Author Question: Bone Infection after Orthopedic Surgery

Sarah Asks:

My character was assaulted and, among other injuries, her right forearm was fractured severely. It was surgically repaired using pins.

My question is: Is it possible for her to develop osteomyelitis after a blunt-force trauma (that does not result in a fracture) two years after the original injury? If not, is there another scenario that could cause osteomyelitis after the fact like that? And what would be the immediate treatment plan following the second injury and osteomyelitis? Also, if left untreated for a period of time, could osteomyelitis become life-threatening?

Jordyn Says:

The first part of your question does not seem plausible to me. First, you imply that there isn’t a fracture associated with the second injury to this arm and the length of time doesn’t quite work. The arm should be fully healed two years post surgery to repair the fracture.

If this character were to develop osteomyelitis near the site where she received a blow by a blunt object, but that arm had been previously fractured two years prior, I don’t see the medical staff thinking these two things are related. They are just too far apart.

I don’t know of another scenario that could cause this to happen two years out– that the blunt force blow (that doesn’t break the skin or cause fracture) somehow ignites an osteomyelitis at a previous surgical site. If it did, I think it would be considered happenstance.

Ostemyelitis generally happens when bacteria gets to the bone through an open wound (open fractures are a great way to write this complication) or the infection to the bone is seeded from another area in or on the body (a septic joint for instance). The infection will generally develop within two weeks.  Even in the article linked in this paragraph, chronic osteomyelitis usually develops within two months. Nothing even close to two years.

The course of treatment for osteomyelitis would depend on what bacteria (or fungus) is causing the infection. Surgery could also be indicated.

Yes, any infection can become life threatening particularly if the bacteria or fungus gets into the bloodstream.

Hope this helps and good luck with this story!

Author Question: Polar Bear versus Shoulder

Laurie Asks:

I’m a debut Christian romantic suspense author and I wondered if you could help me with a medical question.

My hero is mauled by a polar bear. He’s suffered a dislocated right shoulder, tearing of the ligaments, rotator cuff, and whatever tendons are in the shoulder and across his scapula. He’s got bite punctures on his upper arm, his right ear was bitten and repaired via plastic surgery. He’s got a scalp laceration with twenty-eight staples to reattach it.

My hero is an RCMP cop and he needs to get back to work.

Can you tell me what he’d have done surgically to repair the rotator cuff and ligaments? How long would he realistically be off work and need physical therapy?

Jordyn Says:

I reached out to Tim Bernacki, an awesome physical therapist, who rehabbed by own shoulder after I dislocated it. If you live near Castle Rock, Colorado check out clinic called Front Range Therapies. I highly recommend him.

Tim Says:

A massive rotator cuff tear (RTC) along with ligament tears and dislocation would lead to quite a surgery. One of a kind. The massive tears I’ve seen used multiple anchors (versus one or two for the “common” repairs).

Some of the massive tears also used either synthetic or pig skin patches because of the tear size. The ligaments would also need to be repaired with more anchors. This person would be in a sling with an abduction pillow at the side for probably eight to ten weeks (versus six weeks for the smaller tears).

Therapy could start earlier than when the sling comes off but would entail only passive range of motion (provided by the therapist). The tricky thing here is that if one portion of the RTC is torn, the protocol would incorporate stretching of that repair last in the sequence of stretches. Likewise, strengthening would incorporate moving in that one direction later than others.

With this person, all directions of movement would need to be respected. This person will need a truly great therapist, or I would expect them to get about eighty percent of their range/use/strength in the end. If all goes well, I would anticipate full range around four months post-op.

Strengthening would begin around three to four months post-op and could go on for at least three to four months itself. For full duty police work, minimum time from date of surgery to return to work I’d guess is eight months, but more likely around ten months. Most police officers return to working on restricted/light duty (if the injury was work related). Light duty is typically communications and/or desk work, working cold cases, helping with investigations, but not leaving the station.

Author Question: Rehabilitation after Gunshot Wound Injuries

Sean Asks:

Hi Jordyn!

Looking for a little bit of help with some 9mm gunshot wounds. I was going for non-lethal aside from possible bleeding out and injuries that would have long recovery time.

I have a character get shot at point blank range in the lower right abdomen from the front. Then in the right shoulder/clavicle, also from the front, about five to ten feet away, breaking the clavicle. Finally, in the left calf from behind from ten to fifteen feet away, breaking the tibia which is made worse when the shooter grinds his foot into it.

