A few thoughts on collarbone fractures

Triathlon Forum
1

There have been a couple threads on collarbone (clavicle) fractures recently and I thought it appropriate this January 1, 2015 to further the discussion about this, the most commonly broken bone in the body…as I’m sure many of you have already found out.

In the not too distant past the overwhelming majority of these injuries were treated non-surgically. However, with the advent of better treatment options, a growing percentage are fixed surgically. In some studies this approaches 20%. One major benefit to surgery can be returning to sport sooner. Absolute indications for surgery would be open fractures (bone comes through skin), nerve involvement, and some feel multiple extremity involvement as well. It’s been said that repair “can be the best treatment option for displaced midshaft clavicle fractures in competitive athletes early in the season but that not every clavicle fracture needs surgical fixation.”*

No one would undertake an operation without first understanding the potential complications like numbness at the incision site or irritation from the hardware since we have so little subcutaneous fat in that area. There are also small chances of infection, wound problems, delayed union, etc. Diabetics and those who use tobacco products predictably do worse. Early on in clavicle surgery the complication rate was significant with high reoperation rates, plate removal, etc. but these have come down.

My take: To me one of the major advantages of surgery in the setting of a displaced, shortened clavicle is putting it back together “the way it came from the factory.” In a sport where returning relatively normal shoulder mechanics for reproducible swim strokes are important, restoring anatomic length and rotation I believe essential. But if displacement is acceptable staying away from the OR would be preferable as healing is generally quite good. We understand that regardless of treatment, surgical or nonsurgical, some studies have shown a degree of shoulder girdle weakness for months afterwards, in some patients even a year post injury. With either method, the (hopefully short term) imbalance that stems from injury be it stiffness, weakness, pain, etc. can take a good while to work out.

So if you find yourself post-crash, cradling your arm with the other (in what Phil Liggett calls “the broken collarbone position” regularly while announcing the TdF), facing this decision, here are a few questions you would want answered to help decide what’s best for YOU:

  1. If I do have the operation, what are my specific risks, how long will I be in the hospital and how many of these operations have you done?
  2. If I don’t not have the operation what are my specific risks/benefits?
  3. When will I be able to use my arm, return to work, return to sport?
  4. Do I have some underlying bone weakness?
  5. Should I be taking calcium or vitamin D
  6. Should I be reading Slowtwitch.com on a more regular basis?

Hopefully this will be helpful to those of you in the coming months who are faced with this dilemma.

*AAOS Now

2

#6: Yes.

I would add:

Is the deformation likely to cause me day to day life issues?

I’ve broken both (one Ultimate, one bike) and the resulting bumps (especially bike one) cause me some issues with backpacks or messenger bags.

Also totally ruins my look in strapless evening gowns.

-Jot

3

Probably not. Since this fracture is so common, were that a major issue I suspect we’d have many complainers.

Given your 100% fracture rate of owned clavicles, it’s a good thing you only have two!

John

4

as a type 1 diabetic, what complications can arise from wound healing, delayed union? Does this ‘count’ if said diabetic is ‘well controlled’? I am yet to do a collarbone, although i sometimes think its a matter of time with my increased interest of road racing. Having said all that, i dont think our doc would give us the choice, and would make me wait it out.
Just as a side note- anyone still run while they are on the mend? trainer workouts with arm supported somehow?

5

Had surgery on mine and so glad I did. Im 3 years post surgery now with no pain, no numbness and 100% range of motion. I really think the decision for surgery should be primarily based on the severity of the fracture as well. My fracture was in several places and displaced too far for any real chance for union. Very happy with the outcome I had.

6

Given your 100% fracture rate of owned clavicles, it’s a good thing you only have two!

That’s funny! :slight_smile: I had this vision of that distorted John Madden turkey with like 8 legs… “Yep, he’s broken all eight of those collarbones…”

-Jot

7

I fractured mine in a race in late Sept. Given the marked degree of displacement, it was recommended by several orthopedists that I consider ORIF. 2 days post-fx I was in the OR, and am the proud owner of a 2 intra-medullary screws, a plate, and 6 fixation screws.

I’m glad I’ve had it done, and while the recovery has gone a bit slower than I had hoped, I am now back to running and biking. Still having some ROM issues that prevent me from getting into the pool, but with rehab that is improving daily.

8

In motogp it’s not uncommon to have a plate put in. Jorge Lorenzo crashed on a Friday, had a plate put in on Saturday and raced to 5th place on Sunday! No pain meds while racing, obviously. The next weekend he crashed again and had to take some time off, but it will definitely get you back on the bike sooner.

