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As cyclists we all know that sooner or later we are going to fall off of our bikes be it training or racing. Giving this inevitable fact chances are that you or someone that you know has been sidelined with a clavicle (collarbone) fracture as a result. When we look at fractures as a whole in cyclists, the collarbone is the most frequent bone to be broken.
This year’s crash-marred Tour de France is a good case in point with the high number of abandoned riders with clavicle fractures and gives us a good opportunity to take a closer look at this injury that plagues the peloton.
The clavicle is an S-shaped long bone that acts as a strut to attach the shoulder to the axial skeleton. Its most anterior apex attaches to the sternum via the sterno-clavicular joint and at the posterior apex it broadens and flattens to attach to the acromion via the acromio-clavicular joint. The bone acts as an attachment point of several muscles such as the sternocleidomastoid, pectoralis major, and the sternohyoid muscles medially and on the lateral side the anterior deltoid, trapezius and the pectoralis major’s clavicular head.
With respect to characterizing clavicle fractures we tend to divide the bone into thirds with a medial, middle and lateral portions.
Fracture to the medial third of the clavicle are rare and make up less than 3 percent of breaks, while the lateral third is the second most frequently involved portion and accounts for 15-30 percent of all fractures.
The middle third of the clavicle is the narrowest section of the bone and lacks the muscular and ligamentous attachment of the ends. These facts when taken together are thought to make it more susceptible to injury and it is indeed the most frequent site of fracture (70-80 percent of all clavicle fractures).
Displacement is a term that means the bony ends of a fracture do not align and these mid-shaft fractures tend to have high rate of displacement with an incidence found to be between 48-73 percent. This high rate is likely related to the muscular attachments at the ends of the clavicle pulling the fracture fragments of bone away from their normal anatomic alignment, along with the actual weight of the upper extremity itself contributing to this distraction in some cases.
One of our own takes a fall
To illustrate the clinical aspects of clavicular fracture in cyclists, Boulder Center for Sports Medicine’s very own Neal Henderson, Director of Sport Science, has given his blessing to share his case. Neal, while racing a criterium in June this year, fell hard and took a forceful direct impact to the left shoulder. He felt a snap in the anterior shoulder area and found it painful and difficult to move his left arm afterwards.
Neal would soon after seek medical attention and x-rays revealed a left middle third clavicle fracture that was displaced and comminuted, which means the bone was in more than two pieces. This direct impact to the shoulder that he sustained turns out to be the most common injury mechanism in clavicle fracture with the second most being a Fall On an Outstretched Hand (FOOSH) injury.
In cases of clavicle fracture it is extremely important to assess for concomitant injuries to the lungs, the surrounding neurovasculature, and other musculoskeletal issues such as associated rib fractures, AC joint separation and other scapular injuries to name a few. In Neal’s case he was fortunate to have only a painful case of road rash to accompany his fracture and was giving a sling to immobilize the shoulder for comfort and was told to follow up in the Sports Center.
In these injuries the clinician’s goal from a management standpoint should be to heal the clavicle in a fashion that recreates its function as a solid support for the shoulder girdle to elicit the return of pain-free range of motion, normal strength and to avoid bony non-union and malunion (bone fragments heal together but there is persistent pain and or loss of shoulder function). The means of accomplishing this goal by bringing about the least risk and harm to the patient is ideal.
To operate or not?
Historically in regards to midshaft clavicle fractures it was thought that the best approach was non-operative management even in cases of large displacement with damage to vasculature/nerves, open fractures (bone fragments pierce the skin) and painful non-unions being the most common indications to proceed with operative intervention. Over the last decade this approach has come under increasing scrutiny, with newer studies of completely displaced fractures showing much higher patient dissatisfaction rates than previously thought in those treated with non-operative management. These rates were secondary to a markedly increased rate of non-union than formerly documented (up to 21 percent) as well as malunions causing considerable shoulder girdle dysfunction. Taking this into account with the improved surgical fixation techniques and much lower complication rates over the last decade, it has made operative interventions much more viable from a management standpoint.
The approach to the patient with clavicle fracture should be on a very individualized basis with age, activity level, personal preferences, fracture type and monetary/insurance concerns playing important roles in the decision process. In Neal’s case having a comminuted and displaced fracture put him at increased risk of non-union/malunion, and this along with his desire for decreased pain and faster return to cycling activities made operative repair the best choice. His choice was made with the awareness of surgery specific risks of post-operative infection, collateral injury to soft tissue via surgical approach, and the inherent risks of anesthesia as well as the potential of hardware failure and the possibility of the eventual need for its removal.
It was three days after his initial injury that Neal underwent successful and uncomplicated open reduction and internal fixation of his left clavicle fracture with titanium plate and screws. The choice of plate and screws was made over the alternative intramedullary nailing technique given the multiple bone fragments at his fracture site.
Interestingly enough during the surgery it was noted that soft tissue and trapezius muscle were interjected between the fracture fragments and would have in all likelihood increased his risk on non-union if he would have undergone non-operative management.
Neal would eventually be able to resume riding on an indoor trainer one week after surgery and go on to resume outdoor training at four weeks. His case demonstrates the benefits of surgical fixation of the displaced clavicle fracture and acts as a best case scenario in terms of the more rapid return to cycling training, the decreased risk of non-union/malunion complications and the immediate return of stability to the shoulder girdle itself.
I again must reiterate that each case has to be approached on an individual basis and poor surgical candidates as well as minor and or non-displaced clavicle fracture would in most cases be better served with a conservative non-operative approach and should be a discussion with your orthopedic surgeon that is not to be taken lightly.
— Jason Glowney, M.D.
Medical Director, Boulder Center for Sports Medicine
Boulder Center for Sports Medicine was founded by Andrew Pruitt, EdD, PA-C, in 1998. For the past 12 years BCSM has been providing athletes from around the world with the highest possible level of care. BCSM offers a wide range of services, including Orthopedic Clinics, Physical Therapy, Expert 3D Bike Fitting, Running Gait Analysis, Coaching & Training, Nutrition Services, Performance Testing, and more. For more information, visit www.bch.org/sportsmedicine, or call (303) 544-5700.