FAQ Category: General

Necrotizing fasciitis (NF) is an infection of the soft tissues — primarily the fascia or connective tissue. It’s a rare condition but one that can have very serious consequences.

Necrotizing fasciitis (NF) is caused by a bacteria or fungus — there are over 25 different types known to cause NF. You have mentioned two of the more common names staphylococcus and streptococcus. Many times there is more than one organism present contributing to the problem.

Treatment by a multidisciplinary team is required for successful outcomes. Antibiotics are used to inactivate all organisms contributing to the problem and prevent further spread of bacteria.

The bacteria produce several toxins, causing severe breakdown of skin, muscles, soft tissues and organs. Blood vessels supplying oxygen and important nutrients to the cells can be destroyed in the process. That’s where oxygen therapy comes in.

Hyperbaric oxygen therapy (HBOT), also known as hyperbaric medicine is the use of oxygen at a level higher than atmospheric pressure. The patient is placed in a hyperbaric chamber.

There are different designs but it basically looks like a rubber, plastic, metal or glass tube with air locks to maintain the delivery of 100 per cent oxygen. Some facilities have a room-size chamber or large enough unit to hold several people at one time. There is an intercom system so the patient can communicate with others.

Increasing oxygen to the body helps the immune system make good use of the antibiotics and improve tissue repair. There are some early studies that suggest hyperbaric oxygen therapy reduces the risk of amputation. It may even prevent the most serious complication of necrotizing fasciitis (death).

The use of hyperbaric oxygen therapy for necrotizing fasciitis is still under investigation since some studies have not found it to be beneficial. It will not harm the patient but it may not help.

Whenever necrotizing fasciitis is the problem, a wide range of treatment approaches are required. Antibiotics, surgery, and supportive therapy such as oxygen therapy and good nutrition are essential to preventing loss of limb and ensuring full recovery.

According to the results of a recent systematic review, studies show that accuracy of joint injections can be improved. In the shoulder, coming in from behind (posterior approach) is more accurate than from the front (anterior approach).

Additionally, the surgeon who uses ultrasound, fluoroscopy (real-time X-ray), or magnetic resonance imaging to guide the needle to the right spot will also be more accurate. And that was true for all joints (elbow, knee, or shoulder).

X-rays taken before the procedure help the surgeon see if there are any anatomic changes, deformities, or problems like arthritis before making the actual injection. Real-time imaging during the actual procedure assists the surgeon in making sure the needle goes into the joint space.

Taking a look at the larger (combined) sample created by the review, here’s what they found for accuracy. With and without imaging to guide the surgeon showed differences of 79 per cent (without imaging) and 95 per cent (with imaging) for the shoulder. For the knee, accuracy improved from 79 per cent to 99 per cent.

But does improved accuracy mean better results? Accuracy and benefit in terms of patient outcomes are two separate things. People who receive joint injections often improve regardless of the accuracy of the needle placement. The placebo effect (patient expects to get better and does) may have as much of a role in results as accurate placement.

Compartment syndrome can occur as a result of an injury such as a bone fracture, snakebite, surgery, or stab wound that causes swelling inside the entire forearm. Other reported causes of forearm compartment syndrome include gunshot wounds, hemophilia (blood clotting disorder), phlebitis (inflammation of the veins), use of a tourniquet, and drug abuse. In the case of shooting up drugs, the use of a tourniquet to help the drug user find a vein can trigger a compartment syndrome.

With any compartment syndrome, fluid from swelling is trapped inside the osteofascial envelope. This envelope is a layer of connective tissue around the muscles, tendons, blood vessels, and nerves.

The pressure placed on these sensitive soft tissues can cause death of the tissues. This condition is usually considered an emergency requiring immediate surgery to release the skin and soft tissues and let the fluid drain out. That procedure is called a fasciotomy.

Early diagnosis is important to prevent serious complications. Patients must be observed carefully for any signs of contracture (muscles tighten so much that joints can’t move), gangrene, deformity, and complex regional pain syndrome (CRPS).

With death of tissue (called necrosis, the surgeon performs a procedure called debridement. The dead tissue is removed and the area is cleaned out with a saline solution. If enough tissue has to be cut out, the patient may need a skin graft to close the wound.

