clavicle fracture and return to play

Tuesday, December 19, 2017

Primum non nocere – First, do no harm

It was a win or go home week in the NF and for many teams on the bubble, a loss brought an end to their playoff dreams for the year. For fans of the Green Bay Packers, their loss to Carolina effectively ended their season. But with still two games to go, the Packer faithful’s next worry was whether injured and almost rehabilitated Aaron Rodgers should be allowed to play those last two games. Though the team medical staff cleared him to play after surgery, was he really okay or had they rushed him back with the hopes of leading the team to victory and a run to the post-season.

Back up 2 months, where quarterback Rodgers breaks his right clavicle (collarbone) as he is tackled and thrown to the ground. It’s his dominant arm, the throwing shoulder, and a decision is made to undergo surgery, open reduction and internal fixation, with plates and screws to keep the bone fragments aligned while they heal. Now here we are almost eight weeks later, and Rodgers is cleared to play but after the loss there are effectively two meaningless games left and should he take the risk of playing. The question becomes, is there a difference between cleared to play and totally healed.

The clavicle lies just below the skin and is easily felt. its S-shape, from the breastbone (sternum) to the shoulder joint, allows the muscles that move the shoulder more room and freedom to do their job. As well, the bone protects the major arteries and veins that run from the heart to the arms and neck. It is a commonly broken bone, but no break is the same treatment depends upon  a variety of considerations: upon the type of break (one or multiple pieces, is the skin torn), where in the clavicle the break occurs (near each end when the bone attaches to another, or in the middle) and what stresses will be put on the bone once it heals. For most people, the treatment is a sling to allow the bone to heal on its own.

There are a variety of reasons to consider surgery, but the benefit of an operation should outweigh the risk. Some indications for surgery ( ORIF=open reduction and internal fixation) include shortening or overlapping of bone ends, tenting of the skin because of bone fragment, and displacement of the bone so that it potentially affects the arteriues, veins, nerves and other structures that run beneath it. But with surgery comes some risk including infection, blood clots (deep vein thrombosis or DVT), delayed or non-union where the bone at the fracture site doesn’t heal, and malunion, where the bones heal in an unacceptable position.

 

 

Shortened, overlapping fracture                Plate and screw ORIF

 

A quick aside. When it comes to bone: fracture, break, crack all mean the same thing.

 

Mr. Rodgers has surgery to repair the collarbone and is cleared to play, but is he healed?

There are four phases of bone healing:

  • During the first phase and lasting about a week, there is the inflammatory response. Bleeding happens where the bone ends break and this causes a nonspecific inflammation response, no different than what occurs with any other injury in the body. Signals get sent to the body to mobilize and deliver the cells that fix things and they show up at the fracture site to do their work.
  • Within a week, phase two begins with granulation tissue forming a bridge between the ends of the two ends of the fracture. It’s important to not have the broken bone ends move much so that the bridging can occur and a soft callus of immature bone can be laid down.
  • Once the initially bridging occurs, phase three starts and osteoblasts (osteo=bone +blast=immature) and chondroblasts (chondro=cartilage) invade the area to start the formal bone rebuilding process. In the next many weeks, from 4-16 (1-4 months), the body lays down bone and cartilage woven together to form a scaffolding to promote a bony callus, a glob of bone that has calcium laid down for strength.
  • The final fourth phase may take months or years to complete. The bony callus is replaced with harder and stronger lamellar bone that is layered in parallel to the bone and allows reshaping and remodeling.

And that is where the question now lies with Mr. Rodgers, the Packers, their fans and the medical staff. Once phase three is complete, a player can return to play, knowing that the bone has healed enough to function, but the healing process is not necessarily complete and there is no magic test to say that phase three is done. The question becomes whether the bone is strong enough to withstand another trauma and is there a risk for re-fracture? When Tony Romo, then of the Dallas Cowboys and now a television analyst broke his collarbone early in the 2015 season, he sat out seven weeks to heal, but two weeks later he reinjured the site and subsequently needed surgery for repair. With repeated exams, and x-rays, the science of medicine would have said that he was ready to go, but that was proven wrong retrospectively by the bone breaking again.

And the answer for Packer Nation? The art and science of medicine do not always align….so who knows.

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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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