Happy Chinese New Year 2012

As we bid goodbye to the year of the rabbit, on the 22nd of February we usher in yet another year on the Chinese calendar, the Dragon year. A mythical creature, the dragon symbolizes power and therefore represents the ultimate in success and happiness.

The Bomoh Tulang would like  like to wish all celebrating a very Happy Chinese New Year and Gong Xi Fa Cai! May this Year of the Dragon be an auspicious one, filled with love, health, prosperity and happiness for everyone.

For the rest of us, many of whom are heading home for the long holidays, enjoy your holidays and have a safe trip home.


-The Bomoh Tulang -

Gastrocnemius Muscle Tear (Calf Tear)

The patient was a 46 year old man, referred from his neighborhood GP.

The story was that he was helping a friend push a stalled car. While doing so, he heard a "snapping" sound from the back of his right leg. This was accompanied by pain; however he still managed to limp back. Back home, he applied some ice onto the leg (good for him), the swelling and bruising didn't appear until the next morning.

He related the story to me on the initial visit, nine days after the injury. Why nine days? Well apparently I was the fourth medical professional he has sought, the 3rd one being the GP who finally referred him here.

Listening to his story carefully, my initial suspicion was that he may have torn his achilles tendon. However a complete tear would render him almost incapable to walk; he was limping to my clinic, sure, but not to the extent that he had to be wheeled into the room.

Examination of his leg showed some swelling of his lower leg, with bruising around the ankle and foot. Tenderness could be felt around the calf muscles. There was no palpable defect on his achilles tendon indicating a torn tendon nor was Simmons test positive for achilles cut.

So that rules out an achilles tendon injury.

Hmmm...

Bruising lower leg

with swelling of the lower leg

An ultrasound or MRI scan would help in this matter. I promptly sent him across the hallway to see the radiologist requesting for an ultrasound of his calf muscle, failing which we may proceed on to do a MRI scan.

The ultrasound report noted fluid/blood collection within the medial gastrocnemius (calf) muscle, which in the light of the patients history, confirmed the patient's diagnosis:

Gastrocnemius muscle tear (calf tear)

A tear of the gastrocnemius muscle  most commonly occurs in the middle-aged, male athlete (the "weekend warrior") when the muscle actively contracts against a foot which is dorsiflexed with an extended knee, as may occur in tennis or jogging; in this particular case, the patient was loading the calf muscles while pushing the car.

As in this patient, the diagnosis can be confused with an achilles tendon rupture. However as explained above, palpation of the achilles tendon should demonstrate an intact tendon. In any case, imaging studies such as ultrasound and magnetic resonance imaging (MRI) can be useful to ascertain the diagnosis.

Only conservative management is required to treat ruptures of the gastrocnemius muscle. 

RICE (Rest, Ice, Compression , Elevation) therapy together with adequate analgesics are the mainstay of treatment for the first 24-72 hours after injury . Ambulation with crutches is advised with gradual weight bearing in the following weeks. A walker-type brace can be used. Physiotherapy is initiated as soon as the patient feels comfortable out of the walker.

A walker type brace - patient would need a longer version

Swelling and bruising should gradually decrease over the next couple of weeks. Recovery may take up to 6 weeks or more depending on the severity of the injury. Patients can expect a full recovery provided that the rehabilitation protocol is followed.

- the BomohTulang -

Merry Christmas and a Happy New Year - 2012

Well we have come to that time of the year where we bid adieu to 2011 and look forward to another awesome year ahead.
The Bomoh Tulang would like to wish all loyal readers a very happy new year and one that's filled with peace, prosperity and happiness always.
For those celebrating, a very Merry Christmas and happy holidays for the rest of us!

- the BomohTulang -

Congratulations to Dr Mel

The Bomoh Tulang would like to congratulate Dr Mel for passing her part 1 masters exam for Orthopedics in UM recently. It was tough but u made it! Wishing you continued success in your journey to become a certified Orthopod!

