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Interviewer: If you break bone, do you still get a plaster of Paris cast that your friends can sign? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists" with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi. I'm Dr. Tom Miller and I'm here with Dr. Bruce Thomas. He's an orthopedic surgeon here at the Department of Orthopedics at the University of Utah and also practices at our Farmington facility in Farmington, Utah.

Bruce, do we still use plaster of Paris? I mean, when I was training, we'd go into the cast room and they had this big, goopy bin full of plaster of Paris. And they wrapped you up and put all the plaster of Paris on there. It dried and then your friends wrote all over the cast. Times change a little bit or not?

Dr. Thomas: For most things, times have changed.

Dr. Miller: I would suspect.

Dr. Thomas: Plaster is . . . It's been good. It's traditional. It's heavy. It's dirty. And for a long time, orthopedic surgeons felt like it held the molds better. There are studies that show that fiberglass will hold the mold that we put on the cast as well as fiberglass. And when we mold the cast, we put pressure on the bones in the right place to hold the fracture in place. The orthopedic axiom is crooked cast, straight bone.

Dr. Miller: So you can mold the fiberglass right around the arm or leg in the same way that you did with the plaster of Paris?

Dr. Thomas: You can. And when they've looked at it scientifically, the results were very similar.

Dr. Miller: So I suspect it's a lot lighter than that big, clubby plaster of Paris cast that people wore around for eight weeks.

Dr. Thomas: Significantly lighter, much cleaner, and your friends can still write on it.

Dr. Miller: That's great. How about the cast itself? These fiberglass casts, can it be removed so that you can shower or put back on? Does that just depend on the type of fracture?

Dr. Thomas: It does. It depends on the fracture and how stable it is. Once the fiberglass is on, it's not easy for the patient to take it off, but we can cut the cast and make it removable, if there is a fracture that is stable and we're not worried about a lot of displacement.

Dr. Miller: So casts are lighter. You can still write on them. And sometimes you can even take them off to take a shower.

Dr. Thomas: True.

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Dr. Miller: You have a broken collarbone or a fractured clavicle? Do you need to have the treated surgically or can it heal naturally?

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists" with Dr. Tom Miller is on the Scope.

Dr. Miller: I'm here Dr. Bruce Thomas. He is an orthopedic surgeon here at the University of Utah in the Department of Orthopedics. Bruce, tell us a little bit about fractured clavicles.

Dr. Thomas: Fractured clavicles are a common sports injury, men more than women, and the treatment of it has evolved over the years. Traditionally, many of them were treated without surgery and the rate of non-healing was about 3%.

Dr. Miller: Before we get into that, how does one fracture a clavicle or bust the collarbone as they say on the athletic field?

Dr. Thomas: Usually, it's a fall to the shoulder.

Dr. Miller: Outstretched hand, that sort of thing?

Dr. Thomas: Mostly, not outstretched. More to the point of the shoulder and occasionally from blunt trauma. But usually, it's a fall to the shoulder or a side impact.

Dr. Miller: Mostly seen in contact sports like football?

Dr. Thomas: Contact sports, you see it in soccer and skiing as well. The contact with the ground is usually the contact. Most of the collarbone fractures occur in the shaft and in the mid portion of it and the smaller percentage will occur way out towards the end of the clavicle near the shoulder. Those require treatment almost uniformly. The ones in the shaft, less, less uniform require treatment.

Dr. Miller: So does it matter what type of an athlete you are? Might you consider surgery to get back into the playing field sooner in some cases?

Dr. Thomas: They're finding it definitely affects the biomechanics. Traditionally, you would accept 2.5 centimeters of shortening before you would consider surgery and now, the number is about 1 centimeter. And keeping that strut at the right length helps in the position of your shoulder and the movement of your shoulder blade.

Dr. Miller: So if it doesn't heal appropriately or if the distance between the fracture is, you know, there is a gap I guess, then you could lose function or sacrifice some function in the shoulder?

