Sunday, April 1, 2012

Distal Humerus Fracture

Jeff released the ER records from when Justin took Ayla to the ER for her broken arm on November 12, 2011. People have also had questions about the ortho doctor reports also so I will address those reports too. I broke my post into two parts; this first part will consist of explanation of the injury described by doctors.

Let's start with the ER report:
I added the numbers in red. I will address the information that is following the number. I figure everything else is self explanatory, if you do not understand something leave a comment.
1. There is ecchymosis in the antecubital of the left arm. Ecchymosis is the escape of blood into the tissues from ruptured blood vessels; usually a purple color. Antecubital area is the inside of the elbow area, think where they draw blood from.
antecubital ecchymosis
2. I got a pulse ox. Pulse ox is how much oxygen is being carried in your blood. It is measured by a clip placed on your finger.
3. I could not palpate her pulse because of the amount of swelling she has, and her pulse was bounding and capillary refill was excellent. The doctor could not feel her pulse because of the amount of swelling. A bounding pulse is a strong and forceful pulse. Capillary refill is the rate at which blood refills empty capillaries. It can be measured by holding a hand higher than heart-level, pressing the soft pad of a finger or toe until it turns white, and taking note of the time needed for the color to return once pressure is released. Normal refill time is less than 2 seconds.
4. The x-rays show really a distal humerus fracture above the flare of the metaphysis and there is definite rotation and angulation so it is going to require closed reduction at the very least, and a pinning at the very most, but this is not truly a supracondylar fracute. It is really a distal humerus fracture. Distal humerus fracture is a fracture of the bottom of the upper arm bone, closer to the elbow. With a rotated fracture, the bone will break and one piece will turn around, but otherwise remain in the correct place. In the case of an angulated fracture, the bone will remain in essentially the right position, but one broken piece will tip either up or down. Closed reduction is realigning or resetting the broken bone by manual manipulation by the doctor. Pinning would be done by cutting into the skin and placing pins to hold the bone together. A supracondylar fracture is one of the most common fractures in children but this is not one.
Humerus bone. The black line is the area the fracture is located according to the doctor; a distal humerus fracture above the flare of the metaphysis. (Note: The picture is labeled in German; metaphyse=metaphysis.)

This is on the intake form from the ER, the doctor draws the areas of Ayla’s injured arm that can be seen. The outer circle would be the area of the swelling, noted by the “S”. The inner circle noted, with an “E”, would be the area of ecchymosis. There is also a small abrasion noted, marked "Abrasion" (part of abrasion is cut off).




Next we have the ortho appointment from November 14, 2011:
The ortho doctor notes most of the same things the ER doctor does; arm swollen, ecchymosis, and broken distal humerus. The difference is this doctor notes not specifically state no rotation and states not much angulation. If there was indeed rotation, the fracture would have been caused by a twisting motion. According to this doctor, the fracture is slightly displaced in two planes which means that the bone is shifted to the side and to the back.  The bones are pretty much aligned with each other with hardly any angling of the bones and it is slightly displaced to the back and to the side.

Ayla was placed in a splint in flexion, meaning her arm was bent to keep from moving to promote healing. What Trista saw, relayed by Jeff: Trista said that doctor made it so that Ayla could not move her arm. They put a splint on first and then covered it with a material that had to be wet down.

So from my understanding a cotton layer would have been put on, then some sort of splint device to give support to the fractured area and a bandage you wet to set, which I would assume would be a softcast type material. This would not be as easy for a toddler to take off as an Ace bandage and would not be as stiff as a cast for more comfort especially since her arm was still swollen.

Now the last appointment Ayla was seen at on November 21, 2011:


They did more x-rays that revealed callus on the fractured area which means it is healing. 10 more days and the splint can come off.

Justin and Phoebe's description of  Ayla’s injury:

Phoebe DiPietro said the injury appeared to be a bad bruise, but nothing serious. During the day, however, Phoebe DiPietro noticed the full extent of Ayla's swelling after looking under the toddler's sleeve.

