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Bikers frequently fracture clavicle

Treatment for 'road rash'

Physicians who treat cyclists need to know about "road rash," an abrasion of the skin after skidding on the ground, says Ted L. Edwards, Jr, MD, former team physician and chairman of sports medicine for the US Cycling Federation. "My approach has been to anesthetize the road rash using a lidocaine hydrochloride gel spread on the area," Edwards says. "Give it a few minutes. Then use peroxide and gauze to scrub out all of the road grit and cover the wound with a light dressing."

Cyclists—whether urban commuters, road racers, or mountain bikers—are most likely to injure their arms and shoulders, and, if they fracture a bone, it's most likely to be a clavicle, according to two recent studies. The results were presented at the annual meeting of the American Association of Orthopaedic Surgeons in February.

Kevin D. Plancher, MD, and Jeffrey O. McGillicuddy, MD, studied emergency-room records of 91 urban commuters injured in cycling accidents and 9-year injury records of 65 licensed amateur road racers belonging to a riding club (1). The urban cyclists tended to be untrained, while the club members were experienced racers with up-to-date equipment, said Plancher, who is director of Plancher Hand and Sports Medicine Orthopaedic Associates and an assistant professor at Albert Einstein College of Medicine in the Bronx, New York. McGillicuddy is a resident at Montefiore Medical Center in New York City.

Thirty percent of the urban commuters and 32% of the club cyclists suffered significant orthopedic injury, the study revealed. Clavicle fractures accounted for 23% of the commuters' and 58% of the road racers' fractures.

Plancher had expected that fractures would most often result from collisions with motor vehicles. Although many of the urban commuters did report collisions with vehicles, he found instead that most fractures occurred when cyclists fell over the handlebars and landed directly on their shoulder. None of the clavicle fractures was the result of an accident with a motor vehicle.

The second study (2) presented information about injuries and bone fractures among competitive mountain bikers. Mary A. Bos, MD, and a colleague used 1995 data from the National Electronic Injury Surveillance System as well as from groups such as the National Off-Road Biking Association. She found that 21.5% of mountain bike injuries were to the upper arm, upper trunk, and shoulder. Of these, 21.5% were fractures of the clavicle, ribs, or proximal humerus. Nearly 18% of all injuries were to the hand, wrist, or forearm, and about 13% to the lower extremity. Only 2% of the injuries were to the head; competitive mountain bikers are required to wear helmets. Most other injuries were cuts, bruises, and scrapes (see, "Treatment for 'Road Rash,'" below).

Bos, a mountain biker herself and an orthopedic sports fellow at the Institute for Bone and Joint Disorders in Phoenix, found that 60% of the injuries occurred when a rider struck an obstacle on steep, rugged terrain. The resulting fall was not directly over the handlebar but more forward and to the side of the bike, with the bicycle rider landing on his or her shoulder.

Ted L. Edwards, MD, calls clavicle fractures a "hazard of the sport, particularly if you're going to race and put it all on the line." Edwards is presently in private practice in Austin, Texas, but was active in the US Cycling Federation (the organization that develops Olympic cyclists, now the USA Cycling Federation) as chair of sports medicine for 2 years and team physician intermittently for 10 years.

"The fractures that I saw over the years were primarily of the clavicle or the wrist," Edwards says. "Someone comes off the bike and hits the shoulder or the wrist when the hand braces the fall....I see many more recreational bikers today than world-class racers, but they have the same injuries as the world-class athletes, though they are going at slower speeds."

All three physicians stress helmet use as the most effective means of preventing serious injury, especially to the head. Plancher says there are no simple ways to prevent clavicle fractures. "The problem is that cyclists don't like added weight, but for the everyday recreational person we could recommend shirts and any type of shoulder padding."

Given the high incidence of fractures, Plancher suggests that physicians pay attention to the clavicle when examining a patient who has had a biking accident.

For those interested in mountain biking, Bos emphasizes lessons on proper riding technique—steering, braking, and cornering—and the need to "ride at your skill level and not above." For cyclists drawn to road racing, Edwards suggests beginning by biking "with skilled riders who will show you how to ride in a group."


  1. Plancher KD, McGillicuddy JO: Clavicle fractures in cyclists. Presented at the 64th Annual Meeting of the American Academy of Orthopaedic Surgeons, San Francisco, February 13, 1997
  2. Bos M, Giacobetti F: Mountain biking injuries, epidemiologic data. Presented at the 64th Annual Meeting of the American Academy of Orthopaedic Surgeons, San Francisco, February 14, 1997

Van Anderson

Choosing the best exercise for seniors

What's the ideal exercise program for seniors? The answer is becoming clearer as researchers pit exercise routine against exercise routine.