We are not painting a very optimistic picture here. This condition has the potential to be very serious. If the problem is diagnosed early enough and pressures can be relieved, the patient can have a successful outcome. Sometimes it’s even possible to treat it without surgery. We hope that’s the case for your son.

Untreated, poinsonous snake bites can kill people but this doesn’t happen as often as most people think. Movies, of course, dramatize events like snake bites. The updated version of True Grit did an excellent job of portraying the need for emergency treatment.

After administering first aid to the girl, the main character (Rooster Cogburn played by Jeff Bridges) rides with the girl until the horse gives out. Then he carries her through the night the rest of the way. In the end, her life is saved but her arm has to be amputated.

In a real situation of untreated snake pit (or delayed treatment), the arm can develop a condition called compartment syndrome. The inflammatory response to the poison causes excess fluid and swelling.

This fluid from the swelling gets trapped inside the osteofascial envelope. This envelope is a layer of connective tissue around the muscles, tendons, blood vessels, and nerves.

The pressure placed on these sensitive soft tissues can cause death of the tissues. This condition is usually considered an emergency requiring immediate surgery to release the skin and soft tissues and let the fluid drain out. Today that procedure is called a fasciotomy.

The events of the movie inferred that by the time the girl received medical care, necrosis and gangrene had set in. The only way to save her life was to remove the arm. Today, modern treatment with early surgical intervention and antibiotics has reduced the incidence of compartment syndrome considerably. Complications can still occur but amputation is not the usual final outcome.

Compartment syndrome describes a condition in which fluid (swelling or blood) builds up inside one or more of the individual compartments of the arm. The “compartments” are easier to understand if you think of each group of muscles and tendons as being surrounded by a protective sheath or lining of connective tissue called fascia. There are individual compartments on the front and back of the upper arm, forearm, hand, and fingers.

In each compartment, the fascia fits closely to the outer layer of the soft tissue it surrounds — like a sleeve or envelope. The structures are lubricated with a glistening fluid that allows everything to slide and glide against each other. There isn’t a lot of give or room for increased volume of fluid from swelling.

Traumatic injuries, especially bone fractures that puncture the soft tissues are a common cause of compartment syndrome. A splint or cast that is too tight can also cause this problem. The use of a tourniquet during surgery (or with drug abuse) can contribute to compartment syndrome. Other causes include surgery for blood clots, bypass surgery, trauma from electrical or chemical burns, crush injuries, and snake bites.

Compartment syndrome is a challenging problem to work with. Early diagnosis and proper treatment are required to save the affected limb. Serious complications can occur without treatment. Without appropriate care, the patient with compartment syndrome could be at risk for death.

Death of muscle tissue eventually leads to replacement with scar tissue called fibrosis. Fibrosis is stiff and unyielding. It can apply additional pressure on nearby soft tissue structures, including nerves. Tight tissues lead to contractures (muscles no longer stretch) and loss of joint motion. The final outcome can be chronic pain, loss of sensation, and loss of function.

With treatment, the results are generally good. Prognosis does depend on how soon an accurate diagnosis is made and treatment started. But there are some factors that affect the final outcomes including severity of injury (e.g., damage to the soft tissues from the injury) and length of time with elevated pressures.

Loss of blood supply, involvement of nerve tissue, and patient’s overall general health can also make a difference. The presence of other health problems (heart disease, diabetes, blood clotting disorders) can complicate matters.

There are many challenges for patients and surgeons when treating compartment syndrome. Patients with this condition must be prepared for a long course of treatment followed by months of rehabilitation. Repeated surgeries are often needed to clear out all dead tissue. Infection, poor wound healing, and open wounds in need of skin grafts further complicate recovery.

One of the biggest challenges soldiers face when wounded on the battlefield is infection. Explosives of any kind but especially the improvised explosive devices (IEDs) causing so much trouble for our U.S. soldiers in Iraq create a high-energy injury.

IED injuries penetrate the skin, muscle, and other soft tissues, leaving a gaping wound and that is open to the elements (dirt, debris). If the bone is broken and the skin laid open (very common), the wound is at risk for tissue contamination.

