Patient: “Sports injury” categorization is the closest category I could find to summarize this injury. A month ago my mother fell breaking both wrists. They were not set properly and have healed a bit misaligned. At the time she fell, she also hit her face very hard and the skin on her forehead, upper lip and around her nose was red for a couple of weeks. The skin that was red is still swollen and when she touches it, the sensation is different than elsewhere on her face. Also, the wrist that had the worst fracture is now swollen worse than when she broke it. What would cause this sort of swelling and what can be done about it? JFYI, surgery is out of the question. We are not in the US and due to a weak heart, she would not survive the way they do surgery here. (She is 76.)
Symptoms: Swelling of hand and places on face. The radius sustained multiple fractures. The scaphoid is also possibly broken, but we don’t know for sure. The swelling, however, is now all over the hand. Originally, the swelling was just over the wrist. Although she fell on July 27, and has been in a cast since that time, she has more swelling than in the beginning. Also, where she bled under the skin on her face is still swollen, although there is no longer discoloration. The only medication she takes is thyroid and multivitamins.
Doctor: Hi.Thanks for your query and an elucidate history about your Mother.Read and understood the detailed history your ha ve provided.The possible reasons that can explain the problems she is facing at the moment are:-Since your Mother is hypothyroid and under 200 microgram dose, it is possible that it may be insufficient at the moment as the injury and the trauma of all sorts increase the requirement of the thyroid hormone and usually missed. Please get the Free T3 and Free T4 and TSH done and if needed get an increased dose.-Osteoporosis and osteoarthritis itself are the hindrance to good healing and can contribute to the problem she has. The body tries to compensate by way of over-deposition of the bone (callus) and the area under treatment appears swollen.- Cardiac problem can contribute.-Tight plaster can cause the swelling as you have explained.-Dependent edema due to the position of the affected part below the heart level.I would advise you to get the necessary consultation of the Specialist Doctors to get a clinical evaluation, examination and investigations to correct any of the defects and add treatment as per the findings.Investigations for Hemoglobin (anemia), Serum proteins particularly albumin are necessary and if not satisfactory need to be supplemented. These are very important in proper healing.Elevation of the affected limb above the heart level when in lying down position is also very very important in reducing the edema that you have explained.There may not be necessity for any surgery as such if the healing is proper as seen on X-rays or MRI/CT.I hope this answer helps your Mother to get the correct diagnosis, deficiencies that get corrected and getting a good healing and results.Wishing Her the best recovery and great health.
Comments / Follow Ups
Patient: Thank you so much for your detailed answer. It was very helpful and informative. It has taken me awhile to respond as I wanted to get the blood work you suggested done before writing back.
There are two issues concerning us still: 1) her face; 2) her hand.
When she fell, she hit so hard that it knocked her two front teeth slightly inward. It clearly bled under the skin around her nose, her upper lip and onto her forehead between her eyebrows. The strange thing was, it never bruised! Considering how hard she hit, I expected her to turn every color of the rainbow, but she didn’t. Her face was red and stayed a bit swollen around her nose and mouth and forehead for almost a week, but it never bruised.
This is strange because even now, almost two months after her fall, that skin stays feeling different. It is harder and when I run my finger over where the swelling occurred, it still feels slightly puffed up from the normal skin surrounding it. It has also turned extremely red again and swollen, in response to pain on the hand. (More later.)
Is it possible her blood is too thick? I know a lot of old people are on blood thinners, but she isn’t. I am very concerned about this as her heart is already very weak.
The lab emailed me her blood work but when I tried to attach it, it said it wouldn’t recognize the pdf file. You can see her lab results if you go to www.laboratoriomedicos.com. Click on the green tab at the top right of the page that says “RESULTADOS.” Her user name (Usuario) is 46132 and the password (Clave) is GTZUHX. You will be able to see her blood test results. Finally, click Entrar.
The test results we ordered after receiving your recommendations are dated Sept. 8. They are in Spanish, but the medical terminology is close enough to the English, I don’t think you’ll have any problems.