I’m guessing the shoulder/clavicle and calf/tibia would require a sling or cast and a serious amount of PT. The abdomen wound I’m guessing would require some reconstructive surgery depending on if and how much the bullet bounced around?
I figured it would take her almost a year to walk without assistance from those.  Am I close in that assessment? Thanks in advance for ANY help!
_______________________________________________________________________________________________

Jordyn Says:

 

Since this is largely a rehab question I reached out to Tim Bernacki, a great physical therapist, who I highly recommend from personal experience. If you live near Castle Rock, CO look up his clinic, Front Range Therapies.

Tim Says:

Generally, time frame of healing is 6-8 weeks for most things, especially soft tissue. All these injuries would require surgery. The clavicle fracture would require an open reduction/internal fixation (ORIF)—this means that there is an incision made and hardware placed to stabilize the fracture.

I wouldn’t know what is done if the clavicle is “shattered” and is in a multitude of pieces. The wound would have to be a glancing hit that results in a fracture. Anything more severe in the area could result in ruptured arteries, as well, and the person cannot die from this wound.

The tibia fracture also would require an ORIF—either plate, screws, or rod with locking screws. The difficult thing in all this would be that due to the leg recovery, the person will be using an assistive device, but probably cannot use crutches due to the clavicle pain. Perhaps a walker could be used. Depends on how conditioned the person is, how young, etc . . .

The leg injury would require limited weight bearing for 6 weeks I would guess. If all heals as expected according to x-rays, then they would transition into weight bearing as tolerated (WBAT). Probably would have a limp for several weeks after that. Likely wouldn’t run until four months following surgery if all goes well. The clavicle would probably have a sling for maybe 2-4 weeks (if no repairs to muscle or rotator cuff were done). After that, overhead reach would be most affected and for several months.

As for the abdominal injury, other than not bearing down with pressure for a short time, I wouldn’t think there are other issues to consider.

I’ve seen some gunshot wounds (GSW) where the bullet enters, hits a long bone, changes course and travels along the bone. This assumes the round is a practice round (full metal jacket) and not a hollow point. Hollow point bullets or defensive rounds open up when they hit something, resulting in a much-enlarged object/wound. I’ve seen rounds left in place because taking them out was unnecessary and I’ve seen rounds removed because of the location. Sometimes there are exit wounds and sometimes there aren’t depending on what stops the round. Sounds like there wouldn’t be an exit wound with the clavicle and leg but could be with the abdominal (perhaps in the low back).

Hope this helps and good luck with your story!

The Good Doctor S1/E5: Lying to Kids is a Good Thing?

When The Good Doctor starts messing with pediatric scenarios . . . well, I just cannot keep my mouth closed. You can see other posts I’ve done on The Good Doctor here, here, here, and here.

In this episode (spoiler alert!) Shaun is convinced that a pediatric patient, a boy around the age of fourteen, has been misdiagnosed with cancer. This patient first comes to the hospital for a bone fracture and Shaun goes in to consult. Shaun is over identifying with this patient because he looks just like his brother that died during his younger years.

Issue #1: A first year surgical resident consulting on an ortho case. There’s really no reason for Shaun to even be consulting on this case. An orthopedic resident, yes. If no orthopedic resident, then an ortho attending. But this is outside the realm for a general, first year surgery resident.

Issue #2: There is a tendency in these shows to separate parents from children during treatment. This is not really done or encouraged at all anymore unless the presence of the parents put the child at risk in some manner.

Issue #3: This child has had a cancer diagnosis for SEVEN months and his parents haven’t told him he has cancer. This is unconscionable. We don’t need to lie and hide the truth from children. They are so much stronger than we give them credit for! Also, this is highly unethical and would not be supported by any decent pediatric medical team. Great effort would be made to help the parents give their child this news.  It doesn’t benefit him or protect him to be told this lie. Plus, is he not receiving treatment? The episode proves this point when the patient tells Shaun he already knew he had cancer.

Issue #4: Because his parents haven’t told him, Shaun decides to without their permission. Again, we would work very hard to have the parents tell the child this news. It’s unethical for any healthcare provider to do this without the parents permission no matter what. So much would be done to help these parents talk to their son. I’ve never seen this happen in pediatrics . . . like ever.

Issue #5: In order to prove his alternative diagnosis, Shaun decides to perform a medical procedure on the patient without the parent’s consent. This is legally dicey and Shaun should suffer disciplinary repercussions for doing so.

Issue #6: A patient after having open heart surgery is in recovery with only an IV and simple monitoring. Any patient who has had open heart surgery will have a variety of tubes— like chest tubes. It’s not a simple recovery.

