James Reimer - "headaches"

Hey folks. Just thought I'd write a quick note on James Reimer, goaltender for the Toronto Maple Leafs (a.k.a. guy with one of the most badass nicknames in sports... with the exception of Calvin "Megatron" Johnson).

As you know, he was involved in a collision in a game against the Canadiens' last Saturday primarily involving his head. There has been no official statement released if he has had a concussion, post-concussion symptoms, etc.

Apparently today he developed headaches while at practice which worsened as it continued. Obviously with a combination of impact to the head + headache a few days later makes everyone jump to a concern of concussion but it's really only speculation at this point. When it comes to concussions, it involves a full clinical history (especially the day of injury at the time of the collision and hours after) and likely a number of symptoms rather than just relying on headaches alone.

If there was no evidence of a concussion last Saturday AND if he only had an isolated bout of headaches today, it makes it very difficult to claim that a concussion is the most likely diagnosis. With that said, if he had a concussion on Saturday and he's developing symptoms with activity today, there obviously has to be concern they're related. Confused yet?

So either the Maple Leafs are trying to keep a concussion out of the spotlight, or Reimer just got some unrelated headaches today. Either way, they're playing it safe which is a very very good idea.

I'll write more if/when more details become available.

Jerome Harrison UPDATE: Brain tumor was an ependymoma

These were the details I was looking for!

An update by ESPN shed more light on the nature of Jerome Harrison's brain tumor. To summarize (and elaborate):

• Harrison had surgery and the neurosurgeons believed they were able to remove all of the tumor. The tumor was located in the fourth ventricle of the brain (see diagram to the right for the anatomic location). It's actually located lower down in the brain just in front of the cerebellum and is one of the spaces (i.e. ventricles) that contain cerebrospinal fluid (CSF). The function of the CSF is to act as a buffer between the brain and the skull. The brain literally "floats" in the fluid.
• The tumor was identified, presumably via histology, as an ependymoma. I'll talk about ependymomas below.
• Apparently Harrison also had an arteriovenous malformation which may have contributed to the tumor. I posted about arteriovenous malformations earlier when Eagles DT Mike Patterson had a seizure in training camp presumably as a result of one. I didn't actually know AVMs were a risk factor for tumors. You learn something new every day I guess.

Now, about ependymomas...

Ependymomas are a rather rare form of neurological tumor. They can actually occur almost anywhere in the spinal cord, not just the brain, although most commonly in the fourth ventricle like in this case. They only account for about 10% of all central nervous system tumors and 25% of all spinal cord tumors. These tumors arise from tissue called ependyma which are cells that normall produce CSF. 

They are definitively diagnosed through histology and with molecular genetics although when they are seen on MRI or CT there are certain visual characteristics that may make an ependymoma vs. other type of brain tumors more likely. 

Treatment, as stated before, involves surgery to remove as much of the tumor as possible. With ependymomas, some patients receive radiation therapy after surgery.

Prognosis: A number of factors affect chances of recurrent disease. These factors include... 

1. how much of the original mass was resected in surgery (the more removed, the better obviously), 

2. Grade (cell appearance) - patients with high histological grade tumors (i.e. cells that do not resemble the original tissue) tend to have higher tumor recurrence rates

One study cited disease-free rates at 5 and 10 years at 84.8 and 76.5%, respectively.

Jerome Harrison - brain tumor

Click here to see my UPDATE (10/23) on this story

As you may have heard, Lions running back Jerome Harrison was diagnosed with a brain tumor.

The way the malignancy was discovered is probably the most fascinating detail of the story. Harrison was supposed to be traded to the Eagles for RB Ronnie Brown this week. While undergoing a physical, an MRI of his head was performed, which is how they found the tumor. What puzzled me the most is that when performing a "routine physical" on someone, you don't usually just randomly MRI their brain. It turns out that Harrison had been suffering recurrent headaches and that's why he got the MRI.

The term "brain tumor" is vague to say the least. First off, a cancer in the brain can either be a primary malignancy or metastasis. A primary malignancy means that this was the site where the cancer originated. Metastasis refers to the cancer showing up in the brain as a result of spreading from another site. The origins of brain metastases are most commonly from melanoma (WEAR SUNSCREEN), lung cancer, genitourinary cancers (e.g. testes, kidney), osteosarcoma (bone) and breast cancer.

Now even presuming that this is a primary brain malignancy, it's still a super vague term. There is a multitude of tumors that can grow in the "brain" region. Sorry, multitude is the wrong word. How about THE LONGEST SHOPPING LIST EVER.

How is it found? Sometimes masses in the brain can cause generalized symptoms as a result of its size and growth alone. Think about it - your brain doesn't like getting pushed on and moved around. General symptoms include headache, seizures, nausea/vomiting, altered level of consciousness and decrease in cognitive function. And these symptoms tend to occur slowly or sporadically over time; they're unlikely just to pop up all of a sudden. Sometimes, the tumor can cause some specific symptoms based on its location - seizures (again), weakness or sensory loss into certain areas of the body, difficulty speaking, or vision problems. Now I know about half of you that are reading this now think you have a brain tumor. Stop it. Far more common things cause all of the above symptoms.

Treatment: neurosurgery. I won't even dare go further into explaining how, when or why some get treated or some don't because ... it's neurosurgery. I do know that size, rate of growth and location all play a role in whether all, some or none of it is operable but that's really all I know.

Mario Williams - pectoralis major rupture

Quick post tonight.

Mario Williams of the Houston Texans ruptured his pectoralis major (i.e. torn pectoral) against the Oakland Raiders in Week 5. He had surgery on it a few days ago to repair the injury. He will be out for the rest of the season rehabilitating.

