Pat proximal humerus 2-part fx

I was in a hurry to get to the gate. The traffic from Marin to SFO was obnoxious and the TSA line very slow. I was wearing a heavy backpack. Optimistic about getting some work done on the plane, I had filled it with medical journals and my laptop. I was also pulling my wheelie. I was walking my usual fast pace when the ball of my left foot struck the floor first—it had been happening a lot lately—and I stumbled. As I tried to get my balance, the backpack slid up towards my head and propelled me forward and down—hard.

I took the brunt of the fall on my right shoulder, but the worst pain was in the middle of my upper arm. I couldn’t use it to help me get up off the floor. A kind passerby got down on the floor next to me and said, with confidence, “I am certified in first aid. Can I help?”  Grateful, I directed her to take my left arm and gently pull me into a sitting position. By now, I am the center of attention, surrounded by airport police, passengers, and a United Airlines representative who told me, in no uncertain terms, that I would not be getting on my flight to Tucson (I actually asked him to please take me to the gate in a wheelchair). Although he kindly booked me on a later flight, just in case the injury turned out to be something minor, he had already called for an ambulance.

So that was how I ended up as a patient in the ER I used to work in. The emergency physician on duty was one of the few people I still knew at Kaiser South San Francisco. He sewed up a small laceration in my right eyebrow and arranged for the x-ray. The radiologist, an old friend from my running days, gave me the bad news. I had a displaced fracture of the greater tuberosity of the humerus plus a non-displaced surgical neck fracture. I was definitely not going to Tucson.

Why a fall is not just a fall

There are so many interesting and important questions raised by my fall that I want to share with you because I learned that a fall is not just a fall and a broken shoulder is not just a broken shoulder. Bear with me as I take you through some of my thinking.

First of all, there’s the question: Why did I fall? The folks at the airport and the clinicians in the ER asked all the right questions to make sure it wasn’t something that needed an urgent evaluation. Did I have chest pain, dizziness, palpitations? No. Did I trip on something—an uneven tile or an object on the floor? No. I am very clear on why I fell. I tripped over my own left foot. Once I explained that, people lost interest in why I fell and concentrated on the result of my fall—the proximal humeral fractures. But, we will come back to the why later on because it is one of the most important questions that can be asked about a fall.

The next question was what did I need for pain? I opted for 1 gram of IV acetaminophen; it worked like a charm and left my head clear so I could sort out the other issues, like notifying my client that I wouldn’t be at their meeting in Tucson the next morning and figuring out the best way to get home without having my husband schlepp an hour to retrieve me.

An obviously important issue to address: What’s the treatment? You can’t put a shoulder in a cast. I was given a sling and a follow-up appointment in Orthopedics for a week hence. I opted for NSAIDs for pain because I don’t like the nausea and foggy head that accompany opioids. It turns out that was all I needed.

The discharge from the ER was amazing. My friend, the ER doc, gave me a white and blue pocket folder filled with all the information I would need until I would see the bone doc. It included several sheets of paper that described upper extremity fractures, outlined the home care and follow-up instructions, and explained when to seek urgent medical advice. It also provided instructions on how to take the pain medication together with a note telling me that I could pick up my prescription at any pharmacy; it was already entered into the system-wide EHR (eat your hearts out, all you people getting care outside of an integrated delivery system). I tucked the paper copies of my X-rays in the folder, paid my $5 (no kidding) copay, and said my thank yous to the staff who had treated me so kindly and professionally.

I took a Lyft home, whining to the driver about how I was missing a great meeting in Tucson and, even more important, how I was going to miss the upcoming family trip rafting the Middle Fork of the Salmon that I had been looking forward to for months.

 

Follow-up

Pat's arm bruised from shoulder fracture
Pat’s arm bruised from shoulder fracture

I got plugged into Kaiser’s orthopedic department and had regular x-rays to ensure healing was going ok. Of course, I spent hours on PubMed and other sites on the internet trying to determine what was the best treatment for my particular fractures. My fellow internists won’t be surprised to hear that the Orthopedic literature is a mess. Most of the papers I read insisted surgery was the treatment of choice, but I was being treated conservatively with a sling and physical therapy (PT).