9

You know, way more than most posters, that diabetes is considerably more than “sugar disease” or “he just needs to take a sugar pill/shot” type stereotyping. You could tell us that it’s a systemic, total body process that effects eyes, kidneys, you name it. As to your question, in many orthopedic scenarios the diabetic population has a less good outcome secondary to slower wound healing, higher rates of infection, etc. That said, since you’re on this web site, to some degree your lifestyle says “up yours” to the diabetes and that you’ll do things on your own terms not those of some disease process. Forewarned being forearmed, maybe just being a little more careful on the bike, a little more aware of road surfaces or vehicular traffic than the no-nothings with whom I ride (note I include myself in this group) and avoidance of situations that will get you into trouble will prove the best medicine.

Best of luck.

John

10

Broke mine 2 years ago at the age of 54. I am glad it didn’t require surgery. It healed up fine and today I would never know it was broken. Maybe I am one of the lucky ones, but to me when surgery is optional always opt not to do it.

11

I broke mine no surgery it’s fine lol
.

12

Broke mine Oct 8. Ortho (ex Div 1 swimmer) recommended no surgery - unless the bone wouldn’t set. My break was way on the outside and it would need a second surgery in 8 weeks to remove the hardware. Today I feel darn good, swimming is back to ~90% which isn’t too bad considering, and, it’s only January.

But I do acknowledge that the “bump” though small, is a bit disconcerting. Oh well… Cheaper than surgery - that’s for SURE.

13

I agree with the posters that have stated if surgery can be avoided it should be. I did not mean to imply (if I did) in my post that I was advocating for surgery for all. For most individuals, supportive management with immobilization will be adequate. In some ways, this thread highlights one of the key issues (highlighted by OP) of seeking medical advice on a forum. EVERY situation is going to have some nuance to it in terms of the fracture, the protoplasm (comorbidities), and the surgeon.

That being said, my being a gastroenterologist and quite familiar with the problematic nature of internet-based medical advice did not stop me from surfing the slowtwitchies before and after my surgery. Hell, if it wasn’t for the anesthesia and brachial plexus block, I probably would have surfing intra-op…

It’s human nature to try and gather as much advice as possible, I guess.

14

good points re: “internet medical advice.” With a previous malady (long story) the internet information led me far far astray, everything worked out after (shock and surprise) a specialist looked at me. In the case of my collarbone - I let the chips fall where they may with what a Ortho was going to say. I did some internet homework, but, nothing too serious with a mindset of prepare for the worst, and, hope for the best. Got lucky, and, am better than I would have anticipated (knock on wood).

Main point is - professionals (Doc’s in this case) are pro’s for a reason.

15

i broke my right clavicle when in the 7th and 9th grade. both healed w/out surgery in the standard 8 weeks. in 2002 my left went non-union when a horse took off bucking like a rodeo pony and sent me flying. that did not heal on its own (likely b/c my dominant hand, i lived alone, and had a 10 week old puppy). it was repaired with a plate (pins were not yet common practice) and the plate broke w/in six months with the bone still non-union underneath. i was referred to a clavicle guru at duke university and he repaired with a pin. sadly, the broken plate stripped all the periosteum off the bone so i no longer knit bone. 3 or 4 months later the pin was removed (they don’t like to keep those suckers in). i broke it again six months later when i crashed in a bike race. after bone stimulators etc, my ortho inserted another pin and then removed it, however, the bone was still weak and went non-union again. a third pin was put in and the end eventually rubbed through my skin, causing me to ooze like niagara falls (nasty). when the ortho attempted removal of that pin, he concluded the bone was still too weak so he cut the end off and i have it forever (it keeps the hunk of cadaver bone company). the third pin caused enough swelling that my hand was completely paralyzed for four weeks and i had no fine motor skills for four weeks after that. it sucked and was scary (again, my dominant hand). i have had some level of numbness in my left arm for the past decade. all of this to say, i wish my left had healed in the typical 8 weeks and that i had never had surgery. or that i had just gotten a pin the first go around of surgery.

16

Many excellent, thoughtful and well reasoned responses. Way to go. So we’ve determined correctly that:

  1. Most clavicle fractures will heal without surgery with a little TLC from the owner
  2. Frequently there will be a “bump” at the fracture sight but other than different looking it’s of no consequence
  3. In those instances where there is significant displacement, surgery with hardware fixation may be the preferred way to go
  4. Surgery, in this case or any case is not without complications or negative outcomes on occasion and you (as in YOU) should understand these pre op. You’ll sign a Permit for Surgery saying that you do
  5. This thread has been just one example of how good information can be shared knowing that sometimes internet medicine will lead you down the wrong path

Have a nice weekend.

John