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Dear Dr. Roach: Pain management help needed for 94-year-old's sacral fracture

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Dr. Keith Roach


Dear Dr. Roach: My 94-year-old mother has a sacral fracture, diagnosed after a fall six weeks ago. A CT scan diagnosed the fracture. She was put on Tylenol 3, and when that didn't help the pain much, they added Advil. This past week she experienced additional pain and can hardly walk. She said her left leg hurt in the groin area. I took her to the emergency room, and they did another CT scan that showed nothing new. They gave her a shot and a pill for pain, prescribed a muscle relaxant and sent her home.

She has to get up every two hours to go to the bathroom, but she says she can't walk, that it hurts too much. She sits on the walker, and I wheel her to bathroom. Calls to her doctor have not yielded much except to say that they will have home health call. But I haven't heard from them. It is so frustrating to see her hurting and be unable to help. Do you have any suggestions?

-- W.E.

A: There are many different types of sacral fractures. A few require surgical treatment, but the majority of sacral fractures in older adults are due to osteoporosis and are managed medically.

Principles of treatment include getting the person mobile quickly, and this requires appropriate pain management. It sounds like, in her case, the pain has not been controlled well enough to allow her to be mobile. Treating pain in a 94-year-old is tricky because the risk of side effects is higher in a person as old as your mother.

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Physical therapy may be the most important therapy, but again, she has to have the pain under control in order to get benefit from PT. Since her regular doctor doesn't seem to be helping, a consultation with an expert, such as a pain specialist or a rehabilitation specialist, may be of immense benefit. Treatment of the osteoporosis, which she is extremely likely to have, should be strongly considered.

Dear Dr. Roach: I have been diagnosed with granuloma annulare by two dermatologists. The rashes are on my hands, arms, legs and the back of my neck -- and they're spreading. Online research tells me that the cause is unknown and therefore there seems to be no cure. I have used two prescribed steroidal creams and taken high-dose niacin with no success. What can you tell me about the prospects of a cure?

-- K.M.

A: Granuloma annulare indeed has no known cause. Infection has been long suspected, but many attempts to identify an infectious agent have been unsuccessful. It varies quite a bit in appearance but most commonly looks like a ring, anywhere between skin color to dark red. It is sometimes itchy. The kind it sounds like you have, called the generalized form, affecting many areas of the body, happens more commonly in people over 30; children and adults into their 20s tend to have the limited form. It is more common in women.

I refer cases to a dermatologist, and my patients often have had success with injection of steroids. It is more effective than steroid creams or ointments. Some people require systemic treatments, such as hydroxychloroquine (Plaquenil). The vitamin A derivative isotretinoin, most commonly used for acne, is also sometimes used.

GA can disappear as mysteriously as it comes. About 75% of people will be free from disease in five years.

Dear Dr. Roach: I read your recent article in response to someone about what to avoid to prevent kidney stones. One of the suggestions was to avoid cranberry juice.

I take cranberry whole fruit powder (Vaccinium macrocarpon) in a probiotic to prevent UTIs. Does this active ingredient in cranberry whole fruit powder in tablet form make me susceptible to kidney stones? I really hope not.

-- L.D.

A: Cranberries and cranberry juice contain oxalates, which will increase the risk of a calcium oxalate stone in people who are predisposed to form stones. Some evidence shows that drinking more cranberry juice increases stone risk, and a study looking at cranberry tablets showed an increase in oxalate in the urine. So, I recommend against cranberry juice and supplements in people who have a history of oxalate kidney stones.

Cranberry products are often recommended to prevent urinary tract infections, as you are doing. Cranberries contain one or more substances that prevent bacteria from sticking onto the walls of the bladder, and thus might reduce urine infections. The evidence is suggestive that cranberry juice is helpful, but that's not universally accepted.

Vaccinium, by the way, is a plant genus with hundreds of species, known since antiquity, and has nothing to do with vaccines. The word "vaccine" comes from the Latin word for "cow" and reflects the historical use of cowpox to prevent the deadly disease smallpox.


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