So, I made an appointment with the shoulder specialist at my Kaiser medical center to review the literature—yes, you can do that. He described several studies—one from the UK that I had already read—that found that outcomes were the same for people treated with surgery and those treated with a sling, even if there was displacement of the greater tuberosity like I had. Further, he pointed out, the top of my humeral head had a good shape and there was plenty of room between it and the acromion so impingement syndrome was unlikely.

I was lucky. Even before I started PT, my shoulder range of motion started to improve. With PT, I am about 80% of the way to normal shoulder function (Hooray!).

 

A deep dive into falls and fractures

Because there is so much more to the falls and fracture story, I have decided to divide it up into different posts. Here are some of the issues related that I will be exploring over the next several months:

  1. The humerus is a big bone. Why did mine break after a simple fall from a standing position? Had my long-standing osteopenia progressed to osteoporosis? If I have osteoporosis, what is the best treatment? And, what are its side effects?
  2. Why did I trip? Did I have foot drop or some other gait abnormality? Or was it just a problem with my shoes, my clumsiness, or my inattention? Equally important, what can I do to prevent falling in the future—a huge source of morbidity for women (and men) “of a certain age.”
  3. How can I get back full and normal function of my right arm? Believe it or not, I was so good at holding it still by my side that I had to consciously remember to use it once it was freed from the sling.
  4. How do I overcome my newly acquired fear of falling and mental images of falling when I go up and down stairs or walk with my big old black lab? Is this a form of PTSD? What’s the best way to renormalize my disturbed sleep?

I want to explore all of these aspects of falling with you because I think all too often clinicians, friends, and family members,—and even patients—think that a fall is just a fall. But in many cases, as I have learned, a fall may be so much more.


If you would like to add to this list of issues to explore, please pass them along either as a comment on this post or as an email to info@thedoctorweighsin.com.

24 COMMENTS

  1. After caring for my sick husband for over 15 months, I had lost 40 pounds when he died. After 6 months of changing names on titles and other stressful tasks. I was headed to bed when I hit my toe on some object and was thrusted forward into the corner of a wall. I hit right side of face and shoulder and then totally spun around landing on hardwood floor. I hurt and was dazed. I just laid there trying to comprehend what happened. My right arm hurt but I could move fingers. I used my left arm to move my right arm over my chest. I searched around in near darkness and found a wide ribbon I had saved from Christmas. I used it to tie right arm to my neck. I was in food physical condition and scooted down hall to staircase and used rails to stand up. I called my daughter. It took her over an hour to get to me and I decided to just sleep. I thought may it was fractured but thought I would wait. Next day decided to go to ER. Yep, 3 fractures. A spiral fracture to upper humerous and fractures on both sides of humerus head. After 5 miserable weeks in sling I started using arm. No, I started to move it but I could hardly lift it. I had home therapy. BTW 80 years old and l live alone. I could lift 20 pounds and drag 30 pounds but now I couldn’t even reach a lightswitch. The worse part was not being able to cook decent meals. Now over a year and a half later I can do much more but I am always in pain. Sometimes a 2 level and sometimes an 8. Using a vacuum cleaner is torture. Even using a computer mouse is painful. So I am concerned that the pain will never stop. As for fear of falling, I was an ice skater and never feared falling and usually went with the fall. This made me fearful of falling. I was walking sort of fast when I fell. Now I walk slower. We use our arms to balance when we walk. So having an arm in sling changes our balance. While in sling we are less active and leg muscles get weaker as do other body muscles. I think PT should be a whole body activity. I had always done PT exercises for legs when I cared for my husband. I have resumed them. I also thing possibly being less mobile might do something to our inner ear balancing. My arm was black and blue from shoulder to my hand. My age and diabetes definitely had negative effect on my recovery.

  2. Thanks for your reply – 95% range of movement sounds like a great result. I’m definitely focusing on one day at a time & avoiding the worst case scenario/catastrophising, which would be terribly unhelpful. I’m expecting to begin physio in the next fortnight, so that’ll be a real positive step.
    Again, thanks for putting your story & analysis on the web.

