Wednesday, May 30, 2012

Colonoscopy - When Do You Need it?




                                           


 A man went in for a colonoscopy.  The gastroenterologist examined him, and then turned him on his side to begin the procedure.  The doc immediately noticed a large piece of lettuce protruding from the gentleman's posterior.  "Sir", she said, "did you know that you have lettuce hanging out of your bottom?"


 "Yes," replied the man, "but that's just the tip of the iceberg."


______________________________________________


 Jill Triathlete, a prominent local real estate attorney, was at her Primary Care Physicians office recently for a cold which just refused to go away. Jill thought she might have pneumonia from that Saturday long run in the cold and rain. Fortunately, after the evaluation, it was a relief to find out she didn’t. The doctor was idly thumbing through her chart and when she settled on the Health Maintenance page she noted, “Jill Triathlete, you’re 50 and you haven’t had your screening colonoscopy.” Jill’s mind went ablaze with thoughts. “Colonoscopy? Put something where the sun don’t shine? Take a ride on the black stallion? The snake? OMG…if I can just get to the Delorean quickly enough to activate the flux capacitor…..” yet she replies a cool, “Oh, really?”


___________________________


The American Cancer Society and the American College of Gastroenterologists "recommend routine testing for people age 50 and older who have a normal risk for colorectal cancer."


Your doctor may recommend earlier testing if you are at a higher risk for cancer.  This could include blood in your stool or rectal bleeding, dark or black stool, chronic diarrhea, iron deficiency anemia, unexplained weight loss, etc.


 Colonoscopy really isn’t such a big deal these days. Most are done under sedation although there are those who, potentially not so wisely, think, “If I can finish an Ironman without sedation, I can sure as heck fire do one these little tests without it. “ But they’re not always correct….as they find out in short order.


 It’s the prep that gets folks. And it’s not that it hurts or anything, it’s just inconvenient and their body does things that under ordinary circumstances would be considered very abnormal. The day before the procedure goes something like this:


 Hearty Breakfast – 2 cups of tea, no milk or cream,


Lumberjack’s lunch – as much beef bouillon as you wish


PM Snack – either tea or bouillon, take your choice


Supper – Dulcolax pills and this delightful beverage called Miralax, as in laxative. It’s the same plastic jug that you buy a gallon of milk in, but looks, and tastes, like Secretariat’s urine. Only worse. The good news is that there’s a whole lot it.


 Now is the time one learns the definition of explosive diarrhea. Leaving the house is not an option. Leaving the sight of the commode may not be an option either. Think garden hose velocity liquid coming out of you. But (butt) think of it this way, you’re getting your innards spic and span so that if there’s anything of interest, your gastroenterologist can see it quickly.


 


                                                          


 The Colon Cancer Foundation describes the procedure as follows:


 Colonoscopy (koh-luh-NAH-skuh-pee) lets the physician look inside your entire large intestine, from the lowest part, the rectum, all the way up through the colon to the lower end of the small intestine. The procedure is used to look for early signs of cancer in the colon and rectum. It is also used to diagnose the causes of unexplained changes in bowel habits. Colonoscopy enables the physician to see inflamed tissue, abnormal growths, ulcers, and bleeding.


 After your IV's been started and sedation given, the doctor will ask you to lay on your left side and he/she will insert the scope, a flexible tube with a light at then end and video capabilities projecting the image on a screen that you and the doctor can watch simultaneously.  As the scope gets further into the colon, air can be passed through it to inflate the colon making both vision and scope passage easier.  The whole procedure lasts about half an hour, sometimes a little longer when something out of the ordinary is discovered by the examiner.


 You will recover there and in an hour or two, and when most of sedation has worn off you can leave.  Most do not find it an unpleasant experience and occasionally they give you the photos from "down inside." I wouldn't suggest putting them in your Christmas cards, however.


 In short, a great deal of information can be obtained in a short period of .  Processes, once considered fatal, can be located and treated early, often without surgery.  Make sure you say thanks to the doc.  With a little luck, you won't have to do this again for 10 years.


 Workout of the Week


One day this week in the pool try this for a main set.  After your usual warm up, pick an interval, say :45sec/50 yards and do the following.


Swim 100y on 1:30, 50y on :50 then 50y on 1:30 (to catch your breath), repeat 3 times - total 800y.  We did this one on Friday and it's a good push.


 The gent next to me in lane 5 swam 100 yds, jumped out of the pool and did 10 push ups, then hopped back in the water, all under 2:00 min.  Repeat 10 times. Total work out time 20:00.


 


 Credits for the above; Patricia Raymond, MD


                  Colon Cancer Foundation


 



Colonoscopy - When Do You Need It?



                                           


A man went in for a colonoscopy.  The gastroenterologist examined him, and then turned him on his side to begin the procedure.  The doc immediately noticed a large piece of lettuce protruding from the gentleman's posterior.  "Sir", she said, "did you know that you have lettuce hanging out of your bottom?"

"Yes," replied the man, "but that's just the tip of the iceberg."
______________________________________________

Jill Triathlete, a prominent local real estate attorney, was at her Primary Care Physicians office recently for a cold which just refused to go away. Jill thought she might have pneumonia from that Saturday long run in the cold and rain. Fortunately, after the evaluation, it was a relief to find out she didn’t. The doctor was idly thumbing through her chart and when she settled on the Health Maintenance page she noted, “Jill Triathlete, you’re 50 and you haven’t had your screening colonoscopy.” Jill’s mind went ablaze with thoughts. “Colonoscopy? Put something where the sun don’t shine? Take a ride on the black stallion? The snake? OMG…if I can just get to the Delorean quickly enough to activate the flux capacitor…..” yet she replies a cool, “Oh, really?”
___________________________
The American Cancer Society and the American College of Gastroenterologists "recommend routine testing for people age 50 and older who have a normal risk for colorectal cancer."

Your doctor may recommend earlier testing if you are at a higher risk for cancer.  This could include blood in your stool or rectal bleeding, dark or black stool, chronic diarrhea, iron deficiency anemia, unexplained weight loss, etc.


Colonoscopy really isn’t such a big deal these days. Most are done under sedation although there are those who, potentially not so wisely, think, “If I can finish an Ironman without sedation, I can sure as heck fire do one these little tests without it. “ But they’re not always correct….as they find out in short order.

It’s the prep that gets folks. And it’s not that it hurts or anything, it’s just inconvenient and their body does things that under ordinary circumstances would be considered very abnormal. The day before the procedure goes something like this:

Hearty Breakfast – 2 cups of tea, no milk or cream,
Lumberjack’s lunch – as much beef bouillon as you wish
PM Snack – either tea or bouillon, take your choice
Supper – Dulcolax pills and this delightful beverage called Miralax, as in laxative. It’s the same plastic jug that you buy a gallon of milk in, but looks, and tastes, like Secretariat’s urine. Only worse. The good news is that there’s a whole lot it.

