Clavicle Fracture Article Reprint

(-This article was first published in Cycling Utah in the Fall of 2009)

A Bad Break?

- The Current State of Collarbone Injuries in Cycling

Mark D. Scholl, M.D. – Orthopedic Sports Medicine Surgeon

Avid viewers of professional cycling all know that when commentator Phil Ligget sees a crash on the road, he is about to immediately express grave concern for that rider’s collarbone. Despite the fact that occasionally the rider is holding his knee or wrist while the collarbone is getting all the worry, there is a good reason that a seasoned commentator will use this as a first-guess injury from a crash. Clavicle fractures are among the most common orthopedic cycling injuries, along with fractures of the radial head and wrist fractures.

The clavicle is a doubly curved bone that connects the sternum to a projection of the shoulder blade called the acromion. Its primary function is acting as a strut to position the shoulder joint broadly outside the rib cage, to maximize function and range-of-motion. It derives its name from the Latin word “clavicula” which means “little key” because as the hand is taken above the head, the clavicle is seen to rotate on its long axis like a key in a lock.

Throughout the majority of modern medicine, fractures of the clavicle have been treated with limited intervention. Comfort measures such as a sling, or a figure-of-eight brace are used to help support the bone as the healing process occurs over time. Surgery was reserved for uncommon situations where the bone had broken through the skin, or was nearly through and was “tenting” the skin demonstrating significant stretch and risk of pressure injury developing. Traditional teaching instructed us that the vast majority of fractures would heal without intervention, often leaving a residual ‘bump’ but having no detrimental functional effect on the shoulder.

Over the past decade, or so, orthopedic surgeons have begun to re-define what the effects of a clavicle fracture on a shoulder may be. It turns out our previous notion – that all patients who have a broken clavicle and successfully heal the bone go on to have full function of the shoulder without problems – may have been a bit shortsighted. Reports in the Journal of Bone and Joint Surgery (British & American versions) have begun to look at long-term outcomes after successful healing of displaced clavicle fractures. We have found that although these fractures often go on to heal, some patients with a healed fracture still have weakness or other functional limitations in the affected shoulder. Recent articles have shown that even at an average of 4 ½ years after healing a displaced fracture of the clavicle, tested subjects were found to only have around 80% strength in their shoulder compared to their uninjured side.

The key turns out to be in the component of displacement. This is a term that defines how much the fracture has shifted after it has broken. The clavicle has many various forces that act upon it, mostly related to the muscles that attach to the clavicle and the muscles that cross from the chest wall to the shoulder. If you recall, we said previously, that the clavicle was a strut to keep the shoulder away from the rib cage. However, if that strut is broken, there are large muscle groups – such as the pectoralis, which may act to compress or shorten the clavicle at the fracture, and draw the shoulder closer to the chest wall. If the clavicle fracture heals in this shortened place, there is a change in the relative position of the shoulder to the body and this is believed to be responsible for the residual weakness we can sometimes see after the fracture heals. This is one of the main reasons orthopedic surgeons now treat many more fractures of the clavicle with surgery than we did even five or ten years ago.

The other reason we have begun to see orthopedic surgeons recommend treating clavicle fractures with surgery more often, has to do with the speed with which we can rehabilitate an athlete and return them to sport after surgery. Orthopedics has seen important recent advancements in the technology of devices available to stabilize clavicle fractures in surgery. As we are able to hold the fracture more securely, we can be more aggressive with our rehabilitation and get athletes back to sport much sooner than if we treat with immobilization and waiting. Most of the pain from a fracture comes from motion between the bones where there should not be any. Anybody who has had a fracture and has felt the grinding sensation between bones will tell you it’s like listening to nails on a chalkboard while getting stabbed with an ice pick at the same time. Not fun at all. Stabilizing the fracture with a titanium plate and screws brings the bone ends together solidly, so there is no longer motion at the fracture site. This improves comfort much sooner, allowing early advancement in range-of-motion, sooner resumption of cardiovascular activities, and faster return to strengthening. All of these lead to faster return to sport.

When the most famous collarbone in cycling (belonging to the most famous cyclist, Lance Armstrong) was broken in the process of his return to the pro peleton, there was much speculation about how this would affect his chances at his favorite proving ground, the Tour de France. Anybody who follows Lance’s enthusiastic Twittering knows that he had a remarkably speedy recovery. He reported biking on the road just eight days after his surgery (though he did appeal to those following, not to tell his doctor!). This is a bit sooner than most surgeons would recommend for road riding (I often have cyclists on a trainer this early, but for safety, like to keep off the road and trails until healing is a bit further progressed). However, it just goes to show that not only can Lance get up Mont Ventoux faster than you, he can heal quicker as well!

Many of us watched as Lance stood upon the podium at the Tour de France this year, an achievement that might not have been possible had he not gotten past his clavicle fracture like a Category 4 climb. What might have been a major setback, was just a small bump in the road, and early surgical intervention that restored his fracture’s displacement and shortening may also end up maintaining better strength in his shoulder in the long term.

The best clavicle is the one that was never broken, so using caution while riding, particularly in traffic or other adverse conditions, is the best program. However, if you do have a crash and hear Phil Ligget’s voice in your head worrying about your collarbone, have it checked out by an orthopedic surgeon. We may be able to get you back in the saddle sooner than you think, and quite possibly with a better long-term outcome than a few years ago.