  3. So interesting to come across this blog post. I fell a week ago running downhill on cobblestones, wearing hiking boots, something I’d done several times previously. Landed heavily on outstretched right (dominant) arm. Fractured humeral head, not displaced, in sling, expecting to begin physio in a fortnight assuming next xray is satisfactory. Painful & extremely inconvenient. I live with my parents in their 70s, dad v fit, mum quite advanced with Parkinson’s. So my inability to drive will impact seriously on all 3 of us. Dad & I usually share the care/ driving, so next few months is going to be tough.
    Also, I’m a keen outdoor hiker & gym fiend, at my best fitness level since childhood (I’m 46), so serious restrictions on my activity levels is already freaking me out. I can see my OCD has worsened considerably since the accident. I have a long history of depression & eating disorders too, so all those factors are cause for concern. But I do have some excellent longstanding friends, great neighbours & a close family, so I’m hoping to take this thing one day at a time.

    • Hi Kate, I am sorry to hear about your fall and fracture and definitely agree it is very inconvenient to have your arm in a sling. Once you are out of the sling, you will probably be recommended to have physical therapy to get back your range of motion – this is very important. I had a 2-part fracture of my humeral head/neck. I went to PT for a while and did all my home exercises, some of which I still do today – several years later. I have about 95% of my prior range of motion – a very good result. I also had a mild PTSD and terrible insomnia after the fall which is not uncommon. I went to our local zen center to get help meditating which helped with stress and with sleep. Glad to say, all’s back to normal now – except I do watch where I put my feet much more closely than I did before. Be patient with yourself. Recovery takes time. But I am confident that you will get there with the help of your health professionals, family, and friends. Best wishes.Pat

  4. It was interesting to read your report and I thought I’d explain what happened to me. 3 weeks ago I was out running with my husband when I tripped over a root sticking out of a concrete footpath unfortunately I fell forward on to my hands and have broken both shoulders the Dr’s felt sorry for me and have opperated on my right but left the other in a sling gradually I am regaining strength in both. I think I’m a bt of an experiment to see if the final outcome on both shoulders is the same!
    With regards
    Charlotte

  5. Hi Patricia, I appreciate you for sharing and I hope you are doing well.
    On November 28th 2015 while shopping at a local grocery store I fell into the the dairy case (cooler) and came within inches of hitting my face.
    It all happened because I am short and the chip dip was on the top rack and was not fronted so I knew that this was going to be challenging. I put my body as close to the rack as possible stood up on my tip toes and flung my right arm up to reach for the dip only to realize the rack was not locked in place! Everything happened so fast as I reached to the right to prevent my face from injury I grabbed the metal rack and felt something give way in my arm/shoulder. There was a man behind me trying to help, he grabbed my shirt combined with his help and me using every muscle in my right hand and arm saved me from a serious face plant. I felt my embarrassed afterwards and just wanted to leave the area. As I walked away my whole right arm, shoulder and hand felt like it was on fire. I did not know the extent of my injury for about 6 weeks. My doctor wanted to give it time to heal because he thought I had sprained my arm. I was in incredible pain for weeks, finally I had enough and went to see a two different surgeons. After a CT-scan I was diagnosed with a torn rotator cuff. The hand surgeon diagnosed me with carpal tunnel and trigger finger. After all the test were in I was scheduled for hand surgery to fix my problems. He made two incisions on my hand and the shoulder surgeon repaired my arm and shoulder. When the shoulder surgeon opened up my arm he found that I had ripped 80% of my bicep off the bone. It’s been a year since the surgery and my shoulder seems better after the cortisone shot. I wish I had not gone through with the hand surgery.
    Ten days after my shoulder surgery I had a mini stroke. Also I lost three teeth from the tubing they put in my mouth. When woke up from surgery my partial plate was already back in my mouth. I’ve had several surgeries and not once did they put my partial plate in my mouth. I always put it in myself when they bring it to me.
    Thank you for letting me share. I don’t know what to make of all this!

