Random Thought Thread, aka The RTT (**possible spoilers**)
11-07-13, 10:35 AM
Batüwü Creakcreak
That's a fair point. I've asked for another referral partly because I do want an opinion from someone who regularly works with athletes. I'm not anxious for surgery per se, I'm anxious about healing in a way that interferes with my ability to ride a racing bike. If someone has another solution to get my shoulder aligned that isn't surgical, I'm okay with that, too.
Yeah, in my case the broken bone went down, not up. Seems I'm lucky it didn't get any nerves or other important stuff on the way.
I suppose I need to do that homework. I took a look in the mirror today, and the difference between my shoulders is maybe not as bad as I'd feared. But the guy today was saying things like "bursitis" and "impingement," and that worries me. And even if my shoulders aren't as asymmetrical as I first thought, I've had enough experience with bike fit and injury to know that small differences can be significant. So we'll see what the other opinions are.
I suppose I need to do that homework. I took a look in the mirror today, and the difference between my shoulders is maybe not as bad as I'd feared. But the guy today was saying things like "bursitis" and "impingement," and that worries me. And even if my shoulders aren't as asymmetrical as I first thought, I've had enough experience with bike fit and injury to know that small differences can be significant. So we'll see what the other opinions are.
Bursitis just means swelling within a joint. The bursae are fluid filled sacs that pad joints. Impingement can be bad, but it depends on healing.
Sports med docs are often more concerned about getting you back to sport vs longevity. Many, especially in this area, treat athletes that get paid to do their business and there a surgery that will life crappy for them 20 years down the road will pay them millions now. So there's a tradeoff. We don't live in the same world.
If you have access to your surgeon's notes and can text/email me the description of your fracture and if there's a classification, then I'll look and see if I can find any journal articles this weekend that address short and long term quality of life dealing with surgery vs no surgery. I'll send a few to you so you can read them and make your own opinion.
I can tell you that some of the premier trials in back surgery found that with herniations, surgical patients heal faster, but after a year there's little to no difference in their function. Not sure how it works with clavicles. I'm curious about clavicle breaks though.
11-07-13, 10:44 AM
Batüwü Creakcreak
Some stuff:
Open Orthop J. 2013 Sep 6;7:329-33. doi: 10.2174/1874325001307010329.
Fractures of the clavicle: an overview.
Donnelly TD, Macfarlane RJ, Nagy MT, Ralte P, Waseem M.
Source
Department of Trauma and Orthopaedics, Macclesfield District General Hospital, Victoria Road, Macclesfield, SK10 3BL, UK.
Abstract
Fractures of the clavicle are a common injury and most often occur in younger individuals. For the most part, they have been historically treated conservatively with acceptable results. However, over recent years, more and more research is showing that operative treatment may decrease the rates of fracture complications and increase functional outcomes. This article first describes the classification of clavicle fractures and then reviews the literature over the past decades to form a conclusion regarding the appropriate management. A thorough literature review was performed on assessment of fractures of the clavicle, their classification and the outcomes following conservative treatment. Further literature was gathered regarding the surgical treatment of these fractures, including the methods of fixation and the surgical approaches used. Both conservative and surgical treatments were then compared and contrasted. The majority of recent data suggests that operative treatment may be more appropriate as it improves functional outcome and reduces the risk of complications such as non-union. This is particularly evident in mid shaft fractures, although more high grade evidence is needed to fully recommend this, especially regarding certain fractures of the medial and lateral clavicle.
KEYWORDS:
Clavicle fracture, Rockwood pin., internal fixation, locking plate
------------------------
Injury. 2012 Feb;43(2):159-63. doi: 10.1016/j.injury.2011.04.008. Epub 2011 May 24.
A 2-year experience, management and outcome of 200 clavicle fractures.
Singh R, Rambani R, Kanakaris N, Giannoudis PV.
Source
Department of Orthopedics, Leeds Teaching Hospitals, Leeds General Infirmary, Leeds, UK. rahulsingh1@doctors.org.uk
Abstract
INTRODUCTION:
Clavicle fractures can cause pain and functional impairment if not managed appropriately. This article evaluates the prevalence of clavicular fractures, estimates the number of cases requiring operative treatment, evaluates whether removal of implant is a frequent necessity and compares the final functional outcome of the operative and non-operative groups.
