To Operate or Not To Operate… That is the (Clavicle) Question

While it may not be quite Shakespearean, Aaron Rodgers’ clavicle fracture is certainly a tragedy for the Packers and their fans. With the QB heading under the knife soon, it raises the question- why do some clavicle fractures require surgery while others heal on their own?


As Aaron Rodgers came crashing to the turf on Sunday under the weight of the Vikings’ Anthony Barr, so too, most likely, did the Packers Super Bowl aspirations, as it was later learned that the hit had fractured Rodgers’ right clavicle (“collarbone”). It was announced today that Rodgers’ injury would require surgical fixation, almost definitely ending his season. Rodgers’ injury brings up memories of other NFL quarterbacks with clavicle fractures in recent seasons – Rodgers himself in 2013 and the Cowboys’ Tony Romo in 2015. Both of those injuries resulted in the quarterbacks losing parts of their seasons – both missed 8 weeks but were able to return the same season without surgery. Rodgers was injured in week 9 but was  returned for the regular season finale and the postseason, while Romo was hurt in week 2 and came back in week 11, only to re-fracture his clavicle in week 12 and miss the remainder of the season. In both cases, the injured QBs were able to return in the same season without surgery – what was different about these fractures that allowed them to avoid the operating room?

One obvious difference is that Rodgers’ previous fracture and Romo’s fracture were in their left, non-throwing shoulder. That, however, is not the key determinant in whether or not a clavicle fracture benefits from surgery. The primary factor in whether or not to operate on such an injury is “displacement”, or the degree to which the bone fragments have separated.  Rodgers’ 2013 injury and Romo’s fracture were both “non-displaced”, meaning that the bone was broken but the pieces had not moved – essentially a crack in the bone.

Non-displaced clavicle fracture in blue circle

Fractures such as these, or minimally displaced fractures which have moved only a few millimeters, can almost always be treated without surgery.  These still require 6 to 8 weeks to fully heal, as evidenced by Rodgers’ and Romo’s recoveries, with the arm being allowed to rest in a sling for comfort and healing purposes. Essentially all of these will heal without surgery and allow for a full recovery. Given the Packers quick announcement of the need for surgery for Rodgers’ current fracture, it’s safe to infer that this injury falls into another category of clavicle fractures, displaced fractures. In these types of fractures, the fracture fragments have moved apart to such a degree that they are less likely to heal without surgical intervention to re-align the bone.

Displaced Clavicle Fracture

While surgery is not mandated in these types of clavicle fractures, it is often recommended for a number of reasons.  Most noticable for patients, stabilizing this type of fracture makes them much more comfortable in the short term, as the mobile fracture fragments are quite painful.  More importantly in the long term, however, is the fact that surgically realigning the fracture improves the function of the shoulder and arm by restoring the proper shape and length of the bone and decreases the chance that the bone might not heal on its own.  While non-displaced fractures have a rate of healing that approaches 100%, widely displaced fractures can have a 5-15% rate of non-union (failure to heal) when treated without surgery.  While an 85% chance of healing might be enough for the cheesehead in the discount double-check commercial, it’s certainly not high enough for the All-Pro quarterback in the same ad.  Primarily for this reason, Rodgers will undergo surgical fixation sometime in the near future, resulting in an x-ray that will likely resemble the following plate-and-screws construct:

Clavicle Fracture After Fixation with Plate and Screws

Post-operatively Rodgers will likely be in a sling for 4-8 weeks, gradually resuming range of motion and light strengthening before resuming more aggressive workouts. Full contact would likely not be allowed for about four months, and given that this is Rodgers’ throwing shoulder, it will likely take him at least that long if not longer before he is comfortable making the throws he will need to make.  The end result of all this is that Rodgers’ season is almost definitely finished, but he should make a good recovery from this injury – the rate of healing after this type of surgery is very high and should allow him to regain full strength and throwing accuracy.  Long story short – don’t plan on getting any fantasy points out of Rodgers this season, but if you’re in a keeper league, hold onto him – he should be good to go for 2018.

Watt the Heck is a Tibial Plateau Fracture, Anyway?

Ok, that’s a terrible pun. But the Houston defensive star’s latest injury is no laughing matter 

By now, everyone knows that JJ Watt, All-Pro defensive end for the Houston Texans, suffered a season-ending left knee injury in the Sunday Night Football game against the Chiefs. Watt went down awkwardly while rushing the passer in the first quarter and had to be helped off the field, unable to bear weight on his left leg. It was later announced that he had a tibial plateau fracture which underwent surgical fixation, resulting in Watt being placed on Injured Reserve and ending his season. But what is this injury and what does it mean for Watt’s future?

A tibial plateau fracture is a fracture of the top of the tibia, where it makes up the bottom half of the knee joint.