She’s in good hands because the surgeons from Walter Reed Army Medical Center are very much at the forefront of developing diagnostic guidelines and medical/surgical treatment protocols for war wounds of this type.

Treatment does depend on an accurate diagnosis and gathering as much information as possible about the amount of bone loss, edema or swelling, and the presence of bone abscess.

X-rays, MRIs, and other imaging studies are very helpful. Blood tests will be done to assess the amount of immune system response and the presence of bacteria or fungi in the tissues or fluids.

The careful use of antibiotics along with débridement (irrigating and cleaning out the wound) and reconstruction may be a part of her medical management. The rehab team of physical and occupational therapists will help her get back on her feet and recover motion, strength, and function.

Depending on the severity of her injuries, the treatment from start to finish can take weeks to months to years.

Soldiers returning from the field with battle wounds often have severe trauma affecting the leg. It’s clear now from the many wounded soldiers coming back from Iraq with traumatic limb injuries that early pain control is essential.

Pain clinics staffed by pain experts near the battle zone have helped improve outcomes. Pain conditions treated early and aggressively result in fewer cases of chronic pain, disability, and amputation.

Many times it takes a concentrated effort of many team members to help suffering soldiers find the right mix of medications and management techniques to gain control of their pain. This type of program is referred to as a comprehensive interdisciplinary pain protocol.

Experts in pain medicine work together using any and all tools that might help the soldier or veteran. Complementary modalities such as acupuncture, Reiki, touch, BodyTalk, massage, hypnosis, as well as many other alternative approaches are often tried and incorporated into the program.

All efforts are made to save the leg but constant severe pain may still lead some soldiers to opt for amputation. There is great hope that advancements in pain control will still help others who have lost limbs in the war effort. Pain management research is ongoing on behalf of our service men and women affected in this way.

Treatment may depend on the type of injury, severity, and location as well as any other injuries that may be present.

In some cases, time and support are all that can be offered patients. In patients with transected nerves (cut all the way across) like your nephew, surgery to stitch the ends back together or graft nerve (or other) tissue between the two ends may be necessary.

Nerve transfers are another way to manage some major nerve injuries. A donor nerve taken from the same limb or another area is used to restore valuable function in the affected arm or leg. But nerves are very delicate and disturbing them to move them or surgically repair them has its own downfalls and complications. But patients are warned ahead of time that they may only get partial control back.

We definitely need a breakthrough in our understanding of nerves in order to find better ways to treat nerve injuries. If scientists can break the code of the molecular biology involved in nerve injury and repair, it might be possible to find alternate ways to help the regenerative healing process along.

The body does have a protein called nerve growth factor. There’s just not enough of it to quickly or adequately repair a major nerve injury. So maybe there’s some way to use stem cells to grow more growth factor and thus stimulate faster nerve re-growth.

Other researchers are looking for ways to deal with the atrophy that occurs when nerve tissue is off-line. They are taking a look at the space between the nerve and muscle called the myoneural junction.

This space is where all the biochemical action takes place. Electrical signals passing down the length of the nerve turn into chemical signals that cross the gap between nerve and muscle and instruct the muscle to contract.

With a nerve injury, no messages are being sent down the nerve. No chemical changes occur in the junction. The muscle remains quiet. Perhaps there’s a way to artificially stabilize the neuromuscular junction and stimulate the muscle until the nerve can take over. This could possibly prevent the degeneration that occurs around the nerve cells and perhaps help prevent atrophy as the muscle waits for nerve signals to resume.

Military casualties with nerve injuries from explosive devices has brought this problem to the forefront. Every effort is being made to find ways to approach this problem from all sides.

Missing muscle and soft tissue mass referred to as volumetric muscle loss (VML) is a big problem for soldiers and civilians alike following traumatic injuries. Efforts are being made to document the effect these injuries have so that better treatment outcomes can be developed.

With the increased number of combat-casualties from Operation Iraqi Freedom, military teams have worked hard to put together a standardized protocol that would accurately assess and clearly describe injuries of this type.

A standard assessment protocol should include photographs, video analysis, and tests and measures for motion, strength, and function. Any and all of these tools can be used to document before, during, and after injury effects and progress.

