Fresh! Lateral Tibial Plateau Fracture - A few days post-op...

[jgabrils]

Well, I've broken my first bone. Unfortunately, it's not a bone one ever really wants to break (not that one ever wants to break any bone, but.) I suffered a lateral tibial plateau fracture to my left knee in the early hours of 3/14. No awesome story about how it happened.

Went to the ER that morning, where they took x-rays & had some suspicion about there being a hairline fracture, but told me it was just a sprain (now that I know what a lateral tibial plateau fracture looks like though, it was glaringly obvious on that first x-ray.) They gave me crutches & a brace & told me to stay off it. Later that week (3/18), I had a follow-up appointment with an orthopedic specialist who told me there was definitely a break in my lateral tibial plateau, but that it didn't look too severe - only a millimeter or two - & sent me for an MRI the next day. In the meantime, I was left on crutches & told to be non-weight bearing, to ice, & to keep bending it. I also got a new locking brace (that stays unlocked, haha.)

The MRI came back & at my next appointment later that week (3/25), & the doctor pointed out that although the start of the break was only a millimeter or so, it sloped down toward the back of my knee to about 3-4 millimeters (imagine, in side elevation, a chunk of bone in the center of the side of tibial plateau is just pushed down.) He said he still would just let it heal, but that I should get a second opinion from someone who deals with this often.

Went into the Mass General orthopedic trauma center for a second opinion on 3/31, & was told that surgery should definitely be an option, given that I'm young & that the amount of depression (compression?) was right on the borderline of surgery being necessary. They were a little put off by the fact that it has been a little over two weeks since the break occurred ("why didn't you come in sooner?" obviously I would have, had I known I should have) but weren't worried. They were able to schedule me for early AM surgery the next day (4/1).

Surgery was a success - they went in arthroscopically, used a few wires to push the bone back up into place, secured it with two screws. There was such a noticeable difference on the post-op x-ray - the plateau looked almost normal again! Slept through most of that day with a morphine drip (took me a little while to figure out that I had to press a button to make the pain stop!), was in excruciating pain the next day on oxycodone until they switched me to dilaudid. I met with PT on 4/2 & 4/3 as well.

so FINALLY, here I am. I was discharged on Sunday (4/3), took my first shower since before surgery today, haha. Started up the exercises that I'll be doing until my next appointment in two weeks:

- AROM - 60 HIP: adduction - supine << these are the most difficult... can't even get my leg moving to the side!
- AROM - 70 HIP/KNEE: flexion, heel slides - supine
- AROM - 90 KNEE: extension, short arc quads - supine
- HOSPITAL/POST SURGICAL REHAB - 1 quad sets


Only complaints/thoughts I have so far (aside from the obvious) are the painfulness/location(s) of swelling: there is swelling around my knee, but also down my shin a bit, where it is the most painful. Why would my shin area be in more pain than anywhere around my knee? It makes it hard to place the straps of the brace there.

What are things I can do to maintain a schedule/help pass the time/keep me occupied while I'm laid up? Most of the time I'm not all that bothered by it, but other times it's just so upsetting to know that even trying to go downstairs for a snack is going to be a (painful) haul.

Also, pros/cons of having a cryocuff? It wasn't mentioned to me at the hospital, but it seems to be pretty popular/helpful.

Finally - I was a competitive runner before this happened. While I'm somewhat resigned to the fact that running may never be the same for me again, I know I can get close to it & my doctors seem pretty hopefully about it. I'd like to hear your stories about recoveries that have led to your return to an active lifestyle. How long did it take? What did you do to motivate yourself, to keep going?

& any other tips/insights you want to offer to a fellow TPF person!


Thanks for taking the time to read this!
- julie.

[Erikka]

Hi, Julie. Just a few small comments about my experience in response to your long and detailed letter:

I slept an awful lot the first 6 weeks post surgery. I do believe that sleep lets the body heal so I didn't fight it.

You can do your exercises a few times a day

I had my iPad with me all the time and it kept me connected to the world via the Internet.

I found a totally addictive game called TradeNations where you build a cute medieval village, put your villagers to work, make money, build shops, and trade with neighbors. The graphics are adorable and the game held my interest for a long time. I am easily amused.

I was able to keep a positive attitude about 90- 95% of the time because you will make progress quickly. Evry month, when you look back, you see how far you have come in the past 30 days. Some achievements are smaller than others ... Look, I can put my own socks on today ... But they all represent progress.

I am 5-1/2 months post-op. I still carry my cane when I go out, mostly as a signal to people not to bump into me, but I don't use it unless I'm on an incline (still tricky). In the last week or so, I have walked out of places without it and had to go back. That's my latest accomplishment because it shows I'm just not so dependent on it anymore.