A fracture of the tibial plateau, by definition, involves the knee joint itself, as opposed to a tibial shaft fracture, which is a fracture of the mid-portion of the bone between the knee and the ankle. This is an important distinction, because a tibial plateau fracture also impacts the structures inside of the knee, including the articular (surface) cartilage, and potentially the meniscus and ligaments of the knee.

Like most things in orthopedics, there is a classification system for tibial plateau fractures, from type 1 to type 6, with the severity of injury basically increasing the higher the number.

Most likely, based on the mechanism of Watt’s injury, he sustained a type 1 or 2 fracture – that involves the lateral, or outside, plateau. Early this week he underwent surgery to fix the fracture with a plate and screws, resulting in fixation that likely resembles this x-ray:

Following this, Watt will be on crutches for 8-12 weeks, with gradually increasing range of motion in a brace. He won’t be able to start significant strengthening until a month or two after that, and won’t be able to resume full football activity for 6 to 9 months after his surgery.

How about the prognosis for Watt’s leg moving forward – will he be the same player he was before the injury?  That’s a question that can’t really be answered based just on his x-rays – the most important factor is the status of the cartilage in his knee, both the surface cartilage and the meniscal cartilage. When a bone fractures into a joint, as is the case with a tibial plateau fracture, the surface cartilage is also injured. The degree of cartilage injury and the ability of the surgeon to precisely align the bones to allow the cartilage to heal as well as possible are important determinants of how Watt will do in future seasons. A significant degree of cartilage injury can be a source of ongoing pain and can even cause early arthritis.

The meniscus cartilage is also commonly injured in the setting of a tibial plateau fracture – most studies estimate between 30-50 percent of patients with lateral tibial plateau fracture also tear their meniscus. If the tear is significant or cannot be repaired, this can also be a source of ongoing pain.

Blue oval shows meniscus tear in a knee with a tibial plateau fracture 

No doubt JJ Watt will put as much effort into his recovery as he has with his previous injuries, including major back surgery last season. How his knee responds, however, will depend largely on factors beyond his control – the status of the cartilage in his knee due to the injury and how his body responds to any damage to those structures. The hope is that his leg heals well and he returns to being the same dynamic player that he was, but the cartilage in his knee will likely be the final determinant of how well he does.

Pedroia’s Patellofemoral Pain – Potentially Problematic, Possibly Permanent

After a season marred by struggles with knee pain which resulted in two stints on the disabled list, there is one lingering question – is there a feasible surgical remedy and if so, is it worth it?

One of Dustin Pedroia’s hallmark characteristics has always been his toughness – his willingness, sometimes insistence, on playing through injuries is one of the things that has endeared him to Sox fans and allowed him to be a productive player throughout his career. This is a player, after all, who once took ground balls on his knees while recovering from a foot injury and played an entire season with a torn ligament in his thumb. His left knee, however, may prove to be a problem that even Pedroia can’t out-tough. Last offseason he had an arthroscopic “cleanout” of his painful knee – despite that he still spent time on the disabled list twice and by the end of the season he was clearly not moving well on the leg and seemed to lack the ability to drive the ball at the plate. At the end of the season he alluded to the possibility of additional surgery on the knee but seemed unsure of the best plan of action, referring to the  “long recovery” surgery would entail.

Given what we know about Pedroia’s knee (his previous surgery, his persistent issues with the knee this year) and what we can read between the lines from his comments about the potential for an extended recovery from any additional surgery, what can we infer as to the status of his knee? My best estimate is that he has some early arthritic changes of the knee – rough spots of cartilage that were the target of his arthroscopic cleanout last year, likely in the patellofemoral part of the knee (under the kneecap). The goal of this type of procedure, a chondroplasty, is to remove any loose edges of cartilage which might be causing symptoms. However, it does not replace any lost or worn cartilage, it merely smooths the edges of whatever is damaged.  The advantage of a procedure such as this is that it is a quick recovery- typically only a couple days on crutches with no running for a month or so.  Pedroia could have easily had a procedure such as this in the offseason and been back in plenty of time for spring training.

Area of abnormal femoral cartilage (blue circle in first picture) undergoing arthroscopic chondroplasty with shaver (green dot in second picture) 

The downside of a chondroplasty is that it doesn’t address the root of the problem, the loss/wear of the surface cartilage, so while it frequently gives at least temporary relief, the symptoms will usually return sooner or later.  If Pedroia was older or less active, he might be a candidate for some sort of knee replacement, either partial or total.  Knee replacement surgery is an excellent procedure for relieving pain, but it’s not compatible with high-level athletic activity.  What, then, are the surgical options for a young, active patient like Pedroia?

Younger patients with cartilage injuries may be candidates for cartilage restoration procedures such as microfracture (poking holes in the bone to stimulate new cartilage growth), OATS (osteochondral allograft transfer surgery, where bone and cartilage is taken from one part of the knee or a cadaver knee and transferred to the abnormal area of cartilage) or ACI (autologous chondrocyte implantation, where a small amount of normal cartilage from the knee is harvested surgically, grown in a lab, and reimplanted in the knee at a later date).