The military rehab team recommends the following for evaluating volumetric muscle loss and its effects:

More than 75 per cent of all combat injuries are to the limbs from explosions. Fractures, bone infections, and loss of soft tissue mass create chronic disability. Experts from the military Skeletal Trauma Research Consortium are studying the problem of volumetric muscle loss or VML.

Volumetric muscle loss (VML) is defined as the loss of skeletal muscle and function from trauma or surgery. Although the focus is on combat-related extremity wounds, nonmilitary personnel (i.e., civilians) can experience the same type of injuries from high-energy trauma.

Even with the best of care, sometimes these injuries still create many disabling problems. With so many war injuries affecting the lower extremity (limb), military medicine is taking a closer look at volumetric muscle loss.

They have discovered that even after extensive reconstructive surgeries, many soldiers choose to have the leg amputated. They find that living without the weak, painful leg is actually easier than trying to work around all the functional deficits.

But not very many people choose this path without first giving every effort to saving the limb. Hence, there is a long season of surgeries and rehab. In the meantime, scientists are studying ways to help tissue regenerate itself. Success in this area of study (called regenerative medicine) would be very helpful in cases of lost muscle mass.

There is some suspicion that common problems among older adults are treated differently depending on where you live. One way regional differences can be tracked for adults is through Medicare-Part B. Data from those records can be reviewed to get a picture of patient demographics (age, sex, race, education level, diagnosis, type of treatment).

In a recent study from Dartmouth Medical Center (in the east), one example of regional differences was published. Trends in proximal humeral fractures among the elderly were reported. Using information compiled through Medicare Part-B, the number of these fractures that have been occurred can be determined year-by-year. Surgical treatment and any repeat surgeries (e.g., remove hardware, perform a revision procedure) are recorded through billing codes used by surgeons.

Proximal humeral fractures refers to a break in the upper arm bone close to the top (but below the round head that fits into the shoulder socket). The reason this particular fracture was chosen is because treatment changed when locking plate technology was developed. These specially designed plates can be used with patients who have osteoporosis (brittle bones) that might not heal well without some extra support.

In order to compare treatment and results, data was collected for two one-year time periods (1999-2000 before locking plates were available and 2004-2005 after locking plates were developed). There are thousands of patients covered by Medicare — too many to include in a single study. The authors selected a 20 per cent sample (all patients with a proximal humeral fracture treated surgically) from each time period.

They did find regional differences but not always in treatment. For example, more fractures occurred in people living in the eastern United States compared to the western states. The reason(s) for this are unknown. The overall number of proximal humeral fractures has not changed from 1999 to 2005.

The group most likely to have this type of fragility fracture was 75 to 84 years old, female, and Caucasian. Most of the time, proximal humeral fractures in this age group were treated conservatively (without surgery). Over time, there has been a 25 per cent increase in the number of patients treated surgically.

This study is landmark because it raises an important public health issue. With more and more older adults entering their “senior” years, the number of fractures is anticipated to rise. The economic burden for fragility fractures will place a tremendous financial strain on the health care system.

Surgeons want to reduce the number of failed procedures or need for additional surgery. Research to support treatment that yields the best outcomes for proximal humeral fractures is needed. When clinical practice guidelines can be determined and published, there should be no regional differences in how this problem is addressed.

The Army Physical Evaluation Board recently reviewed the records of all service members hurt in the line of duty over a four year period of time. They were collecting information to help identify patterns of injuries during Operation Iraqi Freedom and Operation Enduring Freedom.

Just as you suspected combat casualty is high. There is a high rate of disability. Battle injuries and resulting disability are permanently affecting U.S. military strength. Only one per cent of orthopedically injured soldiers involved in Operation Iraqi Freedom and Operation Enduring Freedom return to active duty.

Musculoskeletal injuries from explosions and gunshot wounds disable more soldiers than any other battlefield trauma. In fact, according to this same study by the United States Army, even when other bodily trauma occurs, it’s still the orthopedic injury that creates disability leading to discharge from the military. And that reduces our military’s fighting strength in the current Iraqi war.

