Clavicle (collarbone) Fractures

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Breaking the clavicle or “collarbone” occurs from a fall or direct blow to the area. Contact sports like football, rugby and ice hockey are common high risk sports. Falls while cycling, skiing and motor vehicle accidents are other common ways to fracture the clavicle. Immediately following the injury patients experience pain, swelling and limited use of the arm. X-rays are usually sufficient to make the diagnosis and initial treatment involves immobilization in a sling and use of ice and over the counter pain medications.

X-ray showing a clavicle fracture that is displaced and in multiple pieces

Treatment can be surgical or non- surgical. Non-surgical management simply lets the fracture heal in the position it is in and includes a period of immobilization. The immobilization period is typically 3-4 weeks until sufficient healing occurs so therapy can begin and pain is decreased. Non-surgical management has been the norm for a long time, however, surgical fixation or repair is gaining popularity for certain injuries.

X-ray showing clavicle plate

Surgical repair can be accomplished with a variety of devices, but usually a plate and screws has some advantages. Repair can align very displaced fractures. When the fracture is very displaced and when fragments shorten or ride over each other patients who are active tend to complain of shoulder pain and sometimes weakness or dysfunction. This can be alleviated with surgical repair. In addition, fracture healing time is shortened with surgical repair and risk of fracture not healing is lessened by surgical fixation. Use of the upper extremity is allowed much sooner following surgical repair.

In summary, clavicle fractures can be managed with or without surgery. Treatment decision is made based on fracture type, displacement and shortening. Patients activity level, age and other risk factors are taken into consideration as well. Below is a short presentation on a clavicle fracture I treated utilizing sutures and a plate to restore the anatomy and fix the fracture anatomically.

Presentation of clavicle fracture treated surgically

Tennis Elbow – Minimally invasive micro debridement

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Tennis elbow is a common problem for patients who play tennis or not. The #Tenex device offers a minimally invasive solution for patients not improving with typical treatments and those who do not want to wait any longer to return to activity. I combine this with PRP at time of the procedure.

Shoulder Pain – Calcific Tendonitis

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Shoulder pain is one of the most common complaints that patients come to my office for on a daily basis. There are many causes of shoulder pain including: bursitis, rotator cuff tendonitis, rotator cuff tears, labral tears, fractures of the shoulder, adhesive capsulitis ( frozen shoulder ) and many others. In this post I am going to focus on calcific tendinitis of the shoulder.

Calcific tendinitis is a common painful condition of the shoulder that results from calcium deposits within the rotator cuff. The calcific material is actually calcium hydroxyapatite. The calcium hydroxyapatite can be present in as many as 10% of people that her asymptomatic, although approximately half of these people will become symptomatic or painful from the calcium deposit. This is a more common condition in women. It commonly occurs in patients between 30 and 60 years of age and can be in both shoulders. There is no known definite cause calcific tendinitis, but the res include degeneration of the rotator cuff, repetitive trauma and injury. Patients with diabetes and hypothyroidism may be at higher risk for the development of calcium deposits in the rotator cuff.

The symptoms can include pain which is often severe and constant, limited motion and difficulty with lifting and reaching away from the body or behind the back. Almost all patients have no history of injury to the shoulder. The symptoms often come on abruptly and the pain seems out of proportion to the lack of trauma. The pain is often on the outside part of the shoulder and can radiate down to the mid arm or lower. However, pain can be more diffuse and poorly localized. An x-ray is usually diagnostic and rarely is an MRI, CT scan or other imaging modality necessary to make the diagnosis. An MRI may be indicated when symptoms are not resolving with proper treatment to look for additional pathology such as a rotator cuff tear.

The symptoms can include pain which is often severe and constant, limited motion and difficulty with lifting and reaching away from the body or behind the back. Almost all patients have no history of injury to the shoulder. The symptoms often come on abruptly and the pain seems out of proportion to the lack of trauma. The pain is often on the outside part of the shoulder and can radiate down to the mid arm or lower. However, pain can be more diffuse and poorly localized. An x-ray is usually diagnostic and rarely is an MRI, CT scan or other imaging modality necessary to make the diagnosis. An MRI may be indicated when symptoms are not resolving with proper treatment to look for additional pathology such as a rotator cuff tear.