Now is the time one learns the definition of explosive diarrhea. Leaving the house is not an option. Leaving the sight of the commode may not be an option either. Think garden hose velocity liquid coming out of you. But (butt) think of it this way, you’re getting your innards spic and span so that if there’s anything of interest, your gastroenterologist can see it quickly.

                                                          

The Colon Cancer Foundation describes the procedure as follows:

Colonoscopy (koh-luh-NAH-skuh-pee) lets the physician look inside your entire large intestine, from the lowest part, the rectum, all the way up through the colon to the lower end of the small intestine. The procedure is used to look for early signs of cancer in the colon and rectum. It is also used to diagnose the causes of unexplained changes in bowel habits. Colonoscopy enables the physician to see inflamed tissue, abnormal growths, ulcers, and bleeding.

After your IV's been started and sedation given, the doctor will ask you to lay on your left side and he/she will insert the scope, a flexible tube with a light at then end and video capabilities projecting the image on a screen that you and the doctor can watch simultaneously.  As the scope gets further into the colon, air can be passed through it to inflate the colon making both vision and scope passage easier.  The whole procedure lasts about half an hour, sometimes a little longer when something out of the ordinary is discovered by the examiner.

You will recover there and in an hour or two, and when most of sedation has worn off you can leave.  Most do not find it an unpleasant experience and occasionally they give you the photos from "down inside." I wouldn't suggest putting them in your Christmas cards, however.

In short, a great deal of information can be obtained in a short period of .  Processes, once considered fatal, can be located and treated early, often without surgery.  Make sure you say thanks to the doc.  With a little luck, you won't have to do this again for 10 years.

Workout of the Week
One day this week in the pool try this for a main set.  After your usual warm up, pick an interval, say :45sec/50 yards and do the following.
Swim 100y on 1:30, 50y on :50 then 50y on 1:30 (to catch your breath), repeat 3 times - total 800y.  We did this one on Friday and it's a good push.

The gent next to me in lane 5 swam 100 yds, jumped out of the pool and did 10 push ups, then hopped back in the water, all under 2:00 min.  Repeat 10 times. Total work out time 20:00.



Credits for the above: Patricia Raymond, MD
                                  Colon Cancer Foundation

Sunday, May 27, 2012

Donor Grafts and Tissue Safety

Planning Surgery with potential for needing some type of graft?





The family is in the NC Outer Banks (think Kitty Hawk) for Memorial Day and we had a terrific bike ride this morning. Knowing that the two lane road would be crowded with tourists, we got up with the sun and the ride was done just as the rest o the world was awakening. Plus, we had the advantage of a nice bike lane most of the way. A fun, safe ride.
________________________________________

Heard blasting from a convertible on today's ride. http://www.youtube.com/watch?v=uxVB7gvqWkk

As they say: probably responsible for more speeding tickets than any other track! Ever.
____________________________



This image is used by a Denver Tissue bank and it reminds us that there may be a time we need tissue, blood, or a graft from some one else. I agree that for today this may be a little esoteric but I guarantee you that it will be appropriate for some readers "when they least expect it." I've donated over a 100 units of blood and am registered with the National Marrow Donor Program http://marrow.org/Home.aspx which you may also consider. Those of you who may require ACL reconstruction, a patch on your rotator cuff, knee replacement with bone graft, or other such procedure should keep this blog in mind to fully understand their options/choices at the time of surgery.


Following Medical School and my Orthopedic Surgery Residency, I did a fellowship in Arthroscopic Surgery in Richmond, VA. On day one, I was asked to join the program director on a journey to the Virginia Beach Tissue Bank to see where the grafts we used in surgery came from, their handling techniques, sterility measures, etc. so that we could guarantee their safety to the patient population. As Orthopedic Surgeons, we use these tissues in a host of different procedures as substitute or augmentation of damaged ligaments, tendons, bone loss, etc. It's crucial to be able to certify the safety of these allograft tissues, allograft being another term for body parts that have been harvested from a cadaver, cleaned and sterilized, and prepared for implantation in another person. You might be concerned about the possibility of disease transmission or infection, and yes it has happened, but exceptionally infrequently. We're told by the CDC (Centers for Disease Control) that of the nearly 1,500,000 allograft implants performed annually that approximately 6 cases of disease transmission will occur. Not zero but pretty close. I've read that the calculated risk of HIV transmission has been calculated at 1,000,000 to 1.


Commonly performed orthopedic procedures that occasionally use allograft include ACL reconstruction, spine fusion, meniscus transplant, cartilage transplant, surgical repair of fractures, etc. The surgeons first choice in these cases would be the patients own normal tissue. But, if this is not available, then donated cartilage, tendon, etc. processed by the tissue bank is an excellent second choice. When this cadaveric tissue is harvested, significant efforts are undertaken to make sure the source was free of disease and then processed in a manner to further reduce a negative outcome. It would be carefully screened for hepatitis, Mad Cow disease, AIDS, infection, or any blood borne infection, etc. and then a sterilization technique is performed further adding to it's safety. A variety of steps are taken, including freezing to below -100 degrees fahrenheit!


If you are contemplating having allograft tissue implanted during an upcoming operation, you have every right to question it's source, sterility, track record, etc. Oftentimes this information can come from a web site of the tissue bank which would outline their individual safety record, screening policies used, etc.


Lastly, and this isn't often discussed, the cadaver tissue is handled with utmost respect. I have been involved with cadavers from the first day of Medical School in Gross Anatomy class, teaching Gross to MD - Phd students, various cadaver labs learning/teaching knee and shoulder reconstruction, knee replacement, and the above harvesting techniques for later implantation. I, and surgeons like me, have benefited enormously from the kindness and generosity of those who've left their bodies for scientific efforts. Performing an operation on a cadaver where, if I mess it up, there's little consequence, had made me and other surgeons more skilled at the operations we perform on you and your family. My driver's license signifies me, and countless others, as an organ donor. Perhaps I'll be able to help the next generation of doctors learn just a little more. And, just like at the Virginia Beach Tissue Bank from so many years ago, I know it'll be done correctly.

Image #2 Google Images

Donor Grafts and Tissue Safety

Planning Surgery with potential for needing some type of graft?


 


The family is in the NC Outer Banks (think Kitty Hawk) for Memorial Day and we had a terrific bike ride this morning. Knowing that the two lane road would be crowded with tourists, we got up with the sun and the ride was done just as the rest o the world was awakening. Plus, we had the advantage of a nice bike lane most of the way. A fun, safe ride.