Are you watching The Good Doctor? What do you think of this surgical resident getting away with all these bad things without repercussions?

 

Author Question: Pediatric Fall From Skateboard

Carol Asks:

A four-year-old falls off a moving skateboard onto a driveway (no helmet, or pads.) Someone was doing something he wasn’t supposed to do.

This is what I’m proposing happens to this child.

Result: Greenstick fracture in one of the bones of the forearm and possible concussion?

Treatment: Cast in ER and keep overnight for observation? Possible sedatives or stronger meds (like codeine) for pain that may make her sleepy?

Follow: Specialist?

Jordyn Says:

Thanks, Carol, for sending me your question.

I’ll answer in the same way you sent your scenario to me with my opinion.

Result: Yes, greenstick fracture is good. You can hit the link for further information. However, we don’t use this term (as least not in Colorado.) We say “buckle fracture” as in the bone buckles or squishes a little. Bones in this age group are very pliable. This is a very common fracture in kids. The fracture is not a line crack through the bone. Concussion, yes. And you’re right– this kid needs a helmet on!

Treatment:

Splint in the ER. Casting is rare in the emergency department. The difference between the two is a splint only has hardening material on one side and is secured in place by an ace wrap. This leaves space for the injury to swell and can limit the potential for developing compartment syndrome— though that would be rare for this type of fracture. Casting has circumferential hardening material— usually something like fiberglass sheeting that hardens. Also, some providers are just placing a removable type wrist splint on these fractures since they are very stable and the child will usually self limit activities until the pain goes away.

I’m going to assume your child/character has a mild concussion. No loss of consciousness. No amnesia. Maybe a headache, nausea, dizziness, etc. We would not give any sedative or narcotics to this patient— for the concussion nor for the fracture.

Ibuprofen is the preferred drug of choice for the fracture and even for the headache that might be associated with the concussion. Some providers are against ibuprofen in concussion because of a concern for increased bleeding (ibuprofen makes platelets less sticky), but that’s with multiple dosing. We give Ibuprofen often to kids with head injuries and they do fine. Acetaminophen can be given for headache and it will help with pain from the fracture, but it will do little to help the swelling of the fracture. This is why ibuprofen is preferred for broken bones because it helps with both pain and swelling.

Assuming this child has a normal neuro exam and is at their normal neurological baseline (meaning, they are acting as they normally do at home)— then they would be sent home. There is no reason to obs this kid overnight.

Follow up: With orthopedics in 7-10 days for reevaluation of the fracture with cast placement. Cast would be on for 4-6 weeks.

Hope this help and good luck with this story.

Author Question: Medical Complications for Badly Broken Leg 2/2

Today, we’re continuing with Mareike’s question dealing with a character who has several medical complications from a broken leg as a result of a physical assault. You can read Part I here.

wheelchair-1629490_1920Today, I’m hosting Tim B. (my own physical therapist!) If you’re south of Denver and need an excellent physical therapist I’d be happy to refer you.

Here are Tim’s thoughts on the rehab aspects of this character. He also gives great insight into the medical treatment of such a fracture.

Welcome, Tim!

If a person has a compound, open, major fracture of the leg (the part between the knee and ankle), then the most likely treatment would be an ORIF (open reduction, internal fixation), or plates and screws. People with ORIF are then not given a cast.
If the fracture was comminuted (bone is fragmented versus a straight fracture), the typical treatment might be ORIF or an external fixator (halo). You can view this link for photos.

That person would then be non-weight bearing for at least 6 weeks (or more, depending on radiographic evidence of healing), then transitioned into partial weight bearing. They would use crutches or a wheelchair during the non weight bearing phase. The weight bearing phase would progress according to radiographic healing, more than anything else. There is no protocol, per se.

If a person is casted all the way to the hip, then there most likely would have been a fracture extending into the knee joint line, such as a tibial plateau fracture—which could be one of several fractures, including a compound fracture let’s say in the mid-shaft of the tibia/fibula.

Sometimes, an external fixator is applied (in the case of badly damaged and very swollen surrounding soft tissues). After swelling decreases, another procedure could take place (removal of external fixator and placement of internal plates/screws). A cast to the hip would not be used for a fracture below the knee, most likely. So the knee must be involved somehow for the cast to need to go all the way to the hip. Most people are issued a knee immobilizer after these fixation procedures. Perhaps in regions/countries where immobilizers and braces are not commonly found a person could be casted.

Compartment syndrome could be a result of the initial mechanism of injury—lots of soft tissue damage along with bleeding from the fracture—causing compression of the nerves and blood vessels of the leg. Or compartment syndrome might result from a cast that is too tight. Or a bedridden person who doesn’t move at all (same mechanism as a person developing a DVT due to lack of movement).

