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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triceps tear

Monday, October 23, 2017

When people take about the ironmen of sport, Cal Ripken’s name often heads the list, but it’s Joe Thomas of the Cleveland Browns who should be considered the ultimate sports warrior. As a lineman, there are never any plays off and each play is a battle against the largest players on the opposing team. Mr. Thomas’ streak of more than 10,000 consecutive players that began in 2007, has ended with a torn triceps muscle. It may be appropriate that to sideline this player, it required a triceps tendon rupture that is the rarest of tendon injuries.

The triceps muscle is located on the back (posterior) of the upper arm and is responsible for extending or straightening the elbow. It is balanced by the bicep, located on the front (anterior) of the arm, which flexes or bends the elbow. As its name implies, the triceps has three heads that arise from bones in the shoulder and join together to form the muscle. It then morphs into a tendon that crosses the elbow and attaches into the olecranon, the bony outcropping that can be felt at the back of the elbow joint.

It takes a lot of force to tear the muscle or pull the tendon off the bone and the mechanism is usually a fall on an outstretched arm with the muscle contracted, and there may or may not be a direct blow to the area. The arm collapses and the elbow hyperflexes, pulling on the triceps muscle that can’t protect itself. The injury causes either the muscle to tear in two,  pulls the tendon away from the bone or fractures the part of the olecranon where the tendon attaches. Regardless, the end result is an arm that the player cannot straighten and the diagnosis is pretty obvious to the trainer on the field.

While many athletic injuries have options for treatment, the complete disruption of the muscle, tendon or bone, needs an operation to reattach the pieces and put them where they belong.

The purpose of a muscle is to move a joint. It usually arises from a bony prominence on one side of a joint and then attaches via a tendon across the joint to another bone. When the muscle contracts, the joint moves. If the muscle tendon unit is torn completely (a third-degree strain), The ability to move the joint is lost. Without repair, power and range of motion may never return completely. Interestingly. Some third-degree tears can be treated without an operation with satisfactory results, but not in athletes or active people.

The concept of the operation is easy, but requires skill to prevent nerve or blood vessel damage. Rehab is measured in months returning range of motion is balanced against ripping the repair and having to start over. For that reason, physical therapy is an important part of returning to play. Elite athletes strain to test their repaired body parts too early and need to rein in their enthusiasm to do too much too quickly. Mother Nature and Father Time don’t like to be rushed.

All streaks must come to an end. Cal Ripken was able to orchestrate his last game but most athletes have their streaks ended without knowing when their last play might be. To be fair, that can be said for every athlete, regardless of age. Faster, higher, stronger pits performance against anatomy and physiology, and sometimes the body loses.

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