  • X-RAY of the shoulder showing a calcium deposit in the rotator cuff
X-RAY of Calcium deposit in the rotator cuff on the left and an MRI image on the right

Treatment of calcific tendinitis includes rest from painful activities, anti-inflammatory medications such as Aleve or Advil or could be a prescribed anti-inflammatory. In addition, ice or and physical therapy/home exercises are often helpful. A cortisone or steroid injection into the shoulder can also be performed to ease pain and improve function. On occasion, more than one injection may be necessary over a several week period to alleviate symptoms. When these methods fail to resolve symptoms there are other methods to try and break up or dissolve the calcium deposit. The methods vary in invasiveness and include ultrasound-guided needle decompression/debridement, shockwave therapy, ultrasound-guided percutaneous micro debridement with a TENEX device and arthroscopic debridement of the calcium deposit. Most patients recover with the need for surgery, below is a video of a calcium deposit removal I performed arthroscopically.

The Meniscus: 1 Minute Clinic

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The Basics

The meniscus is a well-known structure in the knee that can cause pain, swelling and mechanical symptoms of locking or catching if injured. The meniscus is a C-shaped fibrocartilaginous tissue made predominantly of type 1 collagen. There are 2 menisci in each knee joint, 1 medial and 1 lateral.

The meniscus functions to provide shock absorption to the knee, provide stability and enhances cartilage nutrition of the joint.

Click on the link below to watch a 1 minute video on the meniscus.

Anterior Cruciate Ligament (ACL): Graft Choices

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Anterior cruciate ligament tears are one the most common serious sports knee injuries that lead to prolonged time out from sports participation. It is estimated that approximately 100-200,000 ACL tears occur per year. The incidence of ACL tears has risen over the years due to increasing sports participation, training and the number of games athlete’s are playing. A concerning statistic is that the rate of tears in pediatric age athletes has increased over the last 20 years.

The ACL is an important ligament that provide stability to the knee particularly with pivoting and cutting movements that are common in sports. It is the primary restraint to anterior translation of the tibia on the femur, but also provides significant rotational stability to the knee. Most injuries to the ACL are non contact and occur with rapid direction changes, deceleration and landing from a jump. It is common for the athlete to feel a pop, immediate pain and develop swelling over the first 24 hours.

ACL reconstruction is the usual recommendation to treat an active person with an ACL tear. This is generally performed through an arthroscopic assisted procedure. One of the major considerations is which type of graft to use. In general, graft options include autograft ( the patient’s own tissue) and allograft ( a cadaveric donor tissue). Common autograft options include the patellar tendon, hamstring tendons and quadriceps tendon. Allograft options include the same plus different soft tissue grafts from other areas. Choosing the best graft for each patient depends upon the age of the patient, activity level and a variety of anatomical factors. I utilize all types of graft options in my practice and base the choice of the graft on multiple factors and discussions with my patients.

Arthroscopic photo of quadrupled hamstring autograft reconstruction

Within the autograft choices, each has its pro and cons. The patellar tendon graft is considered the gold standard, but the other graft choices may be a better option in select patients. Patient size, type of sport, age (growth plates still open) and history of other knee complaints in the past are important considerations when choosing a graft.

Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACL Reconstruction
Prospective Analysis of 2488 Primary ACL Reconstructions From the MOON Cohort
The American Journal of Sports Medicine, Vol. 43, No. 7

It is generally accepted that autografts have a lower re-tear rate than allograft in younger patients, highly active patients and patients participating in competitive sports. Allograft reconstructions have a similar success rate in patients that are older (generally 35 year-old and up) and do not participate in highly competitive sports on a frequent basis. The research continues to define which grafts have the best success in different patients and new information continues to guide our decision making.

Meniscus Tears

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Tears of the meniscus are a common source of knee pain. Tears can be due to sports injuries, slips and falls, car accidents and from degeneration. When a tear occurs from injury, pain is usually acute and sometimes the injury is associated with a pop and the development of swelling. The swelling could be immediate or occur over the next 24-48 hours. Pain is usually located at the joint line on the inside or outside of the knee. Degenerative type meniscal tears often occur gradually and got progressively worse but could have acute onset of pain as well. Associated signs and symptoms of a meniscal tear include pain at the joint line, swelling and sometimes locking or catching. In acute injuries, the meniscus can sometimes displace and cause locking or lack of motion of the knee.

