1983...The Shoulder Bone is Connected to the Wrist Bone...

Getting Old Catches up With You...Sometimes Not So Kindly!

My New Arm...the Ulnar Shortening Osteotomy

How it all began, we think...

Growing up in Connecticut, we always hit the slopes at Big Bear (now known as Thunder Ridge Ski Area) just across the state line in New York.  As most middle-school boys do, there were always people (aka girls!) to show off for.  Unfortunately for me, an over-the-head tumble on one of the Black Diamonds trail in 1983 landed me in the lodge and at the doctor's office on the following Monday.  

This was before the wide-use of MRI for tendon/ligament imaging, but the X-Ray was normal, probably just a sprain.  In a splint for a few weeks and move on with life.  

Fast forward a few years (2020) and taking a fall during a trail run (Shoulder separation)- chapter two of my wrist problem re-emerges.  

Then Act 3- chopping wood in March of 2023 is when I really wrenched my wrist sent me over the edge in pain and swelling.  Urgent care- X-Rays, once again, were negative, only a splint for a few weeks and move on with life (Sound familiar?)

I am sure 32 years of Army Physical Fitness, and millions of push-ups did not help!!!

This time, however, it was recommended to follow up with my PCP and possibly an Orthopedic hand/wrist specialist.  

So, June 2023, I started down the journey of trying to avoid surgery.  Multiple steroid injections,  wrist Occupational Therapy, and more splinting.  When all that was futile, we finally MRI, X-Rays, and wrist fluoroscopy in January 2024.  

The wrist fluoroscopy was pretty cool- under the scope, the Orthopedist could move the wrist and see how the joint and ligaments moved together- or didn't!  The pain corresponded to where the underlying problems were. She was able to diagnose that I had a few torn ligaments (Scapho-lunate ligament) an ulna that was too long and grinding against the Triquetrum and Lunate. 

Bottom Line- over the years the Triangular Fibrocartilage Complex (TFCC) was torn and worn around the edges:  starting way back in 1983 and the final tear caused the final tear and problems today.

My X-Ray showing the 'Ulna Positive Variance' of ~5mm.  The Radius and Ulna should be at the same level- but my Ulna was (now IS) longer.  Over the years, this caused the Ulna to keep rubbing and tearing the various ligaments/tendons/cartilage.

There are two diagnoses that I had:  Ulnar Impaction Syndrome and an Unstable Distal Radial-Ulna Joint.  

SOLUTION:  two-step approach:  

    1.  Arthroscopy of the wrist joint to actually see what is going on and clean up the tears and stitch the             TFCC back where it belongs.

    2. Shorten the Ulna so it is level with the radius so that it won't tear the TFCC again and realign with             the other wrist-bones.

Before the Ulnar Shortening

After Ulna Shortening

This is the plate- about 4 inches long.

This surgery was a tough one.  Not only is it my dominant arm/hand, the 4 in plate and nine screws will alter how I work and get back to various activities.  Recovery will be long - 8 weeks in a splint and cast, then a splint throughout my therapy to regain strength and flexibility.

The short-arm cast I'll be in for six weeks.

Hopefully my appointment on January 27th, 2025 will get the cast off, and into a removable splint.  I'll start Occupational Therapy at that time and get back to a normal routine!  This is all dependent on bone healing at the osteotomy site:

You can see where the orthopedic surgeon cut the (diagonal line) bone with a screw across the gap.  This dark line (hopefully) will fill in as the bone grows back together.  He removed 4 mm of bone to shorten the ulna.

Keeping my fingers crossed that all goes well over the next few weeks.  

Perfect Timing

 

So, there I was...

 

 

 

 

Just cleared by the surgeon to begin full activity on March 9th, 2020.  I had one of the bone staples removed from my foot six weeks before, and had healed nicely.  I was ready to go and the first week of jogging was going well. 

 

Except that the gyms were closed due to the 'Wuhan Red Death' or the COVID-19.  On Friday the 13th of March, I was called up to work in the Pentagon as part of the Army's COVID-19 Response.  I was to be the Army Reserve's Medical Planner.  However, I was not anticipating being a victim of various Army/Defense Health Agency directives that I assisted in writing!  For I did not know how painful Monday, March 16th would be!