________________________________________


Heard blasting from a convertible on today's ride. http://www.youtube.com/watch?v=uxVB7gvqWkk


As they say: probably responsible for more speeding tickets than any other track! Ever.


____________________________


 



 


This image is used by a Denver Tissue bank and it reminds us that there may be a time we need tissue, blood, or a graft from some one else. I agree that for today this may be a little esoteric but I guarantee you that it will be appropriate for some readers "when they least expect it." I've donated over a 100 units of blood and am registered with the National Marrow Donor Program http://marrow.org/Home.aspx which you may also consider. Those of you who may require ACL reconstruction, a patch on your rotator cuff, knee replacement with bone graft, or other such procedure should keep this blog in mind to fully understand their options/choices at the time of surgery.


Following Medical School and my Orthopedic Surgery Residency, I did a fellowship in Arthroscopic Surgery in Richmond, VA. On day one, I was asked to join the program director on a journey to the Virginia Beach Tissue Bank to see where the grafts we used in surgery came from, their handling techniques, sterility measures, etc. so that we could guarantee their safety to the patient population. As Orthopedic Surgeons, we use these tissues in a host of different procedures as substitute or augmentation of damaged ligaments, tendons, bone loss, etc. It's crucial to be able to certify the safety of these allograft tissues, allograft being another term for body parts that have been harvested from a cadaver, cleaned and sterilized, and prepared for implantation in another person. You might be concerned about the possibility of disease transmission or infection, and yes it has happened, but exceptionally infrequently. We're told by the CDC (Centers for Disease Control) that of the nearly 1,500,000 allograft implants performed annually that approximately 6 cases of disease transmission will occur. Not zero but pretty close. I've read that the calculated risk of HIV transmission has been calculated at 1,000,000 to 1.


 


Commonly performed orthopedic procedures that occasionally use allograft include ACL reconstruction, spine fusion, meniscus transplant, cartilage transplant, surgical repair of fractures, etc. The surgeons first choice in these cases would be the patients own normal tissue. But, if this is not available, then donated cartilage, tendon, etc. processed by the tissue bank is an excellent second choice. When this cadaveric tissue is harvested, significant efforts are undertaken to make sure the source was free of disease and then processed in a manner to further reduce a negative outcome. It would be carefully screened for hepatitis, Mad Cow disease, AIDS, infection, or any blood borne infection, etc. and then a sterilization technique is performed further adding to it's safety. A variety of steps are taken, including freezing to below -100 degrees fahrenheit!


 


If you are contemplating having allograft tissue implanted during an upcoming operation, you have every right to question it's source, sterility, track record, etc. Oftentimes this information can come from a web site of the tissue bank which would outline their individual safety record, screening policies used, etc.


Lastly, and this isn't often discussed, the cadaver tissue is handled with utmost respect. I have been involved with cadavers from the first day of Medical School in Gross Anatomy class, teaching Gross to MD - Phd students, various cadaver labs learning/teaching knee and shoulder reconstruction, knee replacement, and the above harvesting techniques for later implantation. I, and surgeons like me, have benefited enormously from the kindness and generosity of those who've left their bodies for scientific efforts. Performing an operation on a cadaver where, if I mess it up, there's little consequence, had made me and other surgeons more skilled at the operations we perform on you and your family. My driver's license signifies me, and countless others, as an organ donor. Perhaps I'll be able to help the next generation of doctors learn just a little more. And, just like at the Virginia Beach Tissue Bank from so many years ago, I know it'll be done correctly.


 


 



Wednesday, May 23, 2012

Do You Know/Follow Bike Etiquette?/Avoiding Distracted Driving


"Soldier on, only you can do what must be done."
                                                                        John Parr, St. Elmo's Fire
Think about this when you're considering blowing off a workout for something trivial.

I wrote last year about a local cyclist killed by a young driver accused of texting. The point of that blog was for all cyclists to carry ID of some kind be it the formal Road I.D. or just a business card.  There are lots of easy ways.  I am personally a fan of Road I.D. as it has my wife's business an cell phone numbers, my blood type, medicines and allergies on it.  But, what ever way you chose, just make sure you get it done.
The stats on distracted driving are startling.
  • 80 percent of all crashes and 65 percent of near crashes involve some type of distraction. (Source: Virginia Tech 100-car study for NHTSA)
  • Nearly 6,000 people died in 2008 in crashes involving a distracted or inattentive driver, and more than half a million were injured. (NHTSA)
  • The worst offenders are the youngest and least-experienced drivers: men and women under 20 years of age. (NHTSA)
  • Drivers who use hand-held devices are four times as likely to get into crashes serious enough to injure themselves. (Source: Insurance Institute for Highway Safety)
We can avoid distracted driving by:
  • The American Academy of Orthopedic Surgeons (of which I'm a member) and Orthopedic Trauma Association encourage all drivers to pull over to use a cell phone, but if you must answer the phone, use a hands-free device. 
  • Do not dial phone numbers on a cell phone, send or read text messages while driving.
  • When in the car, set up a "driving" profile on your smartphone, which switches off text alerts and silences the phone. (This is a function on the Blackberry that can be easily selected from the home screen).
  • To listen to the radio, use the volume and station buttons on the steering wheel, instead of reaching for the center counsel.
  • Before you depart, load compact discs in the player or set up a pre-selected playlist on an mp 3 player.
  • Enter an address in the navigation system before you depart or while in park.
The Second part of this writing concerns the rules of bike riding.  I'm certain, if your bike group is anything like mine, there are one or two riders who refuse to follow the rules.  We have 2 or 3 who always ride two abreast forcing vehicular traffic to go around them.  But some day.....
What follows is one of the best sets of cycling rules that I could find, simple, straight forward, and easy to follow.  It's from Marin County, California,a little lengthy but it covers the waterfront and may be a good resource when you need to "help" someone with their bike rule following.
_________________

