Orthopedic surgeon explains treatments for Olympians, and us
The 2016 Summer Olympics have included legend-making performances by athletes such as Katie Ledecky and Simone Biles. They also have included devastating injuries: French gymnast Samir Ait Said suffered a gruesome broken leg early in the games; crashes by cyclists Vincenzo Nibali of Italy and Annemiek van Vleuten of the Netherlands left them with a broken collarbone and cracked vertebrae, respectively; and Armenian weightlifter Andranik Karapetyan dislocated his elbow while trying to lift 195 kilograms (about 430 pounds).
“No matter how many rules and regulations, how much safety equipment and caution you have in the situation, you have powerful, athletic individuals trying their hardest to move a ball or jump their highest,” says Joel Williams, MD, an assistant professor of orthopedics and a specialist in orthopedic trauma and hip preservation at Rush. “It’s a lot of mass and a lot of velocity, and these sorts of injuries are a risk of being active in these sort of sports.”
Fortunately, medicine and the body’s own healing power in most cases can heal even the most dramatic injuries. Here, Williams answers questions about what doctors do to mend the broken bones of both Olympic athletes and the ordinary patients he sees in his practice, where he treats broken arms and legs.
Outside of competitive events, are broken bones common among athletes?
Williams: The two most common demographics of trauma are young men with too much testosterone who engage in dangerous behaviors that result in an accident, and elderly folks who have a ground-level fall. If these patients were 20 years old, they would get right up, but now they wind up with a fracture.
A close third subset is athletes that are mid-sport or mid-practice and end up with a real traumatic injury like the ones we’re seeing in the Olympics. Just this week I cared for a 14-year-old eighth-grader throwing 80 miles-an-hour fastballs. He was able to generate enough force with his momentum and his muscles that he twisted his humerus (upper arm bone) in such a way that it caused a fracture.
What are the options for treating broken bones?
Surgery is not necessary for every patient. Some can be treated with immobilization, like a splint, cast or brace.
The next modality of treatment is a device called an external fixator. They have metal pins that go through the skin and into the bone above and below the injury. The pins are connected to each other with carbon fiber rods. Sometimes they’re used as the patient’s definitive treatment — the device is put on and kept on until the fracture heals — but most of the time we’ll put it on as a temporary measure until another operation at a later date.
The two most common reasons to use them are if somebody comes in and they’re too sick for surgery, or if there’s a large amount of swelling and it’s not safe to make an incision.
The last two options are internal fixation with a plate or a rod. Plates come in a variety of shapes and sizes, and they’re applied to the bone with screws. Typically, the fracture is aligned to its correct position using X-rays before the application of internal fixation. Sometimes we put them on while we’re looking directly at the entire bone and plate and do not rely heavily on X-rays. Alternatively, we’ll make small incisions and slide the plate under the skin and muscle and use X-rays to place the implant in the correct position.
If we decide to use a rod, it goes inside the bone rather than on the surface of the bone. The decision to use a plate versus a rod is injury specific and surgeon preference. Especially with the rod, we use a lot of X-rays to make sure everything is lined up correctly before the implant goes in.
How do a fixator, plate or rod help bones heal?
They’re all devices we use to hold things in the correct position. At some point, if the body doesn’t heal, any of these devices will fail. Once the surgery is done, the patient needs to heal the fracture on his or her own.
If you’re fixing a broken chair or table, it doesn’t have any healing capacity, so the fixation has to last. But the human skeleton is much cooler, because you align things back where they’re supposed to be, and the body actually builds new bone. It fills in the broken pieces with new bone.
A lot of people may not realize that the body keeps producing new bone even after a person is fully grown. Can you talk a little more about that process and how it helps broken bones heal?
From before you’re born until the day you die, your entire skeleton is digested and rebuilt by very specific cells. Your skeleton remodels itself roughly every 15 years. It’s a highly regulated system and breaks down bone at certain points and builds it back up at other points.
A child’s skeleton is very different. There are growth plates all over the skeleton that are responsible for increasing the length of your arms and legs. Once someone reaches skeletal maturity, the remodeling process still continues. The cells that break down bones are called osteoclasts and the ones that build bone are called osteoblasts, and they signal each other.
The process is accelerated by a broken bone, which sets off all kinds of signals. There’s a huge recruitment of osteoblasts and they gather to repair the broken bone.
I realize you don’t have first-hand knowledge of the incidents at the Olympics, but I’m hoping can you offer some general perspective on them. Have you seen any of the injuries?
I was watching the French guy (gymnast Samir Ait Said) with a small group of people. Most people look away or have an audible reaction, and my fiancé was teasing me because I was bringing my nose closer to the screen and trying to guess what the X-ray would look like.
Can athletes recover from these kinds of injuries?
It just depends on the injury, people’s age and their overall physical health. It’s a factor in our decision-making and how we’re going treat them, and it’s a factor after surgery when they’re going to go to physical therapy.
Young people heal more quickly than older people. Olympic athletes, who are at the younger end of the age spectrum and are in fantastic shape, are going to heal more quickly. Whether they’re going to return to the Olympics depends on the injury.
The weight lifter probably is going to lose some extension of his elbow, which is a huge set back for a weightlifter. He’s probably not going to be able to lift as much weight. For the French gymnast, there are plenty of athletes who have an injury like that and return to competitive sports, but there also are plenty of people for whom that’s a career-ending injury.
(Said, who was attempting an Olympics comeback after missing the 2012 Summer Olympics due to injury, has vowed to compete in the 2020 Summer Olympics in Tokyo and to win a medal.)
My impression is that a broken collarbone, which is what one of the cyclists suffered, isn’t as severe.
Most competitive cyclists have had a clavicle fracture at some point or another because it’s so common. I just finished operating on a 40-year-old bicyclist with a collarbone injury an hour ago.
Without surgery, patients with a broken collarbone do extremely well — 85 to 90 percent of them heal and patients have no complaints long term without an operation. If you put them in a sling and let them be, they’ll recover so why put them in the risk of surgery. This gentleman had an injury that almost was poking through his skin, so I realigned him so he wasn’t at risk of the bone breaking the skin.
The body’s healing power is extraordinary, but obviously, the best thing to do is avoid broken bones in the first place. Are there things people can do to help keep their bones strong, especially older adults who are at risk for bone loss?
Staying active with weight bearing activities. Walking, running if your knees and ankles and hips are in good shape, weightlifting are all great ways to increase bone formation and decrease your chance of getting osteoporosis.
The other thing you can do later in life, after age 50 or 60, to increase your bone mass is to take calcium and vitamin D supplements, which are available over the counter. It’s always better to do it under the supervision of a primary care doctor or an endocrinologist, but for calcium and vitamin D supplements there’s not a whole lot of downside of taking them.