Vitamin C

Osteoporosis is a decrease in bone mass, which can lead to an increased risk of fracture.

Vitamin C actively protects against osteoporosis and has shown to prevent bone loss in animal models. Foods such as oranges, tangerines, pineapple, cantaloupe, broccoli and cauliflower contain high amounts of Vitamin C. The treatment of osteoporosis is going beyond giving calcium and vitamin D. High vitamin C intake is associated with lower 4-year bone loss in elderly men.

Vitamin C mineralizes bone and stimulates bone forming cells to grow, while preventing too much degradation of bone by inhibiting bone absorbing cells. Vitamin C is also used for prevention of the common cold in marathon runners. Vitamin C is vital to collagen synthesis and lessens oxidative stress. It helps cross-linking of the collagen. The collagen is the glue that is present in ligaments, tendons and bones.

Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? About 10% of wrist fracture patients will develop a chronic pain syndrome called reflex sympathetic dystrophy. Taking vitamin C reduces this risk substantially. Taking 500mg of vitamin C per day for 50 days following a wrist fracture is effective for preventing RSD. This double-blind study shows that vitamin C was associated with a lower risk of RSD after wrist fractures.

Phantom Pain Amputation

Phantom pain is a common symptom after amputation of a limb. Up to 80% of amputee patients will have phantom pain symptoms. The patient will feel the sensation of pain in the area where the limb was amputated.

Tingling, cramping, heat or cold sensation may be felt in addition to shooting pain and these symptoms usually decrease or disappear with time.

The patient may feel like the foot or toes are moving or itchy. If the symptoms continue for more than 6 months, the prognosis is usually not good. The causes of phantom pain are not very clear. The brain thinks that the limb is still present. The memory of pain is returned. The signal is interpreted as pain, regardless of the signal from the injured nerve. Peripheral and psychological factors may contribute to the condition of phantom pain.

Peripheral Theory

The pain may result from the nerve endings making a neuroma. The neuroma may generate an abnormal electric impulse that the brain will interpret as pain.

The term “phantom” does not mean that the symptoms are imaginary or “in the patient’s head”. Phantom pain is a real phenomenon. The symptoms of phantom pain may range from mild to severe and the pain may be constant.

Treatment

There are multiple treatment options that will depend on the level of the pain. Heat, massage, biofeedback and relaxation techniques, physical therapy, TENS unit, medications (including anticonvulsant or antidepressants) and surgery may be utilized. Surgery is usually used for neuromas. Neurostimulation technique is used as a spinal cord or deep brain stimulation.

Mirror Box Visual Feedback Therapy

A mirror box is a box with two mirrors in the center (one facing each way) that is used to help patients feel like they still have a limb after having it amputated. The patient placed both the amputated limb and the other limb into the holes of the mirror box. The mirror is used to create a reflection of the non-amputated limb. Some people find that by doing exercises and moving the limb it can help to relieve the pain from phantom pain.

 

Dr. Nabil Ebraheim photo: 11/16/2016

Bone Remodeling in Children

Children have a unique ability for healing of their fractures and remodeling of their deformities. The physician should strive to achieve anatomic reduction of fractures in children.

 

 

The surgeon may not be able to achieve acceptable reduction every time, fractures do not always remodel. The deformity may lead to unacceptable results in cosmesis and function.

What are the rules for remodeling in children?

Age of the patient:

Younger children have better remodeling potential. The younger, the better. Children with two or more years of growth left have a chance for remodeling. The periosteum in children is thick and promotes faster healing of the fracture as well as increased potential for remodeling.

Distance:

The distance of the fracture from the end of the bone. Fracture in the metaphysis remodels better than in the middle of the bone. A fracture in the middle of the bone has less potential for remodeling.

Severity of Angulation

If there is minimal angulation, the bone could remodel completely. Where angulation is more severe, the bone will partially remodel. Angulation in the plane of joint movement is most likely to improve with growth and remodeling.

Remodeling will not improve displaced fractures involving the joint or the growth plate.

Dr. Nabil Ebraheim photos: 11/2/2016

Back Pain

There is certain etiology of low back pain in 85% of cases. Patients with a single occurrence of low back pain return to work within 6 weeks 90%of the time. Moreover, most patients get better with time. In fact, about 60% of patients get better in approximately 10 days.

Low back pain is the second most common cause of work absenteeism. If a person has a history of low back pain, it is likely they could develop occupational low back pain. Persistent back pain for more than 6 months constitutes only four percent of cases. Disability is usually closely related to compensation and litigation.

The least amount of pressure on the discs is measured with the patient lying in the supine position. The highest amount of disc pressure is measured while sitting with 20 degrees of forward leaning with a 20 kg load in the arms. It is better to keep the weight of the load close to the body. This will reduce the compressive forces placed on the lumbar spine. Yoga activities and exercises performed during sitting probably have less pressure being placed on the discs.

Physical factors which lead to low back pain include the following: lack of fitness; heavy lifting of objects; operating motor vehicles; prolonged sitting; operating motor vehicle accidents; prolonged sitting; operating vibrating tools; and cigarette smoking (nicotine causes disc degeneration).

There are many sports-related activities related to low back pain. When golfing, pain occurs as the result of twisting, bad forward bending, and most importantly overarching the spine during the swing. After the age of 40, we lose about 50% of our rotational spine movement. It is important to stretch and warm-up before starting the game. Vibration caused by horseback riding increases the load on the discs. The back muscles work constantly to keep posture straight. Caring for horses could also be detrimental to the back due to the bending and lifting associated with their care.

Virtually any structure in the spine can hurt including: the facet Joints; invertebral discs; spinal canal; sacroiliac joints; muscles; ligaments; nerves; hip joints/Piriformis muscles; and trochanteric bursitis. Red flags for cancer include: over 50 years of age; pain at rest and night; unexplained weight loss; history of cancer; and bone destruction involving the pedicle is pathognomonic. Red flags for infection include: diabetes; fever; drug abuse; urinary tract infection; and previous surgery

Treatment for acute low back pain, without sciatica (leg pain), involves a short period of bed rest, anti-inflammatory medications, and physical therapy for a short period of time. Patients will also be advised to work within the limits of pain.

X Linked Dominant Inheritance

Some orthopaedic conditions that Dr. Nabil Ebraheim has seen throughout his years as a surgeon are caused by genes.

X-linked dominance will not skip a generation.
One example of an x-linked dominant issue is Leri-Weill Dyschondrosteosis (LWD). LWD is a dominantly inherited skeletal dysplasia characterized by short stature, mesomelia, and Madelung wrist deformity. This is a rare genetic disorder caused by a mutation of the SHOX gene. The shortened stature is caused by the homeobox containing gene.
Hypophosphatemic Rickets is a vitamin D resistant rickets. X-linked hypophosphatemic rickets with inability of the renal tubules to absorb phosphates (phosphates levels are down linked to the PHEX gene - Phosphate Regulating Endopeptidase Homolog, X-linked). This is the most common cause of rickets within the United States of America. Dr. Nabil Ebraheim suggests that the doctor will look for a child short in stature, bowing of the lower limbs, and low serum phosphate levels. The Alkaline phosphatase (ALP) levels will also be high. Calcium levels in these patients will be normal, as well as the Parathyroid hormone (PTH). The treatment for this is usually high doses of phosphate replacement and high doses of vitamin D to facilitate the phosphate absorption.
In x-linked dominance, the affected individual has an affected parent due to the dominant gene. All affected males must have an affected mother. All affected fathers will have affected daughters and no affected sons. Dr. Nabil Ebraheim suggests looking to the males. Looking and the sons and fathers will be your clues.

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