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The Physical Exam: Thighs Matters

One of my favorite series of posts I did on my old blog was a run-down of the physical exam.  Some might say I ran down the physical exam as one might run down a pedestrian, I suppose, but it was a fun series to write.  If you didn't get the chance to read it (or don't remember the trauma of first reading them) go here.  If you do, please make sure to do the following:

  • Have bucket handy
  • Buy a bottle of strong liquor
  • Stay away from sharp objects.

Trust me on this.

So, I have decided, I will once again inflict share this series with the readers of this blog.  Feel free to flee in terror.

My last writing on this subject was on the exam of the hip joint, which is, as I pointed out, a very confusing topic.  What most people call "hips" are not actually hips, but the outside portion of the thigh.  To clear this up, I now turn to the subject of the thigh.  The thigh, which is just south of the hip (but is not the hip), is that portion of the leg the spreads out when you sit down, causing many to go on diets and compulsively buy strange products when watching late night TV shows.

 

Underneath the spreading tissue is the largest bone in the body, known as the femur.  The femur connects the knee to the groin. Now, my use of the phrase, knee to the groin has probably brought out one of two responses in my readers:

  1. A dull moan accompanied by cold sweats from male readers who had PTSD flashbacks to middle school
  2. A desire to watch the popular TV show, America's Funniest Videos, which has built an empire on traumatic groin injuries.
It is interesting that two totally-opposite reactions would happen from the use of one phrase: "knee to the groin."  I would speculate that it was a male traumatized in middle school who chose the name "femur" was chosen instead of "humerus" or "funny bone."  Clearly the people who make the show America's Funniest Videos are the ones in middle school who were associated with kneeing, not groining.  Either that, or they have exceptionally good therapists.
Double-entendres aside, there is one thing about the femur none can deny: it's big.  Orthopedists, who definitely were the doctors doing the kneeing and not the groining during medical school, go one step further, calling the femur a big honking bone.  Paleontologists (who were more likely on the receiving end of the knee/groin transaction) also are prone to use the word "honking" (or it's language equivalent) in reference to the femurs found as dinosaur fossils.
This is a paleontologist next to the femur of a dinosaur. I think the sign he's holding says "this is a huge honking bone."
There is some controversy, however, as to the nature of one specimen discovered that dates back to the yabba-dabba-dithic period:

Some scientists believe that the bone in the hair of this child (nicknamed "Pebbles" for unknown reasons) is a femur, noting the similarity to the big honking bone the paleontologist with the sign is standing next to.  Others eschew this theory, pointing the lack of the ball-shaped portion of the bone (acetabulum) that inserts into the hip. The first scientists call the second group a bunch of smart-acetabulums, leading to some more knee/groin interactions.  Despite the acrimony of this debate, all scientists agree on one thing: that's one darling little girl.

(Note, astute reader Ngsurgery corrected me on this one, as the ball portion is actually the head of the femur, while the acetabulum is the socket the head goes into.  I won't change it, as it would make the smart-acetabulum pun drop in its funniness quotient.  I appreciate sharp readers pointing out my brain farts).

The femur isn't the only part of the thigh with size as it's claim to fame.  The sartorius muscle, in its circuitous course from outer pelvis to inner knee, is the longest muscle in the body.

The sartorius muscle gets its name from the Latin word sartor, which means "tailor," and hence it gets the nickname, "the tailor's muscle."  Just why someone chose to name this muscle after a profession not quite known for its physicality is cause for discussion.
There are four hypotheses as to the genesis of the name: One is that this name was chosen in reference to the cross-legged position in which tailors once sat. Another is that it refers to the location of the inferior portion of the muscle being the "inseam" or area of the inner thigh tailors commonly measure when fitting a pant. A third is that the muscle closely resembles a tailor's ribbon. Additionally, antique sewing machines required continuous cross body pedalling. This combination of lateral rotation and flexion of the hip and flexion of the knee gave tailors particularly enlarged sartorius muscles. (from Wikipedia)
I personally think these people have too much time on their hands.
So what's the use of the sartorius muscle?  Again, from Wikipedia:
Assists in flexing, abduction and lateral rotation of hip, and flexion of knee.  Looking at the bottom of one's foot, as if checking to see if one had stepped in gum, demonstrates all four actions of sartorius.
Stepping on gum, a fact of modern life, is not something others have experienced through history. I've uncovered a new possibility for the word origin of sartorius, coming from an Indo-European expression shouted out when people stepped in dog feces.  This sculpture, found in the Metropolitan Museum of Art, depicts such a misadventure.So what about the exam of the thigh?  How did this post devolve to a discussion of people stepping in dog poop?  What about the quadriceps muscles?  What about the hamstrings?  What about Suzanne Summers?I gave you the chance to flee in terror.  Now look what you've stepped in: a bunch of yabba-dabba-doo.

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Physical Exam: Hip Hip

Having gotten (literally) to the end of the upper extremity (what civilians call the "arm"), we now leg down to the lower extremity.  Technically, we are dealing with the transitional zone between leg and torso: the hip. Hip, not hip or hip

Now, the word "hip" creates quite a bit of confusion.  I know many of my readers think of me as one hip dude.  Why do they think I am so hip?  Maybe it is my sick writing skilz.  Maybe it's my overuse of a tired gag about a South American quadruped.  Maybe it's because my mom has bribed them with a Dutch pastry that is light yet satisfying.  Whatever the case, I am not talking about anything related to my hipness.

I am definitely not talking about the fruit of the rose.  I didn't even know roses had fruit.

But the real confusion comes from what most people call their hips. When people say their hips hurt, they are talking about this:

When a person complains about having fat hips, they are not talking about adipose tissue in their hip joint.  They are also not (usually) talking about the fruit of roses.  They are talking about their trochanteric region.  I guess it wouldn't sound good for a guy to say about a woman: "she's got a great trochanteric region (bilaterally)."   Some guys might say that kind of thing, but they wouldn't get very far with those ladies.  I've found that most women are repelled by the word "trochanteric."

This doctor is pretending to do something to the trochanteric region.  Doctors like to pretend like that.

No, when I'm talking about the hip, I am talking about the ball-joint between the pelvis and the femur (the big leg bone above the knee).  We as doctors are used to translating "my hip hurts" to "I have a pain in the trochanteric region," so you don't have to worry about jeopardizing your care by creating confusion.  Still, it is an important distinction as real pain in the hip joint doesn't occur in the place people think of as the hip, it happens here:

I chose the picture of Elvis because he's so hip.

