External Fixator: IN - Internal Fixating Plate: OUT

Well, it's in/on, whichever way you want to look at it:

Last week I travelled to St Thomas' Hospital in London to have my infected non-union treated and operated on first thing on Tuesday morning. As my previous post detailed, this was meant to be a pretty hefty bit of surgery, removing my plate, debridement of the fracture site (which I learnt meant trimming the bone down on each side and re-setting it, which would result in a shorter arm!) and application of an external fixator as modelled above by yours truly.

The good news I was given on the Wednesday morning during my surgeon's rounds was that the situation inside my arm was not as bad as originally anticipated. Usually, according to him, you see tracks of infection leading into the bone where the infection has taken hold... which weren't present. The bone that had started to grow to try and unite the fracture was actually in very good condition and looked healthy. For these reasons, they removed some bad scar tissue and infected tissue, took out my plate and screws and stitched me back up... no debridement! No short t-rex arm! They then made the four incisions for my four lovely pins and bolted my arm together to stabilise the fracture... job done.

I was discharged later that afternoon (not every 36 hours after the surgery started!) with a plethora of anti-inflammatories, painkillers and antibiotics... which, following the swabs which were taken on Monday, are the wrong type for the small infection I do have in the tissue of my arm (the bacteria is resistant to co-amoxiclav, apparently) so they just moved me onto Ciprofloxacin (try saying that five times quickly whilst pissed, I dare you!) to clear that up.

All in all, I'm hoping this is the final straight home!

Infected Non Union of my Broken Humerus

It has certainly been a funny few weeks. We started off with a scheduled appointment with a doctor at the Nuffield Orthopaedic Centre, then it was switched to Stanmore, which was a mistake, and was meant to be UCLH. So imagine my surprise last week when I got a second letter from a hospital in the UK confirming an appointment date in very short notice!

UCLH had confirmed that I had an appointment for the 24th of November to see a specialist there in writing, which I had received on Monday. Thinking that was quite a wait until I saw a doctor again, given the fact that my scar from surgery was still weeping, I arranged an appointment with Mr Surgeon Man's replacement for the Wednesday to get things checked over. However, on Tuesday evening I received another letter, this time confirming a consultation with yet another surgical specialist, at Guy's and St Thomas' Hospital in London for Thursday the 20th of October... the very next day. 

Armed (no pun intended) with this new information, and with the prospect of possibly getting the mess that is my arm seen to sooner rather than later, I saw Mr Replacement Surgeon Man and asked his opinion. He was horrified having seen my arm for the first time and agreed that seeing a specialist as soon as possible was probably the best idea, as in his opinion, I had what looked to be an infected non-union. This was coupled with the fact that my latest set of bloods and swabs had shown signs of infection also. A quick discussion with the surgical team secretary and with the sponsored patient people and I was booked on a flight, along with my old man for support/company, that evening, to attend Guy's the next day.

After being seen by an assistant to the chief upper arm consultant and sent for some xrays, Chief Upper Arm Consultant Man gave me the news:

1. I have, without much doubt, an infected nonunion of my humerus fracture
2. All the metalwork I currently have inside me needs to come out
3. The whole area needs "debridement" with samples sent to test what bacteria is causing the infection
4. I will be placed in an external fixator which will hold things in place until they finally heal
5. This is going to take at least 6 months

So I'm back to St Thomas' two weeks today for an operation on the 8th to have all the above done... but, in a weird way, Mr Replacement Surgeon Man's tact and manner have already calmed me down. He was apologetic for the way things have gone up to now, when he has only just seen me. He was reassuring yet honest, by giving examples and success rates they've had with this technique in the past. 

So, back to square one, as predicted when I first started the blog exactly 2 months ago... I've still not done the back dating of surgery number 2 and the huge pus-filled cyst, but I will get round to it, I'm sure!

Surgical Wound Weeping

Having found out that I was not to be seen by another doctor until the 24th of sodding November, I took it upon myself to have my non-united humeral fracture and its still leaking, weeping wound seen to.

My scar never fully healed over from the original humerus surgery and as such, continues to leak/weep on a daily basis. Due to this, the chances of infection are quite high, so I need to be very careful to keep it clean, etc. This means I have not been able to swim all summer, I've not been able to go to the beach without having it carefully covered. Nor have I been able to do any exercise as sweat running down and into an open wound is never a good idea... hence my expanding waistline!