PATIENTS AND METHODS:
Between November 2005 and November 2007, patients with clavicular fractures were eligible for participation. Patients below 18 years of age and those with pathological fractures were excluded. Demographic details, mechanism of injury, operative versus non-operative treatment, radiographic classification (Allman system), complications, implant removal and functional outcome using the University of California, Los Angeles (UCLA) shoulder-rating score were documented and analysed.
RESULTS:
Out of 16,280 fractures that presented to our University Teaching Hospitals, 200 (1.23%) met the inclusion criteria. As many as 20 patients were lost due to natural attrition. A total of 159 (88.3%) patients were treated non-operatively and 21 (11.7%) patients were operated upon, over half of them for symptomatic non-union. All clavicles united postoperatively. Eighty-one conservatively managed undisplaced medial, middle and lateral end fractures had excellent mean UCLA shoulder scores. A statistical significance in UCLA scores (p<0.05) was noted between the operative and non-operative patient groups in mid-shaft fractures. There was no statistical difference between the operative and non-operative groups in lateral-end fractures. A total of 42.9% required removal of metal implant due to soft tissue irritation with complete resolution of symptoms.
CONCLUSION:
The incidence of clavicle fractures was 1.23%. A small number of patients (11.7%) required operative treatment. We recommend surgical management of symptomatic non-union and removal of metal implant for hardware-related irritation.
-----------
J Bone Joint Surg Am. 2012 Apr 18;94(8):675-84. doi: 10.2106/JBJS.J.01364.
Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials.
McKee RC, Whelan DB, Schemitsch EH, McKee MD.
Source
Division of Orthopaedics, Department of Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada. McKeeM@smh.ca
Abstract
BACKGROUND:
Recent studies have suggested benefits following primary operative fixation of substantially displaced midshaft fractures of the clavicle. We reviewed randomized clinical trials of operative versus nonoperative treatment of these fractures, and pooled the functional outcome and complication rates to arrive at summary estimates of these outcomes.
METHODS:
A systematic review of the literature was performed to identify studies of randomized clinical trials comparing operative versus nonoperative care for displaced midshaft clavicular fractures.
RESULTS:
Six studies (n = 412 patients, mean Detsky score = 15.3) were included. The nonunion rate was higher in the nonoperatively treated patients (twenty-nine of 200) than it was in patients treated operatively (three of 212) (p = 0.001). The rate of symptomatic malunion was higher in the nonoperative group (seventeen of 200) than it was in the operative group (0 of 212) (p < 0.001).
CONCLUSIONS:
Operative treatment provided a significantly lower rate of nonunion and symptomatic malunion and an earlier functional return 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.
------
J Shoulder Elbow Surg. 2013 May;22(5):608-11. doi: 10.1016/j.jse.2012.06.006. Epub 2012 Sep 7.
Clinical and financial comparison of operative and nonoperative treatment of displaced clavicle fractures.
Althausen PL, Shannon S, Lu M, O'Mara TJ, Bray TJ.
Source
Reno Orthopaedic Clinic, 555 N Arlington Ave, Reno, NV 89503, USA.palthausen@sbcglobal.net
Abstract
HYPOTHESIS:
Surgical stabilization of displaced clavicle fractures was once considered to have rare indications. Our purpose was to present the clinical and economic effects of surgical management using data collected from operative and nonoperative patients.
METHODS:
Our fracture database was queried from January 1, 2005, to January 1, 2010, identifying 204 patients with displaced midclavicular fractures. Radiographs and charts were reviewed, and questionnaires were distributed.
RESULTS:
Operative patients had less chronic pain (6.1% vs 25.3%), less cosmetic deformity (18.2% vs 32.5%), less weakness (10.6% vs 33.7%), less loss of motion (15.2% vs 31.3%), and fewer nonunions (0% vs 4.8%). Operative patients missed fewer days of work (8.4 days vs 35.2 days) and required less assistance (3 days vs 7 days) for care at home. Mean income lost was $321.69 versus $10,506.25. Operative patients had a mean emergency department bill of $2,060.51 versus $1,871.92 and had a mean hospital bill of $8,520.30 versus $3,692.65, and anesthesia charges averaged $946.11. Operative patients required less physical therapy, and the mean physical therapy cost was $971.76 versus $1,820. Nonoperative patients required more pain medication ($43.22 vs $45.98). Overall, the cost was $12,976.94 for operative patients and $18,068.27 for nonoperative patients.