A team of researchers headed by Abby C. King, PhD, a behavioral psychologist and an assistant professor of health research and policy at Stanford University School of Medicine in Palo Alto, California, compared an endurance-and-strength exercise program with a stretching-and-flexibility program in a randomized, 12-month study of 103 senior citizens (1). The participants, average age 70 years, were free of cardiovascular disease and sedentary when recruited.

Half of the 67 women and 36 men followed a program of moderate-intensity walking or aerobic dance and strengthening exercises with elastic bands, and half did a flexibility workout of 40 stretches covering head to toe. Each week they exercised twice at a class and twice at home.

Both groups profited, but in different ways. The fit-and-firm group gained significantly in cardiovascular fitness, strength, endurance, self-confidence, and energy expenditure, whereas the stretching-and-flexibility group declined in these areas. However, the flexibility group reported having less daily pain, while the fit-and-firm group reported more. "While seniors can get substantial benefits from endurance and strength exercises, they shouldn't overlook flexibility and stretching," says King.

Though stretching is no substitute for aerobic or strength exercise, it's often neglected in workouts. "The best exercise program combines all three," says Miriam E. Nelson, PhD, associate chief of the Human Physiology Laboratory at the Tufts University Research Center on Aging in Boston, and author of the 1997 book Strong Women Stay Young (2).

Noncompliance with exercise programs often stems from the perception that they are too much work. King's findings suggest that "we do not have to push seniors so aggressively into an aerobic exercise regimen, but we can emphasize walking and stretching," says James Dunlap, MD, an assistant professor of family practice and sports medicine at Michigan State University in East Lansing. Seniors can stay flexible by doing yoga and tai chi or by just doing a simple stretching program, Dunlap says, adding that such programs can be done at home regardless of weather conditions.

To motivate older patients to exercise, Nelson recommends a program that starts slowly and progresses. The first task is gaining strength to prevent falls during aerobic exercise, after which walking or another cardiovascular workout can be added, she advises. Stretching for flexibility should be included with aerobic exercise. "People start looking and feeling better in a short time," says Nelson, "and that becomes its own motivation."


  1. King AC, Oka R, Pruitt L, et al: Developing optimal exercise regimens for seniors: a clinical trial. Presented at the 18th Annual Scientific Sessions of the Society of Behavioral Medicine, San Francisco, April 17, 1997
  2. Nelson MA: Strong Women Stay Young. New York City, Bantam Publishers, 1997

Carol Potera
Great Falls, Montana

World Medical Games: a jock doc's dream

An event like last summer's Olympics surely stirred some lofty athletic dreams for spectators. Physicians have an annual opportunity to pursue such dreams: Every year about 1,300 medical people from more than 20 countries gather to compete for international honors at the World Medical Games, an event that combines sports and continuing medical education.

The 1997 games will be held June 28 to July 5 in Le Touquet-Paris-Plage, France, about 50 miles north of Paris on the English Channel. Unlike the Olympics, the event does not focus on competition between countries. National flags, anthems, and colors are banned. Instead, athletes represent cities, regions, hospitals, or simply themselves. According to the organizers, the event is designed to be a friendly meeting of amateur athletes from medical professions. But the event does have an Olympic-style flavor, with an opening ceremony, medal presentations, and a central village area where participants socialize.

The first World Medical Games were held in 1978 in Cannes, France. The event is open to physicians, dentists, veterinarians, physical therapists, pharmacists, and fourth-year medical students. Sports include soccer, golf, handball, judo, rugby, track and field, weight lifting, fencing, swimming, windsurfing, half marathon, squash, tennis, table tennis, shooting, triathlon, sailing, volleyball, basketball, cycling, and mountain biking. Most sports have age-group divisions.

Symposium topics usually feature sports medicine themes. Last year's topics included sports nutrition and immunization for athletes. When the talks aren't offered in English, translator headphones are available. American physicians who attend the symposium can earn up to 30 hours of AMA Category 1 credit.

The World Medical Games are well attended by members of the European medical community, but organizers are hoping to attract more participants from the United States and other countries. Last year, about 30 people from the United States traveled to the games, says Joseph Del Monte of Velia Travel in Malden, Massachusetts. Del Monte is the appointed contact person in the United States for games registration and travel arrangements. For more information, call (617) 321-6500. Information is also available at the games' Web site:

Jerrold Zeitels, MD, a plastic surgeon in Warren, New Jersey, says he has taken part in the games for the past 3 years because they allow him to compete for a medal in the sport he loves: basketball. He has also competed in swimming. "It's like a mini Olympics, and it seems well organized," he says.

There weren't enough Americans to form a basketball team last year, so he played on a team of veterinarians from Lyon, France; they won a silver medal. Zeitels says he'd like to see more Americans attend the games: "It would be great if we could have an American basketball team. If anyone out there is interested, please call me." Zeitels' office phone number is (908) 654-6540.

The event is organized by Corporate Sport Organisation, a company based in Marseille, France, that also organizes Mundiavocat, a world soccer cup for lawyers.

Lisa Schnirring



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