D/C

Discharged! My physiotherapist discharged me! So it appears that I can close this blog.
However, two days later, my foot started to swell.... so maybe not, so stay tuned....

Latest Updates (Week 13)

My Hospitalisation Leave ends soon, next week. That's why the entries in this blog has dwindled, and hopefully I'll have not much news on my broken ankle anymore since it's NOT. broken, anymore.

The physiotherapist (Yu Chan) seems happy at my progress, but she is right, I need to stretch the muscles more. The muscles around the ankle itself have been really tight and it hurts like the dickens when I try to sit Japanese style (on the bed). I can maybe sit for 3 minutes, then it'll start to hurt.

She is also making me stand on the left foot and balance myself. She wants me to do it with eyes closed, but I am still trying to accomplish that feat with eyes wide opened.

The last visit, it was a rainy day, so she said we have to do something fun. Jump on the trampoline. Then stand on tiptoe on the injured foot.

Whilst I was doing the routine, this malay lady came in to the room to do exercises too and she asked about my injury. She was quite friendly, either that or really inquisitive. I told her I fell down. She asked if I had an operation, and I said no. She was surprised. She told me that she had a shoulder surgery, she had a lock shoulder, and had igmored it til the ligaments tore. So they had to operate and sew it back together. At first she could not lift her arm and she said it was terrible not to be able to brush her teeth, or lift a spoon to eat. It was her right shoulder, but she could fend for herself with her left hand. She said that she's able to lift her hand slightly now, and with that, she could start cooking again and she's a happy woman and extremely pleased with this progress.

I can emphathise. I was really glad when I started standing on my two feet that I started to potter around the kitchen and had baked up quite a storm in the past weeks. I had baked two brownies, quiches, apple crumbles, cakes, cookies, beef and chicken pies. I also cooked seafood risotto. Being able to cook again is truly one of the milestones, other than having removed the cast and being able to stand and subsequently walk on my two feet. :)

More Outings

My friend from Switzerland, Reto and his girlfriend, Samira came a visiting. I have them to thank for getting me out of the house. (more of this at http://dindinsjournal.blogspot.com/)

I brought them on the River Boat Cruise down the Singapore River, and boarded the boat with my crutches. Then the next day, we went to the Night Safari, and I had my trusty crutches. Only on the last day, when we went for a steamboat lunch and when I bid them farewell at the airport, I didn't have my crutches with me. The only difference was more leg room in the taxi and I walked slower.

If not for them I think I would still be at home, "recuperating". I think nothing beats going out and walking, cos, seriously, how far can I walk.. at home? Whilst playing "tour guide" It was my first time since the accident back in town again and just strolling along the streets of Orchard Road - felt so good. Almost felt as though I was back to normal! And strolling is an acceptable pace in Orchard Road.

On their last day here in Singapore, we went for a foot massage. I was worried, but at Footworks, the soft spoken and very nice lady who was my masseuse, Mdm Foo, was gentle with my left foot. Once again, the massage made me feel as though as I was back to normal.

First Outing - YWCA

My first outing in my latest wheels (unfortunately it's only a solo seater)... the posh wheelchair. And the driver. They say the posh people always have affairs with their drivers... bah. what do they know... ;>

Never Forget!

Never forget how uncomfortable it was in the cast. In hot humid Singapore, the cast was like wearing a winter coat in the summer. I felt warm all the time. And sweating was not good. If my leg was sweating, then the sweat would remain in there as "foreign matter" and in a few hours make it itch. With the cast, I could not stretch the muscles. I could not touch, feel or massage my aching leg. I could not clean it, wash it. I was not supposed to poke at my leg to relieve the itching, but I did. My dad got an ultra long back scratcher and straightened it out. And a bamboo cane as well which got into the hard-to-reach corners.

I was afraid that the warmth would make my leg hair grow (some stupid guy told me that), so I tried to keep cool all the time. The other "rumour" was that it grew because it was dark and because of the rubbing alcohol that they used just before putting the cast on. (The hair did not grow in there, my leg was the same when I removed the cast. Only a few days later when everything settled, then the new hair started sprouting. ugh. The "sock" which was the initial / inner layer of the cast they pulled over my leg made my hair grow upwards such that when the cast was removed, the hair stood out for about three weeks. It's only just begun to settle down now.)

