Non-Union Fracture

On the 8th of May 2018, Damien was at Physical Therapy in Ft Lauderdale. It was the last day in Florida before our scheduled flight home on the 9th. Damien was stretching on a machine to improve shoulder flexibility.

At the apex of the stretch, we heard a loud snap (it was more than a green-stick fracture but that was what it sounded like) and Damien's left arm immediately went slack. We removed him from the machine, placed him in the car, and drove directly to the hospital. The ER admitted him, took x-rays and sent him to a room. The doctor looked at the x-ray and told us that the left humerus was broken just above a plate installed during the original 1999 surgery. He mentioned that he would prefer to cast the arm to see if the break would heal. He did not want to operate to remove the old hardware and screws-saying that would be a 10 hour ordeal. Damien was in the hospital two nights. Three days after the release from the hospital, we took Damien to the doctor's office for more x-rays and placing of the cast. The office staff was very good and spoke to Damien. The cast eventually proved to be problematic. The fracture was about 8 centimeters from the humerus crown. They placed the cast as high as possible (barely covering the anterior portion of the fracture) and extending the material past the elbow to the wrist. The cast proved to be very heavy. Damien's ossified (fused) elbow rendered the extensive cast unnecessary. In hind-sight a cast extending over the shoulder would have been preferable. Six weeks later we returned to the doctor's office for the follow up visit. The x-rays indicated that there was no new bone growth and no bonding between the bone ends. They changed the cast to one more flexible, lighter, and extending above the shoulder. Another six-week period did not produce any new bone growth. Summer was over and we needed to get Damien home.

Once home, we took Damien to see Dr Michael Wirth at UT Health Center, an orthopedic surgeon. Earlier, Dr Wirth had performed the surgery to place a reverse shoulder replacement in Paula's right shoulder. Dr Wirth reviewed Damien's x-rays and told us that Damien had a non-union fracture. Previously, Dr Laura Ackright, an endocrinologist treating Damien's osteoporosis, changed Damien from taking Prolea 2x a year to taking Forteo daily for 6 months. A better cast might have permitted the Forteo to help the healing process. As is, the break was still non-union at Dr Wirth's next office visit. He suggested we contact Dr Ravi Karia, a trauma orthopedic surgeon.

Dr Karia forms a great patient-care relationship. He spoke with Damien and explained the x-rays. It was his opinion that surgery to replace the hardware would take less than 2 hours. However, he was concerned about the quality of Damien's bones-a huge unknown. He mentioned that if Damien's bones had the consistency of tissue paper, surgery would be futile. He was not sure if the bones would hold screws or support an internal rod. Dr Karia agreed to speak with Dr Ackright and encouraged us to maintain the Forteo injections.   We saw Dr Karia two more times with no visible, viable improvements in the non-union fracture. We waited until the Forteo prescription had almost run its course before making an appointment with Dr Karia to schedule surgery. At this meeting we discussed Damien's limitations and the concerns and benefits of surgery. We agreed to have the surgery on Wednesday, 4 June 2019 at University Hospital.

Damien arrived at the hospital at 4:30 AM and went through the admitting process. I went with Damien to the prep area. The nurses swiftly got Damien ready for surgery. I discussed their concerns with the Montgomery long-term canula with the anesthesiologists. The doctor suggested that they might have to remove and replace the Montgomery button to ensure proper ventilation of Damien's lungs during surgery. Before they transported Damien to surgery, the nurse exiled me to the waiting room.

The surgery schedule was from 7:30 AM to 9:30 AM. By 11:00 AM, the hospital staff had provided no information to us. About 11:45 AM, Dr Karia entered the waiting area to speak with us. Damien is a very hard "stick". His veins are tiny, roll when touched, or are heavily scared; therefore, nurses find it difficult to insert the lines for proper access to his blood. Thus, the surgery had a late start. Dr Karia was very pleased with the surgery. They made the incision in the original scar from 1999. They carefully found and exposed the nerves to prevent their being damage. He also carefully worked around and through the deltoid muscle. He mentioned it would have been easier just to snip the nerves and muscles; which would not have affected the functioning of Damien's left arm. However, he was concerned that either procedure might cause future, maybe continuous pain in that extremity. Bone had grown over the original plate - obscuring the screw heads. They removed and saved the bone. At the fracture site, they cut the bone tips on either side of the break. The team also saved these fragments. The surgeon butted the severed bone ends together and secured a wider, longer plate to ensure stability. The team pulverized the bone fragments and a cadaver bone and then added bone marrow to form a paste. The paste covered the exposed bone area and filled old screw indentations. The final procedure was to wrap the arm in surgical bandages. We were very pleased with Dr Karia and his crew.

Damien had to remain in the recovery for 6 hours. He became awake quickly and easily. However, his blood pressure did not stabilize and his pulse was very rapid. They attributed the rapid pulse (112 to 138) to the incurred pain. They gave him IV fluids, antibiotics and constantly monitored the blood pressure. It would range from 55/43 to 69/51. Early Thursday morning, they obtained a better BP reading. The BP did not return to normal during the day, but by late afternoon they agreed to release Damien. We took him home in a raging thunder storm. Fortunately, the hospital patient pick-up/drop off area is covered. The drive home was a bit slow - the window wipers going full speed (still not faster enough to keep the view clear), the long wait lines at various stoplights, and the heavy 6:30 PM IH10 afternoon traffic. It took us 67 minutes to make the 16 mile trip home.

We monitored Damien's pulse, DO (dissolved oxygen) and BP for the next few days. We checked and recorded the values every 4 hours. The pulse slowly returned to normal. We got a "normal" BP reading for Damien late Sunday evening. Monday morning we took him to see his regular doctor - Dr Dayani. In the office, Damien's BP, pulse and DO were normal.

During Damien's home recovery, he developed ten fracture blisters under the bandage. The blisters form because the arm is very swollen and the fluid leaks through the skin. The blisters were dime-size to quarter-size tightly filled domes. Their presence bothered us a great deal - we had never experienced this phenomenon before. We made a phone call and by late Monday afternoon (6:30 PM) we were in the surgeon's office to address the blisters. They carefully ruptured each blister, drained the fluids, washed the arm and covered the blister sites and the incision with petroleum gauze. We returned a week later and the blister sites looked very good. They removed the 45 staples from the incision and bandaged the arm. A slight movement at the brake site caused them to place a C-clamp brace on the humerus.

Once home, Damien worked out on the Quadricizer for 90 minutes. We are excited about Damien's progress and look forward to his future healing. With all that he has experienced these last few days, Damien still has a good attitude. He often smiles and interacts with visitors. He especially enjoys his Aunt Cher's visits. (Paula started calling her junior high school sister "Cher" because of her sister's interest in dressing like the singer). All of Paula's sisters enjoy talking. The sisterhood connection is such that they often communicate in fragments. Cher sits next to Damien on the couch and discusses current events, makes silly jokes, and laughs when he obviously understands and smiles. Sometimes he even chuckles when the humor dips to the adolescent level.