Ms S was in Chicago when she was involved in a low-speed road traffic accident in a taxi. She was taken to the local trauma centre and had a full range of scans, which found that she had a proximal humerus fracture (a break in the upper part of the bone of the arm).
A friend who had broken her wrist referred Ms S to Mr Noorani. She had been very happy with his treatment and thought he could help Ms S.
When Mr Noorani examined Ms S at her first appointment, he found her shoulder function was limited and she had quite severe bruising, which is to be expected three or four days after an injury. Luckily the rest of her upper limb was fine, with no hand, wrist or elbow tenderness and her range of motion of these joints was normal.
Mr Noorani’s opinion was that Ms S’s fracture would not need a operation, however he arranged a CT scan of her arm and shoulder with 2D and 3D reconstructions to confirm this was the best course of action.
These scans revealed that Ms S had a three part proximal humerus fracture. The head and the lesser tuberosity (at the font of the humerus) appeared to be in one segment of the break, whereas the greater tuberosity (the prominent area of bone at the top of the humerus) was fractured and fragmented. There was also a fracture line going across the shaft of the humerus.
Ms S summarises this first appointment: “Frankly, I wasn’t really sure what to expect. It was the first time I’d broken a bone, so I was a little frightened. Mr Noorani spoke very clearly about the injury and what the recovery process would be like. He told me about what I should be doing and what to avoid.”
Sometimes, Mr Noorani does recommend operating in cases such as Ms S’s, when the fracture is significantly displaced or very unstable. For Ms S, the displacement appeared to be minimal, although her fracture was likely to be an unstable fracture. He explained the risks and benefit of both non-operative and operative intervention: “These fractures can result in significant stiffness but there is a risk of non-union as well as malunion that in some cases can be improved by an operation. There was also a risk of avascular necrosis (AVN – death of bone tissue due to interruption of the blood supply) due to the nature of the injury. If Ms S did get AVN, there was a possibility that a shoulder replacement maybe required in the future.”
In the short term, Mr Noorani advised Ms S to use a sling to allow the fracture to settle for the following 5-6 days to see if the position improved and more importantly it did not displace into a worse position.
At their subsequent appointment, with a review of Ms S’s X-ray, the fracture looked better. Overall, there was better alignment of the bones and the shaft in the greater tuberosity was in a good position. Ms S was no longer on pain relief and she was feeling good about her shoulder. The bruising had settled down as well, and Ms S’s hand, wrist, elbow and neck range of motion was good. Naturally, moving the shoulder was a bit uncomfortable, but Ms S felt that her shoulder was sitting correctly in the joint and she was not in any discomfort when not moving her shoulder.
Mr Noorani showed Ms S some other exercises to do, including pendular exercises. He suggested that Ms S keep the sling on most of the time, but she was able to remove it for a few hours a day in controlled environments to do her exercises.
A week later and reviewing further X-rays, Ms S’s shoulder was feeling comfortable. These latest X-rays showed that the overall position of the fracture remained good. At this point Mr Noorani recommended that Ms S begin physiotherapy with Chris Jones at Isokinetics to relax muscles of her pectoralis major (major muscle in the chest) and encourage some gentle rotator cuff mobilisation (a tough sheath of tendons and ligaments that supports the arm at the shoulder joint).
A further 2 weeks on and 5 ½ weeks after the accident, Ms S had a lot more movement in her arm and it was clear that the physiotherapy and hydrotherapy was helping, not only to achieve better movement but also to help to relieve some of the pec. major spasm she was getting, as well as to help activate the rotator cuff. This meant that Ms S’s shoulder was now sitting in a better position, which was confirmed via an X-ray.
Ms S’s shoulder was no longer as dislocated as it was in the previous X-rays. Over the series of X-rays, the position of the shoulder had improved. The fracture fragments were in a good position with some evidence of early bone formation.
From this point onwards, Mr Noorani and Ms S discussed a programme to slowly wean her off the sling. Over the next two weeks, she was recommended to use the sling less often, for example when she was at home to see what she could do without it. She was asked to concentrate on movement to push towards active assisted and then active range of motion as long as she had good control of her rotator cuff muscles and it was relatively pain free. However, to limit as much stiffness as possible, her rehab in terms of stretching exercises as well as hydro, were to continue.
At eight weeks, at their next appointment, Ms S’s condition had improved considerably. At waist level she had excellent passive and active range of motion, albeit with some stiffness and weakness. She had very little pain and Mr Noorani was very pleased that her function was so good considering it was only 2 months after the accident.
An X-ray showed further bone formation over the fractures, which was pleasing at such an early stage. Ms S no longer needed the sling, however was recommended to do her own exercises at least five or six times a day as well as continuing with physiotherapy twice a week. She needed to improve upon the stiffness, especially in elevation and pulling her arms out to the side.
At 3 months, Ms S was continuing to do really well as Mr Noorani explains: “I really have no concerns about Ms S’s progress, and she is doing better than most people at this early stage from a significant injury to her right shoulder. She should continue with her shoulder rehab and it is likely that she will see Isokinetics for the next three to four months, followed by a maintenance programme. From my side, I would like to see her in another two months’ time, with repeat X-ray of the right shoulder on arrival. Hopefully at that stage, we will discharge her. There is a small possibility that if there is a mechanical block to abduction still apparent in two months’ time, we will get a scan done to confirm the integrity of the cuff and to see if there is any mechanical impingement this is unlikely to be the case. She appreciates that most people at three months have a slight resistance to abduction, due to the stiffness and this usually settles down with time.”
Ms S says: “Mr Noorani referred me to a team of physiotherapists who he worked closely with on my specific treatment plan. I had a goal and we were able to achieve it with lots of physio and close monitoring. It’s been eight months since the accident and I’m ahead of where we all had expected that I’d be at this point.”
Her advice to other patients: “Understand the process and the timescale to recovery. Follow the advice of Mr Noorani and his associates. Don’t rely upon medication unnecessarily.”
She concludes: “Sometimes out of bad situations we learn and grow. This was one of those. Mr Noorani helped me recover quickly by helping me understand the healing process and what would be required of me. I am actually stronger now than I was before the accident.”