DiPietro said the ER staff originally thought Ayla had a deep-tissue bruise.

"He looked over the X-rays, and said, 'I don't know what they told you initially, but this isn't as bad as they said,'" Justin recalled. "They just put a splint on there with an Ace bandage. She didn't even have a cast or a sling or anything like that."

"Her arm was to the point now, before all this happened, that she was lifting it up. She wasn't bending it, but she would take (the splint) off sometimes, and she was getting to the point where she was starting to use that arm again," he said.

Justin minimized how serious Ayla’s broken arm was. She had a severe amount of swelling. The ER doctor would not have assumed that this was just a deep tissue bruise and if he did he should go back to medical school. Justin saying the doctor thought it was just a deep tissue bruise was to try to show that it was okay that he didn’t rush Ayla to the ER, even the doctor didn‘t think it was that bad; yet another minimization. They did put on a splint and Ace bandage in the ER as a temporary splint until visiting the ortho doctor. So while that is true ,he left out a big piece, the ortho doctor put on a splint that offers more stability and is more difficult for Ayla to take off.

In my next post on the broken arm, I will address the differences in Justin's stories that he told reporters versus the doctors and the plausibilty of this injury happening the way he said.


Thank you to Emerald for helping me with some information on this post.

40 comments:

  1. I'm unfamiliar with all the different types of casts being mentioned. So, can the cast that was wet down, actually BE removed? Or was it really supposed to stay in place? And whether it could be removed or not (even if say for bath time), SHOULD it be removed, or pretty much mostly kept in place?

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    1. The tye of cast described is like a hard cast, it is set up like one, I.e....soft material, then wrapped material (fiberglass) that is then wet down, like a hard cast but because of the swelling they then cut the cast down each side and put it on her arm and wrapped it with an ace wrap. This is the type of cast they use when a fracture is badly swollen because the wrap can be mad looser but still keeps the arm immobile.

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    2. They used a hard cast for months on my son since he was born until his final surgery (severe club foot) in hopes to turn his foot..One Dr turned his foot too much and my son wouldnt stop crying, so I had to remove it...it was a very difficult cast to remove...they started with bandages, added some paste stuff that looked like the stuff you put on balloons when your a kid, but much pastier and then they put ace wrap around it and let it dry. These are the types of casts most people write on...anyways we (help from his grandmother) got it off in about an hour...we had to soak his cast in Epson salt and warm water and slowly rip it off..it can be removed, shouldnt be removed if a child's limb is broken..takes a lot of work to be removed though...Drs hae these cutter things...that take them off in minutes. Those always made me nervous

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    3. Thanks wedi. So it is basically a hard cast, but cut then wrapped up, due to the extensive swelling.

      Maybe you can help me out here. To me, that seems MORE severe than just needing a cast for a broken bone. It seems to me, they couldn't just place a cast on, as often times is done, due to the swelling?

      Now, Justin has tried to minimize this in stating that it wasn't that bad, they just wrapped her arm with a splint and ace bandage.

      Would a cast, in this manner, need to be refitted, as the swelling goes down? I would think it wouldn't properly fit her arm, over time, as the swelling subsides.

      I wish the dr notes were a little more detailed, due to the fact of the DiP's stating that Ayla could take it off, later on, and was starting to use that arm. I know I would not be removing that cast, except for bath time and probably rewrapping it, UNLESS the dr said it was ok to do so.

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  2. So I double checked. My husband Works at MaineMed in Radiology. and I just wanted to add a note. When a child comes into the ER with a fracture there is a red flag when there is a rotation fracture. He stated the characteristics of this type of fracture are considered consistent with injuries that would result from abuse. and always requires closer examination and is 9 times out of 10 reported to DHHS. But it taken very seriously.