Never forget how difficult it was to sit, eat, bathe. Everything that was normally taken for granted was a little challenge. As I had to use crutches to get around, I could not even grab a cup of water on my own.

Bathing was an interesting challenge. Actually, I think not bathing was even more of a challenge. Taking a shower is a mundane activity that most take for granted. What if now you could not stand on both feet and you must keep one foot dry at all costs. So it was a tedious hassle to take a shower and I didn't until I absolutely had to.

Information on Broken Bones

Broken Bone Symptoms
(ref: http://www.doctorsecrets.com/your-bones/broken-bone-symptom.htm)







The following are general SYMPTOMS OF A BROKEN BONE:

Exquisite pain when you move or touch the broken area.
Bruising of the skin over the area of the break as in A above.
Shortening of the limb.
Snapping sound at injury.
Unable to support your weight standing in fractures from the waist down.
Something hard pushing up the skin or through it.

The shortening of broken limbs shown in B above happens because your bones are connected to muscles. When a bone snaps, the two ends can be pulled past each other by the muscles still attached.


How long it takes for Broken Bones / Fractures to Heal
(ref: http://www.doctorsecrets.com/your-bones/time-to-heal-broken-bone.htm)

The following is a rough estimate to HOW LONG IT WILL TAKE FOR YOUR BROKEN BONE TO HEAL in a cast. Remember that if you smoke or drink alcohol hard, this time will be longer because of these poisons.

Bone Broken Time for it to Heal
Collar bone 3-8 weeks
Scapula - shoulder blade 3 weeks
Upper arm 4 weeks
Lower arm 6 weeks
Wrist 3 - 8 weeks
Fingers 3 weeks
Pelvis 2 - 6 weeks
Upper leg 12 weeks
Knee 3 weeks
Lower leg 6-8 weeks
Ankle 6 weeks
Foot 3 - 12 weeks
Toes 3 weeks

Legs take so long to heal because they have to support the full weight of your body so they need to be pretty sturdy before you can resume using 'em.

Types of Fracture / Broken Bones

How you break your bone determines what kind of break you get. For example, twisting your ankle in a hole will make a different shaped break than jumping from a roof onto your feet.

Doctors use geometry to describe these breaks. This geometry is important because some shapes are more stable than others i.e. easier to fix and have different prognoses for healing and times of healing.

Types of Fracture in our Diagram:
Transverse fracture - meaning straight across. The two ends tend to stay together i.e. it's stable.

Comminuted fracture - meaning in many pieces. This is bad news as the fragments will find it hard to stay together on their own. This generally needs surgery using pins to keep everything together until the bone heals.

Displaced fracture - meaning the bone ends are no longer touching. This means they'll have to be manipulated back together before healing will occur.

Greenstick or crush fracture - meaning the bone has not snapped, it's been stretched or crumpled like soft chalk.

Hairline fracture - this is a small crack in the bone from a repetitive action like running which is so tiny you may not see it on xray, but it hurts! This has an excellent prognosis as the bone is midly damaged. You'll just need to keep off of it for a bit.

One other broad way of describing broken bones is whether the fracture is 'open' or 'closed'. Open means that the the skin around the broken bone has split open. Closed means the skin is intact over the fracture. This difference is important because open fractures need antibiotic cover and may need external fixation to heal.

Fracture Fixation

For broken bones that the ends won't stay together or there's too many pieces, we have to find a way to squeeze them back together until they set. This method bone doctors (orthopedic) use is called 'FRACTURE FIXATION'.

There are 2 types: inside and outside the bone fixation. Both are surgical methods.

Outside (external) fixation is shown in our cartoon above at A. You're seeing some pins driven into the bone from outside the skin to hold the broken bones together. This method is preferred in open fractures - because types B & C risk infection when there's a gaping wound - and comminuted fractures - because you can put as many pins in as you like. Once the bone has fused, the pins are taken out and discarded.

