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27 March 2023

By Marco Castenetto 0 Comments Well-being

The top 5 foods that are killing your brain (the 6th is the worst!)

The dark side of the top 5 brain killing foods, that can lead to the worst neurological diseases.

7 January 2023

By Marco Castenetto 0 Comments Orthopedics

The essential guide to clavicle fracture

Learn how to detect a clavicle fracture and avoid possible complications following this particular trauma.

compartment syndrome and volkmann ischemic contracture

27 December 2022

By Marco Castenetto 0 Comments Orthopedics

Compartment syndrome and Volkmann’s ischemic contracture: the real emergency of a swollen limb

Marco Castenetto

Volkmann’s ischemic contracture (also referred to as compartment syndrome), is a pathological contracture of the muscles of an anatomical compartment (e.g. forearm).

An anatomical compartment is a structure in which there is a group of one or more muscles with nerves, vessels, tendons, ligaments, etc., surrounded by a structure called fascia, which is relatively inextensible.

Volkmann’s disease is the final outcome of the compartment syndrome, characterized by increased pressure within the anatomical portion and irreversible muscle necrosis.

The leg and forearm are the most commonly affected structures.

The increase in pressure in the tissues causes an increase in venous pressure.

The drastic decrease in vascular perfusion causes the tissues to receive less blood, up to an insufficient level to guarantee its vitality.

Acute, undiagnosed Volkmann disease can lead to necrosis (death) of muscle and nerve tissue within 4 to 8 hours.

The muscle fibers contract permanently and the muscle is replaced by scar tissue, and the nerves suffer permanent dysfunction.

Clinically speaking, it is defined as the “five P” syndrome (1):

Pulselessness;
Pain;
Pallor;
Paresthesia (alteration of sensitivity);
Paralysis.

What causes Volkmann’s ischemic contracture:

The venous slow blood condition (stasis), increases the intracompartmental pressure, the tissues no longer receive a sufficient amount of oxygen (anoxia) and the local damage created affects the organism both from the physical and biochemical point of view.

It is an event that can occur following bleeding and external compressions (bandages, plaster casts, etc.).

The resulting edema can lead to:

Complete and lasting ischemia, with consequent total necrosis and gangrene outcome;
Complete ischemia with partial necrosis, leading to Volkmann’s syndrome.

The causes can be attributed to:

Fractures (3):

Tibial shaft fracture;
Soft tissue injuries;
Distal radius fracture;
Crush syndrome;
Forearm diaphyseal fracture;
Femoral shaft fracture;
Tibial plateau fracture;
Hand fractures;
Fractures of the tibial pilon;
Foot fractures;
Ankle fracture;
Elbow fracture dislocation;
Pelvic fracture;
Humeral shaft fracture.

Conditions that increase the volume of anatomical structures:

Soft tissue injury;
Crush syndrome (4);
Exercise (5);
Fluid infusion (including arthroscopy) (6);
Osteotomy (7);

Systemic hypotension;

Chronic peripheral vascular disease (subjects with this type of disease are at risk, since their poor tissue perfusion leads to moderate ischemia and edema formation, which increase the pressure in the compartment).

Symptoms of Volkmann’s ischemic contracture:

The symptoms that characterize Volkmann’s disease are:

Too much Pain compared to the trauma;
Paraesthesia or hypoesthesia (complete or partial reduction of sensation) in the foot or hand (for example, of the deep peroneal nerve in the foot and the median nerve in the hand);
Fingers flexion with the impossibility of extension;
Extreme pain when stretching the long muscles passing through the compartment (extension of the fingers in the forearm and plantar flexion of the ankle and toes);
The inability to make a fist or to bring the toes into a hammer shape as a sign of paralysis (in dorsiflexion of the foot, the toes are directed towards the face).

How the diagnosis of compartment syndrome is made:

A patient who has very severe pain in the leg or forearm is usually examined very closely.

The examination begins removing the cast and any other retainers to carefully evaluate the muscle compartments.

When the padding is removed, the structures are normally soft, not taut or stiff.

The motor and sensitive functions of the peripheral nerves and the degree of stretching of the muscles are subsequently evaluated.

The primary test for evaluating Volkmann’s ischemic contracture is the intrinsic minus hand and consists of finger extension with a flexed wrist.

The tissue pressure is then evaluated and, if it exceeds 40 mmHg, the limb must be immediately surgically decompressed.

Peripheral pulses may always be present, but tend to become progressively weaker, until they disappear (3).

The most important exams are arteriography and Doppler.

If suspected acute compartment syndrome, when venous pulses are absent, arteriography is usually indicated.

Doppler ultrasound is instead very useful in clinical research involving chronic compartment syndrome.

What therapy is used in compartment syndrome:

Since muscle necrosis can develop between four to eight hours, even the little suspect requires a treatment, especially if the initial diagnosis confirms the intracompartmental pressure.

Volkmann’s syndrome in the acute phase is a true emergency and therefore an event that must be resolved as soon as possible.

The first approach consists in the immediate removal of any cause that can increase the intracompartmental pressure (casts, restraints, orthoses, bandages).

If constant extremity pressure monitoring does not reveal the complete remission of symptoms, surgical decompression should be performed.

The single most effective surgical treatment for acute compartment syndrome is fasciotomy.

The basic principle of the fasciotomy consists in the opening of the entire anterior structure that goes from the elbow to the carpal tunnel with a very large incision.

Once the limb has been opened, the surgical team decompresses the individual muscle bellies, superficial and deep, to investigate and evaluate the vitality, to avoid infections and muscle necrosis.

Contatti

Bone fractures: the complete guide

This is the most comprehensive guide to bone fractures.

What are their symptoms?

What are their complications?

How long does a bone take to heal?

In this guide you will learn everything about bone fractures.

What are bone fractures:

Bone fracture is a break in the surface of a bone, either across its cortex or through its articular surface.

The mechanism of injury is defined by:

Type of external and unnatural force applied to the bone;
Natural resistance of the bone.

$compound fractures of the forearm and leg and fibula x-rays$

Clinical picture and symptoms:

The classic symptoms of a fracture are:

Swelling: pathological swelling, with an increase in volume of the structure, caused by the presence of the lymphatic fluid in the tissues (edema).

Pain: which is always present and increases with movement and palpation of the affected segment. It can be mild, moderate and severe and can be due to tearing of the periosteum (the outer layer of the bone), soft tissue injury, vascular injury, nerve injury, etc.

Deformity: caused by displacement of the bones, as often occurs in displaced fractures, and by the increase in tissue volume, caused by edema.

Abnormal mobility: Sometimes the limitation of movement is so severe that the person is unable to move the affected segment.

Loss of stability and natural movement of the compromised anatomical area.

Loss of movement in adjacent joints: When you move a limb, its closest extremity is also mobilized or rotated. In displaced fractures, this bone rupture continuity does not allow the movement of the structures adjacent to the trauma.

Crepitus: This is an abnormal rubbing sensation produced by the friction between the two fracture fragments. It can be felt mainly in displaced fractures.

Shortening: Shortening of the limbs to varying degrees is very common long bones fractures.

$bone-fractures-symptoms$

Bone fractures: the main causes

Every day our bones are subjected to considerable amounts of force, given by the muscle action and by the activities we constantly carry out.

The bone has its own mechanism that allows it to protect itself from forces that are unnatural to it and avoid breaking.

However, if an external force applied to the bone is too great and exceeds its mechanical strength, a fracture can occur.

External damaging forces can come from:

Road accidents;
Falls;
Chronic and repetitive movements (stress fractures);
Pathological diseases in progress, which weaken the natural bone resistance.

Bone fractures types and classification:

Bone localization:

The bone fracture types and classification can be defined by many factors.

Depending on the area of the bone involved, fractures may be:

Diaphyseal: the central tubular region of the bone that composes its body;
Metaphyseal: the region of the bone between the diaphysis and the epiphysis;
Epiphyseal: end part of a long bone, which forms the adjacent joint.

Articular or intra-articular: when the fracture reaches the joint, it can compromise the cartilage and may create impediments to the joint movement. In that case must proceed with a fracture reduction as soon as possible;
Specific anatomical locations: for example the supracondylar fractures.

$articular fracture and supracondylar fracture$

Orientation and configuration of the fracture crack:

Transverse: occur when a bone is broken perpendicular to its axis. The crack is arranged horizontally, at right angles;
Oblique: the fracture line is angled, going to form an angle of less than 90 degrees;
Spiral: the fracture line forms a spiral along the bone segment, wrapping around it;
Comminute: fracture that has three or more bone fragments;
Multi-fragmentary: characterized by two fractured bone fragments.

$transverse-femoral-shaft-fracture$ $oblique-femoral-shaft-fracture$ $spiral-femoral-shaft-fracture$ $comminuted-femoral-shaft-fracture$

Type of trauma:

Direct impact trauma: when the bone fractures at the point of application of the injury force:

Impact: they may occur by a contusion and generally manifest themselves with a transverse fracture line;
Meshed - bone fragments are pushed into each other, shortening the bone;
Compression / crushing: fractures also involve surrounding soft tissues and are generally comminuted;
Penetration: fractures caused by firearms, in which the bullet damages both the external and internal components.