I saw Mr Surgeon Man's assistant as the new surgical consult/locum wasn't available to see me, and yet again, expressed my concerns about my arm, the weeping, etc. Whilst he went off to get a testing kit, to check for infection, I took the following photo...

Yeah, nice work! :(

Finally have my date for surgical consultancy at UCLH

24th of November... Words cannot describe how that short phrase made me feel. Sick to the stomach that I would have to put up with the constant pain, aching, discomfort and restriction until at least that day before I'm seen by my new consultant at UCLH. Alas, that was the date that was confirmed, and I now have to wait until the Orthopaedic clinic at UCLH sends over more paperwork so I can begin to get my flights and accommodation booked with the Sponsored Patients department at the GHA.

This, coupled with the news I recently had that Mr Surgeon Man is to leave the hospital, has really brought everything to a head... Pissed off :(

UCLH, Not Stanmore - Getting wound up now!

The words "brewery", "up", "in", "a" and "piss" came to mind yesterday morning. It had been far to early a start what with having to be in the office for 4am for what was eventually a waste of time, so I was already proceeding at quite a pace from "grumpy" to "peeved" and eventually on to "pissed off". The 9:20am appointment with Mr Surgeon Man resulted in a number of admissions, namely:

1. I am no longer seeing Mr Specialist Man at the Royal Orthopaedic Hospital, Stanmore - that was a mistake, he is actually at University College London Hospitals centre in Euston (funnily, even closer to where I used to live in London - a mere 3.6 miles!)
2. Mr Surgeon Man is leaving the hospital as is to be replaced with a doctor with a pretty horrific reputation as he is returning to work in Gibraltar

Now, I can forgive the mixup with the hospital in the UK, it happens... but point two above needs clarification. This is not just some idle slander, this is documented and well known within the local community. There is a great case study here where a patient originally treated by this surgeon went through hell for a broken femur and was eventually fixed properly at a specialist centre in the UK. Which one? Nuffield Orthopaedic Centre in Oxford.

Needless to say, I will be declining treatment by said doctor and have already begun arrangements to continue seeing Mr Surgeon Man privately upon completion of my consultation (and, if required, surgery) at UCLH.

Change of plan, off to the Royal Orthopaedic Hospital, Stanmore

Contrary to last week's post where I was planning to visit the Nuffield Orthopaedic Centre in Oxford, a little bit of internal hospital politics has gotten in the way at the GHA and I'm now going to the Royal National Orthopaedic Hospital (RNOH) in Stanmore, Middlesex... only 10 miles north from where I used to live in London - familiar-ish surroundings at least.

As for the shitty politics, to save going round in circles, the issue can be summarised as follows:

• Mr Surgeon Man knows Mr Specialist Man in Oxford and has referred patients there in the past
• Mr Specialist Man looked at my xrays and case file and decided he needed to see me before making a decision on best course of action
• Mr Specialist Man arranged for an appointment for me at his clinic at the end of October
• Mr Surgeon Man gave this info to the "Sponsored Patients" Department in Gibraltar
• "Sponsored Patients" declined to send me to Oxford... reasons for which are unclear, but I have deduced thus far that it's something to do with cost and/or the fact that they don't have SLAs in place with this centre
• Mr Surgeon Man fought my case with Mr Director of the Hospital Man who refused and told Sponsored Patients to find an alternative
• RNOH is said alternative

I have yet another appointment with Mr Surgeon Man tomorrow where I'll hopefully find out when I'm going to London.

The saga continues...

Off to see a specialist at the Nuffield Orthopaedic Centre

Yesterday I received a call to let me know that I would be going to the Nuffield Orthopaedic Centre in Oxford to see a specialist in non-union of fractures (hereby referred to as Mr Specialist Man). My appointment is scheduled for the 28th of October and I need to go and see the sponsored patients department at hospital to sort out my travel arrangements, etc.

As the Gibraltar General Hospital is just that, a general hospital, anyone requiring specialist care gets referred to a specialist centre such as the NOC in Oxford when their care requires it. As we have a general medical scheme here which means we get medical treatment covered by taxes and social insurance, etc, the Gibraltar Health Authority pays all expenses associated with travelling to see your referred specialist... kind of like going privately, at no expense to yourself.

For now, I only have a consultation to attend in Oxford as Mr Specialist Man wants to see me personally before he decides on a course of treatment... that will be a full 7 months since I originally broke my humerus.