Inside (internal) fixation is shown in B as a rod pushed down the center of the bone, and as C, a plate with screws going into the two ends of the bone. Both of these methods are used in broken bones that will not stay together and where there's no open skin wound.

For B, the skin over the top of the bone is surgically slit and with a special hammer the nail is beaten down from the top, through the center of the bone, down through the crack, into the other end. It is left in the bone permanently strengthening it.

In type C The skin over the crack(s) is also surgically slit and the 'hardware' introduced and screwed in one side of the bone over the crack. It too is left in.

How do bones heal?
(ref: http://www.orthopedicsurgery.ca/faqs.html)

Bones heal by a number of methods. The two most common are healing from a cartilage callus, and healing under a plate (osteosynthesis). In the first type of healing, the bone ends when broken will bleed into the gap we call the "fracture" or break. This "hematoma" eventually turns into cartilage-like substance called "callus" as the bone cells jump across between bone ends laying down this new type of healing bone. Over time the callus will be remodeled by the bone cells into normal bone and become hard and durable again. Bones in good position, and particularly in young people, may heal without a trace of a scar. If there is much displacement or deformity, or if the patient is older, there will be an obvious bump or line that may be visible on the Xray forever. Bone is one of the only tissues in the body that has the ability to heal without leaving a scar.

How long does it take a broken bone to heal?
The time to healing depends completely on the blood supply and stability of the fracture or break. If there is no movement at the fracture site...if the bone is casted, or splinted, or if a plate has been placed onto the bone in the operating room, then the fracture will heal without delay. If the fracture is close to the end of the bone (metaphysis), the blood supply is strong and the bone will heal in a matter of a few weeks. If the break is in the middle of a long bone like the femur (thigh) or tibia (leg), the blood supply is not quite as good and it may take several months to heal completely. Age is also an important factor. Young people heal more quickly than older people.

Dealing With Bone Bruises

(ref: http://www.fightingarts.com/content01/bone_bruise.shtml)

To understand the why of it all is this: when we strike a bone against another hard surface, we cause small fractures in the outer layers of the bone which are called the cortex. The layman's term for this condition is a bone bruise.

The cortex of bone is comprised of small fibers which the body lays down in a kind of cross hatch pattern. It is this cross hatch pattern of fibers which then fills in with calcium to produce the strength inherent in a bone. When we strike the bone hard enough, we actually break some of these fibers. If we break enough of these fibers, the bone can separate and it is then called a fracture. Such a separation can be seen on x-ray, but when only a few fibers are broken, it is impossible to see the damage on an x-ray film (the sensitivity just isn't good enough).

Even though the injury can't be seen on x-ray, the body has to treat the injured area like any other fracture. First it must remove the calcium and damaged fibers from the area, called remodeling, and then it can begin to rebuild new fibers and lay down new calcium to the area. This whole process can take up to 8 to 12 weeks, depending on the size of the injury.

One thing is important, though, and that is: if you strike the area again after it is partially healed, you will be damaging new, poorly protected fibers that the body has just laid down. Thus, the body will have to stop its rebuilding process in the re-damaged area and remove these fibers and the associated calcium before it can resume rebuilding. Now let me state for clarity that the body can tear down the fibers on one spot at the same time it is building up a spot just next to it, but in general re-injuries will significantly increase the healing time. To help improve healing time, use heat (as described later in this article) and to use anti-inflammatory medication to minimize swelling, as swelling delays the healing process.

If you are treating a minor injury, the best thing you can do for it is, of course, to rest the area. The second thing to decrease the amount of swelling. The reason for this is that swelling seems to increase the amount of time it takes for an injury to heal.

The best way to decrease swelling of an area is to elevate the area. DO NOT put an Ace wrap or other constrictive bandages over an injury to prevent the area from swelling. The area probably will swell anyway. It just won't expand outward and will thus compress the injured area including the blood vessels. When that happens you risk cutting off the blood supply to the area which could result in severe complications.