 Bicyclists' Code of Conduct

  1. Never ride against traffic.
  2. Ride as near to the right as practicable*.
  3. Stop at stop signs and red lights*.
  4. Honor other's right of way.
  5. Use hand signals.
  6. With traffic, ride single file.
  7. Be predictable; don't weave.
  8. Follow lane markings.
  9. Don't needlessly block the road*.
  10. Use lights at night.
*--Note that the two most common offenses of bicyclists are running stop signs, and groups of cyclists blocking the road.
1. Stop at stop signs/lights: Stop at all stop signs and red lights. If two vehicles arrive at an intersection at the same time, the vehicle to the right has the right of way. Politely indicate other's right of way with a hand gesture. For your own safety, never insist on your own right of way. Pedestrians always have the right of way. Your courtesy will be noticed and appreciated by other road users.
2. Group riding: a) The California Vehicle Code (CVC sec. 21202(a) and sec. 21750) states that bicyclists are entitled to the full width of the road for at least purposes of overtaking, left turns, avoiding obstacles, when approaching a place where a right turn is authorized, and when riding in a substandard width lane. Generally, it is prudent to stay as far to the right as practicable. When riding with others, do not block traffic, ride single file. Be aware of other road users at all times. b) When stopping for a stop sign in a group, queue up in small numbers and proceed when it is your turn, allowing other road users their right of way. The idea is to cross the intersection as safely and quickly as possible without testing the patience of other road users. Self-policing and courteous riding will go far.
Wear a helmet, bright clothing, and keep your bicycle in good working order. Helpful hint: Modern, good quality brakes along with good technique make stopping at stop signs much easier.
Bicyclists and any passengers under 18 years of age (including children in attached bicycle seats or in or on towed trailers), are required to wear a properly fitted and fastened bicycle helmet. This helmet must be labeled to show that it meets applicable safety standards.
Youngsters under the age of nine lack the physical and mental development to interact safely in a complex traffic environment.
Laws and Safety tips:
  • BE PREDICTABLE

Never ride against traffic. Motorists aren't looking for bicyclists riding on the wrong side of the road. Many other hazards threaten the wrong-way rider.
Obey traffic signs and signals, and basic right-of-way rules. Cyclists must drive like motorists if they want to be taken seriously. Doing so is also the safest behavior. When approaching a stop sign or red light, you are required to come to a complete stop and proceed only when safe to do so.
Use hand signals. Hand signals tell other road users what you intend to do. Signal as a matter of law, of courtesy, and of self-protection.
Ride in a straight line. Whenever possible, ride in a straight line, to the right of traffic but about a car door's width away from parked cars.
Don't weave between parked cars. Don't ride to the curb between parked cars, unless they are far apart. Motorists may not see you when you try to move back into traffic.
Follow lane markings. Don't turn left from the right lane. Don't go straight in a lane marked "right-turn-only." Stay to the left of the right-turn-only lane if you are going straight.
Choose the best way to turn left. There are two ways to make a left turn. 1) Like an auto. Signal, move into the left lane, and turn left. 2) Like a pedestrian. If you are with-in a designated crosswalk, dismount and walk your bike across.
  • BE ALERT

Watch for right-turning traffic. Motorists turning right may not notice cyclists on their right. Watch for any indications that a motorist may turn into your path. When approaching intersections try to stay far enough from the curb to allow cars to turn right on your right. Motorists may not look for or see a bicycle passing on the right.
Look back before you pass or merge. Leave a good 3-4 feet when passing a pedestrian or another bicyclist. A rear-view mirror is a good idea, but don't rely on it alone.
Respect pedestrian's rights. Pedestrians have the right of way. Don't cross side-walks via driveways without yielding to pedestrians. Don't ride on sidewalks. Use the street, bike lane, or bike path. Give a warning: use your bike bell, or call out "Passing on your left".
Keep both hands ready to brake. You may not stop in time if you brake one-handed. Allow extra distance for stopping in rain, since brakes are less efficient when wet.
Avoid road hazards. Watch out for street car tracks and old railroad tracks. Cross them perpendicularly. Avoid parallel-slat sewer grates, slippery manhole covers, oily pavement, gravel, potholes. All are hazardous, especially when wet.
Watch your speed. Observe posted speed limits and obey the basic speed law: Never ride faster than is safe under the existing conditions.
Thanks to AAOS, OTA, Marin County

Do You Know/Follow Bike Etiquette?/ Avoiding Distracted Driving

"Soldier on, only you can do what must be done."


                                                                        John Parr, St. Elmo's Fire


Think about this next time you feel like blowing off a workout for something trivial.


 



I wrote last year about a local cyclist killed by a young driver accused of texting. The point of that blog was for all cyclists to carry ID of some kind be it the formal Road I.D. or just a business card.  There are lots of easy ways.  I am personally a fan of Road I.D. as it has my wife's business an cell phone numbers, my blood type, medicines and allergies on it.  But, what ever way you chose, just make sure you get it done.


The stats on distracted driving are startling.



  • 80 percent of all crashes and 65 percent of near crashes involve some type of distraction. (Source: Virginia Tech 100-car study for NHTSA)

  • Nearly 6,000 people died in 2008 in crashes involving a distracted or inattentive driver, and more than half a million were injured. (NHTSA)

  • The worst offenders are the youngest and least-experienced drivers: men and women under 20 years of age. (NHTSA)

  • Drivers who use hand-held devices are four times as likely to get into crashes serious enough to injure themselves. (Source: Insurance Institute for Highway Safety)


We can avoid distracted driving by:



  • The American Academy of Orthopedic Surgeons (of which I'm a member and Orthopedic Trauma Association encourage all drivers to pull over to use a cell phone, but if you must answer the phone, use a hands-free device. 

  • Do not dial phone numbers on a cell phone, send or read text messages while driving.



  • When in the car, set up a "driving" profile on your smartphone, which switches off text alerts and silences the phone. (This is a function on the Blackberry that can be easily selected from the home screen).

  • To listen to the radio, use the volume and station buttons on the steering wheel, instead of reaching for the center counsel.



  • Before you depart, load compact discs in the player or set up a pre-selected playlist on an mp 3 player.

  • Enter an address in the navigation system before you depart or while in park.


The Second part of this writing concerns the rules of bike riding.  I'm certain, if your bike group is anything like mine, there are one or two riders who refuse to follow the rules.  We have 2 or 3 who always ride two abreast forcing vehicular traffic to go around them.  But some day.....


What follows is one of the best sets of cycling rules that I could find, simple, straight forward, and easy to follow.  It's from Marin County, California,a little lengthy but it covers the waterfront and may be a good resource when you need to "help" someone with their bike rule following.


_________________


 Bicyclists' Code of Conduct



  1. Never ride against traffic.

  2. Ride as near to the right as practicable*.

  3. Stop at stop signs and red lights*.

  4. Honor other's right of way.

  5. Use hand signals.

  6. With traffic, ride single file.

  7. Be predictable; don't weave.

  8. Follow lane markings.

  9. Don't needlessly block the road*.

  10. Use lights at night.


*--Note that the two most common offenses of bicyclists are running stop signs, and groups of cyclists blocking the road.


1. Stop at stop signs/lights: Stop at all stop signs and red lights. If two vehicles arrive at an intersection at the same time, the vehicle to the right has the right of way. Politely indicate other's right of way with a hand gesture. For your own safety, never insist on your own right of way. Pedestrians always have the right of way. Your courtesy will be noticed and appreciated by other road users.