  6. Your photo of the bruising and the x-ray of the fracture look just like mine now. I don’t have your knowledge, so, I am going in for the surgery tomorrow morning. The displacement is well over 5mm and that was the magic number for me to say plate and pin it. My neck popped and has ached since the fall, but, I didn’t mention it, since my shoulder was my main concern. I wonder what the treatment was for your neck.
    My fall was from misjudging my steps coming off a ladder. I was too eager to get cleaned up after successfully repairing a garage door opener. Age 51 years & 51 weeks.
    Hope you had a full recovery.
    I’m not sure how the PT will go on my arm, I tore the bicep many years ago, so, range of motion was already impaired, some.

  7. Thank you so much for this. I’m 11 days out from a shoulder fx incurred while ice skating. The fear of morbidity is far harder to cope with than the pain (I’m 60.) It’s my dominant arm and I fear being unable to draw or to swim, since like you The injury is to the tuberolosity area. I will see the orthopod tomorrow so I will hope get more info then.

    I’m going down stairs with my feet parallel to the tread instead of at right angles. in other words, I am turned so that I face the rail. I don’t advance to the next stair until both feet are on the ‘current’ stair, i.e I play ‘catch up.” If I cone out of this with reasonable ability I’m not givingup cycling but I have thought carefully and I can’t risk ice skating again, even thogh I love it – too easy for ice to be damaged (which caused my stumble and fall) or to be knocked down by overexcited youngsters, etc. Risk assessment is hard – where is the ‘sweet spot” between paranoia and carelessness. The stress is very real and I struggle to get enough sleep. I find sleeping in recliner awkward as it puts a lot of stress on the back for example.

    Nancy your story sent chills down my spine. I wish you and the author the best.

    • Thanks for sharing your story. I think reactions like these are much more common than we have thought and are, I think, by and large, ignored by physicians. I know I didn’t pay much attention to these issues when I was in practice. I would love to hear from others, what is your experience with getting help with emotional issues after a significant health event?

      • Fell hiking in New Mexico 6 weeks ago. Fell on top of shoulder and crushed everything. Fear of falling is a real issue now. Out of sling, will have to have some surgery for impingement. Driving & using arm a bit, but the memory of the fall is a real nightmare. I won’t look at the X-rays. No one discussed anything about the fear. 3 days after my break I tripped on the concrete lip at the end of my garage where it meets the driveway. It was a miracle I didn’t fall. I came so close. Every night I dream about falling: off a bridge, off a mountain trail, off a ledge, out of a tree, off a bike, off a roof, off a cliff. I hate to go to bed.

        • I am sorry to hear about your fall and the fear of falling. The latter is quite common after falls. I had it. Every time I walked down the stairs from my office I could feel myself falling to the bottom. And whenever we went to the airport, I had to avoid the place where I fell.I also had terrible insomnia.It was a mild form of PTSD. It did eventually go away completely, and yours should too. One of the things I did that I think helped me was going group meditation once a week. I also saw a neurologist to be sure I didn’t have any gait issues that could have contributed to the fall, then I saw a PT who helped me both with shoulder mobility and balance. I also have a great massage therapist who has been working on my shoulder to keep it mobile. You will get better, it just takes time and a bit of work on your part. Let me know how it goes. Pat

  8. Absolutely believe in the fear fracture. Though I now almost 72, I can well remember being thrown from a horse and dragged by the stirrup until they could stop him… I was maybe 10? Fast forward to today, when my husband wants to put straps on the pedals of our recumbent bikes. All I can see ifps taking a fall and being unable to get my foot out of the strap. and I’m on a recumbent for fear of falling off a two wheeler.

  9. A year ago I had a fall off my bicycle at a young age of 59. Unfortunately fractured my pelvis bottom to top, and a femoral fracture, fortunately with little displacement.
    3 months in a wheel chair no weight bearing, after back to work and doing OK. Have been back out on my bike , but yes there is always that awareness of what another fall could do.