L-R: FerrariBoy, BomohTulang, Aishah, Mel

Dr Mel is a photography enthusiast too, mainly dabbling in retro analog film cameras and has quite a collection of vintage cameras. So if film cameras are your thing, head on to CGSF where Mel blogs about her film collection!

- The BomohTulang -

SAFETY AT THE PLAYGROUND

Due to its location in a residential area, the hospital sees a fair amount of injuries involving children. The numbers seen in the emergency room usually correspond to the school holidays, where we see an increase in the number of children being brought in due to some kind of injury, usually due to a fall while playing.  I suppose the holidays are the time children are given more freedom to play outdoor, free from the pressures of homework and tuition.

The neighbourhood playground is a natural spot for children to congregate, interact and play; at the same time it helps to build their physical skills, co-ordination and strength. It is also a wonderful place for families to get some fresh air and exercise.  It may look like a safe place, but hidden dangers do lurk. The hospital had a “Smart Parent Safe Kids” campaign earlier this year where I gave a talk on prevention of playground injuries.  Why playground injuries? Well, apart from the home, accidents occur more frequently on the playground than any other places. 
In the US, more than 200,000 playground-related injuries occur annually. Similarly in Malaysia, a recent study has shown that 17% of childhood fractures occur in the parks, second only to the home (35%). Now scrapes and bruises are a normal part of growing up, but injuries that are brought to the hospital are usually of a more severe kind. We see sprains, fractures, dislocations, and rarely, amputated fingertips.

Children can injure themselves at the playground in a variety of ways.  As I have explained above, the majority of the injuries result from a fall from playground equipment. They might slip, lose their grip while climbing, or lose balance while playing on the “monkey bars”. Another way is by improper usage of equipment.

The onus is on parents and caregivers to create a safe environment for children to play. One should firstly choose a safe playground based on the location and surrounding hazards. Watch out for open drains, exposed electrical wires and busy roads among other things.

Close supervision by a responsible adult may be the most important factor in preventing playground injuries.  For young children, adults should be with them the whole time they are playing on play equipment. The word is “Active supervision” – one should not be distracted by other activities such as reading a book, talking on the phone or texting.  Although I do agree that  sometimes  adult supervision might be a problem in urban areas as both parents may be working, delegating this responsibility to the grandparents, housemaids or elder children might not be as effective.  Educating the child on the correct usage of play equipment not only decreases the chance of injuries but also goes a long way in preserving the lifespan of the play equipment.

All these might sound frightening, so should you stop sending your children to the playground? My thoughts are that the benefits of fresh air and exercise far outweigh the danger, and so long as mummy and daddy keep an eye and play an actively supervise, time spent at the playground need not end up a tearful experience.

-The BomohTulang 

Eid-Ul Fitri and Happy Independence Day 2011

The end of August this year coincides with the two largest celebration for Malaysians.

Muslims throughout the country, according to calculation, will observe Eid-ul Fitri on Tuesday the 30th of August, marking the end of Ramadhan, where muslims fasted daily for a month from dawn till dusk. Traditionally the eid holidays (also known as Hari Raya Aidil Fitri) run for two consecutive days but this year, the second day coincides with Malaysia's 54th Independence Day.

So this year is indeed a double celebration for Malaysians in general and especially for the muslims throughout; the Bomoh Tulang would like to take this oppurtunity to wish a Selamat Hari Raya and Happy Independence day to all Malaysians!

Happy Holidays and have a safe journey home!

Selamat Hari Merdeka!

- the BomohTulang -

ACHILLES TENDON CUT due to TOILET BOWL INJURY

The patient slipped in the bathroom and his foot crashed into the toilet bowl. (no he was not squatting on the edge of the toilet seat - see bottom pic)

He sustained a deep laceration over his calf and a clinical examination showed that the achilles tendon was torn.
This was confirmed intra-operatively, where an emergency debridement, exploration and tendon repair was done the same day.

