Long term care for proximal humeral impaction

[Teasip]

Elderly mom fell at ECF Thursday and was found to have the familiar horizontal plane impacted proximal humeral fracture near the greater trochanter (I was able to see the digital image upon a polite request of the ED physician, but only briefly). Based on my recollection from 26+ years ago, though I have seen quite a few in the ED in subsequent years but only in the acute phase, the long-term care is basically to watch for evidence of potential AVN but otherwise let it heal with usage of a shoulder immobilizer. Am I recalling this correctly? Unfortunately the source for the fall is the more chronic concern due to a polymyalgia/MD disorder that predisposes to falls. Inability to rise from a seated position due to proximal muscle weakness in the UE/LE's is not fun, thus motorized chairs/scooters are not an option and obviously bed confinement is not an option until it becomes a last resort. Since ambulation is with walker assistance only, both arms need to be functional which obviously will restrict her mobility at this point for quite some time (x-ray evidence of osteoporosis). For those inquisitive folks, check out inclusion body myositis.

 

As an aside, a long-term referral group that I have sent an unknown number of insured cases to for over a decade declined to see her as a result of a request for ortho/PM&R consultation (I suspect that they didn't want to deal with it since she would also warrant stretcher transport to/from office). Needless to say, no further referrals to that group (the request for appt. I was told went through the requested orthopedist's "team" (PA who I don't know and I suspect didn't confer with the orthopod). I never made mention of my position or history of referrals to the group. Now, I guess I'll go ortho first, ask during appt. if they feel a rehab hospital assignment would be beneficial, and then go forward from there. What she really needs is a motorized wheelchair with a powered seat lift like she has on her room recliner.

[rcdavis]

teasip,

 

so sorry about your mom.

 

you got it right:

immobilization (though most do better with a hanging cast than an immobilizer).

 

unfortunately the gold standard tx for pmr seems to be glucocorticoids,, which of course worsens the osteoporosis, and the cat starts chasing its tail... (also interfrers with fx healing)

 

the powered "recliner-wheelchair" idea is the answer.. along with maybe in home care during the 8-12 weeks of recovery.

 

My opinion is that the shoulder rehab should start after the fracture heals, but that she should be doing some sort of lower body strengthening and stretching now so avoid deconditioning.

 

Start with the ortho, if worth their salt, they will integrate the rehab.. and authorize the home vistis, etc.

 

good luck

 

are you near forsythe? If you can get there, Mike Laughenberger is probably the state's best shoulder guy.

 

rc

[Teasip]

Thanks for the confirmation RC. When first diagnosed back in the late 80's on peroneal bx., treatment recommendation for IBM (my acronym) were gc steroids, which she deferred on. Literature since then however has suggested that risks outweigh benefits (smart decision on her part looking back). I agree with the therapy idea once we can get past the initial pain of the acute injury. Home health through the ECF will have PT/OT return for follow up but obviously there is no PT at this point for the actual shoulder but more for the remaining extremities due to immobility (we/she can sit her up on side of bed to at least minimize tissue pressure points) and frankly not much need for OT since she can feed herself with her dominant arm/hand (silver lining at least). We could also stand her at bedside if we had a point of contact for support on the left side.

 

It is a horrible disease state. She has now developed the dorsal deviation of her hand digits and MCP variations of the hands such as one sees with RA making grip strength minimal at best. It also impacts esophageal motility so a "big bite of burger or steak" is not practical. She leaks CK like a sieve, especially following falls or even manually trying to just stand her up from a car seat to an upright position due to muscle strain to her system (we don't even bother with this any longer). When you factor in neural hearing loss and macular degeneration it really minimizes the overall quality of life for her, but to her credit she doesn't complain. It's a shame that one can assist all those other folks over years of practice yet you cannot help those closest to you other than providing emotional/moral support, but that is life itself. At least I can help her navigate through the system and check things that others might miss out on (they never checked her nasal septum for hematoma though the ED physician said she "broke her nose" so I checked before her discharge). Having dodged the need to focus on billing and the inherent Medicare billing/payment restrictions over my career it is interesting to see now from the patient perspective just how messed up the system is ("she can't be seen by two doctors on the same day" even though common sense says she requires stretcher transportation so you're saving one round-trip by completing your consultations this way at one location with only one trip as opposed to two). She is just down the street (quarter mile) from my home here in N. Texas.