The second thing you can do is to apply ice. Because ice causes your body to contract the blood vessels in a cooled off area (but not close them off completely), ice is a valuable tool. There are a few important things to know about ice: First, make sure the ice is wrapped in something. NEVER put ice directly against the skin surface for any length of time. You may cause frost bite. Second, ice will initially make the pain of an injured area slightly worse because of shivering. This effect last only for about one to three minutes . Then the area will lose sensation and the pain feeling (of both the ice caused sensation and the original pain) will dramatically lessen.

Ice and elevation should be used exclusively for the first 24 to 36 hours after an injury.
After the initial period of the first 24 to 36 hours after the injury, heat can be used. There are, however, some important rules about the use of heat which most people and even some medical professionals are not aware of. If you do not pay attention to these rules then heat will cause you more harm than good. The important thing to remember is that heat does not always help an injury even if it makes the area feel good. When you apply heat to an area, you cause the body to dilate the blood vessels in the area that is being heated. This is both good and bad.

Dilation is good because when the blood vessels are dilated they can bring in more oxygen and healing materials to rebuild the damaged area and remove waste products which have built up. However, blood vessels are like pipes made out of a porous material. When they are small there are very small holes in the walls of the blood vessels. When you expand the pipes the holes also get larger. The longer that you apply heat to an area, the larger the blood vessels become, up to the point where they can't expand any more. When they are fully expanded blood vessels leak like a sieve (forgive the pun). They let small amounts of red blood cells and a significant amount of protein leak into the tissue surrounding the blood vessels. These red blood cells and the proteins break down within a short period of time into substances which cause irritation and thus release more prostaglandins, causing swelling and more pain.

What we have is a situation where a little heat can help but heat for prolonged periods can actually harm. Perfect examples of this are patients I have treated for acute muscular back pain. A significant number of these patients have used a hot water bottle at night for their back injuries. It makes their back feel good they all tell me. But when I ask them what their back feels like in the morning they always admit they feel worse but usually blame it on the fact that the water got cold during the night.

The real problem is not that the water got cold, it's that it stayed hot for too long. The optimal period for applying heat is for about 15 to 20 minutes. During this period the amount of benefits from the increased oxygen and removal of waste products from the area outweigh the small amount of swelling which is produced. After this period the amount of swelling outweighs the benefits.Don't misunderstand me, I do prescribe heat treatments for my patients when that is indicated. I just make sure that they know how to use heat correctly!

Once you have used a heat treatment you must wait for the blood vessels to return back to their normal size before applying heat again. The present belief is that the body takes approximately two hours to return to the base line. If you wait for a period of time which is at least this long, then you can and probably will benefit from the next application of heat.

The proper way to apply heat is to use as hot as you can bear it, but only for a 15 to 20 minute time limit. Moist heat is better than dry heat. A hot water shower with a massage is probably the best possible way that you can accomplish that at home. The next best way is to soak the area. Medical facilities may use ultrasound to ally heat to an area because it penetrates the tissue much better and actually causes less swelling than surface applied heat, but these machines are expensive and thus not likely to be found at home.
In summary, the best thing you can do for an injury is to rest it. Use ice and elevation for the indicated periods of time, then use heat in short periods of time with sufficient intervals of time between treatments for your body to return to its vascular baseline.

Bones at Work

(ref:http://www.fda.gov/fdac/features/396_bone.html)

For skeletal growth and maintenance, the body's 206 dynamic, living bones renew themselves lifelong through a continual breakdown, build-up process known as remodeling. This process is also involved in the remodeling of fractures, says Martin Yahiro, M.D., a Baltimore orthopedist in private practice and a consultant on fracture treatment devices to the Food and Drug Administration's Center for Devices and Radiological Health.

In remodeling, complex chemical signals prompt cells called osteoclasts to break down and remove (resorb) old bone, and others called osteoblasts to deposit new bone. Many elements influence remodeling. Among them: weight-bearing, vitamin D, growth factors, prostaglandins, and various hormones, including estrogen, thyroid, parathyroid, and calcitonin.