We were surprised to see her thyroid is so low. TSH was 0.05. She is taking 250 mcgs once a day. She hadn’t been taking that much – only 150, but she started taking more around the time she broke her wrist.
The hand is still swollen and she does not have full flexibility. She cannot clench her fist. The last digit on her middle finger is like wood. It can’t bend at all. The skin is much darker than on her other hand and the knuckles are swollen.
The radiologist insisted she see a “tramatólogo”. I think that’s a traumatologist? I don’t know what that equates to in English, but he was an MD. He forcibly rotated her wrist and flexed her fingers much further than they could go on their own. This was, of course, excruciating for her. That night and for the next several days, the part of her face that had swollen from the fall, swelled up again and was extremely red. The traumatologist said that she had Complex Regional Pain Syndrome. I have never heard of that and need some more information.
I have attached her two most recent x-rays.
In looking at the x-rays and with the description of her hand and face, do you concur with this diagnosis? What are the protocols for getting her hand better? When she tries to grasp anything with that hand, there is a tremendous amount of trembling. She cannot grasp anything firmly, and when she pinches something between her thumb and her index finger (the only way she has to hold something in that hand) it shakes uncontrollably.
I do not believe that she had a stroke. But why is her hand still like this nearly two months after breaking it? I believe it was a compression fracture and you can clearly see the lump under the skin, but that does not explain the swelling, the discoloration, the inflexibility and the trembling. Also, if it is indeed Complex Regional Pain Syndrome, what, if anything, does this have to do with the swelling and the difference in the feel of the skin on her face?
What can we do to get her better? Are the medications? If you can tell me what sort of medications might benefit her, I can get these here without a doctor’s prescription as long as they are not opiates. What about herbs or exercises? What is going on and, again, is her blood too thick?
Thank you in advance for any advice you might be able to give us. The way they do things here is very different and part of the reason why she does not want to risk having a surgery.
Doctor: Thanks for your detailed feedback and additional information, X-rays and the reports which I can see.
The low TSH is the result of the extra taking in 250 mcgs once a day. She hadn’t been taking that much – only 150. This will suppress the response from pituitary. Her T3 and T4 are normal.
This may be one of the reasons she has been developing the edema over the face and the redness too and the trembling of the hand.
There can be other reasons too.
The problem with the skin, the hardness can be due to the edema, the redness due to the vascular response to trauma, the nerves not yet regenerated.
This looks to be due to the vaso-motor response to the trauma. Another reason can be sort of an angio-neurotic edema in response to some allergy that may not be defined.
The treatment for this anti-inflammatory medicines in consultation with your Doctor. This can be serratiopetidase or any other that suits her.
Blood is not thick as hematocrit is normal > HEMATOCRITO 43.1 % (35.0 – 47.0)
About the hand:
X-rays to me show rarefaction of bone and I feel she needs Calcium with Vitamin D, multivitamins acting as anti-oxidants.
Complex regional pain syndrome (CRPS) is a chronic pain condition most often affecting one of the limbs (arms, legs, hands, or feet), usually after an injury or trauma to that limb. CRPS is believed to be caused by damage to, or malfunction of, the peripheral and central nervous systems. The central nervous system is composed of the brain and spinal cord, and the peripheral nervous system involves nerve signaling from the brain and spinal cord to the rest of the body. CRPS is characterized by prolonged or excessive pain and mild or dramatic changes in skin color, temperature, and/or swelling in the affected area.
CRPS symptoms vary in severity and duration. Studies of the incidence and prevalence of the disease show that most cases are mild and individuals recover gradually with time. In more severe cases, individuals may not recover and may have long-term disability.
The same thing affecting the face and hand can explain.
Since your Mother had a fall and trauma over the face there would have been an injury to the cervical spine adding to the post-traumatic changes.
I would advise to have MRI of the cervical spine to rule out any disc related problems causing the symptoms in the hand.
I hope this answers your query. Please feel free to ask for, if you feel that there is a gap of communication or missed some point.
I have tried to cover all the points raised by you.
Doctor: May be reducing the thyroxine dose to 200 or 150 may help, repeat the Free T3, Free T4 an TSH after 3 weeks of new dosage .