Category Archives: Orthopedics

Transforming Our Approach to Chronic Pain

One of the most fearful and frustrating events in my correctional medicine world used to be when a new chronic pain patient would arrive in my clinic.  A typical patient would be a “Ralph,” a middle-aged man who has had chronic back pain for many years.  Ralph has had a couple of back surgeries, steroid injections and more than one kind of stimulator, none of which has been effective.  He arrived at the jail taking a long list of sedating medications such as muscle relaxers, gabapentin, and sleeping aids plus, of course, big opioids.  In addition, Ralph has alcohol abuse issues.  The reason he is in jail is a felony DUI charge.  Now he is in my medical clinic, looking expectantly at me.  How am I going to fix his pain problem? 

The answer, of course, is that I am not.  I am not that smart.  He has already seen lots of doctors, including pain specialists and surgeons, who have tried almost everything that can be tried and they have not fixed his chronic pain problem.  I’m not going to be able to, either.  In my opinion, the most common and serious mistake made in the treatment of chronic pain in corrections is when we imply that we can eliminate chronic pain. 

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Shoulder Dislocations

NP here….What are your thoughts on shoulder dislocations? Does an anterior dislocation require immediate reduction? What if they go out to ED and come back dislocated again? It is thought that these offenders dislocate on purpose in order to go on a field trip. I have heard that anterior dislocations do not need to be reduced as they do not cause neurovascular problems. What has been your experience? Thought?  Thank you for your time!

Great topic! You have asked two questions here. The first question is whether shoulder dislocations need to be reduced immediately (since transporting a jail patient to the ER after hours can be a hassle) or whether the dislocation can wait until the next day to be reduced. The second questions is how to handle those patients who can dislocate and relocate their shoulders at will, and will use this trick to manipulate both the jail and ER staff.

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Ingrown Toenail Removal: A Pictographic Tutorial

Ingrown toenails are a common presenting complaint in my jail medical clinics, just as they were when I worked in the ER back-in-the-day. Of course, not all toe infections are due to an ingrown toenail (which I will talk about later), but when an ingrown toenail is present, removal of the ingrown nail spicula is instantly curative. And unless you remove the ingrown toenail, the toe usually will just smolder along and not get better. So knowing how to properly remove a toenail is a great and useful thing.

However, I have heard that some Correctional Practitioners are unfamiliar and uncomfortable with the procedure of toenail removal and so when faced with a nail that needs to come off, they instead:  1. Leave the nail on to fester, 2. Over-prescribe unnecessary antibiotics, or 3. Send correctional patients to a foot surgeon to have this simple procedure done. All of these are poor medical practice, in my opinion.

Like abscess I&D that I have written about previously, toenail removal seems to be a daunting procedure, but actually is quite simple. Of course, any medical procedure can be done incorrectly or inefficiently. Today’s JailMedicine post is a tutorial on how to cure ingrown nails by performing a simple toenail removal. Continue reading

Case Study: “I Fell and Hurt My Hand”

An inmate presents to the medical clinic with a laceration on his hand overlying the knuckle of his small finger.  Hand injury He insists that he fell getting off of his bunk.  He has no other injuries on examination.  What do you think happened?  How would you treat this? Continue reading

Food Allergies: Sorting out Truth From Fiction

In my previous incarnation as an emergency physician (before I discovered “The Way” of correctional medicine), I saw a lot of cases of acute allergic reactions. It is a very common emergency complaint; I have probably seen hundreds in my career. But when I began my jail medicine career, I was still unprepared for the sheer volume of food allergies claimed by inmates. Who knew so many inmates had so many food allergies?

Of course, most of them don’t. Most just don’t want to eat something on the jail menu. Inmates believe that if they claim an allergy to a food they dislike, you cannot serve it to them. They will claim allergies to tomatoes, onions, mayo, etc., when really, they just don’t like these foods. Tuna casserole doesn’t seem very popular, for some reason. Continue reading

The Ankle Rules–You Don’t Always Have to Get an X-ray!

Brian, Correctional Mental Health Professional. And his ankle.

Back in the days when I worked in the ER, I ordered a lot of unnecessary x-rays.  Ankle x-rays were a particular problem.  Often I was sure that there was no fracture, but I ordered the x-ray anyway because of habit–patients with injured ankles got an x-ray.  That’s just the way it was.

So I loved the Ottawa Ankle Rules when they came out.  The Ottawa Ankle Rules were developed by a group of doctors in (where else?) Ottawa to determine which ankle injuries did NOT need to be x-rayed.  They have been studied many times and have been found to be  accurate.  When used, Ankle Rules can cut the number of ankle x-rays by a third, easy.

The Ottawa Ankle Rules can be even more important in corrections than in the ER.   There, the only downsides to an unnecessary x-ray were expense and time.  But in corrections, x-rays can be a logistical and security nightmare.  So it is good to know when you don’t have to order an x-ray for the inmate who twisted his ankle attempting to dunk the basketball at rec.

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