If blood vessels and/or nerves are compromised in the initial injury or by permanent damage from compartment/compression, the first attempt would be microsurgery by vascular/neurosurgeons to try and repair. Also, a release of the compartment would most likely take place.

Compartment releases are left open and frequent dressing changes take place until swelling comes down. It leaves a wide and long scar in the long run. It takes a little time to realize if it was successful or not (nerve and vessel repair). Perhaps a week later it would really be evident if the correction was successful, or if the leg/foot was “dying” due to lack of blood supply. Those dead areas would not be able to bleed, would probably start turning color, would start to smell, and might be numb.

PT would vary greatly.  Typically, non weight bearing to partial with appropriate crutch use while working the regions of the body surrounding the leg, including even the upper body for strengthening. Progression depends upon radiographic evidence of bone healing for the most part. Range of motion of the knee, ankle, and hip would be emphasized (for most people who have immobilizer but not casts).

Hope this helped and best of luck with your story!

Author Question: Medical Complications for Badly Broken Leg 1/2

Mareike Asks:

Greetings from Germany!

The character in question has several injuries, the most important of which is a severely broken leg (I’m talking cast all the way up to the hip). He got these injuries by being attacked and beaten up.

knee-1406964_1920I’m thinking open or compound fracture because then I can have him develop a bone infection. What I’m wondering is the order of things and how long it would take to develop what and how to recover, how long it takes, and so on.

I want him to either develop compartment syndrome and/or the above mentioned bone infection. From my understanding of the sources I’ve read, an infection can result from the treatment of the compartment syndrome, but not vice versa, so it would make sense to have that order, right? Those two are the main life/health threatening complications I could find while researching.

My ultimate goal is to write a story of recovery. Of the hardship, the struggle and pain, the setbacks. The physical therapy, the fear of whether or not he can go back to his old job.

Any resources you could point me towards when it comes to recovering from a very nasty break that might or might not require amputation or might lead to a disability would be greatly appreciated.

Jordyn Says:

Greetings from the USA! I’m going to give some thoughts on your question. I also consulted with a physical therapist since a large portion of your question deals with recovery and we rarely know what happens to patients in the long run.

I’ll give Tim’s thoughts on PT next post.

One thing I want to make clear is that treatment in the US is going to differ from medical treatment in Germany. If your novel is specific to Germany, then you really should run these thoughts by a medical person in your country. Some things should be similar, but some may also vary widely (like treatment of the actual fracture— use of fixators versus casting, etc.)

My first thought is it is really hard to get an open fracture of the leg from a beating. It’s not impossible, for sure, but we normally see injuries like this from mechanisms with a lot of velocity behind them— car accidents would be one example. So, sadly for your character, for this to ring medically true, I would probably add a weapon of some sort— like a metal pipe. And it’s more likely from repeated hits than just “one lucky” one.

The other thing is to understand the difference between compartment syndrome and the bone infection you mention which is called osteomyelitis. Compartment syndrome is a condition of swelling leading to a lack of blood supply. When you injure your body, it responds by swelling. Think of a sprained ankle.

Sometimes, this swelling can become so severe that is compresses on the blood vessels inside the extremity and either diminishes blood flow or cuts it off completely. This can be from just the injury, a cast or splint that is applied too tightly, or swelling after a cast was placed correctly.

Things begin to die when they don’t have blood supply. To alleviate the pressure, a fasciotomy is often done, which is a long cut through the skin and underlying tissue. It is a deep cut. If you Google pictures of a fasciotomy you’ll quickly get the idea. Not for the faint of heart. After this type of procedure, you have an open wound. Open wounds are always at risk for infection, but it doesn’t necessarily mean the bone would get infected.

Osteomyelitis is an infection of the bone. An open fracture (where the bone punches through the skin) can place a patient at risk for this type of infection. The dirtier the wound the more apt for infection. Wound infection does not develop immediately. Usually it takes 48-72 hours (24 hr at a minimum). Antibiotic therapy for osteomyelitis is extensive lasting 4-6 weeks. You can read an overview here.

Also, here is a link that deals with treatment of compartment syndrome.

With these injuries, coupled with the  added complications of compartment syndrome, fasciotomy, and/or osteomyelitis (or some other infection), your character is looking at 2-4 weeks in the hospital. He would likely go home on oral antibiotic therapy for his bone infection.

He’ll also need extensive rehab which Tim will highlight next post.