Two articles in two days? You must be kidding me. Does this doc not go to work? I thought that hospitals were short staffed! Maybe he’s doing the locum thing again.
I’m sat at home on a comfortable chair, drinking coffee and listening to some chilled out music. And reading furiously. Some writing. I’m afraid I can’t do much else because rest is the name of the game and crutches are just hard work!
Crutches?
Last week I decided to try to make some friends by turning up at a local fell race on Dartmoor. I should have known that gasping for breath running up and down hills isn’t the best substrate for conversation or making friends and that this would be a mistake. I also should have realised that falling over in front of everybody wouldn’t make the best impression either, but I did.
Descending in standard fell running fashion, arms windmilling with legs outstretched to grasp some sure-footedness over rocky paths, the trail I followed deviated left, steeply falling away down a loosely surfaced bank. Eyes up on the next obstacle, a river with some crossing stones, I can’t remember slipping or tripping as I made the turn. I remember flying when halfway down the bank, landing awkwardly on my right leg, the leg extended at the knee and flexed at the hip, my torso tumbling forwards over my hip. The momentum I had built up before the turn continued my trajectory to the floor, twisting my body from the hips as I fell. This is where a TV show would say ‘this is a reconstruction’ as I can’t truly remember the sequence of events, but I remember a stretch in my groin, a pop, some pain, and loud expletives as I bounced from the floor to my feet. Spectators were impressed but I was not.
Four days, one 11 hour ED shift, a couple of grams of paracetamol and a nice walk with my family later, I limped into my own Minors department to get an x-ray. It felt embarrassing to be the patient when I’m usually the doctor, but hey, medics need to stop fooling themselves by believing that they are superhuman. The next morning I was in a CT scanner, then in fracture clinic, then at home.
Anyone care to make a diagnosis?
It’s written below in white if you want to make a guess:
Right sided, non-displaced posterior acetabulum fracture
Here’s some imaging:
For non-medics, the acetabulum is the hip socket, where the head of the femur/thigh bone articulates with the pelvis. It’s a cup shape that faces slightly forwards and outwards and is lined with smooth cartilage to allow the femur to move easily within it. Acetabulum actually translates into Latin as ‘little vinegar cup’.
Around the rim of the acetabulum, where you would take a sip from a cup, there is a structure of springy elastic tissue called the labrum, that acts to disperse the pressure of the femur sitting inside the acetabulum when we load it by running or walking, but also to act as a valve to keep joint fluid in between the acetabulum and femoral head, and to deepen the depth of the acetabulum to allow the femoral head to sit with more stability.
My belief is that when falling forwards, the head of my femur distracted backwards – and either subluxed/dislocated and popped the rim of my acetabulum off. The rim probably has the labrum still attached to it. The articular surface doesn’t have a ‘step’, which means that the cartilage layer on the inside of the joint is likely positioned at a uniform level, maintaining a smooth-ish surface. Hopefully the labrum is still intact, but I will only know if it isn’t if I develop symptoms such as popping or clicking, or have a MRI.
This is a good outcome as cartilage injury risks early onset arthritis. A ‘step’ would mean a severely disrupted joint surface and would almost certainly indicate long-term joint impairment. The other way to look at this is that the fracture is well positioned and there is no need for surgical fixation (which would be a disaster for a speedy return to full function).
Plan
So, what’s the plan?
Here are the instructions from the (very considerate) orthopaedic team:
6/52 (6 weeks) of ‘non-weight bear’ using crutches to get around.
Off work/take it easy for 6/52, perhaps longer.
Please, please, avoid falling over or suddenly loading the hip.
Maybe swim after 2/52.
X-ray at 6/52.
Maybe partial weight bear e.g indoor bike at 6/52.
Maybe full weight bear at 12/52.
Maybe loaded/impact weight bear ~18/52.
Timeline
Monday was a shock.
Tuesday was a mental panic disaster – a whirring medical mind fraught with short term complications, long-term outcomes and not knowing what to do or when. I forgot all things to be happy for because an uncertain future clouds the mind with fear and worry. I felt very sad, very angry at myself, very lonely in a new place, and very much that I wished I hadn’t signed up to take part in a bloody fell run.
Finding out the orthopaedic plan on Wednesday was sweet relief. Although the recovery ahead will be a long road (~18 weeks until I’m able to ‘load’ the hip), it is reassuring to know that there is a timeline for these things to heal. It’s also empowering to know that I can do light activity, that I can take control over some of the surrounding factors that affect my bone health. Finally, I’m delighted that the gross shape and the articular surface joint isn’t ‘too’ damaged – the most important principles of a ‘ball in socket’ joint being the complimentary forms and smoothness of its components.
I survived Thursday and now it’s Friday!