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    2. haha wow spell check sucks! yes, rotation is a torsion force injury, and due to the translation in 2 planes, and angulation, plus the lack of collateral injuries on her hand, fingers or wrist, and the abrasion in the front all point to her arm being extended, and the point of impact on or near the antecubital fossa. Falling on top of her arm on stairs would have left collateral injuries on her hand or fingers or wrist, not to mention chest and face...but no other injuries were noted...plus it is near impossible to fall on the arm in that position unless carrying a child front facing at waist level, or droppin them face first before falling on them...And how did JD do that with a recently shattered wrist? his mom said it was in 39 pieces...wouldn't he have had a plate, or hardware, or fusion of bones? carrying groceries and Ayla, up steps,in the dark, opening doors, in the rain too...his wrist must be pretty strong...and he can see in the dark....he is confident of his abilities ...it should have been reported...anyone notice the time on the ER report?

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    3. Thanks Emerald. I always enjoy your insight. The ER report is pretty detailed. I know from working in the medical field (office, NOT dr, nurse etc), that any type of fall/accident is usually questioned and explained in great detail in the notes. Although the specialist noted that the fall happened on stairs, I failed to see this noted in the ER notes. What I saw, stated that Dad fell while carrying pt, in the dark; grandmother found them on the floor. I don't see mention of stairs in the ER notes, which is the pt's first medical treatment/encounter for this injury. Stairs would be a pretty big piece of information, for the ER to leave out of their notes (plus carrying groceries as well). I'm wondering if Justin did not tell the stairs/grocery story to the ER, but further elaborated on his lie while at the specialist?

      Also Emerald, were you ever able to find out if a 10 day follow up visit would be "normally" put off for actually 25 days? I fully understand it was the dr office/schedule that dictated this, as Jeff attested to this when I asked if the rescheduling was due to Justin/Trista's schedule or the dr's. Regardless of who's schedule it was due to, I still just can't wrap my mind around how a 10 day f/u, turned into 25 days..

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  3. Kit, since the doctor did not specify if they used a waterproof liner or exactly what materials was used to make the splint, I can't tell you for sure. Maybe Jeff or Trista could let you know what care instructions were recieved from the doctor/nurse for the splint.

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    1. Annie, Truth4Ayla; Regarding care instructions; Trista's direct quote "Justin took them from the secretary and would not let her see them".. She does remember the doctor saying that Ayla was to take Tylenol and keep the arm still.

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    2. it was a full or 3/4 length bent arm splint to immoblize her elbow joint and humerus, right? I have been in medical for years, they are always coming out with amazing new materials...however...I have never heard of a splint with soft cast that is removable(the wet king harden due to a fiberglass weave and resin polymer reaction: it turns hard...it is called a soft cast because plaster(yes, old style plaster cast) is a hard cast...it sounds like she had a splint with soft set CAST material on it...you can not adjust that... can you ask Trista if the material they wet turned hard, and if the entire arm had the wet cast around it(lower forearm to mid humerus)...? I am wondering about the statement that she took it off herself...she would have to unwrap and remove a splint off an arm she could not bend or use...fishy...and why the hell would you let her remove it? should only be off to bathe...

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  4. Great post. I look forward to seeing what the stated mechanism of injury is and how that compares with his story.

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  5. Me too Birdlady.

    I can't quite picture in my mind how the fall, as described, resulted in the injuries Ayla suffered. I'm not saying it is not possible, I just can't picture it, in my mind. I'm further curious about the abrasion, which appears to be located on the inside of her arm/elbow area. For some reason I was imagining the surface/skin injuries would have been on the outerside od her arm/elbow.

    I couldn't quite make out the time of treatment either. Was it around 10:00?

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    1. 1050 am...justin had night classes...so how'd he go and come back early, before 130 am??

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    2. on a class that end a few weeks prior...
      actual truck driving may not have been at night and that's what happened on some Saturdays/ the classroom training was not on Saturdays

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    3. If he was taking his last driving lesson that Sat he most likely left in the morning to go to it. So, I wonder how long that last class was that he claims he left early from because he wanted to bring Ayla to the dr.