Hip pain happens more in the groin than the hip.  It confuses people when you tell them their hip pain is not hip pain and their groin pain is hip pain.  I suppose any pain Elvis would have would be hip pain, which is why I am glad I wasn't his doctor.

Examination of the Hip

The exam of the hip is guided by the complaint the person has.  If the person says they have hip pain (which is, in fact, trochanteric pain), the most likely cause is trochanteric bursitis.  Trochanteric bursitis is diagnosed by poking on the outside of the leg over the hip that's not really the hip.  If the person says "ouch," "yow," "#@%$!!," or punches you, it's probably bursitis.

It is much easier to diagnose if the words "Trochanteric bursitis" are written around the level of the 4th lumbar vertebra, but I am not usually so lucky.  A bursa is a small sack that is sometimes full of fluid, but usually sits there waiting to cause trouble.  Putting ice on it, doing certain exercises, taking anti-inflammatory medications, and sometimes getting a cortisone injection are the means by which trochanteric bursitis is fixed.

So then what about the hip that's not thought of as a hip but rather the groin (but's really the hip)?  Well, that's really what this post is about.  That's a much more interesting exam than the highly complex task of pushing on the side of a person's leg.  The hip joint (see above) is a ball-in-socket joint, which allows for a wide range of movement.

  • Flexion - bending at the hip to bring the knee toward the head.
  • Extension - opposite of flexion; straightening the hip out.
  • Abduction - spreading the legs so the knees are apart from each other.
  • Adduction - moving of the knees together, and even crossing the legs at the knees (which some errantly see as bad for you).
  • Internal rotation - with hip flexed, rotating the leg so that feet move apart from each other.
  • External rotation - opposite of internal rotation (duh); the action more commonly associated with crossing the legs.
  • Hip Hop - can't touch this, gangsta.

Problems with the Hip

I don't regularly examine the hip (except in infants), so the main thing that moves me to do so is pain.  Lots of things can cause hip pain (that's actually in the groin), so I will highlight the common causes.

Hip Flexor Injury is an injury to the ...uh...hip flexors.  These are the muscles right at the front of the hip joint itself.  It is a common soccer, running, and football injury.  Sometimes guys who are old enough to know better take up a martial art and injure their hip flexors when trying to do a kick, causing them to limp around pathetically for several weeks (not that I would know anything about that).

Arthritis of the hip is the most common cause of hip pain, although it often presents with only a decrease in range of motion - especially in rotation.  If it causes pain, it is a pain in the acetabulum, which is the cup part of the pelvis that holds the ball part of the femur.  Osteoarthritis causes narrowing of the joint and spurring to occur (extra bone tissue) on the ball of the femur and the acetabulum.

It occasionally also has the big word Osteoarthritis around the 4th lumbar vertebra, which makes the diagnosis much easier.

Hip Fracture is caused by a fracture of...the hip.  This is one of the most common fractures associated with osteoporosis, and happens on the neck of the femur, right below the ball.  It's actually a very serious thing, associated with a very high death rate when sustained by a person 80 or above.

In pediatric patients, there are two main causes of hip pain.  Avascular Necrosis of the Femoral head (AKA Legg-Calvé-Perthes disease), and Slipped Capital Femoral Epiphysis. These conditions show how pediatricians compensate for an overall lack of hip problems by naming them in ways that cause you to spit on your colleagues.

The first condition (the avascular thingy) happens in school-aged kids, mainly boys.  It is related to a compromised flow of blood to the bone which causes a section of bone to die.  This usually gets better with just resting the hip, although there is a chance of longer-term damage if the condition is bad enough.

The second condition (the slipped capital etc.) happens mainly to obese kids in their early teens.  As if it is bad enough to be an obese middle school student, the bone fractures at the growth plate at the end of the femur, causing the bone to slip back.  This is hard to diagnose, as it can present with minimal or vague pain, but benefits greatly from early diagnosis.  Kids with slipped etc. should go to a pediatric orthopedist if possible so they can get treatment ASAP.  Treatment often involves putting a screw in the end of the femur to stabilize the joint.

Which is one more way that obese middle-school students can get screwed.

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What's a Duck Got To Do With It??

Dear American Academy of Pediatrics: I think there is a mistake.  Kids started coming into the office recently with forms for sports physicals, and the form is different.  See Below:

Someone added stuff to the form!  Not only do we have to continue the inexplicable obsession with the hernia check (for maximum humiliation of boys, we try to use only female examiners for this), there's a bunch of new stuff.  I do understand why we need to check for heart problems, with the risk of hypertrophic cardiomyopathy that can kill previously healthy kids.  But what's this with the femoral and radial pulses?  Yes, I know it is a screening test for coarctation of the aorta, but so is a simple pedal pulse check.  Plus, checking a femoral pulse on kids is almost as bad as a hernia check.

Then there's the "functional" part of the exam.  The kids all think this is hilarious, but we were quite confused.  I never was taught in medical school or residency what a "Duck-walk" was.  I did a Google search and found that it is a brand of wine, but I don't think that's appropriate for a sports physical (you know, with underage drinking being such a problem).

Google also had lots of pictures of Chuck Berry.  I assume his walk in a squat position is referred to as a "duck walk."  So are we supposed to have them do air guitar and pretend to be Chuck Berry?

Would the Chicken Dance be OK?  Most of the kids these days have never heard of Chuck Berry.

Then finally, there's the hopping on one leg thing.  Why would hopping on one leg include or exclude a child from sports participation?  Wouldn't a child who couldn't hop on one leg have a low likelihood of making the team in the first place?  What exactly are we looking for?  I guess if we gave them some of that Duck Walk merlot, they pretty much would do anything.  Come to think of it, I wonder if they were drinking merlot when they made this form.

I wanted to bring this to your attention because it's caused quite a stir among the teens.  They apparently are swapping stories about doing duck walks and are very disappointed with having to do the Chicken Dance.  Somebody thought that hernia checks were not humiliating enough and wanted to share the love with girls as well.

I hope you fix this problem as soon as possible.