Indirect trauma: when the damaging force acts at a distance from the fracture site, spreading along the entire limb or along the spine until it reaches the fracture site:

Traction/avulsion: these are traumatic fractures caused by a sudden and violent muscle contraction, which causes bone detachment at the tendon insertion of the muscle itself;
Compression/impacted: produces a spiroid fracture rim;
Flexion/bending: fracture that generates a transverse fracture gap;
Lateral cut/displacement: produces a displacement of bone fragments;
Torsion: This type of fracture often occurs between the vertebrae, and is caused by an impact on the soft lining of the vertebral bodies;
Combined force or action: it is given by the combined action of one or more forces (for example bending, rotation and compression).

$avulsed-femoral-shaft-fracture$ $impacted-femoral-shaft-fracture$ $greenstick femoral shaft fracture$ $torus femoral shaft fracture$

Violence of the traumatic event:

High energy, as may happen during car accidents;
Low energy, such as an accidental fall at home or even at work.

Skin integrity and soft tissues surrounding the fracture:

$images about open and closed fractures$

Closed: a fracture doesn’t damage the structures around the bone and doesn’t communicate with the external environment; the overlying skin and other soft tissues are intact;
Open: a fracture with a break in the overlying skin and soft tissues, leading to the fracture communicating with the external environment:

a) Internally open (from within): The sharp fracture end pierces the skin from within, resulting in an open fracture.

b) Externally open (open from outside): The object causing the fracture lacerates the skin and soft tissues over the bone, as it breaks the bone, resulting in an open fracture.

Exposure of an open fracture to the external environment makes it at high risk to infection.

Number of fracture foci:

Unifocal: there is only one outbreak of fracture;
Bifocal: there are two outbreaks of fracture;
Trifocal or plurifocal: fracture outbreaks are three or multiple, as happens in polytrauma patients.

Based on the extent of the fracture line:

a) Incomplete fracture: it involves only one surface or the cortex of the bone.

For example, greenstick fractures are seen exclusively in children.

Here the bone is elastic and usually bends due to buckling or breaking one cortex when a force is applied.

b) Complete fracture: the bone is completely broken.

Complete fracture undisplaced (without dislocation of the bone fragments) in which the fracture abutments retain their position, shape and anatomical size;
Complete fracture displaced in which there is a loss of contact between the bone fragments (lateral displacement, longitudinal displacement, axis displacement, peripheral displacement).

$incomplete and complete bone fracture$

Aggravating factors that can cause a bone fracture:

Pathological fractures: when a bone has been weakened by a pathological condition, even minor stresses can cause a break in the structure.

They occur as a spontaneous failure of the diseased bone or from the application of a light or moderate force.

For example, as occurs in the case of some neoplastic diseases (benign or malignant), or also in other diseases that can cause skeletal fragility, such as osteoporosis, bone tumors, etc.

Stress fractures: when a low intensity force is continuously repeated over time, on a specific point of a structure, can cause a stress fracture.

They occur mostly in the lower limbs and in bones subjected to prolonged workload.

The functional overload that derives from the continuous stresses on the bone is typical of sportsmen.

For example, as occurs in some sports such as dance, running, etc.

Normally, the bone damaged by these small micro traumas tends to self-repair during periods of rest.

If an athletic gesture applies a continuous force in the same area that has previously suffered a light damage, it causes a further weakening of the structure, and, over time, the creation of a stress fracture.

Bone fractures complications:

The complications of fractures are rare but can threaten the vitality of the structure affected or cause a permanent alteration of the functional movement, up to involve the whole organism.

In case of open fractures, the risk of further complications is high (which usually brings an infection), due to the involvement of other structures surrounding the fractured bone, such as blood vessels, tissues, and nerves.

Closed fractures that do not involve other structures, especially those that are rapidly reduced, are less likely to cause serious complications.

Immediate (acute) and late complications in bone fractures:

Acute complications include all the problems that occur at the time of the trauma, or during the following days:

Hemorrhage: A common feature of all fractures and soft tissue injuries.

Rarely, internal or external bleeding is severe enough to cause an hemorrhagic shock (for example, as occurs in hip fractures and some open fractures).

Skin lesions: generally occur in displaced open fractures, in which the exposure must be immediately identified, to avoid a becoming infection.

Vascular injuries: some displaced and open fractures tear blood vessels.

Some closed fractures, particularly supra-condylar humeral fractures located both anteriorly and posteriorly, interrupt the vascular supply sufficiently to cause an ischemia (Volkmann syndrome).

The vascular lesion may not be clinically visible, even for a few hours after the injury.

Nerve Injury: bone fragments can damage nerves, if they apply a pression that compresses them, or if sharp bone fragments cut them.

If the nerve injury is caused by a prolonged compression or by a compromised nerve sheath that lines the nerve (myelin sheath), or by a temporary block of the nerve conduction (which can last from a few days to a few months), with the gradual resumption of motor and sensory activity (if the nervous structure is intact, the nerve tends to heal spontaneously).

When the lesion is total, then the nerve has been torn or cut completely, and the sensitivity and the ability to move the structure are compromised.

In this case the only plausible solution is through an immediate surgery.

Pulmonary embolism or thrombosis (DVT): in patients with hip and pelvic fractures, the risk of pulmonary embolism is high.

Pulmonary embolism is the most common fatal complication of hip and pelvic fractures.

It is mostly detected when the patient has an "air hunger syndrome", with breathing difficulty, cough, tachycardia, etc.

That’s why after a surgery treatment, a drug therapy based on heparin is generally prescribed.

It allows to make the blood more fluid and to prevent obstructions in the blood vessels.

Fat embolism syndrome: this is one of the most serious complications, the essential feature being occlusion of small vessels by fat globules.

The fat globules may originate from bone marrow or adipose tissue.

Fat embolism is more common following severe injuries with multiple fractures and fractures of major bones.

Compartment syndrome (Volkmann): it is a syndrome characterized by an increase in pressure within a circumscribed anatomical area (as occurs mostly in fractures of the radius and ulna, in humeral fractures near the elbow, in tibial plateau fractures, and with open fractures of the tibia).

The increase in pressure interrupts the blood circulation and the tissues of that anatomical district (tendons, ligaments, muscles, nerves) no longer receive (or partially) supplements and oxygen.

The consequence of this syndrome, if not picked up on time, brings to a tissue necrosis or death of the affected structure.

The result of the muscles affected by necrosis is a deformity and a nervous deficit, up to the total lack of sensibility.

Compartment syndrome threatens the vitality and survival of the limb, even to the point of requiring an amputation.

The therapy consists in a decompression through fasciotomy surgery.

The anterior lodge of the forearm is incised, from the elbow to the carpal tunnel.

The incision should be left open until the edema resolves; after that the anatomical compartment is closed with a suture or skin graft.

Infection: contamination of the wound with bacteria from the outside environment may lead to infection of the bone(osteomyelitis).

This is when these microorganisms invade the membrane, unleashing an inflammatory reaction, which can lead to the formation of pus.

It occurs more commonly in open fractures, particularly in those where compounding occurs from outside (external compounding).

The increasing use of operative methods in the treatment of fractures is responsible for the rise in the incidence of infection of the bone, often years later. Infection may be superficial, moderate (osteomyelitis), or severe (gas gangrene).

Long-term complications in bone fractures:

A normal consolidation of a fracture should be the result of the formation of the callus, sufficient to withstand the strain.

Once the bone consolidation and healing time has expired, the absence of evidence that the lesion has been repaired can lead to:

Instability: some fractures can lead to joint instability.

Instability can bring disabilities and increases the risk of osteoarthrosis.

Stiffness and movement reduced: fractures that extend to the surface of the joint often damage the joint cartilage.

An alteration of the cartilage surface leads to a scar, which causes osteoarthrosis and compromises the movement of the joint.

Stiffness is more likely after a prolonged immobilization.

Knees, elbows and shoulders are particularly incline to post-traumatic stiffness, especially in old age.

Consolidation delays:

The main factors are given by:

incomplete immobilization;
partial interruption of the vascular supply;
patient-related factors that may compromise the bone healing (for example, corticosteroids or thyroid hormones);
excessive separation of bone fragments;
movement between bone fragments;
presence of soft tissues between the two bone stumps;
an extensive lesion of the external bone cortex;
infection of the bone.

Pseudarthrosis: complete and irreversible compromisation of bone healing, in which little or no callus forms and bone resorption occurs at the fracture site.

It is a pathological situation because a particular tissue called fibrous and fibrous-cartilaginous (the one that can be found in scars and vertebral discs) is formed between the fracture fragments.

The body perceives the bone fragments as if they were separate bones, therefore it tries to join them together.

Bad Consolidation: Occurs when fracture fragments heal in an incorrect position, causing clinical and aesthetic deformity.

It can occur when a fracture has not been adequately reduced and stabilized.

Through corrective osteotomies (surgical operations in which the bone is cut with the intent to correct its shape), the lesion is restored to its normal skeletal morphology and the fragments are stabilized in the desired position, through different osteosynthesis devices.