CONCLUSIONS:
Patients with displaced clavicle fractures benefit clinically and financially from stabilization. They have less chronic pain, less deformity, less weakness, and better range of motion. They return to work sooner, take less pain medication, and require less physical therapy. Their initial hospital bill is higher because of surgical charges but is balanced by less income loss, resulting in a cost savings of $5,091.33 in operative patients.
------------------
The last two journal articles probably come from the best journals. JBJS is one of the premier ortho journals.
Open Orthop J. 2013 Sep 6;7:329-33. doi: 10.2174/1874325001307010329.
Fractures of the clavicle: an overview.
Donnelly TD, Macfarlane RJ, Nagy MT, Ralte P, Waseem M.
Source
Department of Trauma and Orthopaedics, Macclesfield District General Hospital, Victoria Road, Macclesfield, SK10 3BL, UK.
Abstract
Fractures of the clavicle are a common injury and most often occur in younger individuals. For the most part, they have been historically treated conservatively with acceptable results. However, over recent years, more and more research is showing that operative treatment may decrease the rates of fracture complications and increase functional outcomes. This article first describes the classification of clavicle fractures and then reviews the literature over the past decades to form a conclusion regarding the appropriate management. A thorough literature review was performed on assessment of fractures of the clavicle, their classification and the outcomes following conservative treatment. Further literature was gathered regarding the surgical treatment of these fractures, including the methods of fixation and the surgical approaches used. Both conservative and surgical treatments were then compared and contrasted. The majority of recent data suggests that operative treatment may be more appropriate as it improves functional outcome and reduces the risk of complications such as non-union. This is particularly evident in mid shaft fractures, although more high grade evidence is needed to fully recommend this, especially regarding certain fractures of the medial and lateral clavicle.
KEYWORDS:
Clavicle fracture, Rockwood pin., internal fixation, locking plate
------------------------
Injury. 2012 Feb;43(2):159-63. doi: 10.1016/j.injury.2011.04.008. Epub 2011 May 24.
A 2-year experience, management and outcome of 200 clavicle fractures.
Singh R, Rambani R, Kanakaris N, Giannoudis PV.
Source
Department of Orthopedics, Leeds Teaching Hospitals, Leeds General Infirmary, Leeds, UK. rahulsingh1@doctors.org.uk
Abstract
INTRODUCTION:
Clavicle fractures can cause pain and functional impairment if not managed appropriately. This article evaluates the prevalence of clavicular fractures, estimates the number of cases requiring operative treatment, evaluates whether removal of implant is a frequent necessity and compares the final functional outcome of the operative and non-operative groups.
PATIENTS AND METHODS:
Between November 2005 and November 2007, patients with clavicular fractures were eligible for participation. Patients below 18 years of age and those with pathological fractures were excluded. Demographic details, mechanism of injury, operative versus non-operative treatment, radiographic classification (Allman system), complications, implant removal and functional outcome using the University of California, Los Angeles (UCLA) shoulder-rating score were documented and analysed.
RESULTS:
Out of 16,280 fractures that presented to our University Teaching Hospitals, 200 (1.23%) met the inclusion criteria. As many as 20 patients were lost due to natural attrition. A total of 159 (88.3%) patients were treated non-operatively and 21 (11.7%) patients were operated upon, over half of them for symptomatic non-union. All clavicles united postoperatively. Eighty-one conservatively managed undisplaced medial, middle and lateral end fractures had excellent mean UCLA shoulder scores. A statistical significance in UCLA scores (p<0.05) was noted between the operative and non-operative patient groups in mid-shaft fractures. There was no statistical difference between the operative and non-operative groups in lateral-end fractures. A total of 42.9% required removal of metal implant due to soft tissue irritation with complete resolution of symptoms.
CONCLUSION:
The incidence of clavicle fractures was 1.23%. A small number of patients (11.7%) required operative treatment. We recommend surgical management of symptomatic non-union and removal of metal implant for hardware-related irritation.
-----------
J Bone Joint Surg Am. 2012 Apr 18;94(8):675-84. doi: 10.2106/JBJS.J.01364.
Operative versus nonoperative care of displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials.
McKee RC, Whelan DB, Schemitsch EH, McKee MD.
Source
Division of Orthopaedics, Department of Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada. McKeeM@smh.ca
Abstract
BACKGROUND:
Recent studies have suggested benefits following primary operative fixation of substantially displaced midshaft fractures of the clavicle. We reviewed randomized clinical trials of operative versus nonoperative treatment of these fractures, and pooled the functional outcome and complication rates to arrive at summary estimates of these outcomes.