It’s very likely that the total cost of rehab for battlefield orthopedic conditions and long-term disability paid out is much greater than anyone anticipated. As a result, efforts are underway to prevent injuries, minimize damage and disability, and improve long-term outcomes of treatment.

Injuries from explosions and gunshot wounds disable more soldiers than any other battlefield trauma. These injuries are often divided into two main groups: musculoskeletal (damage to bones, skin, muscles, tendons, ligaments, and/or other soft tissues) and nonmusculoskeletal (skull, brain, ear, eye, face, chest, and abdomen). And that doesn’t include the nonphysical but rather psychological and emotional fall-out with post-traumatic stress disorder, mental illness, and mood disorders.

An interesting fact according to a study done by the United States Army is that even when other bodily trauma occurs, it’s still the orthopedic injury that creates disability leading to discharge from the military.

Orthopedic injuries that occur on the battlefield and lead to permanent disability happen more often than anyone in the military realized. For example, scar tissue affecting the arms or legs, pain, spinal cord injuries, nerve damage, and amputations are just some of the conditions that leave a soldier unfit for duty.

Degenerative arthritis is actually the most common condition reported that leaves a soldier unfit for duty. Arm amputation creates the greatest disability, and amputation of the leg affects the soldier in all areas the most (e.g., return to duty, long-term outcome).

Combat casualty is high. It’s very likely that the total cost of rehab for battlefield orthopedic conditions and long-term disability paid out is much greater than anyone ever predicted or anticipated. Future research must be directed toward improved outcomes including returning more service members to active-duty with fewer and less severe disabilities.

There is some truth to your statement. Whereas, penicillin was once touted as the final cure to infection and infectious diseases, its overuse has led to some serious problems. It wasn’t just that antibiotics were given to children and adults for every cold, sniffle, and virus.

Antibiotics were also routinely added to feed that was given to cows (both dairy and beef). This was done to prevent infection and increase milk and meat production. Over time, bacteria have adapted and become resistant to antibiotics. As a result, studies show that some infections respond as well to a placebo (sugar pill) as to a true antibiotic.

Stated in a different way, it can be said that whereas penicillin was once 100 per cent curative, today, sugar pills work as well. Physicians have found that using local antibiotics for things like soft tissue (skin, muscle, joint) and bone infections yields a better result than systemic (oral or intravenous) antibiotics.

Research is ongoing to find better, faster ways of delivering antibiotics to infected tissue. The goal is to find a balance between the right amount of antibiotic to get rid of the bacteria but not so much the local tissue reaches toxic levels that prevent wound healing.

Scientists have shown that a single bacteria cell can make billions more like itself in a 24-hour period of time. Efforts to understand how bacteria signal one another and grow will provide more specific ways to stop their reproductive cycle.

Right now, scientists are just in the experimental stage with more theories than solutions. They expect it may be quite some time before any major breakthroughs change the way significant infections, especially bone infections are managed.

You may be referring to diclofenac topical gel (known as Voltaren Topical). This gel was first approved by the Food and Drug Administration (FDA) in 2007, so it’s been around for a few years. The benefit of the gel is that it can be rubbed on the skin over painful joints and ease symptoms without the systemic exposure of other medications taken by mouth.

Studies report patients obtain significant pain relief and gain improved function when the gel is used for osteoarthritis (OA) of the knees, wrists, ankles, and fingers. It has not been found as effective (or effective at all) for patients with rheumatoid arthritis.

As with any medication, there can be side effects. Reports of numbness over the skin where the gel was rubbed seems to be the most common complaint. The numbness doesn’t last and goes away when you stop using the gel.

Although this gel is available on-line, it’s always best to consult with your physician or pharmacist before using any new medication (or medication you haven’t used before yourself). This is a nonsteroidal anti-inflammatory and people have had severe allergic reactions. Some health problems such as heart disease, bleeding ulcer, or asthma may be reasons not to use this particular medication.

There are some changes in the way seriously injured soldiers are treated in today’s war time. Surgical teams are posted much closer to the front lines than ever before. That means patients get help much faster — sometimes going from battlefield to field hospital in under an hour. Once they are stabilized, they can be transported to Germany within 12 hours and stateside by day 5. That sure beats the 15 hour delay soldiers experienced just getting off the battlefield in World War II.

