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.This entry was tagged Aaron Rodgers, AC joint, broken, clavicle, collarbone, fractured, green bay packers, surgery
Sunday, December 25, 2016
Fractured fibula for Marcus Mariota.
Broken fibula for Derek Carr.
Words matter when it comes to medicine. Patients and their families potentially can get confused when different terms are used to describe the same situation. This is especially true when reporters, people who write for a living, use interchangeable words and readers might presume one injury is worse than another. With the above tweet, ESPN’s Mr. Schefter sows those seeds of confusion.
Fracture, broken and cracked all mean the same thing…the integrity of a bone has been disrupted. One term does not imply a more serious injury. You can’t be a little bit broken, fractured or cracked. However, fractures may be more or less serious than others. Some need surgery while some, with time can heal on their own.
It is important to know that the fibula is a strut bone in the shin that runs from the knee to the ankle. While it is an important structure, it is not part of the bones that make up the knee joint (femur and tibia) or the two that make up the ankle joint (tibia and talus).Fibula fractrues are often associated with tibia fractures but isolated injuries to the fibula do occur. When they do, the fractures are not all treated the same. For the isolated fibula injury, it’s like real estate; it’s all about location.
Fibular head fractures usually occur because of a direct blow or a twisting injury and non-displaced fractures are often treated with supportive care: weight bearing as tolerated, ice and pain medications. Fractures that are displaced, meaning that the two ends don’t align well, may need an orthopedic specialist to consider surgery. The big deal with this injury is the peroneal nerve. It wraps around the fibular head and if it is damaged, the muscles it controls can stop working, leading to foot drop.
Mid-shaft fibular fractures are relatively uncommon, but are usually due to a direct blow. Unless the bone is shattered or significantly displaced (not aligned), the treatment is time.
The distal fibula has a bony protuberance or bulge that is called the lateral malleolus. Ligaments that attach to it help stabilize the ankle. Fractures of the lateral malleolus or the distal part of the fibula may need surgery to maintain ankle stability.
The big thing to remember about fibula fractures has to do with anatomy. The tibia, fibula, knee and ankle form a ring. If there is a twisting injury, there are usually two injuries to be found because it’s hard to twist a ring and break it in only one place. Think of twisting a pretzel and snapping only one curve. For the certified athletic trainer on the field or the doctor in the ER or office, finding an isolated fibula fracture leads to looking for another injury before accepting “just” one injury. And that second injury may be torn a ligament in the knee or ankle that may be more important than the obvious broken bone.
Based on news releases, Derek Carr’s broken fibula may be distal and it required surgery. The location of Marcus Mariota’s fracture hasn’t been released just yet. It’s a reminder that the word broken did not determine injury severity or the need for surgery. It was just a word.This entry was tagged Adam Schefter, broken, Derek Carr, fibula, fibular head, fracture, lateral maleolus, location, Marcus Mariota, midshaft, proximal