METHODS:
A systematic review of the literature was performed to identify studies of randomized clinical trials comparing operative versus nonoperative care for displaced midshaft clavicular fractures.
RESULTS:
Six studies (n = 412 patients, mean Detsky score = 15.3) were included. The nonunion rate was higher in the nonoperatively treated patients (twenty-nine of 200) than it was in patients treated operatively (three of 212) (p = 0.001). The rate of symptomatic malunion was higher in the nonoperative group (seventeen of 200) than it was in the operative group (0 of 212) (p < 0.001).
CONCLUSIONS:
Operative treatment provided a significantly lower rate of nonunion and symptomatic malunion and an earlier functional return 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.
------
J Shoulder Elbow Surg. 2013 May;22(5):608-11. doi: 10.1016/j.jse.2012.06.006. Epub 2012 Sep 7.
Clinical and financial comparison of operative and nonoperative treatment of displaced clavicle fractures.
Althausen PL, Shannon S, Lu M, O'Mara TJ, Bray TJ.
Source
Reno Orthopaedic Clinic, 555 N Arlington Ave, Reno, NV 89503, USA.palthausen@sbcglobal.net
Abstract
HYPOTHESIS:
Surgical stabilization of displaced clavicle fractures was once considered to have rare indications. Our purpose was to present the clinical and economic effects of surgical management using data collected from operative and nonoperative patients.
METHODS:
Our fracture database was queried from January 1, 2005, to January 1, 2010, identifying 204 patients with displaced midclavicular fractures. Radiographs and charts were reviewed, and questionnaires were distributed.
RESULTS:
Operative patients had less chronic pain (6.1% vs 25.3%), less cosmetic deformity (18.2% vs 32.5%), less weakness (10.6% vs 33.7%), less loss of motion (15.2% vs 31.3%), and fewer nonunions (0% vs 4.8%). Operative patients missed fewer days of work (8.4 days vs 35.2 days) and required less assistance (3 days vs 7 days) for care at home. Mean income lost was $321.69 versus $10,506.25. Operative patients had a mean emergency department bill of $2,060.51 versus $1,871.92 and had a mean hospital bill of $8,520.30 versus $3,692.65, and anesthesia charges averaged $946.11. Operative patients required less physical therapy, and the mean physical therapy cost was $971.76 versus $1,820. Nonoperative patients required more pain medication ($43.22 vs $45.98). Overall, the cost was $12,976.94 for operative patients and $18,068.27 for nonoperative patients.
CONCLUSIONS:
Patients with displaced clavicle fractures benefit clinically and financially from stabilization. They have less chronic pain, less deformity, less weakness, and better range of motion. They return to work sooner, take less pain medication, and require less physical therapy. Their initial hospital bill is higher because of surgical charges but is balanced by less income loss, resulting in a cost savings of $5,091.33 in operative patients.
------------------
The last two journal articles probably come from the best journals. JBJS is one of the premier ortho journals.
Last edited by ridethecliche; 11-07-13 at 11:01 AM.
11-07-13, 10:50 AM
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11-07-13, 11:17 AM
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I chuckle when the help trot out their homespun wisdom. Of course none of your bikes are jewels. You're poor, no doubt as a result of ethnicity or simple laziness. Or unattractiveness if you're female.
Last edited by Racer Ex; 11-07-13 at 11:28 AM.
11-07-13, 11:24 AM
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11-07-13, 11:24 AM
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11-07-13, 11:38 AM
soon to be gsteinc...
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11-07-13, 11:38 AM
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11-07-13, 01:03 PM
**** that
But couldn't you have put in a "limit order" to buy at the IPO price, earlier this morning? Fidelity was letting me get far enough to try that, but said my weak ass "odd lot" order of less than 100 shares could go F itself.
So it seems like you could've gotten it at $26, if you bought more than 100 shares. Which is more than I was willing to risk.
11-07-13, 01:05 PM
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11-07-13, 01:22 PM
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Boom indeed.
But couldn't you have put in a "limit order" to buy at the IPO price, earlier this morning? Fidelity was letting me get far enough to try that, but said my weak ass "odd lot" order of less than 100 shares could go F itself.
So it seems like you could've gotten it at $26, if you bought more than 100 shares. Which is more than I was willing to risk.
But couldn't you have put in a "limit order" to buy at the IPO price, earlier this morning? Fidelity was letting me get far enough to try that, but said my weak ass "odd lot" order of less than 100 shares could go F itself.
