Browsing by Author "Clearfield, Daniel"
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Item Nerve Hydrodissection for Impingement of the Suprascapular Nerve(2015-03) Shah, Neel; Clearfield, DanielNerve compressions are common clinical presentations. In this case study, the ability for nerve hydrodissection, a non-surgical technique for the release of a compressed nerve, is established. This patient had a compression of the suprascapular nerve in the posterior shoulder. The patient failed traditional non-operative therapies such as physical therapy and corticosteroid injections prior to this procedure. Immediately after the procedure, the patient noticed a significant decrease in pain with an increase in ROM, and was able to complete physical therapy to maintain a pain free ROM. Therefore, this case study demonstrates that nerve hydrodissection can be a viable non-surgical option for compressed nerves refractory to traditional options.Item NON-OPERATIVE MANAGEMENT FOR A NON-UNION CUBOID FRACTURE(2014-03) Bodenhamer, Sara; Kelley, James J.; Clearfield, DanielThe authors describe the case of a 30-year-old female who presented with right foot pain after a trampoline injury. She was diagnosed with a closed, slightly displaced avulsion fracture of the right cuboid and was managed conservatively. Initial conservative management failed, however after two months of continued electrical bone stimulation and immobilization, bony union with osseous bridging was apparent on imaging. The patient was able to avoid surgery and began a rehabilitation program. This case highlights the use of electrical bone stimulation in the management of a non-union cuboid avulsion fracture. Purpose (a): In this report, we assess electrical bone stimulation in the management of a non-union cuboid avulsion fracture in place of surgical intervention in a 30-year-old female. Methods (b): We reviewed the patient's medical record and imaging to provide a summary of the case presentation and X-ray findings. Review of the literature was also conducted to research the use of electrical bone stimulation in non-union fractures. Results (c): The patient was diagnosed with a closed, slightly displaced avulsion fracture of the right cuboid and was managed conservatively. Initial conservative management failed, however after two months of continued electrical bone stimulation and immobilization, bony union with osseous bridging was apparent on imaging. The patient was able to avoid surgery and began a rehabilitation program. She has since made a full recovery. Conclusions (d): Electrical bone stimulators can serve to enhance healing conservatively, and in cases that are recalcitrant to other modes of conservative therapy. Bone stimulation also provides a less invasive, less costly option leading to decreased morbidity. The use of bone stimulation in non-healing fractures may enhance and expedite the healing process. Conduction of larger studies and on various bones is necessary to assess the efficacy of this treatment and to fully utilize this management option in the future.Item Novel Approach to Skydiving after Right Hemipelvectomy and Left Hip Disarticulation(2016-03-23) Dombroski, R.; Clearfield, Daniel; King, AndrewNovel approach to skydiving after right hemipelvectomy and left hip disarticulation. Introduction. This is a highly unusual case of a patient with a hemipelvectomy on the right with a hip disarticulation on the left who desired to skydive. The goal for this case was to design a protective seating orthosis, that would be 1. lightweight, 2. dissipate impact forces to protect against dynamic overshoot. 3. It would also need to be relatively compact to allow for aerodynamic stability and not create too much drag. 4. We also desired the prosthesis to be affordable (ie. cost $300 or less). These criteria could be directly opposed to one another and costly. We believe this seating orthosis has broad applications to many patients with severe lower extremity trauma and spinal abnormalities, who wish to have the thrill of a completely solo parachute jump. This technology may have potential to be modified to protect our paraolympic athletes who participate in high impact sports. HPI: This is a 24 year old Caucasian male who presented for evaluation for a right hemipelvectomy with a left hip disarticulation and a large amount of heterotrophic ossification in the soft tissue surrounding his pelvis. He sustained a career ending, near fatal, blast injury, while serving in Afghanistan in 2012. Once he became healthy enough to return to his activities of daily living, he had a strong desire to start skydiving. He made an initial attempt to sky dive with uni-density foam from a commercial furniture store. This resulted in soft tissue injury that was significant enough to required hospitalization. He was very