Diagnosis of meniscal tear starts with a thorough history, physical exam and x-rays. X-rays are helpful to determine if there are any fractures with an acute injury, underlying arthritic changes and loose bodies within the joint. Underlying arthritis is frequently associated with degenerative meniscal tears. If x-rays are negative and clinical suspicion indicates a meniscal tear, an MRI may be ordered. Meniscal tears also occur frequently with ligament injuries to the knee, such as ACL tear. Special consideration should be given to meniscal tears associated with arthritic changes of the joint. In this particular situation, it is common to have a meniscal tear and arthritis at the same time. Current research indicates that in the majority of cases, pain comes from the underlying arthritis more so than the meniscal tear. It is common for your orthopedic surgeon to recommend nonsurgical management of a meniscal tear when there are significant arthritic changes present. There are certain indications and situations where more aggressive management of a meniscal tear would be warranted when they are underlying degenerative changes of the knee, a discussion with your surgeon will help determine which treatment method is most appropriate.

There are different types of tear patterns. They include vertical/longitudinal tears, radial tears (meniscal root variant), horizontal cleavage tears, complex tears, oblique tears, degenerative tears, and bucket-handle tears.

Treatment of meniscal tears depends on the level of symptoms, presence or absence of recurrence swelling, mechanical symptoms of catching and locking and the affective these on participation in sports or exercise. Treatment could include physical therapy, activity modification, anti-inflammatory medication and bracing. Treatment could also include injections, especially when there underlying arthritic changes. Surgical management is usually indicated for symptoms that are not responding to conservative treatment. Displaced bucket-handle tears causing locking or lack of motion usually require more urgent surgical intervention. The goal of treatment is to reduce pain, swelling and improve functional abilities and participation in exercise or sports. Below is a short video of a meniscal surgery I performed.

https://youtu.be/ByABwn9ZaiA

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        Rotator Cuff

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        Shoulder pain is one of the most common complaints seen in the orthopedic surgeon’s office. There are many causes for shoulder pain, but one common cause is disorders of the rotator cuff. The rotator cuff is a group of 4 muscles called the “SITS” muscles, this stands for Supraspinatus, Infraspinatus, Teres Minor and Subscapularis muscles. These 4 muscles work in coordination with each other to provide fine tuning for shoulder stability, motion and strength. Disorders of the rotator cuff could range from bursitis to complete tears. Symptoms can develop due to aging, overuse or acute trauma. The most common cause of rotator cuff damage is due to age-related degenerative changes of the rotator cuff tendons. The incidence of age-related degenerative tearing of the rotator cuff increases every decade of life beginning in the 30s to 40s.

        Symptoms of rotator cuff injury can include pain, weakness and loss of motion. Frequently patients complain of pain with lifting the arm above shoulder level, reaching behind her back, reaching to their side and lifting objects away from their body. Pain at night is a frequent symptom and often keeps people awake. After a traumatic event, patients can often have a loss of active motion and strength.

        Diagnosing rotator cuff tears begins with a thorough history, physical exam and diagnostic x-rays. While x-rays may not show soft tissue damage, the x-rays will show if there is underlying arthritis, calcific deposits or other bone lesions that could be responsible for the symptoms. The history and physical exam often gives the orthopedic surgeon an idea of the severity of symptoms, duration of symptoms and amount of physical dysfunction from motion loss or weakness. When appropriate, an MRI may be necessary to confirm the presence or absence of a tear.

        Treatment of rotator cuff tears ranges from non operative to surgical management depending upon the duration a symptoms, level of dysfunction and pain. Initial treatment with physical therapy or home exercises, possible injection and activity modification is usually the first line treatment for atraumatic rotator cuff symptoms. With these modalities fail to resolve symptoms and a rotator cuff tear is identified, surgical management with an arthroscopic rotator cuff repair and possibly open repair is an option. While many patients with known rotator cuff tears have minimal or no symptoms and normal function, it is generally accepted that approximately half of patients will develop rotator cuff tear enlargement or progression over time. It is important to follow these tears on a regular basis for tear progression even in the absence of symptoms, which could indicate the need for operative repair. It has also been shown that earlier repair of rotator cuff tears has higher healing rates from surgery. The treatment of each patient’s rotator cuff problem should be individualized based upon the patient’s overall activity level, level of symptoms, level of weakness or loss of motion and underlying health of the shoulder joint. Below is a short video of a rotator cuff repair I performed. The video shows an arthroscopic double row rotator cuff repair. I welcome comments and questions and will do my best to answer them for you here!

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