      I don't even believe that he left his last class early on his own accord. It was probably a short class or it was dismissed early. I'll believe that when I hear it from the teachers mouth.

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    4. plus it is approx. a 25 minute drive one way to his school...that is a 45 minute return trip...unless he had a very early class, he did not go and return in time to get to the ER at 1050...no ER gets you in at the exact time you arrive unless life or limb...they had to get triaged(notes show the nurse did this and a triage assessment..still waiting to see this if they can get it ...)and likely wait for a room, so they prob. got there at least 30 minutes to an hour before 1050 am...not adding up at all...did it rain that night?

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    5. Haha! At LEAST 30 minutes before!! I don't *think* it rained, thats been debated back and forth though.

      Can you help me out with my questions above, if possible, please?

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  6. A break of that type above the elbow requires a push downward from a threatening height or a good hard kick or punch with steel toe boots or rings on the hand of a close fist that would fracture the bone. The could only be a falling injury if Justin held he back to his stomach and swan dive into a belly flop to force as much damage as possible to her skull placed at his chest level.Sounds like she absorbed enough of the force to avoid skull fracture but injured the arm severely.

    The brusie would come from clutching her tightly at chest level preparing to dive onto the concrete using as her as a pillow.

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    1. the bruise is from ruptured vessels and the impact...she did not hit her head, or anything else...which is weird...

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  7. The Bride Wears BLOOD RedApril 1, 2012 at 5:20 PM

    With callouses already developed, it makes me wonder how long it really took Justin to bring Ayla to see anyone. Granted children heal quickly, but this reeks of abuse. The worst part is realizing if he didn't really fall on her, which sounds like the biggest bunch of BS, then what did he do to her? Held her and twisted her arm backwards? Who does that to a little 2 year old child? Plus the bruising and the limping, it shows Justin enjoyed hurting Ayla and did it frequently.

    Justin, I seriously hope when you go to jail, that you get the same treatment you gave Ayla. And more, much more. Get my drift?

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  8. Poor girl had to be in so much pain! I fell and fractured my arm several years ago. It was not near as severe as her break and it was incredibly painful!

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  9. The Bride Wears BLOOD RedApril 1, 2012 at 5:39 PM

    According to the Dip Supporters, Ayla felt no pain. In fact, the Dip Supporters know hundreds of children who incredibly, had the EXACT SAME break and they claim there is no pain involved whatsoever.

    Isn't it amazing the stories the Dip Supporters tell to vouch for their caveman?

    JUSTICE FOR AYLA!!!!

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    1. They obviously should go have their arm or any limb broken and then say there is no pain. That is there way to try to make the situation look better, but there is NO WAY to make it look better. It is what it is, horrible, tragic, and was painful. They arent the brightest ones in the apple tree...they actually think they can pull one over on the public...I wish she didnt suffer anything...it is too hard to think about...so sad...someone needs to go break their arm and legs...then they might actually feel something.

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  10. That can't be right. I just read today about story time and going to the playground. Everything was sunshine and lollipops with the DP's.

    http://www.kjonline.com/news/aylas-2nd-birthdayspurs-many-memories_2012-03-31.html

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  11. Truth4Ayla, I can't say enough how amazing you are and how much research you put into your posts. I am grateful every day that you asked to help early on and OUR blog would not anywhere near as good if you weren't apart of it. Thank You

    I was so upset to read this and the ER report. In my opinion, Ayla was abused and I base that on the difference in her demeanor in the pictures, the pulled leg muscle, the broken arm, and the blood in the basement. I feel the abuse went too far and led to Ayla's demise and knowing Justin would go to jail they all concocted the phony abduction story. Gabby is not safe in that house and anyone who helped cover up what happened to Ayla deserves to rot in jail for the rest of their lives and I pray LE is close to closing this case.