Intra-op findings

Wound blurred out as deemed too gory for public viewing :

Post operatively, a backslab with the ankle in equinus was applied so as to relieve the tension on the operated tendon. This will be replaced later with a special walking boot allowing range of motion exercises to the ankle, with partial weight bearing of the affected limb. Total rehabilitation would take about 4-6 weeks

Apparently a group of doctors reported on this seemingly "rare" case and got it published in the foot and ankle journal.

On another related note, have you been to the toilets in the malls? you would probably come across this sign:

The bottom right symbol is an apt reminder of what not to do if one wishes to avoid getting the injury that our friend above had... perhaps the mall management might want to use the picture above to illustrate the consequences of slipping into a toilet bowl.. hmm...

- the Bomoh Tulang -

reference:

the AAOS Clinical Practice Guideline on the Diagnosis and Treatment of Acute Achilles Tendon Rupture 2009

FALL PREVENTION IN THE ELDERLY - KEMUNING NEWS magazine article

Broken bones are a very real risk in the elderly, partly due to the fact that bones are brittle at that age, and  minor falls could lead to a catastrophic fracture.
The Bomoh Tulang was featured in the July-September 2011 edition of Kemuning News the other day, featuring a write up on do's and dont's on fall prevention in the elderly.

 

Kemuning News is published on a quarterly basis, exclusively for the residents of Kota Kemuning, which is the housing area adjacent to the hospital.
If you are a resident of Kota Kemuning (or just happened to be in the vicinity), do pick up a copy as the publication is freely available at the convenience stores and the Petronas stations.

In case you have missed it, I have appended the article on my website here.

- the Bomoh Tulang -

SCUBA DIVING - Dr Asri's OW dive certification

As you know I'm an avid diver, having had my PADI dive certification in 2005. Since then I have had the opportunity to log numerous dives around the islands off Malaysia's coast.

I managed to "racun" Dr Asri, our Anesthetist in the hospital to take the Open Water Diver Certification, which is basically a "licence" to scuba dive and the first step to experience what the wonderful world beneath the waves has to offer.
Part of the certification is to do a few dives in the open water (as opposed to the confined waters of the pool)

So one fine July weekend, we took a flight to Kuala Terengganu and met up with Divemaster Halimi of Ocean Elements.The speedboat brought us to Pulau Perhentian where we spent the weekend and for Dr Asri to practice his ability to breathe underwater :P

More pics after the jump..

Before the first dive

SYNDACTYLY - joined together

Syndactyly, or "webbed fingers," is caused by the failure of the fingers to separate during embryological development. It is the most common congenital anomaly of the hand, with an occurrence of 1 per 2000 births. Hereditary causes has been suggested, with up to 40% of patients having a positive family history of syndactily.

Syndactyly can also be associated with a variety of other syndromes, some of them rare - for example in the patient below with Apert Syndrome.

Syndactyly in an infant - part of a larger problem - the Apert Syndrome

Syndactyly is most commonly seen in the middle and ring fingers; it can be classified as simple when it involves soft tissues only and complex when it involves the bone or nail of adjacent fingers. It can also be classified as complete or incomplete depending on the degree of soft tissue union between the fingers.

Timing of separation of the digits depends on the fingers affected. If the affected digits grow at unequal lengths (for example the little and ring fingers) then separation should ideally be done within the first few months of life as the tethering of the skin will cause the fingers to deviate and cause contractures.

Ring and mddle finger syndactyly usually does not pose functional problems, as in the case of the older child below. In this case, it is a simple, complete syndactyly of the ring and middle fingers. Since both fingers grow at equal lengths, surgery to separate the fingers can be delayed later in life.

- the BomohTulang -

Smart Parents Safe Kids campaign

Columbia Asia Hospitals, in collaboration with the parenting website parenting2u, organized a series of talks on children safety at CAHBR recently. This event kicks off a nationwide campaign themed "Smart Parents, Safe Kids". 