Sincerely,

Dr. Rob

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The Physical Exam: Up to Snuff

It's time we get away from all of that serious nonsense, and back to something I am far more comfortable with: taking otherwise useful information and twisting it into utter nonsense.  Yes, it's time to journey back to the wonderful world of the physical exam. My ongoing mission is to explore the human body from my unique (albeit moderately unstable) perspective. For an overview of my previous posts on the physical exam see this post which features Dick Chaney on a Segway (reason enough to click on the link).  Please visit a psychiatry blog to aid in recovery once you have done so. My most recent post in this fine series covered the topic of psychics and about the examination of the hand.  It was mainly about psychics examining the hand, but I did slip in a little doctor stuff to keep the cops off of me.  But then I got a call from the department of homeland security and they said that if I didn't shape up, I'd no longer be able to use the picture of Dick Cheney on the Segway.  It's hard to resist such harsh tactics.

Today I'll take the high road.  The really high road.

You see, the hand is not only celebrated by doctors on blogs, it is also a subject of divine consequence.  The above picture is, of course, a representation of the most famous utterance of the words: "pull my finger."

OK, I guess I can't stay on the high road for long.  I don't think many of you would read this blog in the first place if I did.

Now that we've gotten that out of the way, let's get back to the subject at hand (har, har): the physical exam.  As I said previously, the hand exam is done usually in response to complaints about the hand.  There are a few common hand problems I am able to diagnose through the physical exam.

The Snuff Box

As a medical student, you are taught a whole lot of information that you wonder if you will ever use.  Why, for example, did we have to use up valuable grey mater to learn about the Kreb's cycle, that the spot where you most commonly hurt with appendicitis is called McBurney's Point, that chickens have something called the Bursa of Fabricius (from which the B-Cell is named), and about the spot on the base of the thumb called the anatomical snuff box. Considering the amount of time spent on the anatomical snuff box, you would think it was a window to the soul or a portal to the demonic realm.  I was skeptical about its significance.  But my neurons were relieved to find out that the anatomical snuff box had significance (other than as a place powdered tobacco could be put before snorting it into the nose).

Photographic evidence of the usefulness of the snuff box by Dutch men in hats (credit).

So what exactly is the anatomical snuff box?  It's a depression just above the wrist and right below the thumb that is formed by the space between two thumb tendons.

Technically it's not a box, but the term anatomical snuff depression wouldn't fly with anatomy profs (although I don't think Dutch guys would mind).  The significance of the snuff box for me (I swear, I didn't inhale) is that two conditions make the bones under it hurt.  (Note that the above picture uses the term "snuffbox" instead of "snuff box," which shows which side of the healthcare debate it supports).

Scaphoid Fracture

The first is a fracture of the scaphoid bone.

In this illustration, the scaphoid bone is pink, and has the letter "A" on it.  Scientists are not certain of the significance of the big letters, but some have claimed this as evidence of an intelligent creator.  Opponents of this theory point out that the giant number "3" is actually pointing at 5 bones, which makes the intelligence of this so-called creator suspect.  The debate rages on.

The scaphoid bone can be fractured when a person falls on an outstretched hand.  I broke mine when I was running backwards and was tripped by some microorganisms who jumped up and grabbed my ankles.  I swear that's how it happened.  Normal wrist x-rays can miss a scaphoid fracture, but the astute clinician suspects it when the patient jumps, screams in pain, and threatens a curse on the doctor's descendants when the doctor presses on the anatomical snuff box.

Day-Something Teno-Something

The second condition involving the anatomical snuff box is called De Quervain's Tenosinovitis.  This condition was first described by a Swiss doctor who was unfortunate enough to be named Fritz De Quervain, a name that has baffled doctors and patients ever since Fritz did his discovering.  How do you pronounce the dang name?  Is it "Dee-Kwer-Vain," as it appears, is it "Duh-Kare-Vahs," as the Mayo Clinic suggests, or is it "Deh-Ker-Vehs," as Miriam Webster suggests?  I suggest it be pronounced "Dang-my-thumb-hurts," but this pronunciation hasn't gained widespread acceptance.

The basic problem happens when the tendons (tough fibrous tissue that connects muscle to bone, allowing the muscle to move the bone from a remote location) that straighten out the thumb become inflamed due to repetitive use of said thumb.

Fritz noticed the orange irregular outline, and decided to investigate.  The rest is history. (Credit)

On exam, the person hurts at or near our old pal, the anatomical snuff box, when it is pressed while the person moves the thumb across the palm.  This condition is treated by cortisone injection and a period of torture by a physical therapist.

There is another way to diagnose this condition - a maneuver called the "Finkelstein Test."  The test is named after De Quervain's arch rival, the evil Baron Von Finkelstein.  This test is performed by making a fist with the thumb tucked under the other fingers and the wrist is flexed toward the pinkie.

From Mayoclinic.com

When this procedure is performed, two things happen: the wrist hurts in the region of the snuff box, and it glows an eerie red.  There are three reasons I don't perform this test:

  1. Neither the patients nor me want anything to do with the evil Baron Von Finkelstein.
  2. The eerie red light freaks people out.
  3. The patient is simultaneously in pain and making a fist - a situation most doctors try to avoid.

Well now I have burdened your neurons with more information about the anatomical snuff box than you could ever wish to know.  But there is one more thing I would like to mention about this critical part of the body.

These amazing pictures from the wonderful world of reflexology show that the snuff box is really a mirror to the top of the right leg.  Now that's information you'd never get on Kevin, MD!  I'd better keep quiet about that, however, because he may just flip me the spleen.

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Physical Exam: The Handy Hand

Back to the subject at hand. To those who are relatively new to this blog, one of the most popular...uh...tolerated series of posts has been my series on the physical exam.  If you haven't done so already, you may want to go back and read the posts to get in the proper mindset (or destroy enough brain cells).

Astute readers will note that doctors are not the only professionals to examine the hand.

Long before we knew anything about carpal tunnel syndrome or the thenar eminence, we had Madam Linda and her cohorts looking at the hand for signs of what the future will bring for the individual that happens to be connected to the hand in question.  Just as stars and planets can have a peculiar interest as to whether a person will run into money, the lines on a person's hand can foreshadow a person's future.