During the Viet Nam conflict, soldiers could be transported from the battlefield to a MASH unit (mobile Army surgical hospital) in two hours. Often the wait was much longer. Today’s soldier involved in Operation Iraqui Freedom would be taken to the closest combat support hospital.

Military medical personnel at these level 3 treatment facilities know how to manage the soldier who has what is referred to as polytrauma — a spinal cord injury plus traumatic brain, chest, back, bone, organ, and/or other injuries. Aeromedical transport via helicopters continue to be instrumental in getting our soldiers care faster than ever before.

Right now, military medical experts report that most patients get to a level four care facility (usually in Germany) from Iraq in 12 hours. The longest turn around time from battlefield to level four care is 48 hours. If stable, the soldier will be transported to the United States within four to five days — unheard of in the Viet Nam era. Soldiers were lucky to get stateside until six or eight weeks after injury.

Both of these conditions are systemic — meaning they affect more than just muscles and joints. There can be organ involvement, changes in circulation, immune, and nervous system function, and most likely hormonal influences. Both problems tend to occur in women more than men (one of the reasons scientists think there is a hormonal link).

The question of whether you might develop rheumatoid arthritis and your sister fibromyalgia has been addressed on a limited basis. Scientists hope to be able to predict who among patients with rheumatoid arthritis might be at risk for fibromyalgia. If predictive risk factors can be discovered, there may be a way to eliminate (or alter) the factors. The goal would be to prevent fibromyalgia in this already compromised patient group.

One way to do this is to collect as much information as possible on patients with rheumatoid arthritis (RA) who don’t already have fibromyalgia. Then the group is followed over time to see who develops fibromyalgia. An analysis of the two groups (group one with RA but no fibromyalgia and group two with RA and fibromyalgia) can help shed some light on why the group did develop fibromyalgia.

In a recent study, extensive data collected on 9739 patients with rheumatoid arthritis included their age, sex (male versus female), education level and occupation, income, and marital status. Number of years they had the arthritis was factored in along with their body mass index (BMI), smoking (tobacco use) history, and any psychologic problems such as depression, anxiety, or other mood disorders.

Symptoms (how many, what type, how intense, and how often) were tallied up. Any other illnesses (e.g., diabetes, heart disease, cancer), medications, activity level, previous surgeries, and patient reported (but not tested) fitness level were also recorded. Information on sleep and sleep disturbances and the number of visits to their doctors was also collected.

They found that men and women with rheumatoid arthritis (RA) developed fibromyalgia in equal numbers, so sex (male versus female) didn’t seem to be a factor. Other demographic factors (education, income, marital status and so on) by themselves did not predict fibromyalgia in RA patients. But if demographics were combined with severity of RA or risk factors for fibromyalgia (mood, BMI, fatigue, stress), then the odds increased for developing fibromyalgia for patients with RA.

Depression (mood), BMI associated with obesity, and poor fitness with limited exercise are predictive factors for fibromyalgia in patients with rheumatoid arthritis. These are all modifiable risk factors, which means there is something we can do to change the risk.

Calculating your specific risk of developing fibromyalgia if you have rheumatoid arthritis hasn’t been developed yet. Once a prediction model is complete, then testing will be done to see how accurate the model is before introducing it to the world at large. There are blood tests that help identify rheumatoid arthritis but not fibromyalgia.

From the outside you wouldn’t know by looking at the forearm that there are three separate compartments. Each section is separated by connective tissue called fascia. The hand has 10 of these compartments. There are a total of 15 compartments in the entire upper extremity (arm) from shoulder to hand.

Injuries that increase pressure in any one of these compartments can result in a condition called acute compartment syndrome (ACS). Increased pressure in a compartment reduces blood flow (called ischemia) and can cause death of the tissues (called necrosis.

In mild cases, pressure inside the affected compartments is moniored with frequent checks over time to make sure the situation isn’t getting worse. For moderate-to-severe compartment syndromes, it may be necessary to make cuts called incisions in the fascia. The goal is to release pressure in the affected compartment. The necessary procedure to restore circulation and save the arm is called a fasciotomy.