determined to continue skydiving, therefore, his military contacts helped establish a relationship with Dr. Dombroski. Dr. Dombroski has expertise in blast impact helmet technology, along with having served as a flight surgeon for the US army. A team with Dr. Dombroski, his prosthetist and sports medicine fellow worked together to help him achieve his dream of a completely solo parachute flight. Physical examination: He is a pleasant, goal directed 24 year old male. He has normal vital signs. His height is 37 inches and he weighs 66 lbs. He appears alert and oriented. His HEENT, cardiovascular, respiratory,abdominal exams, spine, and upper extremity exam are all within normal limits. On MSK exam his pelvis demonstrates the absence of an ischial tuberosity on the right. In addition to this he has multiple painful pan pelvic soft tissue masses that represent his underlying heterotrophic ossification. His GU exam is significant for the absence of testicles. His psychiatric exam demonstrates a normal affect. He is intelligent and actively involved in online college classes. He is hopeful that he can be a role model for others with disabilities. DDX n/a TEST RESULTS 3D reconstruction of Pelvis FINAL DIAGNOSIS Right hemipelvectomy Left hip disarticulation with heterotrophic bone formation DISCUSSION There have been no case reports to our knowledge that report on solo sky diving after right hemipelvectomy and left hip disarticulation, although tandem jumps have been completed, this is felt to not be as thrilling. This is important as there are many individuals with congenital and acquired lower extremity disabilities that desire to live an active life and this may include solo sky diving. Our goal is to allow them to share in the thrill of solo free fall. Initially, he did provide us with consent to help design this seating orthoses, write this case report and waived all liabilities to all parties involved. He is well aware of the risk involved with skydiving. Dr. Dombroski than attempted to adapt his knowledge of helmet technology to create a helmet for our patients pelvis. The orthoses was made from a multi density foam and placed at a distance of no greater than 5/8ths of an inch from the skin surface. Several trial seating orthoses were produced in the process. These prototypes included a chair with lumbar support and 4 motorcycle springs, a circular snow- sled lined with the multi-density foam, 3D printed ABS plastic shell lined with multi-density foam and finally a 50/50 weave carbon-fiber shell lined with multi-density foam. These seating orthoses were tested using a 40lb sand bag dropped from a height of 7 feet, which represents 60% of our patient's body weight. Prototype 1 did not work secondary to failure to control landing trajectories and being too heavy. Prototype 2 created two much drag and would lead to unsafe parachute deployment. Prototype 3 worked but the plastic failed after multiple drops. Prototype 4 was successful and allowed to be tested as a live jump. Our patient then tested this technology with a successful live jump. Follow up: Our patient has since completed 19 jumps, and he has video-recorded some of them. He continues to encourage and support others with lower extremity disabilities. We are thankful for his service and his willingness to participate in this case report. We were able to meet all 4 of our initial criteria. We believe this technology can be adapted to a wide range of skydiving application to allow patients with severe lower limb injuries, cerebral palsy, spina bifida, and spinal injuries to experience the thrill of solo parachute jumps. It also has the potential to be adapted for our paraolympic athletes who participate in high impact sports. More research is needed in these area as we encourage our amputees to become more active.Item Platelet Releasate and ESWT for Treatment of a Partial Supraspinatus Tear in an Adolescent Baseball Player(2024-03-21) Bibi, Yasser; Al-Khabbaz, Omar; Clearfield, DanielBackground: Rotator cuff injuries are a prevalent orthopedic concern, often arising from repetitive overhead activities, traumatic events, or age-related degeneration with the supraspinatus muscle being the most frequently injured. As the muscle responsible for initiating abduction of the arm, the supraspinatus is particularly susceptible to strain and tears, contributing to the majority of rotator cuff injuries. The incidence of rotator cuff tears in the general population is 5-30%, the prevalence of the condition is about 25% in people over age 65 and above 50% in individuals over age 80. Case Presentation: An 18-year-old right-hand dominant male baseball player who plays the catcher position presents to the clinic with right shoulder pain. The patient reports that they had a rotator cuff injury in his anterior shoulder area about 9 