2. Group riding: a) The California Vehicle Code (CVC sec. 21202(a) and sec. 21750) states that bicyclists are entitled to the full width of the road for at least purposes of overtaking, left turns, avoiding obstacles, when approaching a place where a right turn is authorized, and when riding in a substandard width lane. Generally, it is prudent to stay as far to the right as practicable. When riding with others, do not block traffic, ride single file. Be aware of other road users at all times. b) When stopping for a stop sign in a group, queue up in small numbers and proceed when it is your turn, allowing other road users their right of way. The idea is to cross the intersection as safely and quickly as possible without testing the patience of other road users. Self-policing and courteous riding will go far.


Wear a helmet, bright clothing, and keep your bicycle in good working order. Helpful hint: Modern, good quality brakes along with good technique make stopping at stop signs much easier.


Bicyclists and any passengers under 18 years of age (including children in attached bicycle seats or in or on towed trailers), are required to wear a properly fitted and fastened bicycle helmet. This helmet must be labeled to show that it meets applicable safety standards.


Youngsters under the age of nine lack the physical and mental development to interact safely in a complex traffic environment.


Laws and Safety tips:




  • BE PREDICTABLE




Never ride against traffic. Motorists aren't looking for bicyclists riding on the wrong side of the road. Many other hazards threaten the wrong-way rider.


Obey traffic signs and signals, and basic right-of-way rules. Cyclists must drive like motorists if they want to be taken seriously. Doing so is also the safest behavior. When approaching a stop sign or red light, you are required to come to a complete stop and proceed only when safe to do so.


Use hand signals. Hand signals tell other road users what you intend to do. Signal as a matter of law, of courtesy, and of self-protection.


Ride in a straight line. Whenever possible, ride in a straight line, to the right of traffic but about a car door's width away from parked cars.


Don't weave between parked cars. Don't ride to the curb between parked cars, unless they are far apart. Motorists may not see you when you try to move back into traffic.


Follow lane markings. Don't turn left from the right lane. Don't go straight in a lane marked "right-turn-only." Stay to the left of the right-turn-only lane if you are going straight.


Choose the best way to turn left. There are two ways to make a left turn. 1) Like an auto. Signal, move into the left lane, and turn left. 2) Like a pedestrian. If you are with-in a designated crosswalk, dismount and walk your bike across.




  • BE ALERT




Watch for right-turning traffic. Motorists turning right may not notice cyclists on their right. Watch for any indications that a motorist may turn into your path. When approaching intersections try to stay far enough from the curb to allow cars to turn right on your right. Motorists may not look for or see a bicycle passing on the right.


Look back before you pass or merge. Leave a good 3-4 feet when passing a pedestrian or another bicyclist. A rear-view mirror is a good idea, but don't rely on it alone.


Respect pedestrian's rights. Pedestrians have the right of way. Don't cross side-walks via driveways without yielding to pedestrians. Don't ride on sidewalks. Use the street, bike lane, or bike path. Give a warning: use your bike bell, or call out "Passing on your left".


Keep both hands ready to brake. You may not stop in time if you brake one-handed. Allow extra distance for stopping in rain, since brakes are less efficient when wet.


Avoid road hazards. Watch out for street car tracks and old railroad tracks. Cross them perpendicularly. Avoid parallel-slat sewer grates, slippery manhole covers, oily pavement, gravel, potholes. All are hazardous, especially when wet.


Watch your speed. Observe posted speed limits and obey the basic speed law: Never ride faster than is safe under the existing conditions.


Thanks to AAOS, OTA, Marin County


 




 



Sunday, May 20, 2012

High Blood Pressure/Hypertension and Beta Blockers


"You might say I'm a dreamer, but I'm not the only one."      Imagine, John Lennon     (Dreamer.... Apropos for triathletes, no??)   

Food For Thought


Last Sunday I wrote my annual blog for Mother's Day on the more common than we might think association of eating disorders and triathlon.  I took the above photo at the local University gym. The hard to read smaller letters say, "Is the number on the scale manipulating your mood?  Realize that many factors influence your weight at any given time: hydration, sodium levels, glycogen storage, time of last meal, menstrual cycle in women."
_____________________________________________

High blood pressure, hypertension, is common in the general population and those in our sport are not immune.  I did a blog about this a good while back and thought it a good time to revisit the issue as that particular blog is among those most viewed.  

The typical letter I get is from an athlete who's either just been placed on this class of meds or someone relatively new to the sport who's not achieving the desired results and wonders if a medication change would be helpful.  They frequently note difficulty setting up heart rate based training zones and/or achieving as high a max heart rate as they feel they should.  But, of course, this is part of the mechanism of action of this medication. Common names include Atenolol, Metoprolol, Carvedilol and Propanolol to name a few.


Indications can include elevated blood pressure not controlled by diet and exercise, those with a heart rate disturbance known as an arrythmia, particularly following a myocardial infarction (heart atttack) and, interestingly enough people with anxiety issues.  Included here would be "performance anxiety" be it those involved in public speaking, stage or acting, even rock star musicians with a sort of stage fright have been know to benefit from their use.  A novel (to me) illegal use is in those involved in shooting or archery, particularly at a high level.  In the 2008 Olympic Summer Games, a Korean athlete was stripped of a medal in shooting when it was discovered that a beta blocker was present in his blood, and on the prohibited list, unfortunately.  It seems to steady their hands, reduce the shakes, and presumably given them a greater degree of accuracy.


So, if you go back to triathlon, and the noted effect of beta blockers to reduce or limit heart rate, you arrive at the crux of the problem.  This would include one's max heart rate as well as resting heart rate.  On one hand they'll make you live longer, on the other some complain of a sluggishness and find that it's more difficult to get a maximal effort on the drug.  If you simply use 220 - your age to predict your zones you'll be inaccurate.  Those in the business suggest that you have your zones set on a bike/running treadmill in a lab using blood levels. I've had it done and it's really pretty easy.  It's also said that if you could set up your testing so that it occurs at approximately the same time of day that you train, your level of accuracy improves.  Racing, however, might be at a different time of day, and slight alteration in the timing of your med, with your doc's blessings, make you even faster.  (The Speed Clinic at the University of Virginia, Jay Dicharry, 434-243-5605, is our local guru but if you ask around I'm sure you can find this service near your home.)

Finally, with each passing year, more studies are performed using different medications, some with different or minimal side effects, and a change to one of these may be just what the doctor ordered.  That would be your doctor, of course.

Hawaii 2011-STPT 250

High Blood Pressure/Hypertension and Beta Blockers

"You might say I'm a dreamer, but I'm not the only one."      Imagine, John Lennon     (Dreamer.... Apropos for triathletes, no??)   