Non-union of my fractured humerus

To be approaching the end of the fifth month after having broken your humerus (following two operations that required general anaesthetic and overnight stays, some day surgery to remove some internal stitches - agonisingly painful without any anaesthetic at all, various trips to physiotherapists and occupational therapists, plastic braces, 6 screws, a titanium plate and more painkillers and medication than you can shake a stick at) and be informed that you have a non-union of your humerus fracture and the metal might need to come out, is pretty soul destroying... Today has been a shit day, summarised below:

Non Union of a Humerus Fracture

When the first words out of your surgeon's mouth after seeing your latest xray are, and I quote: "ohh, shit", you know it's going to be a pretty bad day, especially considering I was only meant to be having the last of my stitches out today. If we take the xrays I had taken on the 27th of July:

with today's:

we can see what the surgeon referred to as non-union and collapse of the fracture site. He quickly gets another surgeon and colleague of his in to take a look and the general consensus reviewing all xrays is that I either have an infection in the bone or my body is rejecting the screws/plate... either way, not good and in all likelyhood the metal is going to have to be removed in a third surgery and I'm going to be back to square one.

For now, I am back in a humerus brace to stabilise the fracture whilst my notes and xrays are sent to a specialist in non-union of fractures in the UK for him to review... great.

Humerus Fracture Operation - Getting My Plate

There are two main forms of reconstructive surgery for a broken humerus that I had explained to me, a humerus rod and a humerus plate. The general gist of each operation goes as follows:

Humeral Rod

This procedure involves drilling through the upper arm and clavical to open up a gap so the rod can be slid down the inside of the humerus. Holes are then drilled through the humerus so screws can be affixed to the rod, securing the break

There is a great photo of the resulting effect on this press release, however, this involves further trauma in order to open up the bone to insert the device.

Humeral Plate

A humeral plate is simply inserted into the arm having made an incision between the bicep and tricep, avoiding the radial nerve and screwed in place to stabilise the break... as model by yours truly below:

Needless to say, the incision to insert a humeral  plate is pretty funky:

As the pictures show, my surgeon decided that not submitting my arm to the further trauma of a humeral rod was for the best and instead opted for a humeral plate. The resulting surgery took in the region of 2 hours and was considerably uncomfortable at first... no surprise there. The most uncomfortable sensation however, was nothing to do with my arm, but hip. You see, they decided that a bone graft was required to stimulate recover within the gap between the bones, and took a piece of bone from my hip, known as an iliac crest harvest. The resulting scar (don't click if you're squeamish) and the sore leg that came with it, were pretty horrific.

Plenty of morphine, tramadol, diclofenac, paracetamol and 3 nights in a private room (beats sharing with "the poor old dear who had obviously left her marbles somewhere back in 1973 who refuses to sleep" again!) and I was released with an appointment to see yet another professional who we will dub: Little Miss Physiotherapy.

Broken Humerus - Time For Surgery

It's hard to believe, approaching the day of my operation, that it has already been over two months since I initially broke my arm with little to no signs of real healing or union as the doctors like to call it. It's Sunday evening, I've been called in to St Bernard's Hospital (yes, the view is actually that nice, from some rooms!) a day early, as the Dudley Toomey Ward already has a bed for me (in a private room no less) and they don't want to lose it (to someone who requires overnight treatment comes in through A&E for example).

I'm issued with theatre stockings (help stop deep vain thrombosis (DVT) setting in) and a gown, offered a bite to eat and reminded that as of midnight there is to be no consumption of solids, and no fluid as of 7am... the fasting starts, the time for surgery is upon me!

7 weeks in a humerus fracture brace - Surgery time!

A couple of nights after the brace was put on and the nice night's sleep with Mr Surgeon Man's prescription for diazepam I was out of hospital, and the next 7 weeks basically followed a pretty structured pattern:

1. Go see Little Miss Radiology or one of her associates on a Wednesday
2. Go see Mr Surgeon Man at the fracture clinic to analyse Little Miss Radiology's pictures
3. Renew my co-codamol and tramadol prescriptions
4. Carry on my day and return the following Wednesday

However, by week 7, with no signs of unison were visible in the fracture area, I guess fixing a broken humerus is harder than originally anticipated... surgery is scheduled for June 6th (a full 9 and a half weeks after the initial break) to insert a titanium plate into my arm. The parts are ordered, I have some pre-surgery tests for infections, that sort of thing and sent on my way, to return first thing on the Monday morning to finally get this sorted!

