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.