Clavicle Fracture - A Cyclists Right of Passage?
Cadel Evans broke his 3 times in one year;
Greg Van Avermaet broke his in April 2016 and won stage 5 of the Tour De France in July and the Olympic road race in August;
Fabian Cancellara, Fillipo Pozzato, David Millar, Sebastian Langeveld all broke theirs in the same year;
Even Lance broke his, and Stuart O’Grady – well I’ve lost count how many times!
As I write this I learnt that a friend of mine just broke her clavicle racing in Europe last night.
Having just recently broken my own clavicle (also known as the collar bone) in a bike crash now seemed like a good time to share some information about this injury and the rehabilitation involved.
For a cyclist, a clavicle fracture is clearly a common injury. The usual mechanism of injury is falling onto one’s shoulder or hand. A fall from just 2 metres onto the side of your shoulder is sufficient force to break a normal clavicle. About 80% of all clavicle fractures involve the mid-shaft.
If the fall is hard enough, you may sustain a more severe injury that damages nearby structures like your ribs and lungs, neck, shoulder blade, or in rare instances the nerves and blood vessels which run under the clavicle. Your initial assessment needs to determine whether these structures have been injured in the accident as well.
So it’s broken. What are my options?
There are two choices: conservative care or surgical fixation. Each option has pros and cons and which you choose for your clavicle injury will depend on your individual situation. When you suspect you have broken your clavicle, the first thing to do is immobilise your arm in a sling until help arrives and further assessment and management can be carried out.
Based on research published in the 1960’s, most clavicle fractures have been treated conservatively, meaning that you wear a sling for about 6 weeks until the bones heal and then start Physiotherapy rehab to restore strength. In the past a figure 8 brace was also used, but recent studies show that this is usually more uncomfortable in the short term and doesn’t appear to produce better long term healing.
When might conservative care be best?
Dr Pritpal Bansi, a specialist upper limb Surgeon, suggests that in general, a 2-part minimally displaced fracture where there is one break in the bone and the two ends are fairly well aligned will heal well using immobilisation in a sling.
What is the success rate of conservative care?
Early research reported very good results with conservative management which is why this treatment has traditionally been the favoured way of managing a clavicle fracture. In modern literature this success rate hasn’t been as high. Recent studies (when pooled together in what’s known as a “meta-analysis”) suggest that up to 15% of mid-shaft clavicle fractures may fail to heal in the expected time frame or may not heal at all. Failed healing is known as non-union.
So why is it that a sling doesn’t work so well in the modern era as it did in the 1960’s? There are likely several reasons, some of which relate to a change in the way in which medical research is conducted. This includes actually asking the patient about really important outcomes like does the injury still cause pain once healed? Was the patient able to return to full function or their chosen sport? Simply reporting on whether bones healed without considering the patients perspective may over-estimate the success of treatment. Symptomatic mal-union (where the bones have healed in a shortened or crooked position) is now recognised as a cause of ongoing shoulder symptoms in some patients treated conservatively. Todays’ patients may also be more active and wish to resume sports sooner than their 1960’s counterparts.
What are the indications for surgical fixation of the Clavicle?
Dr Bansi suggests surgery for more “complex” clavicle fractures. In other words those that involve shortening of the bone, a comminuted fracture (the bone is in more than two pieces), a compound fracture (bone is poking out of the skin) or a significantly displaced fracture (the ends of the bone do not line up or the middle part is rotated). The X-ray above shows a displaced fracture with the middle segment rotated.
Surgery has been shown to offer faster bony healing, a lower incidence of persistent pain, and better return to sports / normal function than conservative care for these fractures. A desire or need to return to sports as fast as possible is why athletes may opt to have surgical fixation.
What is the success rate of surgical fixation?
Surgery, which often involves a plate and screws to realign the bones and hold them firmly together, has become more popular in recent years as it has a lower non-union rate (approx. 2%).
As mentioned above, modern research has shown that a clavicle fracture, even if healed, may not equate with clinical success. Although the ends of the bone may unite with conservative care, for some patients it may heal with deformity, shortening, persistent pain and weakness which may prevent resumption of some activities or sports (Canadian Orthopaedic Trauma Society 2007). One reason to consider surgery is that shortening of the clavicle >2cm not only predisposes to non-union, but the shortening may cause both long term weakness and shoulder pain with overhead movements. Another is that the initial clavicle strength is higher once it plated, which is good news for cyclists as they can start cycling on a stationary trainer about 2-3 weeks after surgery.
Possible complications with clavicle surgery:
Dr Bansi points out there are some potential down-sides to choosing surgery:
Plate removal requiring a 2nd operation: this occurs in about 1 in every 10 patients (depending on which study you read). Plates are usually removed because they break or cause pain. With just skin covering the plate, pressure on the area tends to be painful. This may be a problem in people whose work involves carrying things on their shoulders, such as tradesmen or military personnel.
If the plate is removed the small screw holes in the clavicle create a risk of re-fracture (usually by lifting). The incidence of re-fracture after plate removal is about 1% to 5% in the first 6 weeks whilst the screw holes heal. Having the plate removed would force you back on the stationary trainer for that 6 week period as a fall off your bike would likely break the clavicle again.
Screws may loosen and migrate: This requires another operation to remove.
Fortunately the modern type of locking plates used in surgery today means this is rare.
Infection: Also rare but any sign of infection like increased redness, pain, or swelling requires immediate medical attention.
Numbness below the scar.
There is a small risk of damage to nerves and blood vessels.
Whether you choose conservative or surgical treatment, both normally result in some cosmetic changes. After surgery you will have a scar and a bump from the plate which is visible under the skin, whereas with conservative care there may be a “droopy” appearance of the shoulder and a “bumpy” clavicle bone.
See our next post for how to get back on your bike and tips for successful rehab after your injury.