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Shoulder to Shoulder: HSS Physical Therapist Guides as Patient Puts New Shoulder in Action

When Bettina Lester, a petite, elegant 78-year-old, recently came to visit an old friend in Orlando, she never dreamed she would have an accident requiring a partial shoulder replacement and many weeks of rehabilitation therapy.

Looking years younger than her age, Ms. Lester is fit from a regular routine of walking and swimming. She was injured when her Florida host’s standard French poodle, eager to race out the front door, jumped up and threw her to the tile floor -- shattering and dislocating her right shoulder.

No traveler ever prepares for this type of situation. Stabilized at a local hospital, Ms. Lester called her family for advice about surgery. After contacting a brother in Sweden, Ms. Lester followed his recommendation and took a flight to New York. Within hours she was examined by Frank A. Cordasco, M.D., Associate Attending Orthopaedic Surgeon in the Sports Medicine and Shoulder Service at Hospital for Special Surgery, who days later performed her surgery.

“This was a particularly severe injury caused by the velocity of impact and age of the patient,” said Dr. Cordasco. He explained that (using a fracture classification of 4 possible parts) Ms. Lester had sustained a three-part fracture combined with a dislocation of the shoulder joint. Dr. Cordasco said that once the dislocation is corrected - often in the emergency room - surgery to treat this type of injury should be performed as soon as possible but certainly within 2-3 weeks of injury.

If it is not done within that time period, or if a patient waits, several complications may occur, primarily related to healing of the fracture in poor position, otherwise known as a “malunion.” Ms. Lester was fortunate that the flight from Florida did not result in any blood clots - a risk for patients who have sustained fractures and other types of trauma and travel by air in the acute period.

Dr. Cordasco said that it is sometimes possible to put the pieces of severely damaged shoulder together with plates and screws, known as “open reduction internal fixation or ORIF,” but in a patient of this age, the quality of the bone and the potential for compromise of the blood supply to the ball portion of the shoulder joint may limit the success of this type of procedure.

For this reason, Dr. Cordasco performed a partial shoulder replacement, which is a procedure in which a new humeral head is implanted and the fractured bones (tuberosities) are repaired by suturing them securely to the stem and the bone around it. A total shoulder replacement, which Ms. Lester did not require, also involves a shoulder socket replacement.

While the operation was successful at restoring the anatomy, a process of recovery is necessary and requires a commitment to rehabilitation for the return of flexibility, strength, and endurance. Dr. Cordasco, Jennifer Petrakis, PT, Doctor of Physical Therapy, MLT, Physical Therapist/Advanced Clinician at the Joint Mobility Center, and Ms. Lester all agree that progress comes with patience and perseverance. Overall the challenge is to help the patient move to avoid stiffness, but not to disrupt the areas where bone fragments are healing.

Jennifer said that rehabilitation starts with establishing trust between the patient and therapist. “The patient will feel pain during the therapy. They need to trust that you are helping them recover.”

Ms. Lester, who initially (before the surgery) experienced excruciating pain related to her injury, was extremely grateful for the care she received from Dr. Cordasco and for the close rapport she established with Jennifer. “I was very depressed to be hurt. I am very independent and it was very discouraging to have to depend on some one to pull my zipper or comb my hair,” said Ms. Lester. Her compliance with the therapy regimen is bringing good results.

The early weeks involved passive exercises in which Jennifer gently moved Ms. Lester’s arm and shoulder. As time went by, more strenuous exercises that Ms. Lester could do under guidance and some that she could do on her own were added.

Exercises involved using an arm bike, using a pulley, standing or lying down while passing an object from back to front, and bending at the waist while swinging her arm in a pendular motion. Jennifer explained that supervision is needed to protect the patient from inadvertently injuring themselves and also to ensure that the exercises are done correctly to prevent stiffness.

As Ms. Lester’s scheduled return to France approached, Ms. Petrakis contacted a physical therapist at the rehabilitation center in Paris where Ms. Lester would be continuing her therapy to ensure continuity in the treatment she would be receiving.

As of June 2008, confident that she is well on the way to recovery, Ms. Lester said her summer plans include a vacation in a beach resort in Hammamet, Tunesia, where her arm would be back in action for swimming in the surf.

Image: Bettina Lester physical therapy session with Jennifer Petrakis