 

 

For on Saturday, 14 March 2020 a simple tumble while finishing my run would cause so much pain I would have to go to the Belvoir Urgent Care Center.  My foot was never in so much pain as my shoulder.  I tried to roll as my foot (yes, the one that is finally healed) got tripped up and I ended up right on my right shoulder.  The pain was so intense I had to keep from standing up for fearing of passing out.  I was close to home, and I knew something was very wrong.

 

 

It was/is a classic Acromion-Clavicular Separation (shoulder separation).  In the end, it is a Grade 5- the worst one can have without breaking any bones. Unfortunately, it was the first days of the COVID-19 response for healthcare facilities...so actual contact with a patient was minimal.  

Here is a illustration of a normal shoulder joint. 

Unfortunately for me, I was given a sling and given some drugs for the pain and told to make an appointment with my primary care provider.  At least there was no broken bones, just my collar bone sticking up. 

So, I showed up at the Pentagon that Monday in a sling and in a lot of pain!  But I managed throughout the days of a lot of walking (always a lot of walking at the Pentagon!).

As we have witnessed, the early days of the COVID response, all elective surgeries were cancelled/postponed and all visits were 'Virtual'.  And with my timing, it has been a very painful eight weeks.  I finally was able to get in a physically meet with my orthopedic doctor who said it was a lot worse than initially diagnosed in the ER- but figured that since there was no 'hands on' evaluation.  Again, bad timing!  He discussed in brief how he would recommend fixing it- since it is my dominant arm and still have to pass the Army's physical fitness test!  Basically I tore the Acromiclavicular Ligament and the Corcoclavicular Ligaments.  That's right.  All of them.  These are the ligaments that attach the clavicle to the shoulderblade- which explains why I have so much pain when moving my arm in any directions.  And only a surgical solution was the answer.  But...

Here is a picture of my Type 5 AC Joint Separation. 

 

There is always a but...Unfortunately, it was considered 'elective' and would have to wait.  So he gave me an steroid injection into the joint and told to take it easy and use the sling as needed.  I will have a follow-up at the end of May to discuss what is next and how to work in another 'surgery' with our busy schedules!

Good Bye Boot!

Good Bye Boot!

Finally.  After twelve weeks of Boot, Cast, Boot again, I can wear normal shoes again! 

 

 

It has been almost 16 months since my "incident". Since the end of July 2017:  This journey has been much longer than I anticipated.  The first surgery, February 5th, 2018, failed with the fusion screw started to separate and come out of the joint.  The second surgery, on September 20th, 2018, looks real good.

According to Dr. C, the new technique involved a little more work.  Three staples were placed over the fused joint.

 

 Also, the screw had to be removed.  Below is the picture prior to surgery showing the large gap between the distal and proximal phalanx.  Almost 1/8th of an inch, and it was getting worse along with pain. 

 

This procedure was far more painful all around.  It also included a solution of donor bone-marrow across the joint to enhance bone healing.  The staples on the top and sides of the toe are more painful as I can feel them under the skin.  Or it might just be in my mind!  Dr. C. said that the increase in pain over last time was expected, as she had to do more work in and around the joint to ensure this method was the last time.

 

And it certainly was.  It helped that once the stitches came out, I was in a cast for a month to ensure I didn't cheat and walk.  Although it was a pain not being able to shower, I believe it was worth it to ensure good healing this time around.

 

Now is the time to start recovering and walking with a goal to start a slow walk-run program in January.  Dr. C said that I would probably be doing the Swim Test for the Semi-annual Army Physical Fitness Test in April, with the goal to be back to full running by October of next year.

 

We will see.  At least I can wear both shoes now.

Great Camper for Sale! Has to go! Give me your best offer!

We have to sell it...

 

 

After a good five years of camping and enjoying our travel trailer, our next move does not allow us to keep our camper.  So, here it is!  It has been called our home on wheels, my camper "down by the river" or "Bachelor Pad" where I lived in it for a year while attending an Army school in San Antonio while the family stayed back at Fort Knox. 

 

INCLUDES:  Weight distribution system, hitch, anti-sway bar system, trailer cover, ladder installed to access roof, TV/CD/DVD/AM/FM entertainment system that swivels between main area and master area, microwave/oven/range, mid-size fridge and separate freezer, bumper receiver for possible bike rack, and plenty of storage.  One power slide out to expand the kitchen and sofa area.  Sleeps six comfortably- couch folds out and the kitchen table lowers with cushions for another bed.  Includes all hoses, cable cords, cleaning products, waste attachments, and other useful items.

