On Sunday January 13th 2013, every New England Patriots fan cringed in a terribly uneasy and unfortunately familiar way when our beloved Gronk took a hard fall after catching a ball that was later ruled out of bounds. When Gronk hit the grown and got up holding his arm, all of New England held its breath. Then when cameras showed Gronkowski sitting on the bench grimacing in pain and then be escorted into the locker room for x-rays we all prayed that he would return, but feared the worst. It had happened all over again. Gronk had broken his arm again, yet this time it was in the AFC divisional playoff game.
Immediately there were people doubting the decision to bring Gronkowski back and sportscasters and writers assuming he re-fractured the bone in the same spot as before because of the fact that it was the same padded up arm that he had previously broken in week 11 of the 2013 season. While hearing this and subsequently reading some of the theories and complaints in the ensuing hours and day after the game, I realized that a brief follow-up piece might be helpful in providing some useful information regarding the re-fracture of a forearm after initial surgical fixation with a plate.
As many readers might remember, in my initial article, I discussed and explained the types and mechanisms of the most common forearm fractures in athletics and a few of the methods in which we treat these fractures. I also offered the typical recovery period for an individual to return to his or her athletic responsibilities/duties.
In Gronkowski’s former fracture, it was predicted that he would return in 4-6 weeks. This timeframe is not randomly chosen based upon when an individual might feel better, but is rather a carefully thought out reflection of the process in which bone heals.
Bone, just like any other living tissue is dynamic and undergoes a fairly routine sequence of repair when it is damaged. As was briefly mentioned in the first article, bone healing occurs in three phases: reactive, reparative and remodeling.
This healing process is mostly determined by the outside connective tissue covering of the bone, known as periosteum. It is the periosteum that contains the precursor cells which will later develop into the osteoblasts (cells that lay down new bone) and the chondroblasts (cells that lay down new cartilaginous matrix material).
In the first phase of healing, the reactive phase, the first changes we see are the presence of some red blood cells in the tissue abutting the site of the fracture as well as blood vessel constriction to stop the bleeding in the area. In the subsequent hours we will get a hematoma that forms, within which fibroblast cells will proliferate to form a type of tissue known as granulation tissue, which will form the vascular base and meshwork for which the subsequent healing to occur.
The next phase, known as the reparative phase, occurs in the immediate days-weeks following the injury and involves the cells of the periosteum that were mentioned before. It is in this process in which the chondroblasts will begin to lay down a type of cartilage called hyaline and that the osteoblasts will begin their job of weaving new bone. This process will develop the granulation tissue into something we refer to as the fracture callus. It is the first step in reviving some of the original strength of the bone.
After the formation of the callus occurs, the initial hyaline cartilage that was previously created must be replaced by a stronger type of bone via a process that is referred to as endochondral ossification to form lamellar trabecular bone.
The next and final process, remodeling, occurs over a longer period of time (3-5 years) and involves the slow conversion of the trabecular bone to compact bone as the fracture callus is remolded into the contour that replicates the bones original contour.
So now that we have examined the healing process, we can understand why we remove casts at 4-8 weeks and allow individuals to resume activity. It is because the reparative phase of healing is complete. The remodeling phase does not add much to the overall strength of the bone and is not routinely worried about in terms of the risk of a re-fracture.
We can therefore likely toss aside all of the comments coming from individuals whom are saying that Gronk came back to early and re-fractured the same fracture site. This would seem to be a silly statement that wouldn’t be backed-up very well by our understanding of bone physiology and the surgical fixation that was previously performed.
So this must leave a lot of people wondering, “ if it wasn’t the same exact fracture spot, why, how and where did Gronkowski manage to break his arm again?” Although only Rob Gronkowski, his physician, and the Patriots staff know the full details, it is more likely that Gronkowski sustained a fracture at the point on the bone that lays just beyond the plate that was surgically screwed onto his bone to internally fix the bone after the former fracture was reduced.
There is a great deal of literature available in the orthopedic community that discusses the topic of whether or not plates should be removed after 18-24 months. While generally, it is accepted that items such as plates and screws may remain inside of a normal adult patient as long as they are not causing pain or discomfort, some suggest the removal of plates for a number of reasons ranging from possible exposure to metal ions to the increased stress that may be put on the uncovered bone just adjacent to the plates in contact sport athletes.
In Gronkowski’s situation it would seem reasonable that he likely re-fractured his arm at a site just adjacent to the plate where there is an obvious junction that changes the local properties of the bone. Not only is there a marked difference in the elastic property of the bone segment covered by a metal plate when compared to the segment just adjacent to the plate, but there is increased stress at the junction of the normal bone and plate because the plate acts as a “stress riser.”
This area of increased stress at the junction of the plate and the normal bone has been theorized to be a possible source of complications in a select population of contact sport players. Though some continue the debate regarding the removal of these plates in contact athletes prior to their return to sports, data suggests that an early return to sports in selected cases is certainly feasible.
It would only seem appropriate that Gronk would meet the conditions of a feasible selected case. His risk of re-fracture was not incredibly high. In fact, there is little evidence to even examine in regards to re-fractures at the junction of the plate in athletes. Most of the re-fractures discussed in the literature refer to re-fractures of the bone after plates have been removed. Furthermore, there are definite risks associated with plate removal because it is another surgical procedure.
While there is always more to a professional sports injury than what is being relayed in the popular media sites, it is always helpful to look into the science and medicine behind the injury and treatment. Though often times, such media sources are privileged to have inside information in regards to rehabilitation time, there can be much misinformation and vague language.
Hopefully this article was successful in discussing the timeframe and sequence of bone healing as well as the likely risks and mechanisms behind Gronk’s second fracture of the season.
So as many mourn the loss of our imposing Tight End for the remainder of the playoffs, it remains a promising and exciting time for all Patriots fans as we cheer on the rest of the team in our pursuit of a Super Bowl XLVII victory.
BEST WISHES TO GRONK IN HIS RECOVERY AND LET’S GO PATS!!!!
Please feel free to leave me any comments, feedback, concerns, or insight on this page or email me at c_meltsakos@nymc.edu. Also, if you like what you've read subscribe to the feed to get my articles sent directly to your inbox!
RESOURCES:
Busam ML, et al (2006). Hardware removal: indications and expectations. Journal of American Academy of Orthopedic Surgeons; 14(2):113-120.
Evans NA & Evans RO (1997). Playing with metal: fracture implants and contact sport. British Journal of Sports Medicine; 31: 319-321.
Hanson B, van der Werken C, Stengel D (2008). Surgeons’ beliefs and perceptions about removal of orthopaedic implants. BMC Musculoskeletal Disorders; 73(9):1-8.
Kozin SH, Berlet AC (1992). Handbook of Common Orthopedic Fractures. Philadelphia, PA: Medical Surveillance.
Langkamer VG & Ackroyd CE (1990). Removal of forearm plates: a review of the complications. The Journal of Bone and Joint Surgery; 72(4): 601-604.
Moore KL, Agur AM. (2007). Essential Clinical Anatomy. Philadelphia, PA: Lippincott Williams & Wilkin.
Plowman, SA., Smith, DL. (2008). Exercise Physiology for Health, Fitness, and Performance. Philadelphia, PA: Lippincott Williams & Wilkin.
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