So it seems like you could've gotten it at $26, if you bought more than 100 shares. Which is more than I was willing to risk.
Why won't they let you do small orders ? Maybe a limitation specific to the IPO ?
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Bikes: Old steel race bikes, old Cannondale race bikes, less old Cannondale race bike, crappy old mtn bike.
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11-07-13, 01:25 PM
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Four day weekend coming up.
11-07-13, 01:25 PM
Senior Member
I'm not a doctor so talk to your doctor etc etc etc, but here's my opinion.
Bursitis just means swelling within a joint. The bursae are fluid filled sacs that pad joints. Impingement can be bad, but it depends on healing.
Sports med docs are often more concerned about getting you back to sport vs longevity. Many, especially in this area, treat athletes that get paid to do their business and there a surgery that will life crappy for them 20 years down the road will pay them millions now. So there's a tradeoff. We don't live in the same world.
If you have access to your surgeon's notes and can text/email me the description of your fracture and if there's a classification, then I'll look and see if I can find any journal articles this weekend that address short and long term quality of life dealing with surgery vs no surgery. I'll send a few to you so you can read them and make your own opinion.
I can tell you that some of the premier trials in back surgery found that with herniations, surgical patients heal faster, but after a year there's little to no difference in their function. Not sure how it works with clavicles. I'm curious about clavicle breaks though.
Bursitis just means swelling within a joint. The bursae are fluid filled sacs that pad joints. Impingement can be bad, but it depends on healing.
Sports med docs are often more concerned about getting you back to sport vs longevity. Many, especially in this area, treat athletes that get paid to do their business and there a surgery that will life crappy for them 20 years down the road will pay them millions now. So there's a tradeoff. We don't live in the same world.
If you have access to your surgeon's notes and can text/email me the description of your fracture and if there's a classification, then I'll look and see if I can find any journal articles this weekend that address short and long term quality of life dealing with surgery vs no surgery. I'll send a few to you so you can read them and make your own opinion.
I can tell you that some of the premier trials in back surgery found that with herniations, surgical patients heal faster, but after a year there's little to no difference in their function. Not sure how it works with clavicles. I'm curious about clavicle breaks though.
11-07-13, 01:30 PM
¯\_(ツ)_/¯
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tl:dr
that's what my surgeons pointed to, along with the fact that I was begging them to not leave me in the condition I was in with my 4-piece breaks.
However, over recent years, more and more research is showing that operative treatment may decrease the rates of fracture complications and increase functional outcomes.
11-07-13, 01:36 PM
Ninny
Boom indeed.
But couldn't you have put in a "limit order" to buy at the IPO price, earlier this morning? Fidelity was letting me get far enough to try that, but said my weak ass "odd lot" order of less than 100 shares could go F itself.
So it seems like you could've gotten it at $26, if you bought more than 100 shares. Which is more than I was willing to risk.
But couldn't you have put in a "limit order" to buy at the IPO price, earlier this morning? Fidelity was letting me get far enough to try that, but said my weak ass "odd lot" order of less than 100 shares could go F itself.
So it seems like you could've gotten it at $26, if you bought more than 100 shares. Which is more than I was willing to risk.
11-07-13, 01:52 PM
Batüwü Creakcreak
You should also ask the surgeon what literature says about op vs non-op for your case. See if they can give you a reference or two to think about. They'll be much more up on that stuff (or should) than I am. Ortho is often considered a jock specialty, but the surgeons have some of the highest board scores in medicine and many of them are very interested in research.
You're probably right. The complications from surgery are more predictable than that from bones not healing properly. Also, they have definitive course of treatment for the complications in the most part. The only thing is worrisome is infection, but a good hospital with a low rate shouldn't be an issue. It's not that long of a surgery. I'm guessing it's like 1-2 hrs for them to instrument and fuse? Some of the spine surgeries here are like 4hrs, 8 hrs, etc. The longer you're open the higher the chance of infection, but honestly this is a relatively rare occurrence and something that they go over in the pre-op appointment.
11-07-13, 01:56 PM
**** that
Luckily it feels like "play money" since I sold MSFT shares that I got for free.
11-07-13, 01:57 PM
**** that
Ha, shows what I know!
11-07-13, 02:35 PM
11-07-13, 03:00 PM
Making a kilometer blurry
gah!
11-07-13, 03:36 PM
11-07-13, 03:45 PM
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11-07-13, 08:55 PM
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Sometimes you just need to sit down and have a good chat to clear the air and get things headed in the right direction...