The condition is one that can have some serious complications and problems. Hospitalization gives the surgeon a chance to monitor the patient closely. Sometimes more than one surgery is needed. If blood loss leads to death of muscles, tendons, and/or skin, then additional reconstructive surgery may be done with graft materials to replace the dead tissue.

Results are good when the condition is caught early and treated quickly.

Understanding the problem may help you evaluate your mother’s situation more realistically in order to determine risk of developing osteonecrosis from taking a corticosteroid like prednisone. First, osteonecrosis of the femoral head refers to death of the round ball of bone at the top of the femur that fits into the hip socket. Another term used for osteonecrosis is avascular or ischemic necrosis. Avascular and ischemic both mean a loss of blood supply to the area is the cause of the problem.

What turns off the flow of blood to that area? That’s the real cause or etiology. The is more than a dozen potential causes or etiological factors. From a broad perspective, the etiology of femoral osteonecrosis is the result of genetics, risk factors, and specific events. This is considered a multifactorial etiology.

Let’s take a closer look at some of the more common causes and risk factors first. Number one is trauma: a hip fracture or hip dislocation with damage to the blood vessels supplying the femoral head is the most commonly reported cause. Most of the time, older adults are the prime group at risk.

Number two is the use of corticosteroids — medications such as prednisone used to reduce inflammation and the immune system. Adults with arthritis, anyone who has had an organ transplantation, and cancer patients in treatment are just a few of the types of people taking corticosteroids. Usually long-term use of corticosteroids is the trigger but there have been reports of patients developing osteonecrosis within a month of starting these drugs.

Number three: lifestyle factors. Smoking and alcohol abuse compound the problem and increase the risk of femoral head osteonecrosis. Even occasional drinking (once a week) increases the risk of developing avascular femoral necrosis. But the odds are much higher for those who drink daily and especially if they drink more than one alcoholic beverage in a 24-hour period.

The more risk factors there are, the greater the chances for developing an adverse effect from taking prednisone such as osteonecrosis. Could this happen with just a month’s trial of the medication? Yes, studies show that osteonecrosis can develop within that first month of taking the medication. Most cases develop during the first year of drug use.

The best thing to do may be to sit down with your mother and her prescribing physician and review her risk factors and weigh the benefits versus drawbacks of the present plan-of-care. There may be nothing to worry about but taking a closer look can’t hurt either.

A stress fracture is a hairline crack in the bone that can grow larger over time if not treated properly. What you have noticed about the rise in stress fractures is very accurate. Stress fractures were once most common among military personnel who marched and ran day after day.

But today, stress fractures are on the rise in athletes, from distance runners and sprinters to skaters, hurdlers, and tennis, volleyball, soccer, and basketball players. Dancers and gymnasts are not immune either. Men and women in these two sports who train more than five hours a day have been shown to be 16 times more likely to develop a stress fracture.

Besides being a soldier or an athlete, being a female in either of these groups increases the risk of a stress fracture. Other risk factors include biomechanics (alignment of the foot, ankle, and lower leg), muscles mass and strength, and bone density and bone geometry (shape, thickness).

For women who are overtraining while also limiting calories, a better balance of eating and nutrition may be helpful. Females who have an eating disorder or disordered eating are common among athletes where “lean is mean” (a desired state of body and mind) in some sports. In such cases, nutritional and behavioral counseling are advised.

Training schedules can also be reviewed and altered if training is too much, too often, too long, or too intense. A sudden change in the athlete’s training routine (increased intensity and/or duration) is the biggest training error leading to stress fractures. Gradual increases in training may be able to avoid this mistake.

Muscle mass and muscle strength can be increased with a strength training program. Smaller muscles and muscle fatigue may result in an increase in the force placed on the bone with activity. Women may be at increased risk of tibial (lower leg bone) stress fractures because the female’s calf muscle just isn’t as large as the male’s.

For girls or women who experience a stress fracture (and especially if there has been more than one), some additional laboratory tests may be needed. Your doctor can advise you specifically but ask about a DEXA (bone density) scan, thyroid test, and hormone testing. There may be some additional body chemistry factors that will show up with testing and that could be managed more carefully in preventing further stress fractures.