 

Asking Price:  $15,500 or best offer.

 

2013 Coachmen Apex 288 BHS Ultralight Travel Trailer.

 

Length: 31 ft, Width 8 ft

Weight  Dry Weight 4,882 lbs.

Payload Capacity 2,118 lbs.

GVWR  7,000 lbs.

Hitch Weight 585 lbs.

 

Holding Tanks

Number Of Fresh Water Holding Tanks 1

Fresh Water Tank Capacity 50.0 gal.

Gray Water Tank Capacity  35.0 gal.

Black Water Tank Capacity 35.0 gal.

Number Of Propane Tanks 2

Number of Doors 2

Slideouts 1

Awning:  1, 16 ft. (192 in.)

Oven / Stove

Number Of Oven Burners 3

Overhead Fan

Refrigerator:  Electric / Propane

Aluminum Wheels

Two Axles

Battery Power Converter

Air Conditioning and Heating:  13,500 BTU, Ducted

It is currently at Fort Sam Houston, Texas. Contact me via e-mail at plymouthrock1969@aol.com.  If you want to see it and do not have access to Fort Sam, let me know and we can make it happen. 

 

Second Surgery

What Went Wrong?

New X-ray prior to surgery.  Taken on 13 September 2018.

Well, nothing actually went wrong.  Looks like the screw and my body didn't get along and was part of the 5% of the population that this procedure and device that had a mal-union.  Don't know why, but such is life.  By the time surgery came around, the surgeon could manipulate the whole joint, which is not supposed to happen.  The screw in the proximal phalanx (end closes to the mid foot) was moving around with each step, along with a corresponding painful reminder that something was wrong.

There should be solid white (bone) all around the screw.  It doesn't take a radiologist to figure out that there is a lot of gray and black (lucency) around the distal end of the screw.  For those carpenters in the audience, the screw stripped the wood and was not holding the two pieces together anymore.  Have to take out the old screw and find another method to hold the two pieces together.

What is Next?

This is the X-Ray right after surgery on 20 September, 2018.

Well, the solution was to use compression staples around the joint.  And this is what the joint looks like now.  Three staples, surrounding the joint.  Dr. C said I would have more pain all around the joint compared to the one screw down the middle.  She removed the screw and resurfaced the joint.  The staples are 'compression' and I think that these are the kind that are temperature-reactive.  Once they are removed from their storage temperature and achieve the designed body temperature range, the 'legs' contract providing constant compression along the joint surface.  

There is a big difference between the last post-op surgery X-Ray and this post-op X-Ray.  There is no lucency at all along the joint space.

However, the strange part of this is that she used donor-bone solution to bridge the joint gap and to fill in where the screw was located.  I was given a 'donor card' and the opportunity to write a letter of appreciation (anonymously) to the donor family.

Glad I kept these Gloves!

I am glad I kept these gloves, as I will need them again for the next three months.  These gloves are lifesavers as I get up and around.  I will say that this surgery was more painful than the last one.  But as my wife says, anesthesia wipes away a lot of the pain we remember, and that is true.  Anesthetic and the interactions with the Mind and Body is amazing.  

➢I remember waking up after surgery, but don't remember the X-Ray the took shortly thereafter.

➢I remember putting on my clothes and driving home, but not how I got from my bed to the car!

➢I remember talking to the nurses in the surgery suite, but not the trip from the pre-op to the surgery suite.

➢I don't remember talking at all in post-op, although my wife said I was carrying on a 'somewhat normal' conversation.  

I Love My Wife!

I cannot say this enough!  She has taken care of me now for the second time.  Of course, one could argue that our wives take care of us husbands since our wedding!  But she has waited on me  and helped me during both recovery times!  She is a true gift from God, and a true Proverbs 31 wife!

Second Time is a Charm (There is no Try, only Do!)

Here We Go Again, Same ol' Stuff Again!

Well, the revision surgery is this Thursday, 20 September.  Pain has increased over the past few weeks, and the X-Rays from two weeks ago, along with my pre-op exam with Dr. C shows why.


The joint that was fused with a screw is moving.  The joint move when I walk normally, which is not supposed to happen. 


