Saturday, June 26, 2010

Clavicle Fractures

"Oh, somewhere in this favored land the sun is shining bright,
The band is playing somewhere, and somewhere hearts are light,
And somewhere men are laughing, and little children shout;
But there is no joy in Mudville — mighty Casey has struck out."
Casey at the Bat

The clavicle is the first bone in the body to ossify and among the most commonly fractured, particularly in children. It can be fractured via several mechanisms including the classical fall on an outstretched as well as striking the point of the shoulder. It's not uncommon to also suffer rib, scapula and/or cervical spine fractures and is seen repeatedly in cyclists. Frequently a patient will tell me they actually heard the bone crack when the fracture occurred. This injury can be confused with an AC separation, a rupture of the ligaments at the end of the clavicle. They're treated differently.

Displaced fractures are pretty easy to diagnose as the whole shoulder seems to fall forward and the patient describes a crunchy sound/feel. Xrays will define the specifics of the break and help guide treatment options. One also checks carefully for any accompanying nerve or vascular damage.

For non-displaced fractures, immobilization without surgery has been the norm and usually gives good results in a short period of time. The athlete can ride the stationery bike indoor as pain permits (but not outdoors - there's no value in copying Tyler Hamilton)and should be back astride the bike by 5-6 weeks post injury. When the fracture is displaced, consideration of surgery to achieve the best long term outcome is considered. If there's notable shortening or displacement at the fracture site, then surgical stabilization actually shortens the healing time, reduces the potential for non-union/delayed union, and more reliably gets the patient back into life. That said, surgery is not with the potential for significant complication as nerves and vessels are close by.

So, if you think you may have broken your clavicle, the ER is the next stop for you with a careful evaluation of the entire shoulder and neck, xrays, and some of you'll get to meet the Orthopedic Surgeon on call. Say Hi!

Saturday, June 19, 2010


"Water, water everywhere, and all the boards did shrink. Water, water everywhere, nor any drop to drink." Rime of the Ancient Mariner

It's summer. By now your racing fluid plan should be well established. Gone are the days, as pointed out in recent blog, where you've ignored your fluid intake as, "It wasn't that long a workout," or "It was only a sprint triathlon," (but it was 86 degrees!)

Although there are a lot of opinions on rehydration efforts out there, the only one that really matters is yours. You've calculated your sweat rate (weigh your self right before and right after a few lengthy runs to determine the % lost), read up on hyponatremia (dilution of the blood stream from excessive drinking for the current conditions) and have a general idea of your own needs. So why is it that so many athletes find themselves like camels at the oasis or that they don't pee for 6 or more hours - despite continued fluid intake - after an event?

Much of the current literature will show that we've come full circle. Tim Noakes supports the drinking according to one's thirst regimen. Joe Friel points out that the winner of a race might be, "The most dehydrated competitor there."
We remember that fluid losses come through respiration (ever breathe into a mirror?), evaporation from moist surfaces like the eye, sweat, vomit (for some), feces, spit and urine to name a few. Since the body maintains fluid levels as a constant by a process called osmoregulation where, when the blood becomes over concentrated by dehydration, it's sensed by a part of the brain known as the hypothalamus. The hypothalamus in turn notifies the pituitary to release more ADH which will increase water absorption by the kidney. Not all that confusing is it?

So, you don't mind getting a little behind on fluids but not a lot. It's been shown frequently that excessive loss will negatively impact performance. It's also been demonstrated that as we age, the thirst center in the brain is somewhat less sensitive to thirst. Thus, in my mind, since the occurrence of under hydration far exceeds that of over hydration, that like insulin, our bodies need a constant liquid supply. I would plan on starting a race "topped off" with fluids. Not overly hydrated as may have been proposed in the past, but not behind. Having to pee in the middle of a 70.3 bike, or worse twice, teaches you that lesson in a hurry. And then plan the locations of drink availability, aid stations on the bike and run, and what seems to be the best for you. I doubt that a Camelback will be required but a heightened sense of awareness goes a long way. You'll be surprised how well you race when you're not overly behind on fluids.

I'll drink to that.