I'm sure others with more athletic tendencies will give you more practical advice about running, but I wanted to share my comments. Wish you the best of luck! I'm sure you're lucky to be treated at MassGen.     

[maryc]

Welcome Julie - sorry you had to join us.  Sounds like you're doing well.  I found that if I made appointments with myself (a set time for grooming, eating, exercising) the day went faster.  Of course the first few weeks any schedule was thrown for a loop with the frequent naps.  Your body does it's best healing while you sleep, so give in and take naps.  I also took an online course (once I was able to concentrate - this injury does seem to scramble the brain a bit).
I had a cooler next to my "nest" filled with healthy snacks and water bottles.
I did my PT exercises 2-3 times a day, I also had an hourly routine that consisted of quad sets, ankle pumps, towel stretches and alphabets.  Check with your PT about the last 3, but they helped keep my achilies and ankle flexed and stretched - essential when you begin walking again.
I didn't use a cryo cuff - just frozen peas and ice slushies.  I would use them after exercising and they helped with the swelling.
We've  had several TPFer's who have returned to active lifestyles (skiing, cycling) or active jobs (policemen, construction). 
Everyone's injury and recovery are unique.  The best advice I can give is follow your OS/PT instructions.
Sending healing rays your way

[pattyb]

Hi Julie,
I read your case with great interest since we have very similar injuries.  My TPF was depressed by 4mm.  From what I read that is sort of borderline between surgery and non-surgery.  I didn't find all this out until my 3 month check up. I think, no I know, that my OS was surprised when I asked her how displaced in mm was my injury.  After I found out it was borderline I spent a lot of time second guessing whether or not she should have operated on me.  I mean, wouldn't it have been a lot easier for me not to have the ORIF.  Well, after reading many, many posts I have come to the conclusion that for me, I'm glad she went ahead with the surgery.  I think in the long haul my tibial plateau will be much better supported with the plate and screws.  I sure don't want to have a boatload of arthritis ahead of me.  Of course, no one knows what the future holds but I feel confident that my OS did the right thing.

My OS also told me in the operating room than she had the option of doing my surgery arthroscopically but decided to do it the other way for greater control over the surgery.  It's so funny that I remember bits and pieces of what she and the other doctors said to me, but between being on that wonder drug (morphine) and not having a clue as to what she was talking about, it's a wonder that I remember any of it.  I wish I knew then what I know now.

Best of luck, and please let us know how you are coming along.

Patty

[kariberi]

Hi Julie
Sorry that you had to join us.
I spent alot of time sleeping after my surgery for the first 3 weeks. I had 2 bottles of water, and my brother left me a peanut butter sandwich on my nightstand every morning before he left for work so that i didn't have to worry about going down the stairs. I also had my laptop in reaching distance, and played alot of the games on facebook, and searched the web for more info about my injury... in fact that was how i found this site.  I also did alot of word puzzles in the first month or so.  I also caught up on my movie watching. I pretty much watched all the new movies on my pay per view.
As for the pain being in the shin area, i asked the exact same question. that's where most of my swelling was, and still is after a long day.  It is also where i started getting the pain when the nerves were regenerating.... that was crazy, even the sheet touching my leg hurt. My first few weeks were miserable! i had a hard time staying possitive, but finally came around thanks to some amazing friends, and co-workers.  Even now i have an office of 35 people cheering me on when i dont want to go to physio..( like today  )
All the best in your recovery! and i hope you are able to get close to your previous running abilities

[MSD]

Before I came home from hospital my wife moved a bed downstairs for me and improvised a wardrobe with some clothes. This has made life much more comfortable, it's much easier to be based on the ground floor because I don't have any need to go upstairs.

I have found that, 3 weeks after the injury (TPF resulting in a plate and 7 screws) I'm in quite good shape physically. I'm working hard on PT and it's going well. I've been going for long walks on my crutches and it's been great to get outside in the fresh air. However I'm still mentally very tired. I went back to work this week, but after two days I've had to throw in the towel and go back to 50% sick leave. So my advice is to not be too ambitious about getting back to work, get as much rest as you can.

I got my injury skiing. I'm a trainer at my local alpine club and I compete in veteran races. My ambition is to be back on skis next season and to be competing again the following season. I think the main problem is to realise that goals necessarily have to be quite long term with this kind of injury. So you have to be patient and see every small success as a step along what is a very long road. But without ambition and drive nobody succeeds in anything, right?

Mark

[jgabrils]

@ Erikka --  Thanks for your input! I'm sleeping a lot now, too - I feel like I'm being really lazy, but sometimes I just can't keep my eyes open. I think that once I start seeing more improvements, it'll help with my attitude - just being able to take a shower on my own the other day was great!

