Any orthopaedic surgeons / consultants in the house?

[jmsgld]

My mother tripped (dark, unexpected chair) and fell from standing the other night. She has broken her right arm rather badly.

I spoke to her shortly after returning from A&E and she reported " proximal humeral fracture with multiple fragments and significant displacement", unsure whether the head is involved. She returned 3 days later for re-assessment, and now has a cast and a brace, with an expected recovery period of 4-5 months. Rads only, no CT. This was 1 week ago and she is still in debilitating pain despite the Oromorph and NSAID.

She is mid 60s, slightly frail for her age with some degree osteoporosis likely. She has Bupa cover but doesn't like to make a fuss.

I am a vet and have not seen the rads, but my thinking would be a CT to fully evaluate, and that from the description it sounds likely surgical rather than conservative.

Am I way off the mark here or should I suggest that she seeks a second opinion via Bupa?

I am never sure with the NHS if they are too influenced by cost / fear of being sued if complications arise, or if this is genuinely considered best practice?

[The_Doc]

Did she see a shoulder/elbow Consultant in Fracture Clinic?
Why do you doubt the plan she's been given? Could you ask that the plan is run by an NHS shoulder specialist?
We never make plans with money in mind, it's just the press that's obsessed with money in the NHS
Would you accept it if she never regained *full* function, even if it was impossible to?
Is a more complex plan with an operation worth pursuing if the risks of anaesthesia or infection are unjustified?
Is a CT going to show anything that plain films do not? Often it doesn't.

I can't answer these questions, but this is what I consider in my fracture clinic with 3 or 4 part Neer fractures

[jmsgld]

Thanks for the response. I was really querying whether conservative management was considered best practice for Neer 3-4.
I hadn't checked pubmed at the time of writing and was reassured after reading a couple of meta analyses. I fully appreciate that this kind of damage is unlikely not to leave some lasting problems, although I had hoped that meaningful function was likely to return.

Unfortunately my fears were however justified, the fracture is now open and has likely been for a few days. I maintain that CT should be minimum database for fractures of this nature. I am lead to believe that just a single AP was taken at day 3 although I find this hard to accept.

Surgery is booked for tomorrow, several orthobods are now involved / aware. Any ideas on complication rates for implants on 3-4 day old open fractures in people? Animals always seem far better at resisting infection than people.
I know it's "how long is a piece of string" , but any ideas on expected time as an inpatient? eg minimum 7d IV ABs etc?

Thanks, James

[The_Doc]

Impossible to comment on this, I'm afraid. Too many variables. Gustillo and Anderson Grade 1 fractures don't usually get infected, but add in arthroplasty and I really couldn't say.

I wish you and her the best

[jmsgld]

Thanks. I know, far too many variables. I suspect we are a long way from Gustillo I sadly. The fracture happened 10 days ago and has been open for up to 7 days now. I can't imagine the soft tissue, let alone the exposed bone, is overly happy. I am at least reassured there are now multiple consultants involved.