 


Food For Thought


 


Last Sunday I wrote my annual blog for Mother's Day on the more common than we might think association of eating disorders and triathlon.  I took the above photo at the local University gym. The hard to read smaller letters say, "Is the number on the scale manipulating your mood?  Realize that many factors influence your weight at any given time: hydration, sodium levels, glycogen storage, time of last meal, menstrual cycle in women."


 


High blood pressure, hypertension, is common in the general population and those in our sport are not immune.  I did a blog about this a good while back and thought it a good time to revisit the issue as that particular blog is among those most viewed.  


 


The typical letter I get is from an athlete who's either just been placed on this class of meds or someone relatively new to the sport who's not achieving the desired results and wonders if a medication change would be helpful.  They frequently note difficulty setting up heart rate based training zones and/or achieving as high a max heart rate as they feel they should.  But, of course, this is part of the mechanism of action of this medication. Common names include Atenolol, Metoprolol, Carvedilol and Propanolol to name a few.


Indications can include elevated blood pressure not controlled by diet and exercise, those with a heart rate disturbance known as an arrythmia, particularly following a myocardial infarction (heart atttack) and, interestingly enough people with anxiety issues.  Included here would be "performance anxiety" be it those involved in public speaking, stage or acting, even rock star musicians with a sort of stage fright have been know to benefit from their use.  A novel (to me) illegal use is in those involved in shooting or archery, particularly at a high level.  In the 2008 Olympic Summer Games, a Korean athlete was stripped of a medal in shooting when it was discovered that a beta blocker was present in his blood, and on the prohibited list, unfortunately.  It seems to steady their hands, reduce the shakes, and presumably given them a greater degree of accuracy.


So, if you go back to triathlon, and the noted effect of beta blockers to reduce or limit heart rate, you arrive at the crux of the problem.  This would include one's max heart rate as well as resting heart rate.  On one hand they'll make you live longer, on the other some complain of a sluggishness and find that it's more difficult to get a maximal effort on the drug.  If you simply use 220 - your age to predict your zones you'll be inaccurate.  Those in the business suggest that you have your zones set on a bike/running treadmill in a lab using blood levels. I've had it done and it's really pretty easy.  It's also said that if you could set up your testing so that it occurs at approximately the same time of day that you train, your level of accuracy improves.  Racing, however, might be at a different time of day, and slight alteration in the timing of your med, with your doc's blessings, make you even faster.  (The Speed Clinic at the University of Virginia, Jay Dicharry, 434-243-5605, is our local guru but if you ask around I'm sure you can find this service near your home.)


 


Finally, with each passing year, more studies are performed using different medications, some with different or minimal side effects, and a change to one of these may be just what the doctor ordered.  That would be your doctor, of course.


 


Hawaii 2011-STPT 250



Thursday, May 17, 2012

Preventing Your Torn ACL

Play the game, you know you can't quit until it's won."
                                                                                                                       John Parr, St. Elmo's Fire




The youngest patient I ever did an ACL Reconstruction on was 12. He'd been in a dirt bike accident and torn up his knee pretty badly. This is not a good injury to have, and at 12 years of age, even reconstructed, the outlook is fair to partly cloudy. Plus, it's a risky operation and the fact that we didn't have complications was a great stroke of luck. I asked his father, no I ORDERED his father not to let him race dirt bikes again.

Two years later, guess who's back in the office for the opposite knee? Same mechanism. Very fortunately there was no major injury. You can lead a horse to water....




I've written about ACL tears several times but the focus here will be prevention. The normal ACL spans the knee joint between the femur and the tibia. It's a stout structure which limits the forward travel of the tibia under the femur as well as playing a role in rotational stability. While seldom injured when a blow occurs to the limb, they will rupture when a twisting force, like falling off a bike or slipping on a wet pool deck, is applied across the joint. A majority of ACL injuries are noncontact in nature. When this happens, the knee fills with blood and it's normal stability pattern is frequently lost. A torn ligament is not repairable.

Approximately 100,000 torn ACL's are seen in this country each year according to the Journal of Bone and Joint Surgery, and "costs associated with the evaluation, therapy, rehabilitation, and possible loss of funding and scholarships of affected athletes total $625 million to $1 billion annually." Although we've come to think, ok it's torn and I've had it fixed, now I'm fine, research has shown this to be far from the truth. Even those who've had the surgery are at risk for osteoarthritis down the road. In other words, whether one has had his/her own tissue used as a ligament substitute, or cadaveric tissue, the odds are still about 50-50 that arthritis will develop by 14 years post op.

Strong evidence for ACL injury prevention programs has been uncovered in recent years. For example, one study was done in over 1000 female soccer players. Against a control group, those who received "sport specific training intervention.....consisting of education, stretching, strengthening, plyometrics, and sport-specific agility drills" saw an 88% decrease in ACL injuries in the first season and a 74% decrease in the second season.

This was seen throughout a number of sports and is highly supportive of a planned program to reduce the frequency of Anterior Cruciate injuries. Think about this for your legs next time you see someone who's recently undergone reconstruction and is hobbling past you.

Peanut Allergies.   I sat in the same row on a recent flight as a gent who claimed to have a peanut allergy and a novel "cure." "Sure, if I drink whiskey I can eat anything I want!" We'll have to run this by our friends in the allergy clinic.


Image #2, Google images
JBJS Vol. 94-A, No.9

Wednesday, May 16, 2012

Preventing Your ACL Tear

"Play the game, you know you can't quit until it's won."


John Parr, St. Elmo's Fire


Hawaii 2010 182


 


The youngest patient I ever did an ACL Reconstruction on was 12. He'd been in a dirt bike accident and torn up his knee pretty badly. This is not a good injury to have, and at 12 years of age, even reconstructed, the outlook is fair to partly cloudy. Plus, it's a risky operation and the fact that we didn't have complications was a great stroke of luck. I asked his father, no I ORDERED his father not to let him race dirt bikes again.


Two years later, guess who's back in the office for the opposite knee? Same mechanism. Very fortunately there was no major injury. You can lead a horse to water....



I've written about ACL tears several times but the focus here will be prevention. The normal ACL spans the knee joint between the femur and the tibia. It's a stout structure which limits the forward travel of the tibia under the femur as well as playing a role in rotational stability. While seldom injured when a blow occurs to the limb, they will rupture when a twisting force, like falling off a bike or slipping on a wet pool deck, is applied across the joint. A majority of ACL injuries are noncontact in nature. When this happens, the knee fills with blood and it's normal stability pattern is frequently lost. A torn ligament is not repairable.


