Question: After watching so many crashes in this year’s Tour de France, it happened to me on a group ride the other day. I touched wheels with the rider in front of me, and in a split second, I was on the pavement. I reached out my hand to try to stop my fall and ended up breaking my collarbone. I’m wearing a sling, as it was not a “bad break,” I’ve been told. Still, I’m wondering if this is the best treatment, and if I’ll be able to return to my normal riding routine when I’m healed. – Ben S.
Dr. Edward Fink Replies:
In the midst of cycling season, this scenario is not uncommon, Ben. Clavicle fractures are the most common fracture associated with cycling. Fortunately, prompt healing and good outcomes take much of the pain out of this injury.
The clavicle is an S-shaped bone that acts as a strut connecting the shoulder to the axial skeleton through attachment points with the sternum (breastbone) and the acromion, part of the shoulder blade. (Injuries to the acromion-clavicle junction, or AC joint, will be discussed in a forthcoming article.) These attachment points are maintained and strengthened by ligaments that connect bone to bone, and the clavicle provides points of attachment for many muscles responsible for movements of the shoulder.
Falls directly on the shoulder or falls onto an outstretched arm can produce fractures of the clavicle or injuries to the AC joint, though fractures are much more common. Forces from the fall are transmitted to the clavicle, causing a break, usually in the middle of the long bone.
The diagnosis of a clavicle fracture is usually not difficult as there is pain over the clavicle with touch or with movement of the arm. While broken clavicles are often solitary and unassociated with other injuries, a complete vascular, neurologic, and pulmonary examination is imperative due to the close proximity of these structures.
Clavicle fractures are best assessed with x-rays that demonstrate the fracture and the amount of overlapping, if any, between the bone ends.
The majority of clavicle fractures can be treated non-operatively, with predictably excellent results. These would include isolated fractures with less than two centimeters of overlapping bone ends. Treatment would include placing the affected arm in a sling for approximately two weeks and allowing movement of the shoulder according to comfort.
The sling would then be discontinued, allowing increased motion of the shoulder as the fracture continued to consolidate. After two to three weeks, one could be allowed to ride on an indoor trainer if there was no pain at the fracture site and no discomfort with riding. Full movement would be anticipated by four weeks, and return to non-contact activities, including outdoor cycling, by eight weeks. Sometimes a bump may result from irregular healing, yet the deformity is usually only cosmetic.
Surgical treatment has become increasingly popular as cyclists like Lance Armstrong in 2009 had surgery to place a plate and screws on his broken clavicle to promote faster healing and a quicker return to the bike. This is a reasonable alternative for a professional cyclist who can return to the trainer within one week.
There are reports in the orthopedic literature stating that individuals whose fractures have healed with greater than two centimeters of overlapping may have increased pain and diminished strength of the shoulder. These reports, along with more refined surgical implants, have prompted an increasing use of surgery for treatment of displaced fractures. Surgery involves either placing a plate and screws on the bone across the fracture or a metallic device within the hollow bone to keep it in place while healing occurs.
The benefits of surgery are faster healing of the fracture and some improvement of shoulder strength. Yet, any type of surgery involves increased risks and potential complications, including infection and irritation of the skin as the plate lies immediately beneath the skin and often requires a second surgical procedure to remove the metal.
The overwhelming majority of individuals who sustain clavicle fractures will have an excellent result with non-operative treatment, permitting a full return to accustomed activities. The treatment and management of these fractures should always be based upon individual evaluations and thoughtful discussions with the treating orthopaedic surgeon.
Dr. Edward Fink is a pediatric orthopedic surgeon and avid road cyclist. He specializes in trauma, works and teaches in developing countries, and promotes cultural competence in medicine.