The aim is to educate parents and caregivers on the importance of children's safety and also highlight the hidden dangers found at home, the parks and in the water.

Given the fact that the ortho surgeons deal a lot with children's fracture, guess who was honoured with the chance to talk on playground safety?..

Earnestly talking

what's this about

Part of the audience

activities for kids

The talks will be held at the Columbia Asia Hospitals nationwide, so check out your nearest hospital for the date of the roadshow.

More on the campaign can be found here

- the BomohTulang - 

In appreciation of our Nightingales - HAPPY NURSES' DAY

International Nurses' Day is celebrated between 6-12 May every year. 

CAHBR had a celebration on the 11th of May this year- where the agenda was "speech, makan and more makan":P

Ehem.. on a more serious note - this year's theme was "Closing the Gap: Increasing Access and Equity". The International Council of Nurses notes that there are still some areas of the population that has minimal or non existent access to health care - they believe that nurses, as a frontliner in the provision of healthcare, have an important role in bridging the gap to reduce health inequities and providing better access to healthcare for the general population- hence the theme for this year's International Nurses' Day.

okay, enough of the ceramah dudes! on to the pics..

The nurses day cake

Matron with the staff

More makan

 - the BomohTulang -

sources:

the international Nurses Day Wiki

International Council of Nurses, ICN

Elbow fractures in Children - Supracondylar fracture of the humerus

We see a fair number of children's injuries in the hospital, the reason being that the hospital is situated in a residential neighbourhood.

Children frequently fall, and in the process, has the tendency to extend their arms out to protect themselves.
This fact makes injuries involving the upper limbs more frequently seen in the ER (Emergency Room) as compared to the lower limb. The force from the fall, if large enough, can fracture the bone in two common places - the wrist or the elbow.

For the elbow, the forces from the fall travel through the forearm, levers the elbow joint in extension and the bone breaks at the weakest part of the arm - the supracondylar part of the humerus.
This is the so-called supracondylar fracture of the humerus and is the commonest elbow injury seen in children, seen most frequently in the 3 to 8 year old age group. It is also the 2nd most common children's fracture, second only to wrist fractures.

Patients with a suspected supracondylar fracture of the humerus frequently present to the ER with a history of fall, with associated swelling of the elbow and inability to bend the elbow.

*For the parent, if there is a suspicion of an elbow injury or fracture, one should ideally immobilize the limb in a sling prior to bringing to the ER. Besides providing comfort to your child, it limits further movement and displacement (moving out of alignment) of the suspected fracture. Dont know how to do it? look it up here. *

And that was how I met my 7 year old patient in the ER a couple of months ago. He had a nasty fall and was brought to the ER by his parents. His left elbow was deformed and swollen, and painful to the touch.

Swollen left elbow

X rays confirmed my suspicions: a supracondylar fracture of the left humerus.

Now fractures which are minimally displaced, or better yet, undisplaced, can be treated with nothing more than a plaster slab and an armsling. However our patient had what is known as a type III Gartlands fracture, where the fracture ends are totally not in contact with each other. This necessitates an operative reduction (where the surgeon manipulates the fracture ends into place) and fixation with wires.

Fortunately the parents understood the gravity of the situation and agreed for surgery that night. Here are the before and after pics of the X rays:

fracture site (arrowed)

frontal view of the elbow showing the fracture

Fracture reduced (put back) and temporary wires in place. Compare with the first picture

You can see that humpty-dumpty the bone ends has been put back together again.
The wires were removed after a month -   on the x rays below you will note that the fracture is healing well with new bone around the fracture site.

after 2 months

There was still some slight stiffness of the elbow on the last day of treatment which should go away after some physiotherapy. Now our patient is well on his way to playing football again and probably has a nice story to tell his kids later!