Wedge osteotomies of equal size are then performed in opposite directions, which can be used to correct a translational deformity and restore mechanical axis alignment of the lower extremity.

Osteonecrosis: Part of a fracture fragment can become necrotic, especially when the vascular supply is damaged.

Closed fractures at risk of osteonecrosis are carpal scaphoid fractures, displaced femoral neck fractures, and displaced talar neck fractures.

Arthrosis: fractures that interrupt the continuity of a joint can cause joint misalignment, resulting in instability and future degeneration of the joint cartilage.

Limb-length discrepancy: when a fracture in children involves a growth epiphyseal plate, growth itself can be affected, resulting in a shorter than the other one.

In adults, surgical repairs of a fracture, particularly hip fractures, can cause a leg length discrepancy, which can lead to a difficult deambulation and the necessity of a footbed for the shorter leg.

Algodystrophy (Sudek's disease or CRPS): it is defined as a complex regional pain syndrome.

The causes are currently unknown; it can be imputed to a presence of an initiating noxious event, or a cause of immobilization.

It affects the arms, hands, legs and feet.

CRPS describes an array of painful conditions that are characterized by a continuing (spontaneous and/or evoked) regional pain that is seemingly disproportionate to the usual course of any known trauma or other lesion.

The pain is regional and the person has a sensation of burning, stiffness, sweaty and shiny skin, edema, muscle contraction disorders, color change of the anatomical structure concerned, pain that remains present even when the painful stimulus is no longer present.

There are two types:

Type 1 CRPS (as previously mentioned) occurs following a trauma such as fractures, sprains, surgery, and repeated microtrauma.

Type 2 CRPS occurs following an injury to a nerve branch.

Osteomyelitis: it is an inflammatory process that affects both the external and the internal component of the bone, including the bone marrow.

The most common cause is bacterial or fungal.

The infection causes the formation of abscesses.

The pus thus formed finds its way out through the area of least resistance.

The developed abscess spreads through the soft tissues and outwards, forming a breast that breaks the skin, or slips down, towards the shaft, between the cortex and the periosteum.

Post-traumatic aseptic avascular necrosis: due to an insufficiency or lack of blood supply, all the cells of a portion of the bone tissue die, not for causes associated with infections or the introduction of bacteria that damage the structure.

In severe cases it leads to bone collapse.

Bone fractures treatment:

The main goal of the fractures treatment is to guarantee the complete and physiological bone consolidation, without any alteration of the morphology, allowing the complete recovery of the functionality of the joints, muscles, and all the adjacent structures.

Therapy and treatment are essentially two:

Conservative treatment;
Surgical treatment.

Conservative treatment:

Conservative therapy is usually used for non-displaced, incomplete, and compression fractures.

It is composed by three phases:

1. Fracture Reduction:

Usually performed under general anesthesia, it consists in correcting the displacement of the fracture stumps, returning them to their anatomical position.

In some cases the fragments decomposition does not allow an adequate reduction procedure, and an attempt is therefore made to place in a position as favorable as possible.

The doctor manually repositions the bones in the correct physiological position and, if this is not possible, special tools such as continuous traction are used.

For example femoral shaft fracture traction in children, balanced skeletal shaft femoral fractures traction in adults, etc.

2. Retention:

Once the fracture fragments have been repositioned, they must be hold in that position until the fracture has healed itself, otherwise it may shift due to muscle action and gravity.

Some of the most common methods of restraint are, for example, cast showers for the arm and leg, or a functional brace, which allows the mobility of the contiguous joints, while the fracture is still consolidating.

$most-common-methods-of-retention-in-bone-fractures-such-as-showers-casts-for-arm-and-leg-or-brace$

3. Physiotherapy and rehabilitation:

The physiotherapy and rehabilitation program include:

Active and passive movements of all joints of the injured limb;
Physical therapies, massages and muscle strengthening to improve muscle tone and performance;
Functional rehabilitation exercises of the limb with the aim to restore generic and specific movements of the patient's daily life activities.

Surgical treatment:

Surgical therapy is performed when the previous reductions have not given an effective result or in case of specific problems, for example:

Loss of reduction;
Displaced fractures within the joint (joint fractures);
Bone failure;
Multiple fractures;
Delayed union;
Pathological fractures;
Neurovascular injuries;
Open fractures;
Aesthetic reasons.

The operation consists in opening the fracture site, removing any obstacles between the injured bone heads (muscles, soft structures, etc.) and making an osteosynthesis, immobilizing the bones with various implants based on the surgeon's choice:

Screws;
Plate and screws;
Prosthesis (such as knee and hip replacements);

$screws, plate and prosthesis surgical treatments after a bone fracture$

Intramedullary nails;
Spine implants;
Interlocking nails;
Kirschner threads;
Steel wires.

On the other hand, during the external fixation operation, rigid wires are inserted, which penetrate the bone, in opposite poles to the fracture site, joined with an external fixation system that acts as a bridge.

It is adopted in cases of open/exposed fractures.

Most common tests done to diagnose bone fractures:

Radiography (X-rays):

The most used technique to diagnose bone fracture, joint disorders and traumatic conditions, is the conventional radiography.

The radiologist should obtain at least two separate views, anteroposterior and lateral, and for each view should include two adjacent joints.

This reduces the risk to miss a fracture (as occurs in micro fractures of children, and it is often necessary to obtain an x-ray of the contralateral limb), a dislocation, or other associated injuries to a remote site far from the apparent primary lesion.

In some cases, special projections are required (for example an oblique image), depending on the clinical situation of the bone examined.

The radiography allows the doctor to:

Confirm the clinical diagnosis;
Better study the anatomy of the fracture;
Better study the fracture fragments displacement;
Detect further cracks and stress fractures;
Detect bone dislocations (dislocations);
Plan the treatment;
Ascertain post-reduction status of fractures.

Magnetic resonance imaging (MRI):

MRI evaluation is mostly used during traumatic bone and soft tissue conditions diagnosis.

With this technique is possible to have a full evidence of bone contusions and microfractures that aren't shown with a conventional radiography or computed tomography.

It allows to have a clear separation of the different tissues including muscles, tendons, ligaments, vessels, nerves, cartilage and bone.

While MRI has many advantages, there are also some disadvantages.

These include:

Cardiac pacemakers;
Cerebral aneurysm clips;
Claustrophobia;
The presence of metallic objects, such as ferromagnetic surgical clips:

Metallic objects create "holes" in the image, distorting the image.

Computed tomography (CT) scan:

Tomography is an x-ray of a section of the body that allows for more accurate visualization of lesions that are too small to be seen on conventional x-rays or that show anatomical details obscured by overlying structures.

CT is indispensable in the evaluation of many traumatic conditions, various bone and soft tissue tumors, but also useful for evaluating the bone healing process.

It is extremely useful for defining the presence of the fracture and its extension (or dislocation), of various intra-articular anomalies (such as damage to the articular cartilage or the presence of non-calcified osteo-cartilaginous bodies) and of the adjacent soft tissues.

It can also detect any small bone fragments that have been displaced in the joints after an injury, a fractured vertebral body, and any concomitant spinal cord injuries.

Bone scintigraphy:

Scintigraphy is a test that detects the distribution in the body through a radioactive agent injected into the vascular system.

Its main feature that all other imaging techniques haven't, is the ability to visualize the entire skeleton all in once.

Traumatic conditions such as, tumors, arthritis, infections, and metabolic bone disease are the right indications for a skeletal scintigraphy.

During traumatic conditions, a scintigraphy is extremely useful in the early diagnosis of stress fractures.

These fractures may not be visible on conventional radiographs or even tomographic studies.

$bone scintigraphy of the human body during the investigation of bone fractures$

BONE FRACTURES HEALING AND REPAIR PROCESS:

Right after a bone fracture, the body immediately starts a healing process to repair it through specific sequences, restoring the injured structure to its original state.

As already mentioned, the basic rule to ensure that a bone is completely restored is to keep each fracture segment together and in contact.

The two fracture segments must not make any movement, otherwise the bone and the adjacent structures healing process would be compromised (if the repair process fails, a false joint forms between the fracture stumps, defined as pseudoarthrosis).

According to the subject, the healing and repairing processes are:

Inflammation stage;
Repair stage;
Remodeling stage.

1. Inflammation stage:

The inflammation begins immediately after the injury.

It reaches its peak within a few hours and lasts until 1 week after the fracture.

At the beginning of the lesion, blood drops out from the torn vessels, resulting in a hematoma (a lot of blood in a confined site) around the fracture and between the injured stumps.

The surrounding areas, alarmed by the damaged cells, release a series of chemical agents, which cause a dilatation of the vessels near the lesion, which release a liquid (inflammatory exudate), to spread throughout the area.

The inflammatory exudate is full of specific immune cells, responsible of the thickening of the fluid which, converting it into a gel, completely cover the wound.

The swelling and the pain resulting from the damage are always part of our body's "defense plan", which tries to hydrostatically block the fracture.

In this way he warns us that he wants to protect the injured area and that we must move it as little as possible, so he has the possibility to repair it without obstacles.