months prior which led to him sitting out of his previous season. On ultrasound imaging, the supraspinatus muscle showed a twenty-five percent partial tear on the bursal surface of the anterior aspect, with no retraction seen on dynamic exam. There was no other tendinosis or tear noted, with normal muscle appearance without any atrophy or fatty infiltration, or evidence of impingement with dynamic imaging. The ESWT was conducted before the Platelet Releasate injection procedure. With the patient in a supine crass position, 3000 total pulses at 15 MHZ were applied to the affected area using 2.6-3.6 bars of energy with a D-Actor C15 tip. The patient portrayed good tolerance to treatment, with a reported decrease in pain and improved range of motion. Following ESWT, a platelet releasate procedure was conducted on the right shoulder. On imaging, the patient’s supraspinatus muscle showed significant improvement in the tear, with only ten percent of the tear in the anterior supraspinatus still apparent (15 percent reduction total in the supraspinatus tear). There was evidence of acute supraspinatus tendinitis, with no impingement on dynamic testing. There was also some newly acquired bursitis in the subacromial bursa. There was no other noted tendinosis or tear, with a normal-looking muscle appearance. Conclusion: Generally, it can be difficult to highlight specifics and attribute them to the therapeutic effects of a treatment that facilitates various regenerative and healing properties. The main point of this case is to surface a less popular therapy compared to PRP: platelet releasate/ESWT and their therapeutic effects for MSK-related injuries. Platelet releasate paired with ESWT is a minimally invasive outpatient procedure and should be presented as a potential therapeutic treatment option to patients before considering invasive alternatives.Item Platelet Releasate Injection for a Novel Treatment of Ulnar Neuritis at the Elbow(2023) Bejarano, Michael; Martinez, Richard; Clearfield, DanielBackground: Ulnar neuritis is a common entrapment neuropathy in the upper extremity that results from chronic compression of the ulnar nerve. Typical conservative treatment includes activity modification or brace immobilization. Platelet-rich plasma (PRP), an autologous product of concentrated platelets, has yet to be thoroughly investigated as a treatment option for ulnar neuritis. Platelet releasate, the supernatant of thrombin activated PRP, has potential to accelerate healing in injured peripheral nerves by releasing growth factors that promote nerve repair. Case Report: This case presentation discusses a novel treatment of ulnar neuritis with platelet releasate injection in a 42-year-old female patient presenting with right-sided neurogenic thoracic outlet syndrome and ulnar nerve entrapment. Initial imaging at the right elbow demonstrated ulnar nerve entrapment within the Arcade of Struthers. The patient’s symptoms were first managed with home exercise and and dextrose 5% in water (D5W) hydrodissection at the elbow, which decreased but did not resolve her pain. Intraneural and perineural platelet releasate injection of the ulnar nerve at the elbow was subsequently performed. Six weeks post-procedure, the patient reported her pain was 80% better and continuing to improve. Provocative tests at the elbow were negative and imaging demonstrated a normal appearing ulnar nerve. Despite these results, the patient was not completely symptom-free; continued symptoms were attributed to her concomitant neurogenic thoracic outlet syndrome. While platelet releasate injection has not previously been explored as a treatment option for ulnar neuritis, this case demonstrates how platelet releasate injection may facilitate healing in an ulnar nerve injured by entrapment. Conclusion: This case report investigated the use of ultrasound-guided nerve hydrodissection and platelet releasate injection for treating ulnar nerve entrapment. Although D5W hydrodissection proved useful in reducing the patient’s pain and paresthesia, platelet releasate injection was instrumental in resolving the patient’s localized entrapment. As current literature supports platelet releasate as a key driver of nerve regeneration, it is likely that the platelet releasate injection played a role in reducing the patient’s pain by enhancing the healing response of the injured ulnar nerve. Further research is indicated to determine if the clinical application of platelet releasate injection may be solidified as an efficacious treatment modality for ulnar neuritis and other peripheral nerve entrapments. Given the outcome for this patient, this case illustrates the prospect for platelet releasate treatment to continue to be studied as a monotherapy or synergistically with D5W hydrodissection for ulnar nerve entrapment and similar