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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fracture times three: the shoulder, the back and the ankle

Tuesday, November 4, 2014

In the past few days, what we’ve learned from football is that not all fractures are created equally. From Nick Foles’ collarbone to Laquon Treadwell’s ankle and Tony Romo’s back, all broken bones are not the same and the approach to treatment is tailored to not only the bone but also to where in the bone the damage has occurred and what surrounding structures are damaged. Perhaps the first lesson is a reminder that broken, fractured, cracked all mean the same thing. One word does not make an injury more or less significant. It’s uncomfortable to watch the replay of an injury but those slow motion images can help explain the mechanism of injury and the stress that is put on the skeleton of the body.

Eagle quarterback Nick Foles was sacked and as he was being tackled and taken to the ground, lands directly on the point of his shoulder. This force of the fall is transmitted to the clavicle or collarbone and can cause the fracture or a separated shoulder where the AC (acromio- clavicular) joint is torn. The damage depends upon which structure cannot withstand the force applied. For Mr. Foles, his collarbone injury will be allowed to heal without surgery since the bone is not displaced, meaning that it aligns reasonably well and nature will fix it over time. That will take weeks and cannot be rushed. Last year, Aaron Rodgers same injury took a little less than two months to recover and return to play.

ac joint

For Dallas’ Tony Romo, a knee to the back caused the psoas muscle to go into spasm. The force of that spasm avulsed or tore off the transverse processes of two vertebrae in his lumbar spine. Muscles and tendons attach to bone to help support and move the body. In Mr. Romo’s case, the muscle attachments were stronger than bone and when the injury occurred, the tendon didn’t tear which would be a strain, instead, the bone tore away. The purpose of eh back, aside from allowing the body to be erect, is to protect the spinal cord and when the words broken vertebrae are spoken, the fear is that there is damage to the cord or the nerves. In this situation, the injury is far removed anatomically and functionally from the spine canal and while painful, is treated like a contusion or bruise. Return to play happens when the muscle spasm and pain can be control to allow the player to run, twist and bend over.

psoasTP fracture

Psoas muscle insertion                                  Transverse process fractures

 

 

Ole Miss receiver Laquon Treadwell is not as lucky. A twisting injury to his leg cause a fracture dislocation of the ankle and is a reminder that the body cannot easily tolerate a torsion or twisting force. As he reached for the end zone, Mr. Treadwell’s lower leg was caught up in the pile. Not only did his fibula fracture but the ligaments that held his ankle stable were torn (a sprain). The tibia and fibula that connect the knee to the ankle form a circle and like trying to breaking a pretzel in just one place, a twist will always have two injury sites. In the ankle, it is either two bones or one bone and a ligament that give way. Either way, the stability of the ankle joint is compromised and the muscles that cross the joint cause it to dislocate. In most cases, surgery is required to stabilize the bone and fix the ligament to keep everything in place to allow healing to occur.

ankle ankle dislocation

 

Three fractures, three different mechanisms of injury, three different treatments and three different healing times. It’s a reminder that the body does a good job of self-healing but sometimes it needs a little help. The bottom line is that like in real estate, the key to injury diagnosis, treatment and outcome has to do with location. Understanding the mechanism and anatomy can help decide what treatment will best help Mother Nature repair the body.

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