As 80 percent of the mature skeleton, compact cortical bone supports the body, providing extra thickness mid-shaft in long bones to prevent their bending.

Cancellous bone, whose porous structure with small cavities resembles a sponge, predominates in the pelvis and the 33 vertebrae from the neck to the tailbone. A fibrous membrane called the periosteum covers bone. For healing and health, living bone must have a steady supply of nutrients. Blood vessels permeate bone to provide this lifeline. Blood-forming elements fill the long bone inner canals.

When a Bone Breaks

Fracture breaks continuity of bone and of important attached soft tissue--including blood vessels, which spill their contents into surrounding tissue.

Even before treatment, the body automatically seeks to repair the injury. Inflammatory cells rush to destroy, dilute or isolate invaders and injured tissue. Tiny new blood vessels called capillaries begin growing into the site. Cells proliferate.

The injured person usually must endure pain, swelling, and increased heat at the breakage site for one to three days.

New tissue bonds the fractured bone ends with a soft callus, a mass of connective tissue and exudate (matter escaped through blood vessel walls). Remodeling begins.

Within a few months, a hard callus replaces the soft one. Remodeling restores the inner canal. Once restoration is complete, which may take years, the healed area is brand new, without a scar.

Usually thicker, the new bone may even be stronger than the old, Yahiro says, adding that if the bone should break again, it's unlikely to be at the same place.

And children's bones have a healing boost: They're growing.

"The growing skeleton is just geared to make bone," Yahiro says. "A very young child's wrist bones grow a millimeter a month, to rapidly correct misalignment or length defects. An adult may take six to eight weeks to heal a wrist fracture, a 5-year-old only three."

When the ends of a fractured bone, such as an arm bone, form an abnormal angle, the doctor must decide whether to push the ends together (manipulation) to reduce the fracture, possibly under anesthesia. Simple x-rays aid evaluation. "If it's a large angle, we'd want to reduce that fracture," Yahiro says. "But if it's a small angle, especially in a young child whose growth will correct it, we'd probably just put the limb in a cast."

Surgery for Joint Fractures
An external fixator--a pin-and-rod frame--can keep the joint from being compressed by other bones, to heal before a load, or stress, is put on it again. Pins are inserted on one side of the limb through the skin, muscle and bone, out the other side, and attached to the external rod, forming the frame.

Surgery to remove a screw in the very old may be too risky. For a 20-year-old, benefits of a second surgery may outweigh risks. In the ankle, plates and screws are customarily removed. Yahiro says, "The bones are so superficial, the device often rubs on the shoe."

Boning Up
The most important influences on fracture healing are nutrition and overall health, including bone health, before the injury, says orthopedist Martin Yahiro, M.D., a consultant to FDA. "That's why it's so important all your life to do weight-bearing exercise such as walking and get enough calcium and vitamin D, so you lay down as much bone as possible during growth and keep as much as you can later on."

The Recommended Dietary Allowance (RDA) for calcium is 1,200 milligrams a day for people ages 11 to 24 and for pregnant or breast-feeding women. For men and women older than 25 who no longer have to meet the greater demands of growth, the calcium RDA is 800 milligrams a day.

In general, genes decide bone shape and size. But mechanical stress by muscle, body weight, and physical activity influence bone shape and density--and health--throughout life.

Simply put, loaded (stressed) bone strengthens, and unloaded bone weakens. As examples, astronauts' bones weaken in outer space with no gravity pull on them, and the shaft of the humerus (long upper arm bone) in a professional tennis player's dominant arm gets denser and thicker from the extra load.

The body increases its bone mass until, usually, the mid-30s, after which a gradual loss begins.

Ahhh... AT LAST!

To be able to stretch properly at last! And it didn't even hurt. At last!
Imagine waking up from sleep and not being able to stretch a limb properly. And as a result, a muscle cramps. That was how it was like in a cast. Then, after the cast was removed, the leg muscles were to weak so it hurt to stretch.

These days, there's nothing better than to wake up and give both legs a equally good stretch. Even better is that I don't have to expect the left leg to cramp at night.