We actually have two pectoral muscles - the pectoralis major and pectoralis minor. The pectoralis major is the one most people know about, with each one spanning half of the chest starting at the clavicle and along the sternum and inserting into humerus. Since it spans such a large area and has multiple attachments, it can perform a number of actions:

1. flexing the humerus (lifting your arm at the shoulder joint)
2. extending the humerus (lowering your arm at the shoulder joint)
3. adducting the humerus (bringing your arm closer to the midline - e.g. think of the lifting action of the bench press when you draw your elbows inward)
4. medial rotation of the humerus (turning your entire arm inwards)
5. aiding with deep inspiration

Needless to say, it can be pretty important. The pectoralis minor, on the other hand, is relatively small in comparison and actually hides underneath the pec major. It starts on the third, fourth and fifth ribs and goes to attach to the scapula (shoulder blade). It mainly acts as a stabilizer for the scapula, bringing it down and forward.

Obviously, of the two the pectoralis major is used far more often. Strangely enough, pectoralis major ruptures are relatively uncommon, possibly due to its size and strength. One source mentioned there were fewer than 100 documented cases in the past 25 years. It requires a very large load to overcome this large sheath which is why it makes sense that most of the time this type of injury occurs when weight-lifting (i.e. bench pressing) large weights. 

Williams wasn't weight lifting that Sunday but you can imagine the forces involved in football are pretty comparable.

Patients suffering from this injury usually present with marked weakness in the arm where the corresponding pec major inserts as well as extensive bruising (or ecchymycosis). 

In many non-athletic people, they can get by without surgery since they usually don't require the pec to function at 100%. Understandably, athletes usually elect to receive surgery so they can hopefully return to perform at high levels. As usual though, rehab is key. With proper physiotherapy, the athlete can usually return to pre-injury performance of the pectoralis major. 

Taylor Fedun - complex femoral fracture

I feel awful for Taylor Fedun. This player was a guy is 23, an undrafted free agent, and was not supposed to come close to making the Edmonton Oilers starting line-up. This preseason, he was giving management something to really chew on given his strong play.

... then this happened. The view isn't great but you don't want to a clear view of someone fracturing their femur. Trust me, it's not pretty. Now, Fedun's entire playing career is in jeopardy not just because he will have to fight hard to make a team again, but also because of how catastrophic a femur fracture can be and the loooong (but very important) road through rehab. Unfortunately, it's not an unheard of injury. People in the hockey community know what happened to Kurtis Foster almost three years ago and how long it took for him to recover. Those who watch football may remember Vikings' E.J. Henderson's injury in 2009 and his slow but eventual return.

Photo source: myhealth.alberta.ca

Picture source: Wikipedia

The femur is the longest and strongest long bone in the body. It is the only bone that runs through your thigh and forms joints at the hip and the knee. In healthy people, it is very difficult to break and these fractures are usually seen either in high velocity motor vehicle accidents or falls from a height.


Surrounding the femur are three muscle compartments - anterior (to extend the knee and flex the hip), medial (to adduct the hip), and posterior (to flex the knee and extend the hip). The strong pull of all these muscles can actually lead to a greater angle of the fracture and separation of the fragments. Also, it has a very rich blood supply which can be disrupted from the fracture and cause a lot of bleeding. Fortunately, there is often enough supply from the blood vessels in the bone itself that can provide nutrients to help with healing.

Definitive treatment involves orthopaedic surgery where a nail is inserted to help the union of the two fragments and enable strong fixation. It is associated with 98-99% union rate.

The Oilers have already revealed these following details via twitter:

Fractures can be classified (via the Orthopedic Trauma Association) as simple, wedge, or complex. Complex fractures occur when there is no contact between the main fragments, and there is usually (not always) more than two fragments broken off. A fracture is usually classified in many other ways including the angle of the proximal and distal fragments, if the bone broken through the skin (which would require immediate IV antibiotic therapy), etc. These details were not disclosed though, and understandably so because it is not useful public information.

Also, it's good to hear he went through surgery successfully. Early surgery in this case is usually associated with better outcome.

Below are reasons why this injury is concerning:

1. It can be life-threatening if not addressed promptly. The rich blood supply of the femur means that a fracture can result in a lot of bleeding. You can lose up to 3 L of blood, although the average is closer to 1 L. FYI, we generally have a total of 5 L of blood in our bodies at any given time. Maintaining adequate volume early (via IV fluids) in the injury is a very high priority. The femoral artery (largest artery in the lower body) and the sciatic nerve (largest nerve in the entire body) run nearby, but because they are surrounded by muscles, they are usually protected from injury.

2. It is a long road through rehabilitation. Early physical therapy is important, like for many orthopaedic injuries. Of course, each case is different, and activity depends largely on how well the fragments are fixated. Actual healing of the fracture itself takes anywhere from 3-6 months, and then muscle rehabilitation begins. Baseline function and strength can return anywhere from six months (esp in young patients with aggressive physical therapy) to two years (older patients). Athletes usually take a solid year to return to sports.

Fortunately, prognosis is usually excellent. Complication rates are relatively low. These complications include infection (~1%), malunion (healing at the wrong angle) and/or nonunion (no sign of healing at 3 months) of the bone (3-5%) and neurovascular injury.

It's a long road.

I remember thinking when I was younger that I loved touch-icing because of the odd time the offense beat the icing call and generated an exciting scoring change. Now, I agree with the NHLPA and I can see the likelihood for these serious injuries outweigh the potential for 'entertainment'.



Sources: UpToDate