How can I speed my healing time?
So onto the next challenge – while time and endogenous repair mechanisms do their work, what can I do to make things better?
Optimising Bone – Understanding the tissue.
- How does bone normally heal?
- What can I do to maximise resolution of the fracture?
- Was I at risk of fractures in the first place?
- Can I make the bone as strong as it was before, or can I even make it stronger?
Optimising Nutrition – building blocks.
- How can I tailor nutrition to suit bone healing?
- How much energy is needed to repair bone?
- What are the macronutrients demands for protein?
- Can a high dietary protein intake mitigate muscle loss?
- What about micronutrient cofactors for healing?
- What about specific nutritional considerations for connective tissue?
- e.g. collagen and Vitamin C to rebuild the matrix in bone, articular cartilage or labrum?
Optimising Hormones – the signals for recovery.
- What are the hormonal considerations for bone healing?
- What about Vitamin D?
- Found in the diet, produced endogenously, blurs the line between a vitamin and a hormone).
- What about local cellular communication?
- Can I influence the inflammatory and healing cascades using polyunsaturated fatty acids or by influencing specialised pro-resolving mediators?
Optimising Exercise:
- What can I do to prevent muscle wasting of the affected leg, unaffected leg and the rest of the body?
- What are some suitable ‘closed chain’ exercises for my body?
- What would my graded exercise protocol at 6/52 look like?
The non-sexy and overlooked stuff:
- How do I not make this worse?
- What can I do to adapt my environment to prevent me falling over on crutches?
- What can I do to optimise my sleep for recovery?
- What can I do to make my life at home streamlined to minimise crutch journeys?
- What about my mental health? What about long-term ‘coming to terms’ with injury?
Trauma will kill you
Many people in the health and wellness space focus on small things to improve their performance now or other small things (e.g. dietary supplements, dietary restrictions) as an attempt to stave off chronic disease. I’m also one of those people who obsess over the 1%, the details, the edges, and I too hope to find a pot of gold at the end of the ‘optimisation’ rainbow.
But let’s face it. As a young and otherwise healthy man, illnesses such as Alzheimer’s disease, cardiovascular disease or cancers are very unlikely to kill me now. They may kill me later, but hopefully not for a while. In reality, the thing that is going to kill me at my current life stage is either myself or somebody else, accidentally or deliberately. Trauma, violence and suicide. Falling off a mountain counts as trauma, as does falling over and breaking an acetabulum when doing a typical young male thing – racing unnecessarily.
Obsessing about small details in health and performance (taking 5 grams of creatine rather than 7g, or taking metformin for life extension, or consuming anything for life extension actually) seems trivial in comparison to trying hard not make stupid mistakes. While young and healthy, it seems more appropriate to pick good habits, do the basics and focus on details sparingly. There are more gains to be found in avoiding poor decisions, such as avoiding driving tired or while using a mobile phone, re-considering downhill mountain biking or choosing life paths that avoid entering critical environments without an adequate and thorough risk mitigation strategy.
In place of all that avoided damage, choose things that build resiliency – getting stronger, moving better, thinking better. For at least this will make you less likely to fall, and for when you inevitably fall, you will be more likely to bounce.
The same approach should be employed with my acetabular fracture recovery; the primary goal is to not cause any more damage. This allows time for body’s own ability to heal to kick into action. Anything I meddle with will likely have zero effect at all, and even if it did help, I wouldn’t be able to prove that it did. I can just be comforted and reassured that I’m trying the best I can.
Last words
I think there’s no shortage of furious reading I will be able to do over the next 6/52, paired with the academic work I’ll pick up in my new hospital and the current projects I’m involved in.
It’s ironic that I worked in orthogeriatrics (full of people with broken hips) and intensive care (full of detail-hunting and dial-turning) and that I’m interested in sports and exercise medicine – it turns out that I’ve picked a very personally relevant injury to sustain that will build on my recent work and make me a better and more understanding clinician for individuals who sustain these injuries in the future.
Finally, a few things to be grateful for:
- I didn’t land on my head. The Trauma gods have given me another chance.
- I still have another working leg, I have a working arms to use crutches.
- I met a guy in the carpark on crutches but he had only one leg – ‘That’s cheating!’ he said as as I wobbled by. Likewise, credit to the veteran I met on the beach with a blade runner prosthesis – at least my hip will grow back.
- I have a very supportive girlfriend, great friends and a loving family.
- My employer is understanding and isn’t too pissed off at me.
- I have plenty of things to do and a reading list to start.
- Mail-order coffee exists. Can anyone recommend me a coffee grinder?
- I have the opportunity to do a lot of pull ups and dips to fulfil my dream of looking like a lobster.
Dr Rory Heath 