As the gel begins to form, the blood vessels become more narrow, and as the blood supply decreases, the lymphatic ducts are also closed, to prevent the spread of infection.

Other types of immune system cells, which act as scavengers, are called to the injured area, and clean it of infectious agents and debris.

Then they remove all damaged tissues, bone fragments, and blood that has leaked from the torn blood vessels.

In short, the organism places the damaged site in quarantine.

This process lasts up to 48 hours after the damaging event.

The best way to help our body in this phase, is to apply the strategy called PRICE:

Protection;
Rest (rest);
Ice (ice);
Compression (compression);
Elevation (elevation).

As the inflammatory response subsides, necrotic tissue (dead cells) and exudates are reabsorbed and the bone repair phase begins.

2. Repair phase:

The repair phase lasts about 2-3 weeks.

In this phase some specialized cells begin to produce a new bone matrix, the temporary callus of the fracture.

The callus is the first sign of union visible on radiography, usually 3 weeks after the fracture.

In this stage, new blood vessels are generated to form new bone between the fracture lines.

Immobilization (e.g. a cast) is required to allow the blood vessel formation.

These cells begin to proliferate, differentiate, and produce the fracture callus made up of fibrous (such as the tendon and ligament tissue), cartilaginous (such as the tissue that makes up the nose), and bone tissue.

Callus fills and surrounds the fracture site, and in the early stages of healing phase, can be divided into hard or bony callus, and softer fibrous and cartilaginous callus.

The bone initially formed in the periphery of the callus is called the hard callus, while the soft callus is formed in the central regions.

The bone gradually replaces the internal tissues, enlarging the hard callus, increasing the fracture fragments stability.

The stability of the fracture fragments progressively increases, thanks to the formation of the internal and external callus.

However, at this stage, unfortunately, the healing is not yet complete.

The fracture callus is still weak compared to the normal bone physiology and it only gains full strength during the remodeling phase.

The repair phase can be defined completed, when the pain ceases, the end part of the fractured bone can be moved and the diagnostic examination does not detect any movement of the bone stumps.

3. Remodeling Phase:

The remodeling phase aims to the definitive replacement of the newly formed bone with lamellar bone tissue, reducing the size of the callus, and restoring the normal vascular supply.

In this last phase the strength of the bone returns to being almost like the "healthy" contralateral one and the possibility of a new fracture decreases.

In the last stages of the remodeling phase, after all bone tissue has been replaced, the superfluous bone is resorbed and the new trabecular bone is formed.

The transition of the fracture callus to woven bone and the process of mineralization, which stiffens and strengthens the newly formed bone, may last for months or even years.

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Jutta Hochschild. Apparato locomotore, anatomia e funzioni. Edi-Ermes.

Federico A. Grassi, Ugo E.Pazzaglia, Giorgio Pilato, Giovanni Zatti. Manuale di ortopedia e traumatologia. Elsevier; second edition 2012.

Mark D.Miller, stephen R.Thompson. Miller’s review of Orthopaedics. Elsevier; 7th edition 2016.

Maheshwari, Vikram A.Mhaskar. Essential Orthopaedics. Jaypee Brothers Medical Pub; 5h edition 2015.

John Ebnezar. Textbook of Orthopedics: With Clinical Examination Methods in Orthopedics. Jaypee Brothers Medical Pub; Supplement edition 2010.

Greenspan, Adam. Orthopedic Imaging: A Practical Approach. Lippincott Williams & Wilkins; 4th edition, 2004.

Frederick M Azar & James H. Beaty & S. Terry Canale. Campbell’s Operative Orthopaedics Volume 1,2,3,4. Elsevier; 13th edition, 2017.

Rafael Orozco, J. Miquel Sales, Miquel Videla. Atlas of Internal Fixation: Fractures of Long Bones. Classification, Statistical Analysis, Technique, Radiology. Springer; 1st edition 2000.

Schüenke, E. Schulte, U. Schumacher. Prometheus – Anatomia Generale e Apparato Locomotore. Edises; 2°edizione 2014.

Nigel Palastanga, Derek Field, Roger Soames, S. Boccardi, G. Fraschini. Anatomia del movimento umano. Struttura e funzione. Elsevier; 5° edizione 2007.

I movimenti da evitare per sempre post intervento di protesi di anca

23 November 2022

By Marco Castenetto 0 Comments Orthopedics

Hip replacement surgery guide 2022

This is the most comprehensive guide to hip replacement surgery.

In particular, we're going to clear up:

what are the pros and cons about the surgery;
what are the post-operative risks and possible complications;
what are the do's and don'ts after the prosthesis surgery;

Let’s get started.

What is hip replacement?

Hip replacement is the substitution of the hip joint with an artificial prosthesis.

It is the most complex surgical treatment to fix a compound fracture of the femoral neck.

The replacement can be:

Total (also called arthroplasty): the head of the femur and the concave component of the hip, the cup, are completely replaced;
Partial (endoprosthesis): it only consists in the substitution of the femoral portion;
Resurfaced: the femoral head is not removed but completely resurfaced, capped with a smooth metal covering;
Cemented: in very elderly patients, with poor bone quality and/or in the presence of associated bone pathologies (such as osteoporosis), an acrylic cement is applied to give more stability to the prosthesis.

The hip arthroplasty consists of two components, the femoral part, which is inserted into the bone marrow, and the cotyloid part, which is fixed to the pelvis.

It is recommended in patients between 60 and 75 years.

A fixed dome, defined as the prosthetic head, is applied to the femur and inserted into the fixed component in the pelvis.

On the contrary, in the endoprosthesis, only the femoral portion is replaced, without performing any particular surgical treatments on the pelvis joint.

If the cartilage is in good condition, there is no need to do any hip surgery.

A metal head (dome) is applied to the femur, which articulates with the patient's cup.

It is recommended in patients over 75 years, because it is simpler, faster and less risky for the elderly patients.

Furthermore, with a total hip prosthesis, post-operative precautions are few.

On the other hand, the resurfacing prosthesis only provides the resurfacing of the acetabular component and the femoral head, thus replacing the cartilage worn by arthrosis.

The advantage of this type of prosthesis is that it does not upset the anatomical profile of the joint and, consequently, avoids length differences of the limbs.

It also reduces the risk of implant dislocation (luxation).

Cemented prosthesis allows you to quickly recover the limb strength after the operation, giving you the possibility to walk almost immediately, and avoiding the complications due to immobilization.

The load on the limb is to be considered complete already after the operation.

Conversely, if the prosthesis is not cemented, it is recommended to limit the load on the operated limb, from the first postoperative week, up to 3 months, the right time for an effective rehabilitation.

The difficulty during the walk in the first postoperative period is caused by the inhibition that the body adopts to protect all the affected structures.

So all the muscles, joints, the nerves, etc., are working a bit slower than normal.

It is recommended in patients over 60 years old.

However it is contraindicated, for patients who are severely overweight or are physically very active.

How is hip replacement surgery done?

The standard accesses used during prosthesis surgical procedures are:

Posterolateral access: This type of surgery is the most frequently used.

It allows short surgery times, less blood loss and less risks of infections.

This type of surgery gives excellent hip stability in the next post-operative period, it does not interfere with the adductor muscles (the muscles that bring the knees together when we stay in a sitting position), and avoids losing their strength in the immediate period of convalescence.

2. Lateral access:

It is the most used technique to access the upper third of the femur, but it involves the splitting of the vastus lateralis muscle, fascia lata tensor and the partial dissection of the tendon insertion of the gluteus medius.

This type of access can lead to a depletion of the hip abduction mechanism and consequently it may be more difficult for the patient to bring the leg outward.

An adequate physiotherapy strength protocol, can further reduce muscle weaknesses and fix walking abnormalities (as occurs in Trendelenburg's sign).

3. Anterolateral access:

It is mostly reserved for operations such as revision or reconstruction arthroplasty, in patients with muscle imbalances caused by neurological pathologies, in which posture and gait are characterized by a flexion and an internal rotation of the hip.

This is the main reason why the first approach (the posterior-lateral) is absolutely not indicated.

The advantage of this type of access is that it guarantees excellent stability in the period following the operation, but the cons are that more structures are cut and repositioned, compared to the other two approaches.

4. Minimally invasive approach:

The aim of this approach is to reduce complications to the soft tissues during the operation.

The skin incisions are 10 cm maximum and this helps:

the recovery time of the structures during the period in hospital or when you return back home;
blood loss reduction during surgery;
postoperative pain reduction;
lower limb mobility recovery times;
the scar which, in addition to being aesthetically better, avoids creating excessive tissues adhesions, and consequently hypertrophic or hypotrophic keloids;
most of the muscles are not injured during the operation, and the insertion of the prosthesis.

What types of materials are hip prostheses made of?

The most commonly materials used in hip prostheses are:

the stem is made of a metal alloy of cobalt-chrome and titanium and is covered with porous materials capable of promoting osseointegration within the femoral marrow;
the head, usually in ceramic, plastic, or more rarely in metal and is positioned on the collar of the stem;
the insert is made of a type of plastic called polyethylene;
the cup is made of a titanium alloy; it is lined with a thin layer of porous material, as it allows bone growth. The holes in the dome were created in case of need to keep the structure more in contact with the acetabular cavity of the pelvis, using screws.