@ maryc --  I've been keeping a little journal of the exercises I'm doing, how they feel, etc, which is helping to keep me motivated. When I stop wanting to sleep so much, I think a schedule (as boring as it's going to end up being) will be good, too. I've started doing pumps/the alphabet with my ankle/foot - thanks for the suggestion!

@ pattyb --  That was exactly my situation - being right on the edge of 'needing' surgery. I'm really thankful that my original doctor told me I should get a second opinion because, looking at the before & after images, it's amazing what the surgery was able to fix! Only time will tell whether or not it actually made things better, but let's hope it does.

@ kariberi --  Did you find that anything specific helped with the swelling pain in your shin? Mine has decreased a little now that I'm moving around more, but it's still more than noticeable at times. I'm glad you have such a solid support system! Good luck with the rest of your recovery!

@MSD --  Going for walks outside sounds so refreshing - even if it's just to the end of my driveway! I hear what you're saying about how a 'full' recovery from this type of injury isn't immediate - I guess I've just never found myself in a situation where it'll be a year out & I still can't fully do something - something that was such a huge part of my life. Regardless, best wishes on your own recovery - keep me posted on how ski season turns out!

[kariberi]

Hi again Julie
 For the selling it was alot of ice packs, and continues to be. As I push it at Physio, the swelling has started up there again as well as the ankle.  My favorite is a bag of popcorn seeds frozen. they last about 15 min and are so much easier than peas. i also invested in a few actual ice packs as well.  Hope all is going well for you! and stay positive
kari

[LK]

Hi, Julie, just stay positive!  It's rough when you can't bear weight, but once you are through that and can start doing PT, it will get better.  I am a competitive dressage rider so I have a little inkling how frustrated you must be! 

This is a good time to do research on new equipment, locations, and trainers, etc.  It helped me stay sane to keep up on all of that and it turned out kind of nice because when I was uninjured, I never had time to read.  I hope that you are able to find some small positives out of the downtime.  I started out very frustrated, and then over time, as I got more upbeat and mobile, I have found that I am getting to go back and learn some things that I never had time to think about having to do with my sport.  I'm also boasting a very beautiful spring garden this year, since I could not ride but could plant flowers.  In any event, I hope you are soon back to all of your previous activities!! 

It does get better!  Ice is your friend!!  Oh, and whatever you can do to get the best physical therapist possible, do so!  I drive quite a long way to see mine, but he is the best in the area and he makes a huge difference.  I doubt that I'd have as good a result with a different PT.

[jgabrils]

@LK --  I don't even know where to begin the search for the ideal PT - there's the affiliated physical therapy department within the hospital I had surgery at, which is phenomenal, & I also asked for recommendations from the two physical therapists that saw me while I was still in the hospital, so I have one other recommendation, but beyond that, I'm clueless. I don't know anyone who has had this kind of injury except for the people on this site!

What are some good things to look for in a physical therapist? What equipment will be important (already know about the importance of the bike)? What are good questions to ask? Anything else I should be thinking about? I know what I want the goal to ultimately be - running, fully active, etc, etc. Sorry to bombard with questions, but I really, really want to do this right!

(Or if anyone from MA has any recommendations on where to go...)

[maryc]

Here's how I would approach the search for a PT
Unless you plan to pay for PT yourself you will need to get a list of approved PTs from your insurance company.
Armed with that list check out online reviews (always take these with a grain of salt - look for patterns, complaints about cleanliness, cancelled appointments).  I would then call and start asking questions.  Do they have any experience with TPFs or knee injuries or replacements?  What equipment do they have?  How long are their sessions? 
After reading reviews and making some phone calls I chose a PT group that specialized in sports and dance rehab, I figured that dancers were especially hard on joints and needed expert rehab.  My evaluation session was spent not only assessing my knee but asking about my day to day activities and what I hoped for as a final result.  After my first evaluation session the rest of the sessions followed this pattern.

Before my session began 5-15 minutes on a recumbent bike (graduating to an upright the last few weeks).  Next I would do one set of each of my exercises while my PT watched and made corrections to my form if necessary.  Then new exercises would be introduced - my PT would make sure I had the form down right and would tell me such things as "you should feel the tension in this muscle, or hold your stretched position for the count of 10" etc.