Dr. Thomas: You could. Without a nice, strong strut there as you load the shoulder, you'll feel weakness. But interestingly, the older literature shows that half of the patients that have a non-union don't have a lot of symptoms. But that could be depending on what their activity is.

Dr. Miller: What their activity level is. So kind of who you are matters in terms of whether you might consider surgery. So I guess it's a bit of a personal decision and you as the orthopedic surgeon explain that to the patient.

Dr. Thomas: That's true. And what your demands are make a big difference on whether you need surgery or not.

Dr. Miller: And so how do you repair the clavicle? Do you put a plate in or do you just . . . I mean, it's kind of hard to put a cast on the shoulder, obviously.

Dr. Thomas: That's true. And so, the hardware serves as an internal cast and supports the bone and keeps it aligned while it heals. And most commonly is used a plate, either on the top of the collarbone or on the front of the collarbone.

Dr. Miller: And you leave that in after the period of healing?

Dr. Thomas: On the top, eventually the bone heals, the swelling goes away. And on top, there's not much tissue between the collarbone and the skin. And those are kind of prominent and people will feel them with their seatbelts or backpacks. And so if the plate is on top, it's more likely to be removed later.

Dr. Miller: So would you say that anyone who has a clavicular fracture should probably see an orthopedic surgeon and discuss the reason for her need for surgery or healing?

Dr. Thomas: I think that's a great rule and especially if you're in high demand sports or heavy activities, making sure that your strut is the right length and ensuring healing is important.

Dr. Miller: Once you fracture a clavicle, whether it's plated or not, how long is the period of healing, generally?

Dr. Thomas: It varies, obviously. In young children, it will very quickly, four to six weeks. Adults, six to eight weeks, usually, and a small number up to 12 weeks.

Dr. Miller: And so physical therapy, is that any part of the rehabilitation of the shoulder or clavicle, rather?

Dr. Thomas: It certainly is. People tend to get stiff when you immobilize them or after a surgery. And as the fracture becomes more stable, early motion helps reduce the amount of stiffness and aids people getting back to their activities quicker.

Dr. Miller: So generally, somebody who's been injured in a sports-related activity or at work, they would know if they had a fracture. I mean it's painful, it's prominent. You can see the changes because the bone is so close to the skin.

Dr. Thomas: That's true. Most of the time, they know instantly and pretty quickly, everyone around them can tell as well.

Dr. Miller: So bottom line, then, for our listeners would be that if you have a clavicle fracture, called the collarbone in everyday usage, but if you have a fracture, you should probably see an orthopedic surgeon and have that evaluated because surgery might assist you in healing. And a certain percentage of patients will go on to surgery and have a good result.

Dr. Thomas: That's true.

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updated: October 26, 2018
originally published: January 15, 2017

Dr. Miller: You've injured your knee, what's the next step? Should you have it scoped? We're going to talk about that next on Scope Radio.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Bruce Thomas. He's an orthopedic surgeon here in the Department of Orthopedic Surgery at the University of Utah. He also has a practice at our Farmington facility. And Bruce, what's the story? There's been a lot of changes. I think folks who have injured their knees and have some swelling or clicking or pain, it used to be that a number of people would obtain or go to the orthopedic surgeon and they would have an arthroscopic procedure. That is, they would put a little scope inside the knee and look around. And more recently, there's been some changes in that thinking.

Dr. Thomas: That's true. There's more of a collaborative effort. In the old days, a doctor told the patient what the treatment was, and these days the doctor will share information with them and make recommendations. Not every meniscus tear requires surgery. Many people can do their regular life activities and the pain will subside, and it's not clear, in those patients, that knee arthroscopy will help them.

Dr. Miller: It's interesting to me because, I mean, do they know that they have a meniscal tear before we do the arthroscopy, or do we do the arthroscopy to find out that they have a meniscal tear? Or there might be a misunderstanding among patients about the purpose of the arthroscopy.