What is the surgical program and how is it performed?

The hip replacement surgery program is already planned and consists of the following phases:

Pre-surgery day:

During your hospitalization, the medical-nursing staff will give you all the information about your hospital stay, including various controls, x-rays and blood sampling.

The blood sample taken will then be stored, in case it proves necessary for a transfusion, which will allow it to replace the normal blood loss during the operation.

You will receive a visit from the anesthesiologist, in order to evaluate your general conditions and suitability for anesthesia and to give you all the necessary information about the prosthesis surgery.

Some tests will be performed before undergoing definitive surgery, including:

assessment of the pain perceived at the current time of the visit;
past and current medical history;
examination of joints range of motion;
muscles strength;
balance test;
gait test and the need for assistance during walking;
leg length measurement.

The day after the surgery treatment:

The next day after the operation, the limb will be placed in a rubber foam support (called splint), which has to be kept for a few days, because it helps to contain and immobilize the limb.

The bags and drains have the purpose of avoiding the formation of thrombosis and are removed after 24 - 48 hours.

A physiotherapist will give you the necessary instructions to walk with a walker or a rollator and in the next phase with crutches, how to go upstairs and downstairs.

Length of the hospital stay:

The hospital stay length is on average 7 days.

It can last up to two weeks, if a patient's clinical conditions require extended times.

What not to do after hip replacement surgery?

The following indications consist of postures and/or movements you absolutely have to avoid, because they can cause a dislocation of the implant.

You should pay this kind of attention from the first postoperative period, up to at least three months after the surgery.

When you are lying in bed in a supine position (with your face pointing upwards):

do not cross your legs;
if the bed is too low, lift it with risers;
do not lie on the operated side;
do not rotate the upper body towards the non-operated side when lying down, as you’re trying to reach something on the table near the bed (the operated limb ends up in adduction through this movement).

When you’re sitting on the bed or on a chair:

do not cross your legs;
the seat must not have the angle between the leg and the pelvis greater than 90°;
the knees must always be kept below the height of the hips;
don't sit on low or too soft chairs;
don't lean forward to pick up things from the ground or to tie your shoes.

When you are standing:

do not cross your legs;
avoid twisting your upper body to both the right and left sides;
don't lean forward to pick up objects from the ground or crutch if it falls on the floor;
when you change direction, do not pivot on the operated leg, but on the other one, or make small steps.

In the bathroom:

use a toilet bowl that avoids to keep the knees above the height of the hips;
have a shower sitting on a raised chair or, if there is a stable surface under your feet, and you can stand independently;
don't lean forward too much to brush your teeth.

What are the pathologies and problems that may require a hip prosthesis?

rheumatoid arthritis;
arthrosis;
osteoarthritis.
osteoporosis;
bone tumors and neoplastic diseases;
ankylosing spondylitis;
osteonecrosis;
epiphysiolysis;
nonunion;
dislocations;
hip dysplasia;
congenital deformities;
epiphyseal osteochondritis;
Perthes disease;
failure of the conservative treatment or previous surgical reconstruction (e.g. osteotomy, resurfacing, femoral stem hemi-arthroplasty, total hip replacement);
stiff hip.

What are the contraindications to a total or semi-total hip replacement?

Absolute contraindications:

joint infection currently present;
systemic infection or sepsis;
chronic osteomyelitis;
significant loss of bone after cancer;
hip neuropathy;
severe paralysis of the muscles surrounding the hip joint.

Relative contraindications:

localized infection of the bladder or skin;
gluteus medius insufficiency;
progressive neurological disorder;
progressive bone disease, which compromises the femoral bone;
young patients participating in high-impact physical activity.

What are the general guidelines about taking the decision of a hip replacement surgery?

Arthroplasty:

It is indicated for both young and elderly patients, still in good health, even in the presence of a femoral bone fracture.

It is performed in patients between 60 and 75 years old.

Endoprosthesis:

It is only used in very elderly patients who have suffered a fracture of the femur.

It is given to patients over 75 years old, because it is simpler, faster and less risky.

The choice of an endoprosthesis reduces surgical times and, therefore, the operative risks, allowing a rapid recovery of walking.

Resurfacing prosthesis:

It has the advantage of sacrificing less femoral bone and, therefore, is suitable for young patients who, above all, want to go back playing sport, since the large dimension of the prosthetic head avoids prosthesis luxation.

What are the general guidelines about taking the decision of a hip replacement surgery?

debilitating pain affecting daily living activities;
severe hip pain during movement;
severe limitation of the hip joint range of motion;
failure of conservative treatments (e.g. drugs, physiotherapy, etc.);
the patient is medically fit for surgery;
no active infections, anywhere;

Which exams have to be done before a hip replacement surgery?

The diagnostic procedures are made before the surgical treatment of the hip, with the aim to investigate the state of health of the coxo-femoral joint (medical term to define the hip joint).

Each exam provides a high degree of specificity, based on the current suspected pathology that doctors are trying to identify:

Radiography:

It is performed on two projections, posterior-anterior and lateral.

Radiography allows to identify the actual condition of osteoarthritis based on:

the reduction ratio of the joint space;
femoral head deformity.

It also highlights pathologies such as femoral head necrosis, dysplasias and dislocations of the femur.

Scintigraphy:

It allows to identify joint inflammation and necrosis.

It specifically highlights the area where there is a lack of vascularization (when the blood supply to the femoral head is insufficient compared to the normal physiology of the joint).

Nuclear Magnetic Resonance (MRI):

It highlights accurately the necrosis of the femoral head and the areas in which femoral cells are beginning to die.

It is able to highlight synovial hypertrophy during inflammatory and rheumatic pathologies (for example rheumatoid arthritis), (inflammation of the synovial membrane) and intra articular effusion (increase of fluid inside the joint).

Computed tomography:

It is a diagnostic test that reconstructs the hip joint three-dimensionally.

It allows to identify malformations and/or congenital deformities, like dysplasias, childhood pathologies and traumas.

What are the complications after hip replacement surgery?

General complications of hip arthroplasty surgery are the same that affect all large joint surgeries such as:

thromboembolic problems;
cardiovascular problems;
prosthesis dislocations: this is a very dangerous event, which causes to the patient very severe pain and a total functional impotence (the subject is no longer able to move the leg until the event has been resolved);
risks of falls that can lead to a bone fracture, and the prosthetic component; mobilization of one or both prosthetic components due to mechanical failure of the implant (mobilization) or due to biological failure;
risk of crural nerve and/or sciatic nerve neurological damage when trying to balance the limb length;
implant infection (the prosthesis is always a foreign implant within the body and can act as a decoy for any bacteria that have penetrated into the surgical site during the surgery);
different length of the lower limbs: osteoarthritis causes a deterioration of the bone cartilage and consequently a progressive shortening of the limb, therefore the surgeon slightly lengthens the limb to better ensure the stability of the prosthesis and avoid dislocation risks as much as possible;
detachment of the prosthetic components.

The end solution, in case of implant failure and even standard conservative methods such as antibiotics and implant cleaning are not enough, there is a particular surgical procedure called reimplant.

Prosthetic reimplantation consists in the further replacement of one or more components of the prosthesis:

Partial reimplantation: replacement of the cup or prosthetic stem;
total reimplantation: replacement of the cup, stem and other related structures.

At first, the surgeon removes the previous prosthetic implant and then all the components that:

have suffered a fracture or deformation;
have been mobilized and came out from their site;
have been cemented, removing it.

Once the first “cleaning phase” of the hip has been completed, the surgeon proceeds with the reimplantation.

If there may have been some bone loss due to the removal procedure of the previous prosthesis, they proceed with a bone graft (generally the bone interposition is taken from the iliac crest, the bone of the pelvis which you can perceive from both sides of the waist).

How long does a hip replacement last?

Prostheses have an average life of 15-20 years depending on the patient and the daily living activities.

4 October 2022

By Marco Castenetto 0 Comments Orthopedics

Difference between walker and rollator: which one to choose?

During your life, you may find yourself having to deal with some situations in which medical conditions can affect walking, balance, and strength of the lower limbs.

Unfortunately, a similar need is not always felt in old age, but also in childhood.

The causes can be different.

The most common are caused by:

trauma (bone fractures, soft tissue injuries, etc.);

neurodegenerative pathologies (Alzheimer, Parkinson, etc.);

surgical treatments (hip and knee prosthesis, etc.);

Generally the first step concerns the use of aids such as rollators and walkers.

Not an easy choice, as they are often used as synonyms, giving confusion and uncertainty about which device is the best to adopt.

What is the difference between a rollator and a walker?

Although they have similar purposes, a rollator and a walker are actually very different.

The rollator is a device capable of giving support and mobility over long distances.

It consists of two front and two rear wheels.

Some models are equipped with accessories that give support to the patient - they are applied to the person’s pelvis or body - with the aim of facilitating movement and at the same time decrease the body weight on the lower limbs.

The rollator gives you the ability to move freely while walking, and at the same time, ensuring greater stability.