The next 10-15 minutes would be spent using equipment- Leg press, rocking balance board and treadmill (walking backwards is great for getting rid of a limp). 
The last 5-10 minutes would be spent doing "everyday things".  Starting with just getting up from a chair without using the arms, going up and down stairs and finally getting up and down from the floor without holding on to anything.
The session would end with icing.
With the exception the bike warm up and the icing at the end, my PT never left my side.  He always answered my questions and made sure that I knew why I was doing each exercise.  He would ask pointed questions about when I felt pain or discomfort.  Every 4 or 5 sessions we would sit down and talk about progress and set the plan for the next course of sessions and he would do a gait assessment.
I don't think I would have had as good a recovery without his help.
Sending healing rays your way.

[LK]

Mary has some good suggestions.  I also would ask your surgeon who he thinks is the best.  Especially if you like your surgeon and trust him/her.  Then, of course, check out their on-line reviews.  I did not want to go to a PT who had assistants, which might mean I was assigned to a senior PT but then working with a more junior PT.  A friend advised me to watch out for big corporate outfits where you will not work with the same PT every session.  That's never a good thing.  You will want to see the same PT every session, because he or she should see exactly how your knee looks and how hot it is, etc., from one week to the next.  Keep your eyes and ears open when you are at the initial PT session -- are other patients there, do they seem pleased with their progress?  Are people coming from long distances away to work with a specific PT? 

It's really a maze but the big thing is not to stick with a PT if you do not like working with the individual.  PT should be hard but you should always make progress.  I usually walk out of PT feeling better than when I started, even if some of the work was uncomfortable.  Also, your PT should distinguish between "sore" or "uncomfortable" and "painful."  Pain is not ok.  Sore or uncomfortable or stiff or achey, not usually a problem.   I should add a caveat that I apparently have a really, really high pain threshold and my PT says his problem is keeping me from doing too much, not getting me to do more.  I'm not sure that's entirely true -- I feel like a SLUG and at times, I get overwhelmed and feel that I will never be 100 percent.  I also hate being at a gym this time of year.  I'd much rather get my exercise going up and down the hills outside, but that's not exactly what I am supposed to be doing right now.   

[MSD]

I think a mixture of junior and senior staff often makes a more dynamic atmosphere. Junior staff are usually enthusiastic and hungry for the latest knowledge and that in turn keeps the more senior staff on their toes. That's certainly how it is in my job - I'm a professor and I have the expectation that my grad students know more than me about aspects of my subject. I learn from them just as much as they learn from me.

My operation was done by two doctors - one senior and one junior who was doing specialist training in orthopedics. I was quite happy with this situation, because it means that learning is happening. And without learning I don't believe you can aspire to excellence.

Mark

[jgabrils]

Thanks for all of your replies with regards to PT! Very thorough.

I had my two-week post-op appointment with my doctor on 4/14 - took x-rays, got a new brace because one of the straps on my original one was too short (why not just replace it, I don't know.) He checked my knee for instability (prior to surgery, I had about 5+ degrees; now, there's virtually none) & then bent it. I've been getting to 100-110° on my own very comfortably, so he pushed it to 120-125°. It wasn't so much painful as it was tight & ...really uncomfortable. My next appointment is in four weeks - by then I'm supposed to be able to match the ROM in my good leg - heel to butt! I've got some work to do. He also gave me sleeping pills because I've been having a difficult time trying to sleep - seems like at bedtime I have to move every 10 minutes to be comfortable. Also, not a back sleeper!

Then the bad news: NWB for another 10 (now 9!) weeks. Crutches until July 1. Also, my doc said PT wouldn't really do much for me until I can begin to put weight on my knee - they'd pretty much just give me exercises for ROM & tell me to come back later. Is this common (minimal/no PT until weight-bearing is allowed)? I was kind of hoping for PT to give me something to do with my time during the week, so I'll probably go for those one or two sessions & hope that they give me more stuff to do. When is PT usually started for these kinds of injuries/when does it become most useful?

It seems like there's a mix of methodologies on this board - some people are NWB for minimal time, then move onto PWB & FWB pretty quickly; others are NWB for the max amount of time, then move on. I guess I'm in the conservative group.

[maryc]

I was NWB for 7 weeks and then went straight to WBAT.  My break was pretty clean with no soft tissue damage - I had a really good OS with as he put it "great carpentry skills".
I had home PT once every  2 weeks while NWB.  My exercises took about 45 minutes a session (2-3 sessions a day) and included using light upper body weights.  I did heel slides, SLRs, Quad sets - basically almost every lower limb exercise you could do while NWB.
It not only helped pass the time, but the little victories helped keep the depression at bay.
My home PT directed me to this site - and created a list of exercises from it http://www.cyberpt.com/cptvidlist.asp
Once I was WBAT I went to PT twice a week for about 5 weeks, and then once a week after that.
I know how impatient you are getting, but it does get better.
Sending healing rays your way