, for example, it's always only on the lateral side. That means on the outside, not the inside. Usually, it's just mildly small and the patient still can go for weight bearing. [inaudible 00:01:53] sort of pain or maybe just a sore, not necessarily the pain. They don't have the swelling on the medial side, on the inner side. This is for me the mild sore.

If the patient does present with a swelling with some hematoma, that means some color change, on the medial and/or lateral side, there's definitely need to perform or to do the radiographs, the X-rays to exclude a bone fracture.

Dr. Miller: What about if right after the ankle is sprained that they cannot weight bear? Does that make a difference? I've heard that sometimes, if the person who sprains their ankle is not able to put weight on that foot for a period of time right after the injury, they should receive an X-ray.

Dr. Barg: Usually, right after the injury, almost everybody who has ankle sprains cannot bear weight. I would definitely wait a couple hours. Usually, those patients have some substantial pain relief within four to six hours after the injury, especially if they do elevate the foot, if you do the cooling of the injured ankle.

If they still experience a very severe pain after six hours so they cannot walk on it at all, there is definitely an indication or the need to do the radiographs. Another question is if the patient continues having pain two or three weeks after the injury, it doesn't matter whether it was a mild injury, they need an x-ray. They should go to the clinic and, first of all, the orthopedic surgeon should take a look at it.

It can be a foot and ankle surgeon, it can be also the guy or the colleague who is experienced in sports injuries and then, finally, we will decide whether this particular person needs radiographs or not.

Dr. Miller: Question for you, is the injury of an ankle sprain usually to the inside or the outside? Medial or lateral on the foot?

Dr. Barg: Most likely, it is on the lateral side. On the lateral side, we have actually three ligaments and especially the anterior ligament. That means that the ligament in the front. It's a very thin ligament and almost everybody of us has already injured this. Fortunately, they do heal very well and I would say only maybe five percent of those patients with the lateral ankle sprain, that means the sprain on the outside, they develop the chronic instability that needs to be treated.

That is different on the medial side. Fortunately, on the medial side, the injuries are definitely rare. They are not as often than on the lateral side. However, most likely, the patient with the severe sprain of the medial ligaments, that means on the inner side, they do develop later the chronic instability that needs to be treated surgically.

Dr. Miller: After an ankle sprain, we determine it's not a fracture. What are the sorts of things that a patient can do, a person can do to eliminate the discomfort, the swelling and then get back in the game, so to speak?

Dr. Barg: Usually, I divide the severity of ankle sprains in four grades. Like first grade is a very mild sprain, the fourth grade is definitely the severe sprain. The mild sprain, the patient with the mild sprain doesn't need a specific therapy. They can [below] the ankle if it's comfortable for them.

Usually, we can start with physical therapy pretty quickly and the physical therapy, the main of the physical therapy is the first main, is to decrease the local swelling. The second main is the so-called proper [inaudible 00:05:20] exercises. Proper [Inaudible 00:05:22] exercises would work meaning that the physical therapist can teach the patient how to better control the ankle.

Again, if the sprain is more severe, for example, when I have a feeling that all ligaments on the lateral side are torn or even those medial ligaments can be damaged, in those patients, I recommend immobilization in a boot, for example, six weeks with only partial weight bearing. During that time, we're just trying to give the ligaments the chance to heal, time to heal. Exactly.

Dr. Miller: What I'm hearing is if a person has an ankle sprain, number one, look to see if there's discoloration. So anything that looks like blood beneath the skin. By discoloration, you mean black and blue?

Dr. Barg: Yes, and I do mean exactly this.

When Do I Get an X-Ray?

Dr. Miller: You probably need an X-ray or should get an X-ray and seek attention for that. If you can't weight bear immediately after, that doesn't necessarily mean that you have a fracture, but if that persists beyond a day or 12 hours to a day, then you probably need an X-ray. Even if it's a mild sprain and you're still struggling with pain after a couple of weeks, then you need to seek attention for that and get radiographs to make sure you haven't had a fracture.

Dr. Barg: Yes, absolutely. Another specific situation in this patient group is, for example, again, 95 percent of this group do heal without any restriction in the long term. However, those five percent, they still have, for example, four, six months after the initial injury, they still have some pain in the ankle or especially the instability feeling. Specifically, when the patient tries to walk on an uneven surface. Those patients need to see the doctor to see whether they need to be treated or not for ankle instability.

updated: October 28, 2020
originally published: September 9, 2015