Most rollators have a fixed-fold-down seat to sit on, making them ideal in case of severe fatigue and if you need to take a break, but at the same time, there is no place available, such as a chair, a bench, etc.

The walker, on the other hand, gives robust support and balance for short and medium distances.

It is made up of four legs (sometimes two legs and two small wheels).

In some cases there are two tennis balls under the rear legs to facilitate the push, if you are not able to lift the walker independently yet.

What are the advantages and disadvantages of using a rollator and a walker?

Rollator advantages:

They do not need to be lifted and can be used without assistance, by patients who do not have stability problems and upper limbs weakness;
they require less energy than walkers, as they must be pushed and not lifted;
thanks to components attached to the pelvis or trunk, they allow you to decrease the body weight;
they are faster than walkers (they are in fact equipped with brakes with a “parking function”; it is possible to lock the walker, even if you release the two levers). They are safer if you are able to fully sustain your weight on both legs and stable enough to be able to walk at a more physiological speed, even uphill and downhill;
in case of neurological deficits like Parkinson's disease and Alzheimer’s, they are very useful to help people to improve walking and core muscles stability, even though most of the time the patient needs some kind of assistance.
in some cases they can be an excellent solution for those who are unable to use their upper limbs and cannot, therefore, force their arms on other supports such as crutches, sticks or walkers;
handle brakes are a standard feature of walkers, which help you stop if you’re going too fast while walking.

Rollators disadvantages:

Many rollators cannot be closed, they are bulky, both for the shape of the model itself, and for the available accessories;
some models cannot be used at home because they are too difficult to bring from one room to another;
not all models are foldable.

Walkers advantages:

Walkers have four legs and provide greater support and balance;
they can be used after surgical treatments (for example knee / hip prostheses) and leg fractures, as an effective method to reduce the postoperative recovery period;
it allows the user to release the weight from one leg and transfer it to the walker;
they are foldable, and can be transported easily, unlike many walker models.

Walkers disadvantages:

The rollator is more difficult to move since four-legged walkers need to be lifted up slightly with every step;
They provide that the weight of the subject is unloaded using the upper limbs, it should be used only if the person is able to lean on the arms without problems;
Over time, the subject may experience severe fatigue in the muscles of the arms, shoulders, and wrist joints.

Which pathologies are rollators and walkers used for?

The pathologies that make the person to adopt a walking aid, can be divided into:

Pathologies / affections of the musculoskeletal system:

advanced osteoarthritis (of the hips and knees);
arthritis (of the hips and knees);
tumors of a limb or of lower compartment;
pseudarthrosis;
congenital pathologies and malformations;
infection in a compartment of a lower limb;
bone fractures (fractures of the femur, leg, etc.);
lower limbs surgeries (prostheses, external fixators, etc.);
advanced osteoporosis.

Neurological disorders:

Parkinson's disease;
stroke;
Alzheimer's disease;
hemiplegia, hemiparesis;
senile dementia;
spinal muscular atrophy;
amyotrophic lateral sclerosis;
myopathies;
ataxias.

Inflammatory, neoplastic and vascular diseases:

multiple sclerosis;
HIV;
tumors;
hematomas, vascular malformations;
cerebrovascular lesions.

How to choose between a rollator and a walker?

Please note: Before making this type of decision, always seek advice from a physiotherapist or healthcare professional, if you need specific help choosing between these devices.

Depending on your physical abilities and your lifestyle, there are some considerations to make when choosing between a rollator and traditional walker:

How is your balance?

First of all you should examine if there are stability complications, and if the walk can be done without any assistance, or if you need an operator, a family member, etc.

What kind of terrain do you need to move on?

In case you have to push the walker on hard surfaces like carpets, you should be able to have enough strength in the upper body and arms.

For example:

Do you spend more time outdoors? Do you walk on street or dirt roads?

Do you walk mainly at home on a parquet or do you deal with rugs and carpets?

In this case the four larger wheels of the walkers, would allow you a greater walking speed and you would be able to manage uneven, and not flat terrains.

How tall are you?

Many rollators and walkers have an adjustable height, but of course there are limits.

Make sure you can adjust it to a point where you can stand straight enough while using the device.

If you find yourself very bent forward, the product probably isn't tall enough for you.

The ideal height must allow the upper limbs to maintain a slightly flexed position and to keep the muscles of the arms relaxed and allow blood to flow.

How much do you weigh?

Rollators and walkers have different weight limits.

Most standard walkers are built for people between 80 and 135kg.

Walkers have similar weight restrictions, particularly if a walker has a built-in seat, which will have to support your weight while sitting.

Heavy-duty walkers can support just a little over 200kg.

How much strength do you have in your upper body and arms?

Upper body strength is an essential factor, particularly for those considering a traditional walker, as four-legged walkers need to be raised slightly each step.

Two-wheeled walkers don't require as much upper-body strength, but on difficult terrain it can still be problematic.

Rollators, on the other hand, do not require the same amount of upper body strength.

If you are unable to lift the aid on your own, it is important that you have some kind of assistance, or a family member, who can help you during walking.

Which type of rollator to choose?

Classic/standard rollator:

Axillary/armpit rollator: allows the weight of the body to be unloaded thanks to the presence of axillary, underarm or antebrachial supports.

Forearm rollator: support the weight of the body, for those who cannot use the upper limbs.

Rollators with 4 or 2 front wheels:

They allow the patient to move in space without having to fully lift the walker;
not suitable for uneven surfaces or uphill / downhill;
they have swiveling wheels and can be all 4 directional wheels or only the 2 front wheels (they change direction as supermarket trolleys);

3 wheels rollator:

It has features deriving from both the “home walker” and the “outdoor walker”;
the wheels are higher, allowing you to more easily, overcoming small differences in height, and are thicker (they usually have a diameter of around 15 cm);
They allows you to more easily overcome small height differences, such as the threshold of the house, the entrance to the lift, carpets, etc .;
the wheels are made in solid rubber, guaranteeing total anti-puncture;
they are foldable and easy to carry by car, public transport and to store in a corner of the house once used;
there are two brakes that intervene on the rear wheels, with a parking block as in standard walkers.

Which type of walker to choose?

Standard rigid and articulated walkers:

They do not have front or rear wheels;
they have 4 fixed legs;
the patient must lift the walker in order to continue walking;
they have a unique, solid structure to give the subject a strong stability during the walk. The articulated walkers allow the person to walk, moving forward by giving support on one side and then to the other.

Narrow walker:

It is useful when walking through narrow doors (for example 60 cm wide), or in narrow corridors and passages.

Specific walkers:

Pediatric rollator/walker for children:

adjustable in height, it allows to accompany the child during growth;
easily foldable and transportable;
it is made with solid and resistant materials, suitable for use on flat surfaces;
it allows great mobility to the child, while keeping the body and pelvis adequately stabilized.

Rollator/bariatric walker:

It is suitable for people who are severely overweight, with limited walking ability or in the rehabilitation phase;
it is made of a folding steel frame and is wider than a normal walking device;
solid wheels offer excellent grip and resistance to skidding, especially on smooth surfaces;
it has a weight capacity of 200 kg thanks to a reinforced structure and solid 8 ”(200 mm) wheels;
the back and seat are padded for greater comfort;
it is equipped with parking brakes and ergonomic grips with adjustable height.

Hybrid walker:

has two rear tips and two front wheels;
you can lift it slightly and sliding it forward, while keeping your body weight on the walker;
it has no seats;
should be used in smaller floor plans, where a full-size walker would be less useful due to its size.

Conclusions:

In this article we have seen the difference between walker and walker.

Both have unique characteristics, which define them by use, characteristics (both of the aids themselves, and the person), advantages and disadvantages according to your needs.

Unfortunately, the common trend is still to use them as synonyms, and all of this leads to more confusion for those who are in serious need of assistance to walk.

What was your choice between a rollator and a walker?

Did you get more benefits from the rollator or walker?

come-dormire-bene-e-svegliarsi-finalmente-riposati

26 September 2022

By Marco Castenetto 0 Comments Well-being

9 Ways to How to Fight Sleepiness at Work You Need to Know

It's a new day.Opening your eyes, you can see a strange and intermittent light, emitting an annoying sound.

It is the alarm clock of your phone.

It's time to get up. How did you sleep?

Maybe you slept 8 or even 10 hours last night, and yet the fatigue doesn't go away.

So you decide to take some coffees and energy drinks, hoping to find that distant hint of energy needed to fight sleepiness at work and make it till the end of the day.

Don't worry, tonight it will be better.

But the following day is still the same situation as the previous day.

Why did you sleep so much, but you are still so tired?

The answer is very simple: you haven't learned the right sleep techniques yet.

In the next chapters we will see how to sleep well and finally wake up rested, giving you the opportunity to apply these principles already for this night:

1 # Let's find out which chronotype are you:

The Chronotype is a natural characteristic of human beings that indicates when your body is most active during a particular period of the day.

The "larks" people are those who get up early in the morning and are most active during the first part of the day;

The "owl" people, on the other hand, are more active during the evening and prefer to go to bed late;

Why is it important to know your chronotype?

Depending on the job you have, you may be more likely to have more energy in the morning than in the evening and viceversa.