I took an interest into why this would be the case.  What would it be that could make the creases in a person's hand have such predictive powers?  The classic palm-reading guide looks like this:

So, having the scientific curiosity I have, I wondered about my hand:

Looking at my own hand, I noticed the following:

  1. My hand is at a 90 degree angle when compared to the typical hand.  I don't know if this has an influence on my future; perhaps it means that I will fall over a lot or get lots of sleep.  I couldn't determine that from my research.
  2. The lines on my hand are lavender instead of red.  From my research, this seems to indicate that, while I do like spicy foods, "atomic" chicken wings are not in my future.  It also means that I should watch out for garden tools and hamsters, as they may cause me significant harm.
  3. I have a very long "fame" line, but my "head" line is not very long.  So, I suspect that while the rest of my body becomes famous, my head will be left out from the acclaim.
  4. My "marriage" lines are shorter than my "travel" lines.  This means that I don't go on enough trips with my wife.  She agrees with this assessment and now is a believer in palm reading (although I am not sure why she had all those lavender markers).

Some sources suggest an alternative guide to palm-reading:

The best evidence for this interpretation is the fact that Steve Jobs has a very big line 7.  I disagree with this interpretation, as my lines 1 and 6 are quite long and I...uh....

So what about the other professionals who examine the hand...you know, doctors?  Well, we docs have our own mad skilz when it comes to examining the hand.  Here is what the typical hand exam entails:

  • Inspection of the muscles of the hand, as smaller (atrophied) muscles can indicate nerve damage.
  • Inspection of the joints, as big bumps on them can signify certain types of arthritis.
  • Checking the strength and movement of all of the joints.
  • Doing special tests that look for certain conditions.

I'm going to ignore the 1st one, because it's hard to explain briefly (it's also hard to explain while only wearing briefs).  So let's move on to the other parts of the exam (and let's also get some clothes on, because it's getting a little chilly in here).

Bumps

There are two problems that cause bumps on the joints of the fingers: osteoarthritis and rheumatoid arthritis.  Osteoarthritis causes harder bumps that happen on the two joints furthest down the finger (called PIP and DIP, for proximal interphalangial and distal interphalangial joints).  These bumps have names that are basically meaningless, but are asked a lot on tests in medical school:

I think that Bouchard and Heberden probably donated a lot to some doctor charity or threw some great parties, and so got part of the body named after them.  I don't see any other reason medical students are forced to learn them.

Rheumatoid arthritis (which is a much nastier disease) causes swelling of the joints at the base of the fingers (called MCP joints, for metacarpal phalange joint) as well as sometimes the PIP joint.  The swelling happens in the capsule around the joint, so it is usually softer than osteoarthritis' bony bumps.

"Affected synovium" is the doctor way of saying: "bump on joint that is squishy."

Hand Movements

The movements of the hands are best appreciated with a flashlight shining on the side of a tent.  The patient is told to make the shape of a pterodactyl and scare the sissy kids in the tent.  If they do so successfully their hands are fine (and they get a lot of laughs).  Most exam rooms, however, don't have tents in them (you see why our healthcare system is such a mess), so doctors instead have the person clench a fist and open their hands back up.  If the patient cannot bring the fingers to a clenched position, then the there is a problem with the muscles, joints, or tendons that help the hand close.  If they can't straighten the finger(s), then the muscles, joints, and tendons that do that job are messed up.  If the patient clenches the fist and leaves it closed, it signifies that the person is angry about their bill.

The tendons in the hands are line marionette strings that pull the fingers into a fist (flexion) or to straighten them (extension).  The muscles that control the tendons are in the forearm, which is a good arrangement, as having the muscles in the hand would add too much bulk to the fingers and get in the way of their function.  Breaking one or more of these tendons causes several common deformities.  The first is the "mallet finger" deformity, where the tendon that straightens out the tip of the finger is broken.

Credit

These injuries are not usually serious, and are treated by splinting the finger for a few weeks.

The second deformity is called the  "boutonniere deformity."  It happens when the tendon extending the middle joint of the finger gets severed while the last joint extension tendon remains intact.

Credit

This most commonly happens when someone jams their finger, but my wife had it happen when she cut it in the kitchen with a Ginsu knife.  I am kidding, it wasn't Ginsu.  If this finger deformity is a complete severing of the tendon, it can be surgically repaired.  If it is not a complete injury or if it is not seen fairly soon after it happens, it can be splinted with a fairly good outcome.

What?

Is that you, Madam Linda?

What are you trying to tell me from the great beyond?

Ah, the future will hold another post about the exam of the hand because this one is going too long.  Ah, I see.  Thank you, Madam Linda.

What?

My What?

It is not big!  I swear, I've been on a diet and it is much better!  I don't care what that stupid line says.

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Overview of the Physical Exam

People are asking for more physical exam posts. People asked for more Millli Vanilli too.  People aren't always smart.

But you ask, I give.  I am just that kind of guy.  It's been a long time (since October) since I have done a post on this subject.  So for all of you "newbies" out there (I just wanted to use that word and sound like a nerd), I want to give you a recap of what I have already done on the physical exam.  That way people who have not inflicted upon themselves read the old ones can get all caught up.  To be honest, this is one of my favorite series as well.  Or is that "serieses?"  Where's Grammar Girl when you need her?

To make navigation easier, I am using two images: one of Dick Cheney riding a Segway, and one of Maggie Simpson.

Here are the links:

1. The Head

2. The Eyes

3. The Ears

4.  The Nose

5.  The Mouth (Listed as part 1, but not followed by part 2)

6.  The Dangly Thingy at the Back of the Mouth

7.  The Pharynx

8.  Psychiatric Exam (No snide remarks regarding Mr. Cheney)

9.  Neck (this is listed as "part 1" which is accurate, but there is no part 2, so I could be sued for false advertising)

10.  The Chest

11.  The Heart (Part 1)

12.  The Heart (Part 2 - yes, there is a part 2 for this one.  Hallelujah)

13.  The Baby (Another listed as Part 1.  I probably should see a doctor about this)

14.  The Baby's Heart

15.  The Baby's Butt

16.  The Abdomen (Part 1)

17. The Abdomen (Part 2)

18. The Anus (No snide remarks on this one either)

19.  The Extremities

20.  The Shoulder (listed as "Part 1" on the arms, which is technically correct, but the post is really about the shoulder)

21.  Directions

22.  The Hernia/Sports Physical

23.  More Shoulder

24.  The Elbow

I hope that gives you plenty to do.  I'll probably turn this post into a page of its own, but perhaps I will get a cease and desist letter from Steve Jobs and have to boot that idea.

We'll see.

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Physical Exam: Elbow Room

I've spent a long time on the shoulder. I really didn't finish it, leaving out subjects like rotator cuff injuries and driving on a road without a shoulder. Truth be told, I am just getting sick of the shoulder. Just don't let my shoulders hear about it.