Approximately 100,000 torn ACL's are seen in this country each year according to the Journal of Bone and Joint Surgery, and "costs associated with the evaluation, therapy, rehabilitation, and possible loss of funding and scholarships of affected athletes total $625 million to $1 billion annually." Although we've come to think, ok it's torn and I've had it fixed, now I'm fine, research has shown this to be far from the truth. Even those who've had the surgery are at risk for osteoarthritis down the road. In other words, whether one has had his/her own tissue used as a ligament substitute, or cadaveric tissue, the odds are still about 50-50 that arthritis will develop by 14 years post op.


Strong evidence for ACL injury prevention programs has been uncovered in recent years. For example, one study was done in over 1000 female soccer players. Against a control group, those who received "sport specific training intervention.....consisting of education, stretching, strengthening, plyometrics, and sport-specific agility drills" saw an 88% decrease in ACL injuries in the first season and a 74% decrease in the second season.


This was seen throughout a number of sports and is highly supportive of a planned program to reduce the frequency of Anterior Cruciate injuries. Think about this for your legs next time you see someone who's recently undergone reconstruction and is hobbling past you.


Peanut Allergies I sat in the same row on a recent flight as a gent who claimed to have a peanut allergy and a novel "cure." "Sure, if I drink whiskey I can eat anything I want!" We'll have to run this by our friends in the allergy clinic.







Sunday, May 13, 2012

Eating Disorders in Triathlon

Happy Mother's Day


 "There once lived a man named Oedipus Rex.  Oedipus had a very odd complex, but he loved his mother."   Tom Lehrer


 As the father of a daughter, every Mother's Day I cover eating disorders.  Although our daughter has invited us to go on a hike in the Blue Ridge Mountains nearby, not everyone is so fortunate.  Maybe in some small way this can help.


 


 














A mother and daughter waiting for their triathlon  'teammate. '



Eating Disorder Awareness


 While touring colleges with our daughter last year, I found this posted in on the wall of the infirmary of a mid west university:


 


                                                            Staggering Facts...



  • 54% of women would rather be hit by a truck than be fat (Martin, 2007)

  • If mannequins were women, they would not be able to bear children.

  • Research shows that just 3-5 minutes of engaging in fat talk substantially increases body dissatisfaction (Stice, 2003)

  • Four out of ten Americans either suffered or have known someone who has suffered an eating disorder (NEDA, 2005)

  • As many as 20 million females are battling an eating disorder such as bulimia or anorexia. Millions more are battling binge eating. (Crowther, J. H., et al. 1992)

  • Most fashion models are thinner than 98% of most women.

  • 81% of ten year olds are afraid of being fat (Martin, 2007)

  • 25% of American men and 45% of American women are on a diet on any given day (Smolak, L., 1996)


While I cannot speak for the reproducibility of these "statistics" you get the point.  Eating disorders are serious business and triathletes are neither excluded nor immune. Even celebrities like Paula Abdul, Justine Bateman, Karen Carpenter, Susan Dey, Tracey Gold, Princess Di, and Joan Rivers have experienced an eating disorder.  EDs have the highest mortality of any of the mental illnesses.  In fact, 20% of people suffering from anorexia will prematurely die from complications related to their eating disorder, including suicide and heart disease.  But, according to the South Carolina Dept of Mental Health only one person in ten with an eating disorder ever receives treatment.


 If you're reading this blog it's because you're interested in triathlon performance.  Compiling a complete piece on eating disorders is beyond the scope of this blog but suffice it to say that it's a serious issue with endurance athletes and will have a negative influence on their performance.


 Casa Palmora is a clinic in California that specializes in those patients with ED.  In their advertising they point toward a number of famous athletes who've suffered with eating irregularities including 9 time Olympic Gold Medalist Nadia Comenechi and Bahne Rabe, a winner of 8 Olympic Gold Medals in rowing who also suffered from anorexia which would ultimately contribute to his early death.


                                                  


Others you'd know include tennis player Zina Garrison, skater Nancy Kerrigan, jockey Laffit Pincay, gymnast Cathy Johnson, etc.  A quick check of PubMed notes a study by DiGioacchmo et al. of 583 triathletes  where 39% of the females and 23% of the males scored below the mid point on a standardized test to construct Calorie Control.  "All of the subjects indicated dissatisfaction with their body mass index (BMI). The study participants revealed attempts to reduce body weight by means of energy restriction, severe limitation of food groups and excessive exercise...  The triathlon seems to be a sport that is susceptible to a higher prevalence of disordered eating." 


 Nancy Clark, RD says that, "Athletes with eating disorders tend to be very talented, hardworking people who ache inside and fail to see their strengths.  Something inside them says they should always be working or studying or exercising.  Taking time to hang out and chat with others makes them feel guilty.  They need to learn being "human" - like the  rest of us - is more attainable than being "perfect."


                                                                                           


So whether you are talking bulimia, anorexia, etc. they can be both treated and, in most cases, prevented.  We define eating disorder generally as an "obsession with food and weight that harm a person's well being."  The cause is incompletely understood, and although initially it may start with a preoccupation with food and weight, this is a multifaceted affliction. Societal pressure for "thin is in" or "you can never be too thin or too tan," excess stress or needing to have the feeling of being "in control" all contribute.


 We already know that in addition to diminished athletic performance, physical problems can effect the heart, kidneys, GI tract, and lead to menstrual irregularities as well as dry, scaly skin.


 For the person with an eating disorder, accepting the fact that treatment is in order may the single hardest step.  Occasionally inpatient hospitalization is required.  Significant counseling of the patient, spouse and family can all contribute to the potential for success.  The Internet is rife with help like the National Eating Disorder Association whose sole goal is to aid those in need by specialized, individually oriented care hopefully pointing to a successful outcome.  They are careful to address both the medical and nutritional components as well as assisting in securing insurance company coverage when needed.


 In summary, this is a common, destructive disorder and if this blog leads to just one person seeking assistance, it will be my most successful writing to date.  Help a friend!


 Credits:  NEDA


                  Google images


                  Denison University Health and Counseling Center


 



Saturday, May 12, 2012

Eating Disorders in Triathlon


Happy Mother's Day

"There once lived a man named Oedipus Rex.  Oedipus had a very odd complex, but he loved his mother."   Tom Lehrer

As the father of a daughter, every Mother's Day I cover eating disorders.  Although our daughter has invited us to go on a hike in the Blue Ridge Mountains nearby, not everyone is so fortunate.  Maybe in some small way this can help.


A mother and daughter waiting for their triathlon  'teammate. '

Eating Disorder Awareness

While touring colleges with our daughter last year, I found this posted in on the wall of the infirmary of a mid west university:

                                                            Staggering Facts...