  10. Sorry we missed you here in Idaho. I hope you have since made your way to the South Fork.
    Several years ago, while on one of my horses, I took a fall. Broke my radius, ulna and the head of my humerus. I was in the Owyhee Mountains about 60 miles from the nearest hospital. Fortunately I was with a friend who is an ICU nurse ( I am also an RN). Getting down the mountainside with my friend leading both horses and holding onto my belt with one hand was painful, to say the least. I was unable to mount my horse as the movement caused my muscles to spasm and the humerus ends to grind. I knew if I got up there and passed out I would be in a real mess. It was my L arm broken and I needed to use it for balance while getting on my horse, couldn’t do it. All this on the side of a mountain trail.
    We managed to get to the horse trailer. She loaded the horses, I wedged myself in the truck seat so I could brace with my feet on the dash. By now every movement caused spasms in my deltoid and I got very light headed. Until we got to the paved road, I was in 8+ pain.
    Got to the ER, nauseated from pain. Don’t remember what meds I got but I sure did appreciate the pain relief. Demerol and Visteril I think. I was taken to the OR and a general anesthesia for the cast on the forearm. Woke up with a cast and a sling.
    I was 39 y.o. at the time and my deltoids were quite strong, the spasms were terrible for weeks. Ended up with my upper arm terribly swollen and bruised and a cast on my forearm. Arm in a sling for several weeks. Sternoclydomastoid (hope I spelled that right) very painful for weeks.
    I am 69 y.o. now, have about 90% ability to raise my L arm over my head.
    I imagined myself bullet proof up until this injury. When my arm had been in a sling and I had the cast on for about 2 1/2 weeks I couldn’t stand the inactivity and put my leg over my kid’s pony. I could make it up there with some difficulty and rode the 1/4 mile, bareback, to the mail box. That lovely pony made my day. His name was Buckshot and he was so patient and kind. He was humanely put down at age 31, several years later.
    I am still going at 69. I do have some PTSD, I think. It did not bother me for years, but now I have flashbacks of the injury. Now I have RA and Lupus and I know that I would be in a bad place if I were injured again. I still ride. I mostly drive a buggy, but injuries from those accidents are also terrible.
    Thanks for the discussion of the aftermath of these falls and fractures. Life is an interesting trail and an interesting trial.
    I live on a hay ranch in Owyhee County, Idaho. My friend, Margaret Cary comes to visit us here in the wilds of Idaho. Maybe you can come with her some time. Happy healing.
    and I am terrified of getting hurt again.

    • Hi Nancy, thank you for sharing your experience with a fall and fracture. I think fear of falling and PTSD are underreported and underappreciated. Hopefully we can change that by sharing our stories. Maggi has often told me how much fun she has visiting you on the hay ranch. Idaho is also underappreciated, but I selfishly hope it stays that way. Pat

  11. Thank you for sharing. As a middle-aged runner who falls occasionally on trails (but so far only ever with bruises and irritations), I fully get both why you need to figure out how it happened and how to overcome fear of it happening again.

    And thank you for your kind words about my employer’s SSF team.

    Wishing you a speedy recovery (and hope you get that rafting trip next summer)!

    • Thanks Murray. Please keep your bones strong so your falls only lead to bruises, not fractures!

      Re: the care at SSF. I didn’t have room to write about all of the great care I got including the Medical Assistant who wrapped me in warmed blankets so I wouldn’t get chilly as she irrigated my wound, the expert care of Emergency Physician Dr. Uli Chettipally and kindness of Dr. Sherry Reynolds the radiologist who read my x-rays. Care doesn’t get any better than what I had that night. Thank you Kaiser South San Francisco.

  12. Thank you for the wonderful essay, Pat. I’m curious to learn of your analysis of the precipitant for your fall. I concur that serious injury consequent to falling creates a type of PTSD–my tri-malleolar fx-dislocation in early middle-age certainly did.

    I’m glad to learn of your steady improvement/recovery. All good wishes for a rapid return to maximal function and activities. Regards./@sjdmd

    • Thanks, Steve. My recovery is going well. My range of motion back to about 90% and I am still in the early stages of PT. I would love to chat with you about your symptoms of PTSD post-fall. I suspect it may be a common, but perhaps unrecognized symptom. We all know that people with hip fractures often die soon after the event (within a year or two). I wonder, has anyone looked to see how much of that morbidity and mortality is related to self-restricted movement because of FOF (fear of falling) related to some variation of PTSD. Certainly an interesting and perhaps an important question – to me at least.

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