A clear, sunny day after a snowstorm is always an excuse to step outside and so I did last March, onto the deck of my client’s multi-million-dollar home, and fell through a rotted plank. The client had stepped into another room to answer a call and as the plank gave way under my right foot, I fell through as elegantly as cracking wood allows. I didn’t scream, and for a minute lay nonplussed on the still-icy deck before carefully extricating my leg and crawling into an upward pose.
My upbringing is British and so I am disinclined to create a fuss. While the client continued his conversation in an inner room, I held a bleeding hand under a kitchen faucet to clean it. Although I had dramatic bruising from my foot to the top of my thigh and on both hands, I didn’t go to a doctor until the fourth day, when I woke and my hands had stopped functioning. I drove to the hospital, steering with my elbows.
X-rays showed a fractured left hand, torn ligaments in my right hand and knee, and bruising so deep doctors gave me blood thinners to stave off a feared embolism. Neither emergency-room doctors nor either of my two surgeons (for the two operations that followed) warned of the implications of a break. An injury that breaks a bone or tears ligaments may also seriously damage other tissues, including the skin, nerves, blood vessels, muscles, and organs. As Danielle Campagne, M.D., notes to doctors in the Merck Manual, “These injuries can complicate treatment of the fracture and cause temporary or permanent problems.”
I’m a stoic person, and so I remained cheerful until the pain kicked in during the second week. I also realized that with thumb-to-elbow casts on both hands and arms, I could not wash my hair, use a knife and fork, or manage anything with buttons or zippers — and since I now struggled to type, I was late with all my assignments and lost a large contract. I couldn’t drive or push a supermarket cart unless I used my elbows to steer; I couldn’t sweep, vacuum, open a jar, or even a medicine bottle. My immune system plummeted and in the remaining weeks of winter, I had five bad colds. My normal cheerful personality became marred with occasional grumpiness, my surgeon shrugged when asked about it, but a nurse said unusual irritability is common in those who experience fractures.
What is the impact of fractures on the brain? Dr. Daniel Cohen — chief of thoracic surgery at the West Roxbury campus of the Veterans Administration Hospital and a surgeon at Brigham and Women’s Hospital — said he had not heard of brain-related impacts after fracture and suggested that it might be a component of post-traumatic stress disorder.
Although there is surprisingly scant research, those who have looked at this rich field have discovered that — in my instance, as an example — what was happening was that my immune system was briefly compromised as my brain shifted resources to heal the injuries. Grumpiness was a side effect of the massive work taking place in the brain to heal one bone, many damaged nerve endings, and two torn ligaments.
Ironically, my brain was also strengthening my elbows to perform tasks that they had never done before — drive a car or propel a supermarket cart. Research by Nicolas Langer, of the University of Zurich in Switzerland, found that, as an example, right-handed individuals whose dominant arm had to be immobilized after an injury showed a drop in cortical thickness in the area that controls primary motor and sensory areas for the hand. At the same time, white and gray matter increased in the areas that controlled the uninjured left hand, suggesting skill transfer from the right to the left hand.
The MRI taken within 48 hours of the injury and another about 16 days afterward showed big changes. Cortical thickness decreased only in the left hemisphere — mostly in the primary motor area and in two clusters in the primary somatosensory area of the hand. Increases were seen in cortical thickness in the right primary motor cortex extending into the premotor cortex, correlating to improved motor skills in the left hand. The greater the improvement in left-hand performance, the greater the decrease in cortical thickness in the zone between the primary motor and somatosensory cortex. The MRI also showed that two weeks after the arm was immobilized, there was a decrease of white matter in the brain’s left corticospinal tract without a change on the right side. Improved left-hand motor skills did correlate, though, with increased white matter in a cluster in the upper-right corticospinal tract. Langer suggests that the “structure of the human brain is altered by deprivation and by transfer of skills from the right to the left-upper extremity.”
Naomi Eisenberger, co-director of the Social Cognitive Neuroscience Lab at the University of California, Los Angeles, has reported that physical pain is felt in the same areas of the brain as social rejection — both experiences induce the same feelings of “hurt.” How distressing your brain determines pain to be, whether emotional or physical, registers in the dorsal anterior cingulate cortex (an area rich in receptors for endorphins). In tests, giving Tylenol for physical and emotional pain worked, with both groups.
Eisenberger has also found that people with a gene that makes them more sensitive to physical pain are also more sensitive to social rejection. For both social and physical pain, support from caregivers can help to alleviate stress factors (that is, to effectively reduce the “pain” felt).
Matters are far more serious for older people, however. One in 13 elders (those 65 and older) with hip fractures will die within three months. For older people that survive a fall, their survival rates are akin to those with breast cancer, and the risk of dementia rises, according to a major study conducted by researchers at Ohio State University. Their results, published in Trauma Reports, show that fractures in older adults increase the risks of reduced mobility and impaired cognitive function, and could even be a warning of early death. Even something as apparently simple as broken ribs sees a mortality rate of 10 percent for young patients and 22 percent for older patients.
The risks associated with hip surgery are so serious that a delay of surgery for more than 24 hours for any reason is associated with increased mortality in patients with hip fractures. These delays can lead to anything from severe anemia to an array of cardiac conditions. Postoperative risks include pressure ulcers, pneumonia, or even renal injury. It appears that the brain is so focused on healing broken bones that it lags on providing adequate immunity against infection or disease.
As for my injury, I spent 10 months in casts and braces on both hands up to my elbows and covering my left thumb. This year I hope to dust off my bicycle and start cycling again. I look with new gratitude at my fingers and hands, the weights they can carry, the intricacies they are capable of these humble stars on my arms, so long neglected, now newly respected.
This article was originally published in Brain World Magazine’s Summer 2017 issue.
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