- the BomohTulang -

references:


Clinical Practice Guidelines
The Treatment Of Pediatric Supracondylar Humerus Fractures
American Academy of Orthopaedic Surgeons 2011

Current Concepts Review Supracondylar Humeral Fractures in Children
J Bone Joint Surg Am. 2008;90:1121-32

Crossed-pin versus lateral-pin fixation in pediatric supracondylar humeral fractures.
Shamsuddin SA, Penafort R, Sharaf I. Med J Malaysia. 2001; 56(Suppl D):38–44.

Wheeless' Textbook of Orthopaedics (online)

DE QUERVAIN's TENOSYNOVITIS - Pain at the side of the wrist

Wrist pain has multiple causes and can be localized to various areas around the wrist; one of the common ones being pain at the side of the wrist near the base of the thumb. This can be attributed to De Quervains tenosynovitis

De Quervain's tenosynovitis refers to inflammation of tendons together with their enclosing sheath on the side of the wrist at the base of the thumb. These tendons, the extensor pollicis brevis and the abductor pollicis longus tendons, help move the thumb a certain way - to extend and to abduct the thumb (hence their names). On their way to the thumb, the tendons passes through a tunnel (the extensor retinaculum) which helps hold the tendons in place. Much like trigger finger, irritation of the tendon causes the lining (synovium) around the tendon to swell, which makes it difficult for the tendons to move and glide into the tunnel. However, unlike trigger finger, there is no 'catching' sensation - just pain at the side of the wrist during certain positions of the hand.

Patients with De Quervain's frequently complain of pain with certain movements of the wrist, for example when pouring tea from a teapot, using a watering can and lifting the grocery bags during shopping. These particular wrist movements will cause a strain on the said tendons - leading to the wrist pain.

The pain can be replicated by bending your thumb inwards into your palm and making a fist - this is the basis of the eponymous Finkelsteins test. (if you can read Thai, here's a DIY video of the test :P)
Here's a picture of the test - it can be quite painful for the patients to perform so I would proceed slowly if I were to conduct the examination.

Patients are commonly women aged 30 to 50, and frequently mothers of infants. Indeed sometimes when the patients of a child bearing age sees me in the clinic for the problem, my usual interview question would include "have you recently had a baby?" Apparently picking up and carrying of the baby puts the wrist in an awkward position, putting strain to the tendon, and hormonal changes in the tissues further aggravates this situation.

Other conditions that may mimic this would include basal thumb arthritis or the intersection syndrome (most commonly confused with)

Treatment is basically conservative. A period of splinting would help to rest the inflamed tissue; there are smaller splints now which are more comfortable to wear, do ask your therapist about it. Non-steroidal anti-inflammatory medications (NSAIDs), ultrasound therapy and ice all help to relieve the inflammation. These conservative means are all that is needed for the majority of patients

Steroid injection directly into the sheath can be given for more severe cases, although there is a risk of discolouration of the skin at the injection site.

Failed conservative management would necessitate a surgical release of the constricting sheath of the tendon ( the 1st dorsal compartment ). This could be done on an outpatient basis, ideally under general anaesthesia.



- the Bomoh Tulang -

references:

Treatment of de Quervain's disease:role of conservative management.

 Journal of Hand Surgery - British Volume. 26(3):258-60, 2001 Jun.

	Ilyas AM "de Quervain Tenosynovitis of the Wrist" J. Am. Acad. Ortho. Surg., December 2007; 15: 757 - 764.

BOMOH TULANG talks about Back Pain - RAPI magazine

RAPI magazine contacted the Bomoh Tulang the other day, and enquired whether would he be kind enough to write about back pain and prolapsed disc? Well of course I obliged.

The April issue of RAPI mag is already at the newsstands and features a four-page spread on all you need to know about back pain and prolapsed disc. So ladies and gents, if you have any questions about back pain, head over to your nearest newsagent and get your copy now. I'll be signing copies at MPH. ;)

..and no, this is not an April Fool's joke..

  

- the BomohTulang -