Dr. Thomas: For many meniscus tears, you can tell if it's present by the patient's history and by the physical exam. If there's questions, an MRI is 96% accurate at predicting a meniscus tear.

Dr. Miller: So now we have way, radiologically, to look at the joint, find out if you have a tear, without doing a surgical procedure?

Dr. Thomas: That's correct.

Dr. Miller: So, if you have a meniscal tear and you either figure that out based on the examination or the MRI, what role would arthroscopy play nowadays?

Dr. Thomas: If the patient has significant symptoms that aren't resolving with conservative measures and it prevents them from doing their regular activities, arthroscopy can assist the restoration of function and decrease in pain. It's a small out-patient surgery with, usually, two or three very small incisions, and the meniscus is either repaired or the damaged portion trimmed out, depending on the findings at surgery.

Dr. Miller: So, what you said I think is important, is that you don't do the arthroscopy immediately, you try some conservative measures first.

Dr. Thomas: That's true.

Dr. Miller: Is that the standard now?

Dr. Thomas: I believe that's the standard, because many people can function with a meniscus tear. The older literature suggested that an untreated meniscus tear will lead to earlier arthritis. Subsequent studies are less clear on that, and it depends much on the size, location, geometry of the tear, as well as the patient's activity level.

Dr. Miller: You know, many years ago they used to go in, when you had a meniscal tear, and they just took out a lot of the meniscus, a large percentage of it, and I think that was the standard back in the day. Is that right?

Dr. Thomas: That's true. Before the invention of arthroscopy, an open procedure would be made and the entire meniscus would be removed. And there are some papers that suggest that those patients would have end-stage arthritis within seven years of that procedure.

Dr. Miller: So they don't do that anymore?

Dr. Thomas: We don't do that anymore.

Dr. Miller: So the concept was, if you used an arthroscope, you could go in and take smaller pieces of the meniscus near where it was damaged, and that that might result in improved function, less pain.

Dr. Thomas: True. That's true. It will decrease their pain, improve their function, and if we can save even a rim of 3mm or 4mm, that's been shown to still function in preventing arthritis for the patient.

Dr. Miller: What were some of the things that patients received arthroscopy for in the not-too-distant past that are no longer done? For instance, I know that some patients have had an arthroscope to wash out the knee joint. Do they still do that, and does that have any therapeutic value?

Dr. Thomas: That really, probably, has no therapeutic value. Arthroscopy is not a treatment for arthritis. You use arthroscopy to treat mechanical symptoms associated with meniscus tears or, infrequently, loose fragments of cartilage. Symptoms like catching, locking, giving out, those kind of symptoms.

Dr. Miller: After you do an arthroscopy, how soon can the patient get back to normal activity?

Dr. Thomas: If there are no surprises and the articular cartilage is in good shape, we usually encourage them to start walking the day of surgery. Swelling takes longer to go away. Maybe four to eight weeks, depending on the setting. Many patients can get back to most of their life activities within eight weeks.

Dr. Miller: Now, are there any risks with arthroscopy? Obviously, there are risks with any surgical or invasive procedure. I would assume that those risks are less than they would be if you had an open procedure, an open, standard surgical procedure.

Dr. Thomas: That's true. The risk of infection, for example, is going to be far less than 2% with arthroscopy. There is some evidence that once you've had a meniscus tear on one side, you're a little more likely to have it on your opposite knee. And with removal of meniscal tissue, the loads on your joint surface are higher, and so you do wear your cartilage quicker and may be a little more likely to get arthritis down the road.

Dr. Miller: So, bottom-line, basically, is if you have knee pain and potentially a meniscal tear, you're going to probably want to go through conservative treatment first, before proceeding onto an arthroscopic procedure, and that you're working with your orthopedic surgeon you can define the best time for that, if that needs to occur.

Dr. Thomas: That's true.

Dr. Miller: Thank you very much, Bruce.

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