So I am going downstream on the arm...or is it upstream? Oh, yeah, I am going distal on the arm and going to the next bend: the elbow.

Whenever I think about elbows, I think about Sesame Street. When my kids were young, there was a song sung by Kermit the Frog that I heard about 20 million times:

I love my elbows Let's get straight to the point I love my elbows Yeah they're my favorite joint They bend my arms with so much charm and finesse

I love my elbows Take my ankles, please! I love my elbows So much I'm weak in the knees Without these two I'd sure be blue I confess

Yeah thanks to elbows, I'm a fella Who's got a hook for his umbrella And for cool and casual leaning, Boy are they great!

The song goes on for a number of verses; if you want to see the rest of them go here. Just have a bunch of hankies with you when you do. In makes me quite verklempt.

If Kermit thinks elbows are cool, it pretty much clinches it.

So what about the exam of the elbow? Again, this joint gets largely overlooked during routine exams, and would probably be completely ignored without the kind reminders from our dear friend Kermit. When doctors do examine elbows, it is due to people saying subtle things like, "I have this pain in my elbow, doctor."

The Exam

The normal elbow exam would be written as such:

Elbow - Normal ROM, no tenderness or effusion.

Doctors who specialize in elbows probably have some secret lingo they use, but I have not yet infiltrated their ranks to find out what it is. They probably abbreviate the elbow as "Elb", but they may use a Latin or Latvian word as well. ROM means "range of motion" although there is a radical fringe of doctors who think it means "range of movement." This group is soon to shrink, however, as the American College of Orthopedics got Max Baucus to hide a clause in the health care bill that allows the ethnic cleansing of doctors who do this.

Caps

The elbow sits at the junction of the humerus with the bones of the forearm: the radius and ulna. It's just like the knee, which is the intersection of the femur and the tibia and fibula, except there is no elbow equivalent to the kneecap. Why did the elbow get short-changed like this? Why is there no elbowcap? I was unable to find scholarly research on the subject, so I had to do some on my own.

I first asked myself: why are there no elbowcaps? That's how you do science, you know. You come up with a question you want to answer; then you test possible reasons for this and see if they hold up. In this circumstance I could think of a number of possible explanations for why elbowcaps don't exist:

  1. The elbows couldn't afford caps - This did not hold up to scrutiny, however, because of the neighborhoods both of these joints inhabit. The knees are between the buttocks and the feet, which is the anatomic equivalent of living between a sewage treatment plant and a pig farm. The elbows, on the other hand, despite living near the armpits, are close to the head, hands and heart. It's clear that if money was the issue, the elbows would have won out.
  2. The elbows don't need caps - This seems to have some credibility to it, as one would think that the knees would take more of a beating. The problems with this theory are: a) The elbows have the ulnar nerve, which is the "funny bone" to protect and it would be really nice to have protection; b) Your legs generally just go back and forth, while your arms go all over the place. It's far more likely for you to whack your elbow than your knee. c) Men have nipples, we are born with an appendix, and some people have way too much nose hair. Not needing something never stopped the body from having it.
  3. Insurance companies don't allow them - This certainly makes a lot of sense in today's world. I would suppose the knees would have had to get prior authorization for their caps if it were up to United Healthcare. But the body is older than insurance company, and the words, "I'm sorry, your policy doesn't cover that" do not appear in any documents of antiquity.

So after asking myself these questions (and getting funny looks while I did it), I asked my wife. She gave me one of those "have you been sniffing the Silly Putty again?" looks and walked away without answering.

Credit

The only other person at home at the time of my research was my dog Holly. I thought it might be interesting to find out the perspective of a different species. When I asked her, she gave me one of those "I don't know what you are talking about, but I sure would like a pork tenderloin" looks (and then added a Silly Putty look for good measure).  She then went back to sleep. I did note, however, that Holly doesn't have kneecaps at all. This made me postulate that kneecaps probably have something to do with a specific attribute of human legs versus dog legs.  The most obvious difference is the amount of hair on them (although I once knew a guy named Lenny who made it close).  But the theory that most made sense to me was that kneecaps allow us to talk. They must have some sort of speech generation software in them. Elbow caps, obviously, would allow humans to have psychic powers, which the insurance companies would never allow.

The Bends

The elbow is far different from the shoulder. It moves only in a hinge-like fashion, without any of the twirly ability the shoulder possesses. It also doesn't rhyme with as many things as a shoulder does. Despite these handicaps, however, one could argue that the elbow is at least as important as the shoulder, probably more.

Why do I make such audacious claims? Have I been smelling the Silly Putty again? Well, yes actually I have; but that has nothing do do with this. You can grasp this importance when you consider what life would be like without it.

  • You would stink - If your arms were one straight bone between the shoulder and wrist, you would have a very difficult time putting on deodorant, brushing your teeth, and wiping after you use the toilet.
  • You would be no fun - You couldn't throw a Frisbee, arm wrestle, or play guitar without elbows.
  • You would go nuts - What happens when your nose itches? How do you put stuff in your pockets? How would you apply lip gloss? How would you whistle for a taxi? How would you put your arm under your armpit and make flatus noises? All of these are essential functions of daily living we all take for granted that would not exist without elbows.

It's not much better if the arms are fixed in a bent position. It is clear that Kermit has a much greater intellect than we give him credit for.

Golf or Tennis

The vast majority of time the elbow hurts is due to problems with one of the epicondyles. Epicondyle is a fancy way to say "bumps near the end" and refers to the bumps near the end of the humerus bone. The one that sits against the body when the hands are facing forward is called the medial epicondyle, and one on the opposite side is called the lateral epicondyle. When there is pain over the lateral epicondyle, it is called lateral epicondylitis; but this is better known as tennis elbow. Not to be outdone, pain to the medial epicondyle, or medial epicondylitis, is known as golfer's elbow.

Because of these names, several questions come immediately to mind:

  1. Why golf and tennis? Why not rodeo elbow or tetherball elbow?
  2. Are these conditions related to wearing argyle?
  3. What were they called in ancient times, slave beater's elbow and pyramid making elbow?
  4. Can a muppet get either of these conditions despite the fact that they can't play golf or tennis?

Wikipedia gave me no answers on this, so I guess it will remain a mystery. But these conditions do still hurt, and are best treated with anti-inflamatory drugs, ice, and rest from whatever activity brought them on.