Since the society doesn't care about this distinction, the best solution for you is to align your daily activities with your chronotype.

Here you can find the information needed to determine which chronotype you are, divided into four types:

Dolphin
Bear
Wolf
Lion

Dolphin chronotype:

Bear chronotype:

Wolf chronotype:

Lion chronotype:

Once we have identified which chronotype you belong to, let's now move on to the next step: resetting your biological clock.

2 # How to reset your biological clock:

Our organism is the same as our ancestors, when they used live in nature and sleeping in caves.

In the modern era, once the sunset and temperature drops, silence falls too (a feeling that is more noticeable during camping, rather than in the city).

Then the brain begins to increase the secretion of melatonin, allowing us to perceive fatigue and providing us with sufficient stimulations, telling us that it needs to rest.

At dawn, the sun rises, the animals start to make us to hear them (sometimes even too early in the morning) and the temperature tends to rise.

The body decreases the production of melatonin and thanks to the sunlight that penetrates from the window, directly into our eyes, it tells us that we have to wake up.

The most important factor that regulates our biological clock is the natural light, as well as temperature, meal times and other external signals.

How to reset the biological clock:

Stay in the daylight as long as possible: if you find yourself spending too much time indoors (at home, in the office, etc.), even if it is a cloudy day, before going out, open the curtains when you wake up, go out to the balcony, have breakfast and get dressed in the daylight.
Get to Know Your Rhythms: Identify your energy peaks, observing how your energy changes throughout the day.
Learn to know your rhythms: identify your energy peaks, observing how your energy changes throughout the day.In the morning as soon as you wake up, slow down. The quality of your sleep depends a lot on what you do in the morning as soon as you wake up.

Just for these little tricks you may already need a few days, unless you are already aware of them.

Take your time to check the energy trends of your body, during the various daily activities.

Once the biological clock has been reset, it is time to understand how to set the night time:

3 # How many hours should you sleep at night?

Sleep in cycles, not hours:

Eight hours is an average amount of sleep per night, which somehow seems to have become the recommended amount for any person, regardless of gender, age, etc.

The fact is that we all are not the same and a “one size fits all” cannot work.

Just imagine the difference between a sedentary person and the amount of calories he needs, compared to a fitness fanatic, who weighs over 100 kg of muscle mass alone.

Our need for sleep also varies throughout our life.

As children, and then as teenagers, we need more hours as adults.

A teenager (between fourteen and seventeen years old) needs about eight to ten hours of sleep, an adult seven to nine.

So when we hear parents telling us, as teenagers, to go to sleep early in the evening, it is like seeing them going to sleep at 4pm.

The body recovers its energy in cycles of 90 minutes, the time it takes to go through the various phases that create a sleep cycle.

Our sleep cycles are made of 4/5 distinct phases:

Stage 1, drowsiness:

It is the state halfway between wakefulness and sleep.

In this stage we can be abruptly awakened by any noise, such as a car going at full speed, a slamming door, a louder voice than normal.

Stage 2, light sleep:

During light sleep, your heart rate slows and your body temperature drops.

Stage 3 and 4, the deep sleep:

It is during this stage that we reap the greatest benefits of sleep, including:

production of the growth hormone (GH);
improvement of our ability to learn, to memorize, to make logical choices and decisions;
strengthening of the immune system;
prevention of infections;
improvement of the metabolic state of the body and the rebalancing of insulin and glucose in the blood;
appetite regulation and body weight control;
lowering blood pressure, to keep our cardio-vascular system in good health.

Stage 5, the REM (Rapid Eye Movement) phase:

The REM phase is where most of the dreams come to life, and at the same time the body is temporarily paralyzed.

When we are in debt to sleep, our brains will slide into REM sleep for a longer time during the first two cycles (stage 1, light sleep and stage 2, deep sleep).

So when we try to "retrieve" by going to bed earlier than usual, or sleeping late in the morning, it's a waste of time.

We never recover the lost sleep; our body, however, is surprisingly good at doing it for us, lengthening the first two initial stages.

How to establish sleep cycles?

Through tests and adjustments:

Start with five cycles, and see how you feel after a week.
If that's too much, go down to four.
If it is too little, go up to six.

You will automatically understand what is the best solution for your body, because once you have tried and adapted to the routine, you should feel good and be in full strength.

To recap:

we have established your chronotype;
restarted your biological clock;
set sleep cycles.

Now we have to decide the right time to wake up.

4 # What is the right time to wake up?

Establish which is the right time for you to get up in the morning and set your alarm as follows:

it must be set at least 90 minutes before the time you need to be at work, school, etc .; remember that you will also have to respect the alarm clock on weekends so set a reasonable time.
Since the wake up time has been established, count backwards based on 90-minute cycles, to know at what time you need to go to sleep.

For example:

If I need 5 cycles to rest properly, and I have to wake up at 7.30 (90 minutes before going to work), I know that tonight at midnight I have to go to sleep.

if I need 4 cycles, however, I will be able to go to rest at half past one.

Personal experience advice:

If you start worrying about how many hours you will have to sleep, especially if you are late and you know you will have to get up early in the morning, you are only making problems in your head, and when you’re focusing on sleep that does not come in the middle of the night, certainly does not help you to fall asleep again.

When you continually think about why you are not sleeping, your body produces stress hormones, such as adrenaline and cortisol, which will make you even more alert and active.

In order to be fully relaxed, you need to distract your mind.

It only needs an initial training and then it becomes natural.

A technique that I always use during stress periods, or when I need to sleep fast, is the following:

Lie on your back (belly up) and inhale through your nose for 4-5 seconds, inflating your abdomen (if you find it difficult, you can put a hand on your belly, thinking about pushing it towards the ceiling, while you accumulate air in the lungs);
Hold your breath for 4-5 seconds;
Exhale through your nose for 4-5 seconds.

The technique is very simple.

As previously mentioned, the mind must be distracted and in this way you take command of your thoughts, focusing on the seconds.

The mind understands that thoughts have changed and sends direct commands to the brain to stop producing stress hormones.

In this way, you should experience a well-being feeling, even after the first controlled breaths.

5 # What to do in the morning to sleep well?

Set a post sleep routine:

A good sleep routine helps you go from a state of sleep to a complete awakening state, giving you a way to manage your day with positivity.

90 minutes may seem a very long time in the morning, but once you know how to use it to your advantage, it will feel like a minimal amount of time.

You can also include various activities, during periods of "dead" time like driving from home to work.

6 # What you shouldn't do after waking up:

You absolutely don’t have to check notifications and messages coming up from your phone immediately after waking up, unless you want to see your stress levels increase:

As soon as we wake up, we are in the worst state to deal with stress coming from the outside, because the body reaches its cortisol peak.

Evolution has allowed us to be able to activate the body quickly, to be alert, increasing the focus of sight.

But we tend to use it to increase our stress even before leaving the house.

The best solution is to buy a normal alarm clock, leaving your phone in another room.

Stop hitting snooze:

Each time you press the "snooze" button you put yourself in a state of resistance to your day, negatively impacting brain function and productivity that can last up to four hours.

If you go back to sleep, you force your brain to start a new sleep cycle.

When the alarm goes off 5, 10 and again 15 minutes later, the cortical region, which is the responsible part of the brain, which processes decision making, attention, alertness, and self-control, is still in the sleep cycle.

It will not be able to wake up for another 75 minutes to complete what has started.

It can take up to four hours for this "sleep inertia" condition to wear off and cognitive functions to return to its full capacity.

That's why you may feel that incredibly dizzy feeling when you get up.

It's not because you haven't slept enough or you're not a morning person. A new sleep cycle has just started and then you stopped it.

Don't leave your phone near your bed:

Don't use it as an alarm clock unless you put it so far away from your bed, so that you have to get up to turn it off.

Open the curtains and let the daylight to come in:

In this way you make your body change hormones, going from a melatonin secretion to a serotonin secretion, giving you a well-being feeling and not anxiety.

Eat something within 90 minutes after waking up:

Your body runs out of water and food for several hours during the night.

Even a small dose of water (just water) is fuel, it will help your body to wake up at full strength.

7 # What to do in the afternoon to sleep well?

Take a nap in the early afternoon:

During the day, you may have a moment of “urge” to sleep, usually around mid-afternoon, between 13 and 15 for most people, or little later for some owl chronotopes.

This happens when our sleep pressure builds steadily as expected, but our circadian rhythm spikes upwards from its morning low, producing an increased urge to sleep that coincides with quite a high need as the day has gone on, which offers up another sleep window:

The question you may now asking is the following:

How can I have a nap of 90-minute if I have a very short break time?

A ninety-minute cycle has a potential drawback immediately afterwards, in the form of sleep inertia, which is the groggy, disoriented feeling on waking.

The thirty minute option is your best bet.

Take some caffeine just before your nap, so that it takes effect towards the end of your nap.

Caffeine takes between 20 and 30 minutes to be effective, and in controlled doses is a useful stimulant.

If you work from home, don't use the bed to take a nap, preferably use the sofa or a chair (the bed should be reserved for a night's rest or a full ninety-minute sleep cycle in the afternoon).