Sunday, June 13, 2010

Road Rash - Limits of Home Care

"The road is long, with many a winding turn." The Hollies, 1969

"You want to know what it's like to crash on one of these bikes? Get in your car, strip down to your underwear, and jump out at 40 miles per hour!" Jonathan Vaughters

There are two groups of riders: those who have crashed and those who will crash. You look at what used to be your skin, red, raw, and painful. Frequently, if you were really lucky, this is just a scrape, a superficial abrasion - a strawberry - like you had falling on the basketball court.

Now what? First, this is why I carry a water bottle - sometimes to drink from but mostly for hygenic reasons...washing off a dog bite or road rash to try to diminsh the chance of infection or leaving a permanent mark on the skin. Once you're back home, a mild soap and water cleansing goes a long way, cover with a light dressing and bacitracin to keep the skin from drying out, and figure out when your last tetanus shot was (normally given every ten years but if there's been a "dirty" injury, and it's been greater than 5 years, get a booster shot).

I crashed a couple years ago while riding with Carl Frishkorn - father of Tour de France rider Will - and Carl was more prepared than a Boy Scout and ER nurse put together. He helped me cleanse the wounds, had antibiotic ointment, some dressings, both Tylenol and Advil for the pain (injured person's choice), and even Benadryl for allergic reactions. I now carry all of these items in my fanny pack on every ride - thanks, Carl.

How about when the wound is a puncture, or deeper and possibly in need of sutures? You're taught as an intern that when people think they need to be sewn up, they're usually right. But, if this is the case, you'd want to proceed to your urgent care facility with modest haste as when there's a delay in wound closure, it can increase the potential for delayed infection as bacteria become entrapped. Very infrequently when the wounds occur in the hands or other joints there can be a fracture or joint penetration. (One of the men in my bike group actually broke his acetabulum - hip socket) this way earlier this year and now owns a couple long surgical screws there. X-rays and/or lavage of these injuries in an operating room is not uncommon. We use a high pressure "water pic" with sometimes gallons of sterile saline to get as much of the debris and bacteria out of the injury site as we can.

So, the take home lesson here is cleanliness, the sooner the better, and professional evaluation if there's any doubt about what you're dealing with.

Monday, June 7, 2010

Are You Ready For The Unexpected

Do you think, when this athlete was topping off the air in his tires this morning, that he thought, "You know, I'm sure glad I'm the the type of racer who never gets penalized..." I wonder if he was prepared for this.

They carried a man off the race course on a stretcher. I heard that he just collapsed on the run;
maybe it was the heat – a low of 80 degrees last night. And the sun came up well before the first athlete was body marked or the transition area opened to further push the mercury toward inferno status… from a racing point of view anyway. You know, one of those days when the heat simply blasts you when it radiates off the asphalt. It’s a good thing most of were wearing hats and could put ice in them at the aid stations. As we watched them load him into the ambulance, we hoped it wasn’t something serious.

Plan “B.” Everyone needs one. You arrive at the race course and – SURPRISE – no wetsuits for the swim (like happened to us today.) Or – SURPRISE – the expected temperature is 15 -20 degrees higher than where you live and train. This happened at the Boston Marathon a few years ago where runners were just finishing a winter of snow running and an unexpected heat wave brought temps in to the mid 80’s. They were dropping like flies. There were so many people with heat related problems that the enormous armory-like building they use at the finish line with cots as far as you can see, was simply overflowing with “bodies.”

All too often, racers just plow ahead “business as usual,” and if they’re lucky, only have a poor performance. They wonder why, despite ample beverage at the post-race party and more on the way home, they still don’t pee for hours. There’s a take home lesson here.

There can be course changes, weather curve balls, rightly or wrongly you get penalized, alterations to the order of events, unintentionally getting kicked in the stomach, or face –hard- on the swim just to name a few things that cause us to re-evaluate our original race plan. How about a flat tire? But, if we’re to survive and do our best on that particular day, flexible we must be. Despite one’s physical suffering, always try to remind yourself that everyone has the same course to ride and run on and just maybe you can do it just a little better than they do. In the immortal words of that famous rock group of the 60’s, Pacific Gas and Electric, “Are You Ready?”

Be prepared (the Boy Scouts were right)
Be flexible
Know when you’ve reached your limit and it’s time for Plan “B