compression neuropathies.Item Stepwise Diagnosis of a Chiari Malformation Post-Concussion and Return-to-Play Management in a High School Soccer Athlete(2023) Martinez, Richard; Bejarano, Michael; Rauf, Ali; Clearfield, DanielBackground: Limited data exist concerning recommendations on return-to-play for patients with a Chiari I malformation (CIM). A Chiari malformation is a condition involving the brain and spinal cord that results from a structural defect of the occiput. This leads to brain tissue extending through the foramen magnum which can places pressure on the cerebellum and spinal cord leading to neurological manifestations. Much of the symptoms associated with Chiari malformations are present due to the build-up of pressure around surrounding structures. (1) Case Information: This case study details the management of a 15-year-old female soccer player who was diagnosed with a CIM following a traumatic brain injury (TBI). The patient initially presented to a sports medicine clinic with concussion signs and symptoms that magnified over the course of the first week following the TBI. The patient’s increase in symptom severity combined with behavioral changes prompted further investigation, which led to the detection of a CIM. Her case emphasizes the potential for neurological deficits caused by a head trauma to be complicated by CIM. It likewise illustrates the need to evaluate prolonged concussion symptoms for potential anatomical abnormalities. In this case report, we follow the patient’s initial diagnosis of concussion and discuss the progression of her symptoms that warranted additional evaluation. We address the neurological workup involved in recognizing how this patient’s presentation suggested a secondary cause for her symptoms. Furthermore, we review relevant literature in reference to current rehabilitative management for CIM. Conclusions: This case presents a model for how an underlying CIM can exacerbate the development of symptoms acquired through a concussion. It also demonstrates the methods a physician can use in the progression of treatment and tools used to pursue when an initial TBI is not alleviated from conservative therapy or medication. Through this discussion, we provide clinicians with a valuable reference when assessing risk in athletes with CIMs who seek to return to their sport.Item Trigger Point Injections as a Potential First Line Therapy for Persistent Myofascial Pain Syndrome(2024-03-21) Srikalyani, Sathvik; Clearfield, Daniel; Patel, ArpanBackground Myofascial pain syndrome (MPS), characterized by pain from myofascial trigger points in skeletal muscles, often responds to conservative treatments. However, in this case, the patient's persistent symptoms resisted conservative methods but found relief only with trigger point injections. Using trigger point injections as the primary treatment method for MPS is unique. While trigger point injections are documented, their role as a first-line treatment for MPS is underexplored. This case reinforces the potential of trigger point injections for patients unresponsive to conventional treatments and underscores the importance of personalized management for myofascial pain. Teaching points in this case highlight the significance of clinical expertise in the diagnosis and the role of advanced diagnostic tools like ultrasonography, emphasizing meticulous diagnosis in cases where traditional treatments fall short. Case Summary A 58 year old male ex-Army Ranger presented with persistent bilateral posterior leg pain and tightness after failed conservative treatments such as massages, stretching, and NSAIDs for more than a year. A preliminary differential diagnosis included chronic exertional compartment syndrome, vascular claudication, as well as myofascial trigger points. Ultrasound-guided trigger point injections were administered, significantly reducing pain, increasing function, and improving their range of motion. This success highlights the efficacy of trigger point injections in treating MPS that resists conservative methods. Conclusion Literature on MPS primarily focuses on non-invasive treatments and explores trigger point injections as an adjuvant to other treatments. However, this case is different because it features a patient with chronic lower extremity MPS unresponsive to conventional therapies. The case challenges the traditional view that non-invasive methods suffice for MPS and highlights trigger point injections as a potential first-line treatment. For similar unresponsive MPS cases, future management should consider the early use of trigger point injections, particularly with ultrasound guidance for safety and precision. This case stresses the importance of individualized care, encouraging healthcare practitioners to explore alternative treatments when conventional ones fall short.