If you can't take a 30-minute nap, set your alarm clock according to your available time.

It doesn't matter if you don't really reach a state of sleep.

What matters is that you are able to take advantage of this moment to close your eyes and disconnect from everything else for a while.

You can just reach that near-sleep point where you daydream and you are not thinking of anything in particular, your thoughts are totally absent.

When you wake up, hydrate yourself and stay in the daylight as long as possible.

Take a late afternoon nap:

Make the most of that time in the late afternoon or early evening, around 5-7pm, when our need for sleep is high, especially if we rested less than normal the night before.

Always use this window for a controlled recovery period of 20-30 minutes.

Take frequent breaks during work:

Use the pomodoro technique.

This technique, developed by Francesco Cirillo, uses a timer to divide each activity into 30 minutes blocks.

25 minutes of hyper-focused work and a 5-minute break.

Each break is called “pomodoro” (from the old timer used in the kitchen, which had the shape of a tomato).

Every 4 tomatoes (around 2 hours) take a 20-30 minutes break.

During the 5 and the 20-30 minute breaks, you just have to relax.

No phone, no TV, or various distractions.

You can find a detailed explanation of the tomato technique at the following link: pomodoro technique.

8 # What to do in the evening to sleep well?

Set a pre-sleep routine:

What you do immediately before bedtime has direct consequences on the quality and duration of sleep.

The same goes for what you do after getting out of bed and it significantly affects the rest of your day and the next night.

Set a 90-minute pre-sleep time frame:

The pre-sleep routine simply means to prepare your body and your mind for sleep.

If you've had a late dinner, you shouldn’t go to bed immediately, because the digestive process takes time and can interfere with the quality of your sleep.

Alcohol also produces the same effect, although it gives a pleasant feeling of sleepiness.

Turn off all the technology:

You must reduce the exposure of your eyes to artificial light coming from electronic devices.

This light, in fact, is like a laser that penetrates directly into the pineal gland, blocking the melatonin production.

Keep the room cool and not cold:

Make sure the duvet is neither too heavy nor too light;

In winter you can turn off the thermostat when you go to sleep;

Take a warm (and not too hot) shower, to raise your body temperature a few degrees, so that, when going in bed, it will be a little cooler;

In summer, keep the curtains and blinds closed all day;

If you have air conditioning, you can use it to cool the room before going to sleep during sultry nights, or just use a fan aimed at your legs, with a bottle of ice water in front of it.

Create the right amount of darkness in your bedroom:

Make sure there is no way for light to filter through.

Dedicate yourself to small, simple and relaxing activities at home:

It can be anything, for example:

Prepare everything you need the next day, such as coffee, clothes, cooking meals, etc .;

Take care of your home, for example ironing, taking out the garbage, etc.

Reset your thoughts:

Reducing the unnecessary use of electronic devices just before going to bed helps to ensure that new reasons for anxiety do not come up, but it does not eliminate existing worries.

Increase your security:

When we sleep we must have the sensation to be as safe as possible.

Closing doors and windows before going to bed will help to instill this kind of feeling.

It helps to reduce any fear or anxiety too.

Make some light exercises before sleeping:

Do light exercises, such as yoga, pilates, gymnastics, stretching, go out for a walk after dinner, a bike ride.

Intense exercises should be avoided just before going to sleep because it speeds up the heart rate and increases the production of adrenaline.

9 # What is the best sleeping position?

Sleeping on your side (also called fetal position) is the best way to get the right amount of relaxation:

The body is more prone to relax on the non-dominant side, because this is the less used and therefore less sensitive side.

So if you’re right handed you sleep on your left side.

If you’re left handed you sleep on your right side.

If you’re genuinely ambidextrous, think about which side you would instinctively use to protect yourself.

The best thing is to stay in this position as long as possible (of course you will move during the night, but your mattress should allow you to keep it for an adequate time).

The brain also appreciates this position because it feels that your body is safe: the dominant arm and leg protect the heart, other organs and genitals.

Use the military half-crawl position:

Lie on your chest with your head on a pillow and turned to the right.

Both arms should be straight by your sides, palms up.

Now bring your right arm up until the top of your right elbow is bent at 90 degrees and your hand is close to your head.

Alternative hand placement: the right hand is under your pillow and under your head.

Next, bring your right knee out to that side until it is bent at approximately 90 degrees.

This is a last resort that works for one simple reason: you can’t move.

It’s like a self-imposed papoose, which the Inuits and other cultures have used to calm infants by immobilizing them.

To toss and turn from the half military crawl position, you have to first lift your entire body off the bed.

Less fidgeting means faster sleep.

Adopt a surface that fits with your body:

If you sleep on the right surface, the pillow is almost completely superfluous; it should keep the head, neck and vertebrae aligned.

If there is a gap of six centimeters (about the thickness of two praying hands) or more, then the mattress you are testing is too hard.

On the other hand, if your side sinks into the mattress and your head is perfectly resting on it, then it is too soft.

A properly profiled surface should fit with your body by distributing weight evenly and giving you a straight posture:

Some people are unable to lie on one side of the body for a very long time and in this case they have to lie on their back.

In this case, to understand if the mattress is too hard, you have to keep that position for a minute.

If after some seconds you tend to cross your legs, then the mattress is too hard, or there is too much tension on your lower back, which can cause muscle dysfunction syndrome.

Give some space to your partner:

The less space we have, the more we can disturb the person sleeping next to us.

For example:

A leg or an arm touching you during the night;
your partner is always turning around, throwing the pillow from one side of the bed to another;
your partner is breathing on you.

All these actions can prevent you from achieving adequate sleep.

Adopt hypoallergenic blankets:

Dust mites proliferate in carpets and rugs, clothes and sheets, preferring humid environments and feasting with skin flaking.

The problem here is not about the mites that trigger allergic reactions, but it's their droppings.

In the wrong environment, you may find yourself sleeping in a cloud of their excrements.

Allergens can hinder breathing during the night, making it difficult through the nose and causing complications such as snoring, sleep apnea, dry mouth, disturbing your sleep.

10 # How can you maximize sleeping well, waking up refreshed and fight sleepiness at work:

Control your diet:

If you eat badly, you can run into serious problems.

A balanced nutrition plan and exercises can only increase the quality of your sleep, life and help you to lose weight fast.

Make sure to have the last meal of the day two cycles (or three hours) before going to sleep, and every light snack no more than ninety minutes before, at the beginning of the pre-sleep routine.

Eat a high-fat, high-protein meal no more than three hours before bedtime:

The meal should contain at least 800ml of cholesterol (for example 4 or more large whole eggs) and 40g. of protein.

Beware of drug abuse:

Sleeping pills can be addictive, cause memory loss and sleepwalking.

They stay in your body longer than you could expect, with consequences on balance, clarity and reaction times the day after taking them.

Medications are not the answer to persistent sleep disturbances.

They are effective in some cases, like short-term insomnia, caused by traumatic events.

Therefore, using potent and addictive drugs without the supervision of a professional figure, is a bad choice.

Use insomnia in your favor:

In fact, insomnia is a word that describes a whole host of sleeping conditions in which the sufferer experiences trouble either falling asleep or staying asleep, and which impairs the ability to function in the waking hours.

Insomnia is caused by hyperactivation, a state in which a person's brain is essentially too excited to sleep.

For someone it means a period of stress, caused by difficult moments at work, in family, etc., which forces the person to deal with short-term insomnia.

For other people, it is a long-term problem, chronic insomnia, a serious condition that may have unclear causes or a sign of other disorders, for example anxiety and depression.

If you can't sleep, find other ways to rest.

Do meditation. Watch a video that can teach you a new skill, use the time to do other things.

It is certainly better than thinking about the fact that you can't sleep.

Get up, make something similar to a second pre-sleep routine and then try to fall asleep at the beginning of another cycle.

Conclusion:

In this article, we’ve discovered 9 ways on how to fight sleepiness at work with a scientific and proven method.

What you needed to know in those ways are:

which chronotype characterizes you;
how to reset your biological clock;
how to count the resting hours, according to the 90-minute technique;
which activities you must do and which one you shouldn’t do during the day, to maximize the night's rest;
how to understand which mattress is the most suitable for your needs and the best position to assume during the night.

Now I would like to hear your experience:

Have you already had the opportunity to try this method?

How long did it take for you to notice any improvements in your sleep?

Bibliography:

Tim Ferriss; The 4-Hour Body: An Uncommon Guide to Rapid Fat-Loss, Incredible Sex, and Becoming Superhuman. Harmony; 1st edition (December 14, 2010).

Nick Littlehales; Sleep: The Myth of 8 Hours, the Power of Naps, and the New Plan to Recharge Your Body and Mind. Da Capo Lifelong Books; 1st edition (March 6, 2018).

Matthew Walker; Why We Sleep: Unlocking the Power of Sleep and Dreams Espress. Scribner; Illustrated edition (October 3, 2017).

Mel Robbins; The 5 Second Rule: Transform your Life, Work, and Confidence with Everyday Courage. Savio Republic; Illustrated edition (February 28, 2017).

4 August 2022

By Marco Castenetto 0 Comments Well-being

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