Compound Fracture Questions

[vmurphy1]

My mother was in an auto accident in March of this year.  Right after the accident she could not put any weight on her legs at all.  After numerous x-rays, the doctors said she had a compound fracture to her lower back(L1) without spinal cord injury.  She stayed in the hospital for over a month with intense physical therapy and she was doing good.  They got her up and walking and had fitter her with a back brace.  When she got home she did good for about a month then her blood pressure started going up and she started getting very stiff in her legs.  Her primary doctor changed her medication and got her blood pressure down but it is getting harder and harder for her to get around.  There is burning and stinging in her arms, legs, and back.  She describes her legs as "wooden legs".  As of the last x-ray the neurologist said her fracture is healing but why is she getting worse?  What could be the problem?

[vmurphy1]

COMPOUND FRACTURE SHOULD ACTUALLY BE COMPRESSION FRACTURE, THANK YOU! VMURPHY1

[Fionajnz]

Did she have an MRI?  It sounds like she is having sensory symptoms in her legs, that *could* correlate with a bulging disc.  Her arms are probably hurting because she is compensating in her posture for her pain and discomfort in her legs and low back. Has she had a neuro surgeon take a look at the workup that she has had?

Some compression fractures really hurt, others not so much.  It may be time to consider another work up or a second opinion.  She should also have a bone density screen and depending on results have an endrocinologist take a look at her bone density and vitamin D absorption, to prevent further fractures.  

I have 5 compression fractures (resulting from medicine combo that I had to take) the ones higher up hurt me more than the ones lower down, but they are very uncomfortable sometimes and I need pain meds to function.  She needs to pace herself and keep up with her home program.  But I would say that my arms/shoulders get really sore if I do too much, because my posture has to compensate so much sometimes.

The neuro here is not having time to answer Q's so you will probably not get a reply.  I emailed them last wk asking why there are not neuro MD responses and that is what they said.  

I hope your Mom feels better soon.

Fiona  

[Joyce K Lee, MD]

Dear Vmurphy1:

Thank you for submitting your question.
I will answer your concerns to the best of my abilities, but please be informed that I am unable to offer a diagnosis based on your history and list of symptoms.
I am extremely limited in not having the opportunity to perform a full neurologic examination on you, nor am I able to review the pertinent imaging.
This is solely for educational purposes and should in no way be a substitute for a formal evaluation by a certified physician.

To begin, my deepest sympathies for the pain that your mother is enduring after her auto accident.
Here are my thoughts after reading your comments:

From your description, it seems like your mother suffered from an isolated burst fracture to the L1 disc without spinal cord injury following her accident.  These types of injuries are commonly seen after motor vehicle accidents (MVA’s) and usually improve after intensive physical therapy and over time.
Your mother seemed to initially improve with aggressive physical therapy but now seems to be deteriorating. From what I can gather, your question is about the etiology of her deterioration.

Based on the timing of her deterioration and the results of her last X-ray which showed improvement of her fracture, I do not think that this is related to worsening of her L1 fracture.
Vertebral injuries following trauma usually pronounce themselves early on and do not have a delayed effect.

Two thoughts however about the cause of her deterioration:
1) Possible disuse syndrome:  It is not uncommon for patients to function at a lower level following MVA’s or injury.  They usually have vague aches and pains, are forced to take some time off of work and suffer from depression because they can’t do the things they did before with such prior vigor and ease.  
Due to a combination of physical and psychological restraints, they use their body less.  
When you don’t use your muscles, they become weaker and stiff . This goes along with your mother’s complains of feeling like her legs are “wooden.”

If you do feel that your mother is showing signs of depression, please seek help. As physicians, we use a screening mnemonic tool, SIG-E-CAPS which include the following:
-Decreased SLEEP
-Decreased INTEREST
-Feelings of GUILT
-Decreased ENERGY
-Decreased CONCENTRATION
-ANHEDONIA (person does not find enjoyment during hobbies previously enjoyed)
-PSYCHOMOTOR RETARDATION (think and act slower)
-SUICIDAL IDEATION

If your mother has a combination of 5 or more of the above, it is a strong indicator for depression.

I’m not saying that your mother is severely depressed or is suicidal, but you need to watch for the warning signs of depression.  Motivation and one’s outlook on life plays a huge role in rehabilitation.
Please also make sure that she has a good support system -- encouragement and support from close family members make all the difference in rehabilitation.

Additionally, you need to make sure that your mother is active – whether this is informal or formal physical therapy is up to you and your mother's.  I recommend FORMAL physical therapy which can be prescribed by any physician and can be done on an OUTPATIENT basis.  If your mother is not undergoing PT, inquire about this  with your physician.

If pain is limiting her, please inquire about treating this appropriately with her doctor.
If her pain is not being managed, this will get in the way of her rehabilitation.

2) At times, I will see patients in my clinic who suffer from the same problems as your mother and believe it or not, we realize that the actual BACK BRACE is the source of the problem!
If braces are incorrectly fitted or worn for inappropriate amounts of time, they can cause pain, sensory symptoms (numbness/tingling) in different parts of the body and even stiffness.
Please make sure that this is not contributing to her problems – see anorthotic specialist for this.
Physical therapists are also well trained at determining whether this is a problem.

Please be reminded that these are only speculations and suggestions.
If your mother worsens, it may warrant more aggressive imaging such as an MRI of the spine.
Please discuss these issues with your neurologist and primary care physician and follow up with them routinely.

I hope this helps,
Best of luck,
JKL, MD