clavicle (collarbone) fracture

Sunday, October 15, 2017

For a bone that is commonly broken, the clavicle (collarbone) gets little attention from the public and medical community. Once upon a time, the broken collarbone was treated in a figure of eight splint with a sling and time was allowed to do its magic to heal the break. Less long ago, the figure of eight splint was dropped and treatment was a sling alone. Slowly, though, the clavicle gained some measure of respect and fractures became the focus of research and surgery became an option in specific types of injury. The spotlight shone again on the clavicle this Sunday afternoon with Green Bay Packer quarterback, Aaron Rodgers, carted off the field.

The clavicle connects the sternum (breastbone) to the shoulder joint that has many important functions. It acts as a strut to give the shoulder muscles room to rotate the head of the humerus. A half dozen muscles attach to the clavicle and help move the neck and shoulder. And the bone helps protect major blood vessels and nerves that supply the arm and neck with blood. Plus, the end of the distal end of the clavicle nearest the shoulder is the site of the AC joint (the acromioclavicular joint) that helps mobilize and stabilize the shoulder. All clavicle fractures are not created equal. There are a variety of classifications describing location on the bone and whether ligaments that stabilize the AC joint have been damaged.

While most clavicle fractures are treated conservatively without an operation, there are reasons to consider surgery.

Some are associated with the broken bones:

  • Do the bone ends overlap and shorten the bone length?
  • Is the bone displaced so the ends don’t align?
  • Does a jagged bone edge tent the skin?
  • Is the skin torn?

Other reasons have to do with associated injuries

  • Is the AC joint torn?
  • Is the joint between the sternum (breastbone) and clavicle damaged?
  • Is there damage to the blood vessels beneath the clavicle?

And reasons for a later operation

  • Did the bones fail to heal (non-union)?
  • Is the patient unable to tolerate non-surgical treatment?

The decision to use a pin or a plate and screws depend upon the type of fracture and to some extent, the surgeons. training and past experience.

Diagnosis is relatively easily, usually by physical exam and confirmed by X-ray. In the back of the care provider’s mind, from the trainer on the field to the ER doc to the family provider, is to look for other associated injuries. While these include looking at the AC joint and shoulder, and the blood and nerve supply to the arm, it’s also important to examine the chest to check for broken ribs or lung bruising (contusion) or collapse (pneumothorax).

It takes somewhere between 4-8 weeks for a broken collarbone to heal without surgery, with only 6% resulting in non-union. The major risk for not healing is smoking!

Surgical healing takes longer. For noncontact sports or the non-athlete who needs an operation, return to play or activity occurs, when x-rays show good healing and when there is painless shoulder range of motion and strength that has returned to normal or almost normal. Usually this takes about 6 weeks.

For athletes who play a contact sport, return to play takes significantly longer to protect against refracturing the bone and the rehab time is measured in months. The player is cleared when the bone is healed both on x-ray and on physical exam. Range of motion and shoulder strength also have to be normal.

The team physicians will likely take time to evaluate Aaron Rodger’s injury. Because he is one of the faces of the NFL, there might be CTs and MRIs involved to decide the extent of the injury and the plan of treatment. Regardless, the speed of bone healing can’t be accelerated, and with less than three months left in the season, the broken collarbone might mean the next time Rodgers leads the Packers onto the field is in autumn 2018.

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tibial plateau fracture

Monday, October 9, 2017

It’s difficult to understand why bad things happen to good people. It goes without saying that the Texans’ J.J. Watt is beloved in his adopted home of Houston. It is also true that his broken leg, a tibial plateau fracture, will call into question whether he will play again in the NFL.

His response on Twitter to his situation?

“I can’t sugar coat it, I am devastated. All I want to do is be out there on that field for my teammates and this city. I’m sorry.”

This from the man who raised tens of millions of dollars for the Houston hurricane relief efforts and who has played and been recognized as the best defensive player in the league. but the demon of injuries is blind to ability to play and a tibila plateau fracture is a big deal.

Broken bones are not all created equally. It’s all about location. The tibia (shin bone) connects to the femur to form the knee, and to the talus to form the ankle joint. Fractures that involve the joint surface have the potential to not heal appropriately and cause long term problems like arthritis, stiffness and loss of range of motion. This is especially true for the tibial plateau.

The top of the tibia, has two shallow surfaces lined with cartilage that allow space for the femoral condyles to slide and allow the knee joint to flex (bend) and extend (straighten). It takes a lot of force to fracture the tibial plateau and in addition to the trauma, there needs to be some bad luck involved, where the knee is just in the right position, so that the force drives the tibia into the femur and shatters that once smooth surface. Most often, these injuries occur in car wrecks or falls from height where a load is placed on an extended leg and all the force is transmitted into the knee.

Anatomy is important in understanding injury patterns. The top of the tibia is expensive real estate. There is a medial and a lateral tibial plateau, both covered with a meniscus or cartilage, and between the two is the intercondylar notch where the ACL (anterior cruciate ligament) and PCL (posterior cruciate ligament) attach. Because the knee is designed to be held in slight valgus, the medial tibial plateau tends to have thicker bone that that makes is less prone to injury than the lateral tibial plateau.

When the tibial plateau is forced into the femoral condyle the bone collapses and the surface where the cartilage sits, may or may not get crushed. The pain is immediate, the swelling occurs quickly and trying to walk on the injury may or may not be possible, depending on the severity of the break. X-rays can show the general injury, but they are only 2D images and the body is three dimensional. CT may be needed to look at the surface of the plateau and understand the extent of damage…and if there is concern that there are ligaments involved, an MRI might also be needed.

When it comes a decision about surgery, it’s all about making certain that the joint surface lines up properly. If there is any step off, inflammation will occur with each step taken as the femoral condyle rubs against the uneven surface. The long-term complications include pain, knee stiffness and arthritis, but other problems might arise, including malunion (failure of the bone to heal) or collapse of the fracture, so that the knee joint has no bone beneath for support.

The bottom line for Mr. Watt is that a tibia plateau fracture is a bad thing that happened to a good person. Depending upon the extent of the injury, his recovery and return to play might span a spectrum that runs months to never. The goal for all patients is to return them to the level of function that they had enjoyed prior to the injury. Unfortunately, most patients aren’t best in class NFL defensive lineman.

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