The X-Rays show that the hardware is moving around: 


FINDINGS: There is no evidence of acute fracture, dislocation or destructive lesion. A single screw is noted through the first interphalangeal articulation. There is increased perihilar hardware lucency involving the screw within the distal aspect of the proximal phalanx of the first toe.


IMPRESSION: Postoperative changes. Increased lucency surrounding the screw within the distal aspect of the proximal phalanx of the first toe. This is suspicious for hardware loosening/osteolysis.


IMAGE COUNT: 3 Attention Patients / Service-members: If you have questions or concerns about the results in this report, Please contact your ordering provider or primary care team.


The surgeon said it is like two pieces of wood that are screwed together.  The screw is countersunk in one piece of wood, but the distal end of the screw is coming out and moving.  And when the distal end of the screw continues to move, it has to be removed and replaced with another type of screw or plate.


So, this time around, it will be a different fixation type- staple/plate/screw.  It all depends on what she finds when she get into the joint and removes the screw. 

Vegas Baby!

Based on my exhaustive research, there is a <8 30="" abuse="" after="" and="" closer="" diabetes="" did="" don="" drugs.="" factor="" failure="" for="" fortunately="" have="" i="" if="" is="" jogging="" my="" nbsp="" not="" obese="" of="" only="" p="" probably="" rate="" requires="" revision="" risk="" smoke="" soon="" surgery.="" surgery="" t="" that="" the="" then="" this="" to="" too="" type="" walking="" was="">

Doctor's Orders

This time I will be extra-conservative, and Dr. C is emphatic our plan of care will be, too.  I will be in a hard cast post-op and for the first six weeks of non-weight bearing.  I will not cheat!  I will not even do a toe-touch with the cast! 

Or Else...

Dr. C said that this is the last attempt to fuse the joint.  The risk for complications increases each time a surgeon goes in and disrupts the vasculature of the joint area.  So, this time it will work...

One Step Foward, Two Steps Back (Literally...)

8 June 2018:  Four Month Follow Up

So...I started physical therapy about a month ago with some walk/run on a weight-adjusted treadmill.  Along with the therapy protocol, I also began stretching and range of motion exercises along with the running/walking.




Unfortunately, my pain in the foot increased with increase in intensity.  Not good.  My orthopedic follow up was a month after I started PT, and Dr. C had X-Rays taken to see what was going on in the joint.  The concern was the pin-point pain I am having around the joint, which was different than the general aching of the whole area.  The latter is acceptable, the former is not!

A Little Knowledge is Dangerous!

I do have a little knowledge of medicine.  A little anatomy here, a little physiology there.  Just enough to be dangerous.  So, when the radiology report says the following:

"Postoperative changes as described above with interval lucency surrounding the screw within the distal aspect of the proximal phalanx of the first toe. An element of osteolysis/hardware loosening is not excluded. Follow-up is suggested."

Words that attract my attention:  Lucency, postoperative changes, and hardware loosening. 

Not Good.  At least I know why I am feeling pain.  When my amateur eyes look at the comparative X-Rays, I can see what the Radiologist is talking about.  I can also do basic math and I do know that after 16 weeks, broken bones should show healing with no Lucency or hardware loosening.



One Week Post Surgery, 16 February 2018

 

Twelve Weeks Post Surgery, 4 April 2018.

Sixteen Weeks Post Surgery, 8 June 2018

Radiologist's Report:  "Postoperative changes as described above with interval lucency surrounding the screw within the distal aspect of the proximal phalanx of the first toe. An element of osteolysis/hardware loosening is not excluded. Follow-up is suggested."

Bottom Line

There should be no light gray or black around the screw, and the joint space should show more bone-growth.  This is Lucency, and it should not be there!  The joint space should not be visible by 12 weeks.  When compared to previous scans, there are 'postoperative changes'.  Dr. C stated that if these findings bear out with further scans, additional mobilization of the joint or revision surgery to further close the joint space with additional fixation hardware. 

Ugh.  Dr. C made it abundantly clear that I was to do NO running and try to limit walking as much as possible until our follow up July 13.  She did say that I probably increased my activity too soon and aggravated the joint hardware area. 

I know this because there are several risk factors for fusion failure:  Obesity (No), Smoking (No), Diabetes (No), Questionable Drug Use (No), Premature Weight Bearing Activities (Yes, possibly). 

So, I will find out in July what the next 'steps' are in the road to recovery.