Monday, December 2, 2013
Packer Nation and all of Wisconsin have all become experts on bone healing, giving their opinions as to when favorite son, Aaron Rodgers should return to play quarterback after fracturing his clavicle and thus resurrect the failing Green Bay team. If only it was so easy to know when a bone has completely healed. Though most athletes who break their collarbone and return to play within a couple of months, the notion that the bone has completely healed is faulty. While the bone may have regained its strength, healing as defined by x-ray may take 4-6 months and final remodeling and sculpting can take years.
The question is: when can a player or a construction worker or a kid return to their activity and not have an increased risk of reinjuring the same bone, understanding that given the same set of circumstances that caused the fracture in the first place, the bone will still break.
Bone healing is a long physiologic process and the body can fix most fractures by itself. Doctors get involved to try prevent complications, keep bones in alignment and return to the body to function as soon as possible. There are a variety of stages in bone healing and they cannot be rushed.
The first stage is reactive. A blood clot forms at the area of the fracture (remember that fracture, break and crack all mean the same thing, that the integrity of the bone has been compromised) and begins the healing process. Though this clot will eventually dissolve and the cells within it die, it allows the formation of granulation tissue or the matrix that will form the scaffolding for new bone formation. Fibroblasts from each broken end start forming collagen, the body’s building blocks that begin to span the space between the broken edges.
Reparative stage happens next. At the broken bone edges, the outer lining called the periosteum gets turned on, generating chondroblasts that make cartilage and osteoblasts that make bone. They form a mix of bone and cartilage that is not well organized called woven bone and has little strength. However, this mass of bone at the fracture site allows for the real magic of healing to occur. The surface of the callus starts to be pitted by small blood vessels and many more osteoblasts. Instead of laying down random woven bone cells, more formal bony patterns develop into lamellar or cortical bone. This bone is trabecular, meaning that there is a lattice work of bony beams and crossbeams to maintain strength and shape.
The last stage is remodeling, where the body takes the extra amount of bone that has been laid down at the fracture site and slowly sculpts it back closer to its original shape. The trabecular bone is gradually replaced by compact bone in a process that can take up to 5 years. Osteoclasts, cells that break down bone, and osteoblasts, the bone makers, work together during this process.
The wider the gap between the bone edges, the longer the process takes to complete. For that treason, many fractures that had once been allowed to heal on their own are now being considered for surgery. The clavicle or collarbone has been studied extensively since it is so often injured. For displaced fractures where the bones edges are moved apart, surgical repair (also called ORIF for open reduction and internal fixation), seems to have better results than just allowing to have the bone heal on its own. Aside from showing healing more quickly by x-ray, almost 12 weeks faster, patients who had an operation had better function and were happier with the cosmetic result.
Mr. Rodgers had a non-displaced clavicle fracture and needed no surgery, but the healing that needs to occur is still the same and cannot be rushed. When the decision is made to allow him to play and should the bone not have gained enough support and strength to withstand injury, there is the risk that the bone will break again at the same spot.
Aside from clinical judgment by the patient and physician, there is no test to know precisely when the bone is physiologically healed. The clavicle will take many months to heal by x-ray but x-rays usually lag behind the clinical situation. The coach doesn’t know, the sportswriters don’t know and most certainly, Packer Nation doesn’t know. Mr. Rodgers will be cleared to play when the doctor’s gestalt, gut feeling and experience say that he’s ready to go. Meanwhile, Wisconsin can’t wait.
This entry was tagged Aaron Rodgers, bone healing, clavicle, collarbone, fracture, green bay packers
Monday, November 25, 2013
A crisis was brewing in room 12. Instead of the Green Bay-Vikings game, there was nothing but fuzz on the local Fox channel. The patient and family mentioned it in passing but clearly they were distraught. All were wearing Aaron Rodger jerseys and there was no doubt that it took a true emergency to bring them to the hospital, instead of being at home watching their beloved Packers play on TV.
There is nothing funny about being a patient in the ER. First, there is the illness or injury that prompted the visit. Second, there is the uncertainty of what the future might bring. Third, there is the unknown wait time, realizing that your care could be delayed because you are deemed less sick or hurt than the person being wheeled in on the next ambulance. And of course you have no real say in who is providing your care. Loss of control is a frightening thing.
But circumstance do arise that remind us of the humanity of the situation and in Wisconsin, football Sunday can bring the world to a stop. The Packers were playing and nothing much else matters to the bulk of state’s population. Our ER sits on the banks of Mississippi and across the river the green and gold is replaced by the purple of Minnesota and it is an easy way to break the tension when walking into the room to mention the colors that the patient is wearing. I’m certain the same situation happens on Saturdays in Alabama and Oklahoma but in Wisconsin, the fans own the team and having an undying allegiance.
The department was busy yesterday, even though the game was on at noon. Often we sometimes joke that patients try to rush in to be seen before the game starts or wait until after the final whistle to seek care, but in truth, the number of patients who register isn’t really affected by when the game is being played. Patients tend not to plan their emergencies, but it seems a little more festive hen the game is on. Normally, the television are turned to a variety of channels from CNN to HGTV (the Property Brothers seem to be a favorite), but on football Sunday, it’s wall to wall Packers. There are occasional cheers that are not because the lab test came back normal and that groan might be from a penalty or missed tackle instead of a spasm of pain.
I saw four plays all game. I watched with a family dressed in Viking home jerseys as Scott Tolzien rushed for his first touchdown as a Packer. They were not happy. They were less happy to know that abdominal CT scan that I had just ordered would take a couple of hours to complete. Never mind that all tests on House or Grey’s Anatomy can be done within the hour including commercials, but real world technology moves a little slower. I watched two plays with an older gentleman who remembered Bud Grant and Joe Kapp from Vikings history. I told him that I remembered those two from the Canadian Football League. He smiled. Play four was a Jordy Nelson catch, or I think it was but I couldn’t be certain in the fuzz of room 12.
There are small things that make the ER tolerable for patients. We have volunteers who provide coffee to families or help watch children. Our social workers try to find ways to keep elderly patients independent in their homes. There are nurses who stay late to comfort the family of a patient who is doing poorly. The art of medicine seems to be on display at the same time the science is being tended to.
And sometimes all it takes is the Packers and Vikings on the screen in the corner of the room to make even the most frightened patient smile just a little. I guess we’re readyfor some football.This entry was tagged ER, football, Packers, Vikings
Dr. Wedro weighs in
“The difference between doctors who look after mere mortals and those who look after elite athletes may have to do with how many tests they can order, regardless of the cost.”