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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concussion: looking out for those who are injured

Monday, November 13, 2017

As the NFL again takes flak this week for its head injury awareness with potential injuries to the Seahawks’ Russell Wilson, the Colts’ Jacoby Brissett and the Falcons’ Devonta Freeman, it’s important to remember that concussion symptoms can be subtle and have a delayed onset. The concept that a brief assessment on the sideline is sufficient to say yeah or nay on the diagnosis fails to meet the criteria set in the most recent consensus statemen from the 5th international conference on concussion in sport, held in Berlin in late 2016.

The bottom line for initial assessment is that all athletes, regardless on level of competition, should be removed from the field of play, if concussion is suspected. If the diagnosis is not in doubt, for example a player who is knocked out, briefly confused or has difficulty with balance, the player should not return to the game. If the diagnosis isn’t confirmed but suspicion exists, then the player needs to undergo sideline testing. But there is not one perfect test that can confirm or deny the diagnosis. Sideline screening can be done but it takes at least 10 minutes for most testing to be completed. While it can occur on the sideline, it is often better to find a quiet place to interview and examine the potentially injured player.

From the consensus guidelines:

“In cases where the physician may have been concerned about a possible concussion, but after the sideline assessment (including additional information from the athlete, the assessment itself and/or inspection of videotape of the incident) concussion is no longer suspected, then the physician can determine the disposition and timing of return to play for that athlete.”

And also from the same guidelines, an athlete with a sport related concussion should not be allowed to return to play on the day of injury.

There is a caveat that symptoms may be delayed and repeated evaluations are warranted. The problem is that the symptoms can be very subtle, from difficulty concentrating, to sleep disturbances, to changes in personality. The ability for the brain to function and process information may be affected so that concussed high school and college athletes may drop a full grade point in their classes for the ensuing semester.

As hard as it is to diagnose subtle head injury, it’s just as hard to decide when the brain has healed enough to allow the athlete to return to play. There is no test that confirms brain healing and most athletes recover within a month. Practically, return to play strategies take about a week if the athlete remains symptom free. That said, concussion symptoms may last for months.

Unfortunately for those who decide whether a Seahawk or Colt or Falcon can return to play, instant replay allows fans at home and in the stadium to witness the consequences of a hit to the head and judge for themselves whether the possibility of a concussion might exist. And when a referee sends a player off because of concussion concern, it’s incumbent upon the team’s medical staff to follow through with a thorough assessment. The player may not know what happened or realize that they were concussed; it’s up to the coaching and medical staff to protect the brain, even if the player actively refuses that help.

Until that is the standard of care, the NFL will continue to get flak.

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