Eat your Spinach

There is one more elbow condition to cover: olecranon bursitis. A bursa is a small sack under the skin that can potentially fill up with fluid. When these sacks get inflamed, they fill up with fluid and can sometimes hurt; this condition is called bursitis. You have these little sacks all over the body, and they only are significant when they mess up. This makes me a little suspicious that the American College of Orthopedics somehow got them included in the body so their members could afford to treat the epicondylitis they get from playing Golf and Tennis.

The olecranon bursa is over the flexor surface (or outside of the elbow when it is bent) and becomes inflamed from trauma or the depositing of uric acid crystals in the condition known as gout. It can also sometimes get infected. Traumatic olecranon bursitis is by far the most common, and typically presents in the office as a man who is tired being teased by his buddies. This is because the condition makes the patient look like a famous spinach eating sailor.

Me? I don't eat spinach. I get my strength from sniffing Silly Putty.

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Physical Exam: Humerus Collar Blades

When you were last enraptured by my physical exam series, I was explaining the different directions doctors use to confuse themselves and everyone else.  I am happy to leave that land of relativity and now re-embark on the actual human body.  I am sure this relativistic view of direction was invented by some liberal anatomist intent on socializing the human body.  It is a stop on the road to death panels, in my opinion. It’s good to get that posterior to me.

My distraction (I get distracted, you know) happened as I was trying to explain how the shoulder works.  Since the shoulder moves in so many directions and with such huge angles, I felt it was necessary to totally confuse you and so hide any chance you would pick up my ignorance.  It’s always good to keep your readers snowed.  So, after spending a whole post making poems about the shoulder (that will no doubt go down in the anals annals of poetry about joints) and another post about the confusing directions we doctors use to confuse other doctors, I will now talk about the actual exam of the shoulder.

As you probably have been taught, the shoulder is the joint that attaches your arms to your body.  Some people refer to the top of their torso as their shoulders (as in “shoulder straps”), but this is not what I am talking about.  The shoulder is supposed to be the joint between three bones:

  1. The humerus  - which is the long bone in the upper arm, and got its name because of its habit of playing practical jokes on the ulna.  The other bones are always inviting the humerus to parties.
  2. The clavicle – also known as the collarbone.  This bone actually looks nothing like a collar, and it resents the implication.
  3. The scapula – called the shoulder blade.  The collarbone is jealous because the scapula has a much cooler nickname.  This causes the scapula to snicker often at the clavicle’s wimpy nickname.

Credit

Examining the shoulder

The examination of the shoulder involves inspection (looking at it), palpation (touching it), and assessing the range of motion.  This means that the doctor has all sorts of ways to inflict pain on the person during this exam - which is a secondary goal for many doctors, as hurting the patient allows us to charge more.

The normal shoulder:

  1. Looks just like a shoulder should.
  2. Doesn't hurt when you push on it (although a karate chop may elicit some pain)
  3. Moves all over the place.

But you seldom see doctors documenting a shoulder exam in a person not complaining of pain.  If they did, the exam would look like this:

Shoulder: Appears shoulder-ish, nontender (aside from karate chop maneuver) and moves all over the place.

It is when the shoulder is messed up that the exam is undertaken.  So let's look at the three parts of the exam and how they relate to things that go wrong.

1.  Inspection

When examining the shoulder, the first thing to do is to look at it.  This is made much harder as people without fail wear thick sweaters or dress suits when coming in for shoulder pain.  So the first step of the exam is to say: “Can you please undress so I can look at your shoulder?”

The patient generally responds by saying:  “It hurts my shoulder when I take it off.”

Which invariably results in me and several of my staff helping the patient to get the top off, usually involving the use of utensils such as shoehorns, putty knives, and plungers.  This makes me wonder how they got the clothes on in the first place.  It also makes it necessary to overlook the trauma caused by the utensils.

One of the nice things about examining the joints is that you have a built-in comparison.  I make it a habit to stand back and look at both shoulders at once, noting any visible difference between the two.  The first notable asymmetry seen is the separated shoulder.  This problem is not the same as a dislocated shoulder. Shoulder separation is a condition where the clavicle and scapula disconnect at a joint called the AC joint (acromioclavicular).   The acromion is a knobby process coming off of the top of the scapula.  Note: my spell-check wants me to change the word "acromion" to "accordion," but I know no condition where the clavicle separates from an accordion.  If it did separate, people would probably be thankful.

Credit

If you want to learn about the horrible threat caused by accordions, please read the two posts I wrote on the subject: here and here.

In the absence of accordions, the AC joint separation can be seen on inspection:

Credit

The first clue to this is the blinking red arrow that appears over the separated shoulder.  A more sophisticated clinician, however, will note the bump over the AC joint region is bigger on the one side than the other.  Personally, I think that the red arrow method is more accurate, but the blinking does get annoying after a while.  A shoulder separation is usually treated by simply putting the arm in a sling and then torturing the patient using physical therapy.  Alternatively, it can be fixed by putting a screw between the two bones.  The latter procedure was perfected by Dr.'s Black and Decker.

The dislocated shoulder, on the other hand, is a condition where the humerus comes out of the socket formed by the scapula and clavicle.

Credit

There are no flashing arrows present, but the big bulge on the front of the shoulder and the pained facial expressions of the patient, make this diagnosis relatively easy.

Which reminds me of a (true) story.

I was vacationing with my family in Puerto Rico a few years ago.  We had toured the island and had come to the west coast town of Rincon to spend the night.  The waves on that side of the island are relatively large, and so Rincon is a popular gathering place for surfer dudes (and babes).

Our hotel was right on the beach, with a bar situated about 20 feet up from the shore.  I was out frolicking in the waves with my kids and decided to show them about body surfing.  Perhaps I felt that they were thinking of me as some doctor dork and wanted to show myself more as the surfer dude type; I am not certain.  But something possessed me to pretend I knew what needed to be done to body surf.

I wasn't too good at it, though, and was starting to give my kids the impression that body surfing involved going into a big wave and getting salt water in your nose.  I didn't succeed in moving much but I did bob up and down, so I thought I was ready to show my surfing savvy.  As a particularly large wave came in, I started swimming forward and moved rapidly toward the shore.  Success.  I imagined the kids bragging to their friends about their cool surfer dad and my wife deciding to wear bikinis around the house to keep the image up.