  • 54% of women would rather be hit by a truck than be fat (Martin, 2007)
  • If mannequins were women, they would not be able to bear children.
  • Research shows that just 3-5 minutes of engaging in fat talk substantially increases body dissatisfaction (Stice, 2003)
  • Four out of ten Americans either suffered or have known someone who has suffered an eating disorder (NEDA, 2005)
  • As many as 20 million females are battling an eating disorder such as bulimia or anorexia. Millions more are battling binge eating. (Crowther, J. H., et al. 1992)
  • Most fashion models are thinner than 98% of most women.
  • 81% of ten year olds are afraid of being fat (Martin, 2007)
  • 25% of American men and 45% of American women are on a diet on any given day (Smolak, L., 1996)
While I cannot speak for the reproducibility of these "statistics" you get the point.  Eating disorders are serious business and triathletes are neither excluded nor immune. Even celebrities like Paula Abdul, Justine Bateman, Karen Carpenter, Susan Dey, Tracey Gold, Princess Di, and Joan Rivers have experienced an eating disorder.  EDs have the highest mortality of any of the mental illnesses.  In fact, 20% of people suffering from anorexia will prematurely die from complications related to their eating disorder, including suicide and heart disease.  But, according to the South Carolina Dept of Mental Health only one person in ten with an eating disorder ever receives treatment.

If you're reading this blog it's because you're interested in triathlon performance.  Compiling a complete piece on eating disorders is beyond the scope of this blog but suffice it to say that it's a serious issue with endurance athletes and will have a negative influence on their performance.

Casa Palmora is a clinic in California that specializes in those patients with ED.  In their advertising they point toward a number of famous athletes who've suffered with eating irregularities including 9 time Olympic Gold Medalist Nadia Comenechi and Bahne Rabe, a winner of 8 Olympic Gold Medals in rowing who also suffered from anorexia which would ultimately contribute to his early death.

                                                  
Others you'd know include tennis player Zina Garrison, skater Nancy Kerrigan, jockey Laffit Pincay, gymnast Cathy Johnson, etc.  A quick check of PubMed notes a study by DiGioacchmo et al. of 583 triathletes  where 39% of the females and 23% of the males scored below the mid point on a standardized test to construct Calorie Control.  "All of the subjects indicated dissatisfaction with their body mass index (BMI). The study participants revealed attempts to reduce body weight by means of energy restriction, severe limitation of food groups and excessive exercise...  The triathlon seems to be a sport that is susceptible to a higher prevalence of disordered eating." 

Nancy Clark, RD says that, "Athletes with eating disorders tend to be very talented, hardworking people who ache inside and fail to see their strengths.  Something inside them says they should always be working or studying or exercising.  Taking time to hang out and chat with others makes them feel guilty.  They need to learn being "human" - like the  rest of us - is more attainable than being "perfect."
                                                                                           
So whether you are talking bulimia, anorexia, etc. they can be both treated and, in most cases, prevented.  We define eating disorder generally as an "obsession with food and weight that harm a person's well being."  The cause is incompletely understood, and although initially it may start with a preoccupation with food and weight, this is a multifaceted affliction. Societal pressure for "thin is in" or "you can never be too thin or too tan," excess stress or needing to have the feeling of being "in control" all contribute.

We already know that in addition to diminished athletic performance, physical problems can effect the heart, kidneys, GI tract, and lead to menstrual irregularities as well as dry, scaly skin.

For the person with an eating disorder, accepting the fact that treatment is in order may the single hardest step.  Occasionally inpatient hospitalization is required.  Significant counseling of the patient, spouse and family can all contribute to the potential for success.  The Internet is rife with help like the National Eating Disorder Association whose sole goal is to aid those in need by specialized, individually oriented care hopefully pointing to a successful outcome.  They are careful to address both the medical and nutritional components as well as assisting in securing insurance company coverage when needed.

In summary, this is a common, destructive disorder and if this blog leads to just one person seeking assistance, it will be my most successful writing to date.  Help a friend!

Credits:  NEDA
                  Google images
                  Denison University Health and Counseling Center

Sunday, May 6, 2012

Clavicle Fractures 2012, Do I Need Surgery?


"I felt so good, like anything was possible."  Tom Petty

Hawaii 2011-STPT 308

We hear and read a good deal about broken collar bones be it from the Tour de France announcers Phil Liggett and Paul Sherwen describing a crash in the peleton to perhaps one of our kids Saturday soccer games.

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 arm as well as striking the point of the shoulder. It's not uncommon to also suffer rib, scapula and/or simultaneous 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 - TdF 2003) 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 undertaken.   In the not too distant past, collar bone surgery was considered both unnecessary as well as unwise. The old adage of "if both ends of the fracture are in the same room it will heal."  Well, while a little silly, for the most part it's true.  But definitely not always.  In many displaced fractures of the midshaft of the clavicle, the separation is so great that a non-union (lack of healing) may develop or the fractures heals with a noticeable deformity (malunion.)  While frequently this is not a functional issue, anytime a male athlete is shirtless or female athlete clothed in a shoulder exposing garment like spaghetti straps, the appearance can be strikingly asymmetric.

According to a study in the 2012 Journal of Bone and Joint Surgery where a systematic search of the literature was performed on operative vs nonoperative care of displaced clavicle fractures, there can be a role for surgery in a higher percentage of patients than previously thought.  Their conclusions were, "Operative treatment provided a significantly lower rate of nonunion...and an earlier functional return when compared with nonoperative treatment.  However, there is little evidence at present to show that the long term functional outcome of operative intervention is significantly superior to nonoperative care."

What does this mean to you?  Well, that there's still a significant role for not having an operation when you break your clavicle for one.  In fact, three quarters of the time, a completely displaced clavicle fracture treated with out surgery will heal with few, if any, long term consequences . However, "It is clear that there is a specific subset of individuals with a completely displaced midshaft clavicle fracture who will benefit from fixation."  This is especially true in the early period after the injury.  They will likely see  more rapid return to function, a decreased complication rate (particularly with regard to the serious negative out come of nonunion.)

So, should you find yourself with a displaced mid shaft clavicle fracture, sitting on a gurney in your ER waiting to talk with the Orthopedic surgeon on call, this may help you make the decision to go for a simple sling or the potential for repair. 

Hawaii 2011-STPT 042Lance Armstrong and Frank Schleck are two good examples of success with surgery in this setting.  But simply because a professional bike racer makes a certain choice when given a set of facts, you don't necessarily have to do the same.  Although a very successful ad campaign in the early 90's would have you "Be like Mike" referring to Michael Jordan, you have the wisdom to make up your own mind.  Hey, you're a triathlete! 


JBJS Vol.94-A No. 8