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  12. I totally agree! I still believe it was premeditated tho cause of the LIP. The cast hasn't been mentioned much...I'm wondering if ayla was wearing the cast when she disappeared? If so, how did it fit under the pj's? those kind of pj's are snug fitting....just wondering

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  13. My daughter had this same break when she was 7. She fell from the top step of a tall slide at the playground. She was in a lot of pain. She was very active and it was the middle of summer. The doctor made up a hard cast, but then split it with this little saw thing. Then the two pieces of the cast were put on her arm with an ace bandage. She was allowed to take the cast off for bathing and to get in the lake for a bit each day.
    I was out of my mind when that happened! Three boys, never a broken bone, and then my baby girl breaks a bone!
    It was a painful and difficult experience for her and she was 7 so she could at least understand what was going on. Poor sweet Ayla didn't have a clue why she was suffering so much.

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  14. It is so sad that not one of the Dips loved Ayla enough to protect her from this abuse.. I hope they all end up in jail and they suffer the same abuse they gave..

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  15. The PR machine is out in force; http://www.kjonline.com/news/aylas-2nd-birthdayspurs-many-memories_2012-03-31.html

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  16. Well, there is that alleged text message from Trista, saying one of Justin's friends saw him throw Ayla. An injury like this, the arm breaking, absolutely could have happened because she was being thrown down and around. It actually would be more likely than Justin's story of falling while holding her. The way people usually hold a small child, it's more likely that when he fell, Ayla's head would have hit first and hardest. Not her arm. The fall story is pure make believe, an abuser's fairy tale to cover up their crime.

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  17. When my son was two months old I tripped with him in my hands down the front steps of my Aunt's house. They were cement and I went straight down..now as weird as this sounds, I felt like it happened in slow motion...I was able to switch the arm my son was being held in and use the other one to catch my body and push myself on my back so he wouldnt get hurt...I wonder some days if I had an angel that day letting me take that fall and I was so grateful I was able to keep my son from being harmed...it was a hard hit, I ended up in the ER with 13 stitches on my knee, cut it wide open and could almost see the bone...I would never think it would be a smart idea to throw a child in the air...I cant even catch a baseball half the time why would I think I would be able to catch a child? There is always a risk the child might not be caught..its plain stupidity to do that and if she had any casts on, even more stupid...senseless..I dont think he fell on her at all. What I did that day was do whatever I could to protect my baby boy, that is what parents are supposed to do and it is so, so sad Ayla's father is the person he is and Ayla was a victim. I wish I could hug her. I wish she could be with her Mom who loved her and wouldnt harm her, who protected her.

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  18. I'm just sick reading all of this. I have allways though that the arm break was not an accident but readin about it again turns my stomach. This poor little girl was kep away from her mother, must have been sooo missing her and then ignored and abused by these animals, and then.... Horrible, just horrible. I cannot wait for the day that one or all is hauled off to jail!!!! tears more than ever tonight ,, :-(

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    1. I know Chicky, SO SAD, Poor baby Ayla, my heart breaks...

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    2. Chicky/RedDawn/Lies : One fake bitch pretending to care. You are so full of dog feces. I caught your fake ass posting as Chicky in a lie yesterday. Fake ass imposter, go back to your own blog with that bullshit. " I don't know why my comment posted under Anon". Because it wasn't your post, it was mine! You want everyone to think the lies blogger is Connie, No way, its you and I have the proof, idiot.

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  19. Interesting that some folks read throwing Ayla as tantamount to playing catch with her. I read it as rage, throwing her across the room.

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    1. me too! like bookat said...throwing by the arm can cause a rotational fracture of this type...no collateral injuries to the hand, fingers, legs, face, chest, arms, chin, head...no other injuries from a grown man falling on her on steps(all 90 degree angles)..how is this possible to hit only on the arm, without even getting a bruise or scrape anywhere else...????

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  20. I think that instead of breaking windows at the Dips house, someone needs to find Justin and snap his arm so he can tell everyone that it didn't hurt...he is so full of shit it's unbelievable....every dog has his day and his day is coming....I cant wait for that day....I will be crying tears of joy when they put that POS and the rest of that family behind bars

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    1. I agree and can't wait for them to all be behind bars..

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