But there was one problem I hadn't considered: the waves were breaking right on the shore.  I noticed this fact as I was raised about 5 feet above the beach and then flung down head-first into the sand.  I instinctively put my arm in front of me to protect my neck from the imminent collision.  My face was rammed into the sand, but my neck was spared injury.  My shoulder, however, was explaining to my cerebral cortex that there was something very wrong.  The pain was severe.

I stood up, with arm hanging at my side, and walked toward the hotel.  Some folks at the bar noted that I had blood on my face and that my arm was dangling.  They also noticed that I said, "I hurt my shoulder!  Ow!  I hurt my shoulder!"  Some very nice bar patrons ran to my aid and walked me to their table.  One of my rescuers explained to me that I probably dislocated my shoulder, and that he was very experienced in putting it back in place.  He suggested I lay on the table so he could fix it immediately.

Dazed, and desirous of stopping the pain, I complied with this shoulder expert.  I laid face-down on the table with my panful arm dangling over the edge.  Another bar patron (who had apparently studied anesthesiology) offered me some beer to help me deal with the pain.  I was not aware of the analgesic properties of beer, so I went without the wonder-drug.

My kids ran to get their mother and someone called an ambulance while the world shoulder authority went to work, pulling my arm downward and then forward.  Instead of the desired "thunk" of the shoulder going back into joint, my cerebral cortex was sent the message: "Who is this bozo pulling on my arm??  It hurts when he does that!"  I explained to my would-be shoulder repair man that it actually increased the pain, and he offered to try other maneuvers he knew.  The anesthesiologist offered some vodka.  I thanked them for the kind offers, but decided to wait for the ambulance to take me to the hospital.

I ended up being diagnosed with a fracture of the humerus - right through the "surgical neck" (little black arrow).  I got to see the workings of a public Puerto Rican hospital (Two rules: bring your own bed-linens, and avoid radiology techs who don't interpret screams of "mucho dolor" as reasons to stop twisting), and I got to experience the wonders of Percocet.

I recovered at home without surgery, although it was several months before I could lie flat in bed.

The morals of the story:

  1. Being a surfer dude is over-rated
  2. Don't go to a bar to get your medical evaluation and treatment
  3. All shoulder pain is not dislocation.

Gosh, I have written this much and haven't even gotten to the other parts of the exam.  I guess this means my shoulder exam posts will continue.  Sorry.

Have a beer; it'll make you feel much better.

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Turn Your Head and Cough

School starts early here in the South, with my kids starting school this next week.  This means that we have the honor of doing sports participation physicals to a throng of uncomfortable teens.  I can't say this is a bad thing, as these exams are really quite simple to do - usually taking less than 5 minutes to complete.

Here are my thoughts on this yearly ritual.

Who decides what is included on these exams?

The standard form is simple enough - just an exam of the head, chest, heart, abdomen, joints, and (for boys) a hernia check.  Some forms, however, contain strange details - asking for exams of the breast, comments on the immune system, emotional state, and other mysteriously important systems.  Let me state clearly that I will never do a breast exam or a female genital exam in these visits, nor am I able to conjure up an exam of the immune system.  If I think it is irrelevant or inappropriate, I ignore it.  I have yet to bear repercussions for this decision.

Somewhere there is someone who thought this was important enough to include on the exam.  My suspicion is that this is not a medical person, but instead some commissioner gives the task to one of their underlings who thinks back to what was done when they were young.  I don't know, but it often seems very random and sometimes bizarre as to what is included.  In my opinion, the most important things for sports physicals are:

  • Is the child at risk for heart disease?  I have to look for signs of hidden heart problems that could lead to an arrhythmia.  We do this by asking if there is a family history of people under 50 having heart problems, and by listening carefully.  Unfortunately, the exam itself won't always show that the person is at risk.
  • Is the child able to physically handle the vigors of sports participation?  This is not really addressed in many of these forms, nor does it seem there is formal education as to how to handle strenuous physical activity.  The summers are very hot and humid here and football practice is an incredibly strenuous thing.  I wonder who prepares these kids for this kind of stress, and if the coaches have a clinically appropriate set of guidelines to follow in leading the practices.
  • The joint exam.  Joints are the most likely thing to be injured - especially in females, whose ligaments are more lax.  The exam is not itself important ("wow, your knee really bends well!") but the history of previous joint problems and education as to prevention of joint injury is important.

Why are we so fixated on hernias?

It seems to me that the hernia exam on boys is some sort of rite of passage to manhood.  Why is this?  Who made me the high priest of hernias?  The focus on this part of the exam seems way out of proportion with its actual importance.

Yes, hernias are bad things, but they are hardly subtle.  Usually the boy has a large bulge in his groin area that may or may not hurt.  Either way, boys are not likely to see this large bulge as something that is a normal part of growing up.  Boys value their genitals, and are unlikely to sit passively as they change their form.

It seems to me that someone in the past felt that if we didn't make sure boys would have hernias before sports participation, we'd have sporting events interrupted by a mass of kids with their intestines spilling out of their groins.

Still, the experience is unique in its own ways.  It is hilarious to see boys react to their first hernia check.  This is usually a 6th grader who is still quite boyish - both physically and emotionally.    The interaction goes like this:

The parent or older sibling in the room has not informed the boy of his upcoming rite of passage.  I am not sure why they don't prepare kids for this, but it probably is because they wouldn't otherwise go.  It seems kind of like when I take my dog to the vet.

"OK, now we have to do a hernia check" I say, putting a glove on my hand.

The other person in the room stands up, grinning, and says "I'll go out for this part."

"Try and ignore the screams" I joke to them, getting a chortle.

The boy eyes me suspiciously, "What's a hernia check?"

"I have to check for a bulge in your groin area.  Can you stand up and pull down your pants?"

His eyes get huge and his face turns pale.  "w..w...w...what do you need to do?  No!  You're kidding."

"I am serious.  This is part of the exam.  I have to check for a hernia."

"No...really? I'm not doing that!"  He starts giggling.

"Yes.  If I don't do this, you can't participate in sports.  Please pull down your pants."

He then pulls his pants down half of an inch, showing the band of his underwear.

"All the way down," I say.

"Do you have to do this??  No..."  Giggles.

"Yes, pull your pants and underwear all the way down so I can check for a hernia."

"What?  My underwear too???  No!  You're kidding!"  Giggles more.

I sigh.  "Yes, this is just part of the exam.  Please pull them down."

He pulls it down a few more inches, not coming close to exposing enough for me to do my exam.

"All the way down!" I repeat.