Microfracture, showing holes being poked in bone to stimulate new cartilage growth

OATS procedure, showing two cartilage/bone plugs implanted into knee

The obvious advantage of these procedures over a chondroplasty, or “cleanout”, is that the root of the problem is being addressed- new cartilage is being grown or transferred to the area of cartilage loss. The downsides, especially when it comes to an athlete like Pedroia, are the extended rehabilitation (4-6 weeks on crutches, no running for 3-6 months, no sports activity for 6-12 months depending on the specific procedure) and the lack of guaranteed success. While the odds are good, there are certainly patients who don’t do well or get back to their previous level of activity- one recent example from baseball was Grady Sizemore, who had microfracture on his knees prior to signing with the Red Sox and while he did make it back to MLB, was never quite the same player.

So where does this leave the protagonist of this tale, the Red Sox diminutive second baseman? As a 34-year-old with four years left on a contract that will pay him an average of 14 million dollars a year, the Red Sox would certainly hope for more productivity and less time on the DL from him moving forward. Having a cartilage restoration procedure might extend his career longevity, but would certainly require him to miss a significant amount of time in the near future. Even if Pedroia were to have surgery in the next few weeks, he would almost definitely miss a significant portion of next season, if not the whole year. Pedroia may decide that the potential upside of having the surgery does not outweigh the definitive downside of missing a substantial chunk of one his last seasons of professional baseball.  That would leave him in his current situation, with a less-than-perfect knee which might be manageable but is likely to flare up at times over the next few seasons.  At the end of the day, there is certainly no perfect solution for Pedroia and the Sox – how they handle it will certainly bear watching in the off-season and in upcoming years.

Tom Brady and the Terrible, Horrible, No Good, Very Bad AC joint 

Ok, it’s not really THAT bad, but everyone’s still worried, right?

By now you’ve no doubt heard that Tom Brady apparently hurt his left shoulder in the Carolina Panthers game in week 4 (compliments of another of the NFL’s ageless wonders, Julius Peppers) and reaggravated it this past week against the Bucs (compliments of the Patriots’ sieve-like offensive line). Reports have come out that Brady had an MRI which showed no structural damage or tears, and he has been diagnosed with an acromioclavicular (AC) joint sprain.

So what does that mean for Brady and the Pats? First, a little about the AC joint in general. The AC joint is the small joint at the top of the shoulder where the acromion (the top of the scapula, or shoulderblade) meets the clavicle (collarbone).

It’s a commonly injured joint in contact sports – usually by falling directly onto the shoulder, not uncommonly with a very large person directly on top of you driving you into the ground with malicious intent, like, say, this:

This picture is, of course, Patriots backup quarterback Jimmy Garoppolo injuring his right AC joint against the Dolphins in week 2 last year. Garoppolo’s injury is similar to Brady’s but different in that it was to his throwing shoulder and was apparently more severe than Brady’s, given the amount of time (2+ games) he missed.

Like a lot of things in orthopedics, AC joint injuries can be of varying severity, denoted by the “grade” of injury. Most orthopedic classification systems don’t go very high in terms of grades because math makes our heads hurt, and AC injuries follow this formula – there are six grades of injury, with grade 1 being the least severe (a sprain of the joint) and grades 2-6 being increasingly severe disruptions of the joint (separations).

The vast majority of these are treated without surgery, but the more severe the injury, the longer the injured player will likely be out.

In Brady’s case he apparently has a grade 1 injury to his non-throwing shoulder, so the outlook is good for him to miss little, if any, action. He did miss practice today but this should be something which is manageable with a combination of training room treatment, Alex Guerrero/TB12 hocus-pocus, and potentially a numbing injection into the joint around game time. Brady’s ability to play will really come down to pain tolerance- he’s not putting his shoulder at risk structurally by playing – and he certainly has a track record of playing through pain in the past.  I’d put my money on Brady being out there this weekend but don’t be surprised if they are more likely to play Jimmy G sooner rather than later in the event of a blowout.  For the balance of the season, if the offensive line can keep Brady upright (big “if”, I know) his shoulder shouldn’t be a major concern.

Welcome to Boston SportsDoc Injury Blog

Welcome to my blog – by way of introduction, I’m Christopher Geary, M.D.  I am a board-certified orthopedic surgeon with specialty training in sports medicine and arthroscopy.  I am the Chief of Sports Medicine at Tufts Medical Center and I am an Assistant Professor of Orthopedic Surgery at Tufts University School of Medicine.  I am also a lifelong diehard sports fan with strong Boston allegiances.  I’ll use my blog to give my insight into current sports injuries and their impact on performance and return to play.  I hope you find it useful – feel free to comment or contact me to ask questions about specific injuries or conditions.