Hurrah!

Post-script edit:
My broken humerus was sure causing some funky bruising in my lower arm during those 6 weeks:

Broken Humerus - First Day In Hospital

The problem with breaking your humerus, isn't so much the break, it's how to fix it (this is going to become a running theme!) quickly and effectively... how to reduce the pain and discomfort, stabilise the break so it can heal and return the patient to as close to 100% mobility, functionality and range as possible.

A visit from the consultant orthopedic surgeon was the first order of the day. Mr Surgeon Man (no permission to name him has been obtained so I won't break privacy laws) is a renowned surgeon in his field and after reviewing my xrays decided that a humerus fracture brace would be sufficient to restrict the fracture and hold it in place so it could begin to unite. In his words, I had a "clean, mid-shaft fracture of the humerus" which was a "perfect candidate" for the use of a brace and therefore avoid surgical intervention.

Brilliant, get me fitted and get me out of here away from "the poor old dear who had obviously left her marbles somewhere back in 1973 who refuses to sleep".

Not bloody likely.

You must take note that at this point my arm from about 2 inches below the shoulder, is hanging by muscles and tendons, being supported by a backslab cast and some bandages, and that's about it. Any movement of the arm is going to cause raw ends of broken bone to rub against each other, and that's a one way ticket to PainVille right there.

Enter: Mr Occupational Therapy Man who has come to fit me with a brace. Two pieces of moulded plastic which compress everything in your arm, thus holding the bone straight to encourage union, as modelled below:

Those who are interested, there's a blurry picture of my own modelling of said brace here.

The process went something a little like this:

1. Remove backslab cast
2. Support arm from elbow to minimise disruption of the humerus
3. Try not to passout from pain
4. Request to sit down as pain is too great and starting to get that dizzy, room spinning feeling again
5. Wait a while
6. Go for it, slide both slabs of plastic around the arm
7. Tighten
8. Try, again, to not pass out from pain
9. Success

Time for a mix of Diclofenac, Tramadol and Paracetamol IV and back to sleep I go... what with the sleepless night, rest was well received.

I'm woken later that afternoon by Mr Surgeon Man who informs me that another night stay is probably for the best... I inform him that a change of room or a prescription for sleeping medication is probably for the best given the other inhabitant of the ward. He agrees, at least sleep will come easier tonight...

Broke My Humerus

Day One

With 10 minutes left to go of a game of rugby versus HMS Monmouth, a tackle which was clean in every way possible resulted in a mid-shaft fracture of my left humerus. If the prop who smashed me ever reads this, I hold no grudges, and actually kept my shirt which they had to cut me out of, in case the ship stops back in Gibraltar after your six month tour of the Gulf... Would be a great souvenir for the ship's club house (galley) and definitely beats one of those silly ties we usually give out!

I knew something was up from the second I found myself laying on the floor. The pain hadn't kicked in yet, but as far as I could tell my elbow and shoulder were relatively straight... so why was my hand under the small of my back? Had I dislocated my shoulder? My elbow? I tried to move my arm and realised it was excruciatingly painful so actually used my right hand to pull my left arm out from underneath me - and that's when the shaking started.

The pain was like nothing I have ever experienced and the resulting surgery comes a modest second in comparison. It wasn't sharp, or dull... it was hot. I remember repeating to the nurse or doctor from Gibraltar's PRMC (fortunately located right beside the rugby pitch) who had kindly sourced some entonox that it felt like my arm was on fire. The slightest movement stoked said fire even more.

A slow ambulance ride to Gibraltar's St Bernard's Hospital (not wanting to move me about to much) after the mission to get me from the ground onto a trolley and into the bus with only some more "gas & air" to alleviate the pain (the ambulance crews out here are not allowed to administer anything stronger) gets me to A&E to be assessed. More pain as some idiot pushes on my mangled, broken, floppy arm to help move me from the ambulance trolley onto the bed in A&E and my body finally gives in and goes into shock.

Blood pressure plummets to 72/50, the room is spinning, I start to feel sick and ask, nae plead, for some pain relief. "Not until your BP is up a bit". The bed is tilted with my feet raised to try and help bring it back up to "not quite blacking out" and finally we get some analgesia, couple with a backslab cast and a bed in the ward for the night opposite some poor old dear who had obviously left her marbles somewhere back in 1973 who refused to sleep.

Didn't even get a post match pint.