Reluctantly and slowly the pants and underwear drop .  I gently push in the groin where hernias are prone to occur (not on the genitals themselves, by the way).  "Turn your head and cough."

He giggles and lets out a little cough.

"Bigger cough."

More giggles and a slightly harder cough.

I put my hand on the other side and he instinctively turns his head the other direction when I direct him to cough.

Let me mention that the only reason we have boys turn their heads during this exam is so that they don't cough on us.  Most people seem to believe that somehow turning the head to the side stretches something that goes down to the groin area.  To my knowledge there is no cerebro-scrotal ligament.  I just don't like spit on my head.

That's about all I have to say about these exams.  We allow them to be done as walk-ins and these are the only visits that we open to non-patients.  They usually come in large bunches, as kids decide late to participate, neglect telling their parents about the form until the day before they are due, or parents forget.  In any case, they are laid-back and often entertaining.

I am not going to turn away the business.

So all you men out there, in honor of this great exam please push down the "Space" key on your computer, turn your head, and cough.

Good.

Now you can comment on this post.

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Physical Exam: Direction Directions

Back to the exam of the human. I suppose I never specified that it was humans that was the focus of this series, but consider it now specified.  There may be some cross-over to the examination of other animals, and potentially to alien species.  But I don't want lawyers from some star system 100 light years away sending a subpoena because I mislead readers by not mentioning the fact that the crxyynsnnt was distal to the ancrunsty thingy.  I also don't want to be attacked by wombats.

By the way, I was kidding about the crxyynsnnt.  It is nowhere near the ancrunsty thingy.

My last post was the first in a series on the upper extremity, otherwise known as the arm.  One of the problems with the examination of the arms (and legs, for that matter) is identifying the relative location of things.  Describing just where exactly bumps or pains are on the body would be much easier if we simply did this:

Life would certainly be much easier if we did that.  Sadly, doctors adhere to the philosophy: "Why use a picture when you can use a thousand illegible Latin words?"  This means that we need to use all sorts of terms that describe where things are.  Here are some of those terms:

Medial and Lateral

Medial - Toward the middle, or toward the vertical midline of the body or organ.  For example, saying "You have a zit on the medial aspect of your right eyebrow," means that your festering follicle is on the side of your eyebrow furthest from your ear.

Lateral - Away from the middle, or away from the vertical midline of the body.  So saying "You have another zit that is lateral to that huge one I just mentioned," means that the first zit has a friend that prefers the climate nearer to the ear.

Medial and lateral can be confusing when used in reference to things on the arms and legs.  The problem is that the part of your arm that is closest to the midline of your body depends on how you are holding them.

  • If your palms are forward and your arms are at your side, your pinkies are closest to midline.
  • If you keep your palms forward but raise your arms over your head, the thumbs are closest to midline.
  • Then if you turn your palms around and hold your arms over your head, the pinkies are closest to midline.
  • If you put your arms down and keep your palms facing backward, the thumbs are once again closest to midline.
  • If you hold your arms out at a 90 degree angle, both the thumbs and pinkies are closest to midline.

If you do all of these in a public place, you will get a lot of inquisitive looks from people and you might get questioned by the police.

So the convention is to use medial and lateral as they occur with the hands down at the side and the palms facing forward.  Why did they do it this way?  I am sure it was rammed through congress as a hidden paragraph in some farming subsidy bill.  I never had a say in this convention.

Another confusing thing about medial and lateral is that it can be used locally and globally.  For instance, the medial part of a blood vessel is the middle of that vessel.  So let's say I have an unfortunate encounter with a wombat and am bitten on the big toe:

Those are not my toes, by the way.  They kind of look like they've been stretched out.  No wonder the wombat bit them.

So the question is, was the bite on the medial or lateral part of this unfortunately ugly toe?  It depends on your frame of reference:

  • If you use the toe as the frame of reference, the bite is lateral to the middle of the toe.
  • If you use the foot as the frame of reference, the bite is on the lateral aspect, as it is away from the middle of the foot.
  • If you use the body of this person (which hopefully looks better than the foot), then it is on the medial aspect, as the big toe is closer to midline.
  • If you use the position of the wombat, then you really have trouble, as wombats are very mobile.

The convention used here (pushed through congress on a bill that makes English the official language of Idaho) is to use the body as the reference.  This wombat bite is on the medial aspect of the foot.

Proximal and Distal

On things like the arms and legs that move around a lot, a useful description of location is the distance things are from where the body part attaches to the torso.  The terms used here are proximal and distal.

Proximalsituated nearer to the center of the body or the point of attachment.  This generally refers to arms and legs, as they are the main things that attach to the body.

Distal - Situated further from the point of attachment.

Sly

In this example, the Bulbasaur tattoo on Sly's arm is proximal to the Pikachu tattoo.

Bow and Stern

There are several terms for the front and back of the body.  The front of the body is referred to as the anterior or ventral side, while the back is referred to as the posterior or dorsal side.  Just why they couldn't pick one or the other is open to question.  I suspect this thing got caught up in committee and then was filibustered in the senate.  The difference in these terms come clear when we look to the animal kingdom.  The fin that sticks out of the water when a lawyer shark swims is the dorsal fin.  For animals that are longer in the horizontal direction, the terms anterior and posterior are confusing.  Is the head of the venture capitalist shark anterior, or is the belly?

Animals that are the same in both vertical and horizontal axes (like wombats) are even more difficult.

Ahead and Afoot

Finally, we have that vertical access in humans (horizontal in sharks, and wombats).  This is the most confusing of all.  Something going toward the head is called one of three things:

  1. Superior
  2. Cranial
  3. Cephalic

While the tail-ward direction has two names:

  1. Inferior
  2. Caudal

I suspect the terms inferior and superior were shot down by those liberals (like horsey boy) who wondered if the self image of things away from the head would be harmed.  But then there is the fact that we have only one other term for tailward and two for headward.  This was probably the conservatives sticking it to them by keeping the lower parts at a disadvantage.

Oh when will you boys and girls stop fighting?

Footnotes

So that is the confusion of it all.  There are more - like palmar, volar, and plantar - but I won't bother you with that.

There has got to be a better way, folks.  I mean, the anterior medial aspect of my cranium is hurting.  It's truly a pain in the inferior posterior medial torso.

Perhaps we should go to Washington DC with a bunch of bloggers, some specialist and some primary care (excluding patients, of course), and voice our opinions on this mess.

Nah.  That's a crazy idea!

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