Thursday, February 08, 2007

Closed reduction vs. open reduction

For those of you unfamiliar with orthopedic surgical lexicon, let me translate.

Closed reduction: externally manipulating the elbow to replace the radial head and align the bones of the arm.

Open reduction: failing success during a closed reduction, surgically opening the elbow and pinning the bones back in place.

Both under general anesthesia (open taking place immediately during the same visit to the OR if closed reduction fails).


It was a long day at the hospital. We had to get up at 6:00 am to call the Day Surgery desk and find out when to be at the hospital. As the doctors were not even in, yet, along with my daughter's case being an "add-on," we were told to sit tight until we were called. Which allowed two more precious hours of sleep. Sorely needed, as both my husband and I agreed that our dreams had been vivid and draining during those few moments when we did nod off during the night.

A little after nine we got the call to head on in to the hospital. Within an hour we were on the road. By eleven we had begun the admission process.

Perhaps hospitals have devised their pre-surgery admission routine to include as much paperwork, question and answer, and moving from waiting room to waiting room with a larger purpose in mind. In the middle of all the tedium and attention to minutiae, one hardly has time to contemplate the enormity of the situation.

I'm not sure when in the process we met with the doctor, but I know we did, because I know he explained in great detail what he was expecting to have happen. Go in, pop the bone back in place, x-ray it, cast it and on to recovery. He also explained what might happen. Sometimes in cases like these, you find that the dislocation is the result of a congenital defect and would require a different approach. However, my daughter did not give any indication (via x-ray) of having the markings of a congenital case. Also, he talked about an intermediate step between a closed reduction and an open reduction, where, failing to get the bone to snap back by itself, he would make a small incision in the elbow and run a k-wire down into the arm bones to hold them in place. A percutaneous pinning, it is called, and the doctor said it's not his favorite thing to do. (I didn't ask him what his favorite thing to do is.) He also explained that because children's bones are what they are, there is a possibility of causing an additional fracture during the mainuplation.

Right after that, a nurse practitioner took us to an exam room to get my daughter's vitals and history. Suddenly, two new concerns arose. First, exactly how much Motrin had we given her since the injury took place? Secondly, how long ago did she have a cold?

The Motrin is an issue because it thins the blood. In some cases, the three doses that we had given her in four days would have been enough to call off surgery, but because hers was not going to be a procedure, even in its extreme, which would result in a lot of blood loss, we got a pass on that one.

Next, the anesthesiologist and nurse anesthetist had a listen to my daughter's lungs for themselves and were put at ease about possible complications with anesthesia due to respiratory congestion. (Prolonged intubation, lungs seizing during administration of anesthesia, the list goes on.)

While I felt very comfortable with the assessment of both of these professionals, it is a bit of torture to add any additional worry to a day that already felt interminable.

Finally, we were taken to a holding room, where my daughter (now dressed in hospital p.j.'s, playing happily in the waiting room full of toys and breaking my heart for all of her innocent unawareness of the extraordinary nature of that vision) was given "giggle juice" (some form of sedative) along with a shot of apple juice to wash it down. As she had had nothing to eat since the night before, and nothing to drink for hours, the apple juice (all one tablespoon of it) made her quite happy.

And then the hardest part. Watching the surgical team wheel her stretcher away from the two of us, her beautiful brown eyes locked on to us the whole time. She was small and brave and no amount of kisses and hugs could have made that separation bearable.

Rather than detail the remaining minutes and hours, which turned into an overnight stay, let me just say that the surgery went fine, as far as we are told. The closed reduction did not work, in that her little bones are so flexible, they wanted to pop right out of place, even after being held there by the doctor for thirty minutes or more. (This is where, perhaps, the local ER failed us, by not catching the dislocation and suggesting that we wait four days before approaching the children's hospital.) While in the OR, the doctor phoned us in the family waiting room (unsettling, again) to tell us that he would be performing the percutaneous pinning. It is, I gather, less than ideal. However, it is better than settling for an unstable closed reduction, possibly necessitating another visit to the OR for an open reduction down the road.

My daughter did great in the OR. Her vitals were strong and her recovery uneventful, aside from the tremendous exhaustion she experienced. That is why we made the decision to stay overnight. She was just zonked, and at nine thirty at night, it was no time to rouse her for a cold car ride home. Of course, I stayed overnight with her. I'm just glad she slept well. :)

By 6:30 the next morning she had me walk her down the hall from her hospital room to play in the toy room. It was easy to see that she was back to herself, giving me specific instructions for playing with her and enjoying all of the different toys.

Now we have three weeks with an ERNOMOUS pink cast, which is about three times thicker at the elbow than a normal cast. She is in great spirits and only took one dose of Tylenol last night around seven. Today was the first day since it happened that she said her elbow doesn't hurt. Hurray! In three weeks the doctor will x-ray and if all looks good, he will remove the k-wire under conscious sedation and replace the cast with a removable splint. That part (sedation) worries me, but at the children's hospital, the protocol seems to place the patients' comfort at the forefront of care. Hopefully there won't be much drama during that visit.

Not out of the woods, but glad to be where we are and no longer where we were.


At 12:41 AM, Blogger Hetty Fauxvert said...

Oh my goodness. Sounds like a very long day. Thanks for updating (though I bet you're still dog tired); I was wondering/worrying how things went. So glad to hear she is already getting back to her normal self!!

Geez. This parenthood gig isn't for sissies, is it?

At 3:30 AM, Blogger Kath said...

Dear Casey, I'm so glad everything turned out all right. It must have been so, so scary and exhausting to go through...

At 2:00 AM, Blogger Sami said...

Conscious sedation - a great thing... for kids and for parents... as a PICU nurse I can attest to that. Sorry things were so hairy but glad to hear your girl is on the road to recovery!

At 5:59 PM, Blogger kati said...

glad your daughter is doing so well! What a scary experience.

At 2:24 PM, Blogger Erin said...

Oh Casey, your poor baby girl! I'm sorry that she (and the rest of you) have gone through so much. It sounds like she's doing better now. I hope she heals really, really quickly. Poor little thing.

At 9:01 PM, Blogger The Town Criers said...

Found your blog tonight. Glad things went well with your daughter. Ouch! Just reading it was making me hold my elbow and grimmace.


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