CLAVICLE FRACTURES

Clavicle fractures are just as much a part of mountain biking as punctures, queuing for porta-loos and saddle sores.

Clavicle or collarbone fractures are one of the most common injuries sustained by mountain bikers. In this column I will explain the implications of these common breaks and discuss the treatment options available.

The clavicle links the mobile shoulder blade (scapula) to the rest of the skeleton; it is a strut which serves as a pivot around which the scapula moves. Its “S” shape makes it resistant to injury when struck from the front (hence relatively few fractures from rugby tackles) but it is vulnerable to fracture when hit from the side, the top or from the back. This is why it is frequently the result of an “over the bars” fall where the shoulder or arm hits the ground first.

Once the bone breaks, the weight of the arm causes the shoulder to droop forward and creates an obvious deformity at the fracture site. Not to mention serious pain.

As the clavicle has a good blood supply, it usually heals well if left alone and for this reason the traditional way of treating it was to leave it in a sling. However, research performed in the past 15 years has shown that fractures left to heal “naturally” may not do as well as previously thought. Particularly those fractures where there is splintering or fragmentation of the bone, or where there is a wide gap between bone ends. Although the bone grows together, the person may be left with dysfunction of the shoulder.

This research lead to an increase in operative fixation of badly broken collarbones by stabilising the broken ends of a bone with a metal plate and screws. This restores the strut and allows earlier use of the shoulder and arm while the bone is healing, rather than only being able to rehabilitate the shoulder after the bone has stabilised itself.

Once an x-ray confirms the fracture, you need to have a discussion with an orthopaedic surgeon about the merits of treating the fracture with or without surgery. There is no substitute for this, fractures are as unique as the individuals who sustain them. Sometimes the fracture itself will dictate treatment. Minor or incomplete fractures do not require any surgery, while severely fragmented fractures (often combined with other injuries) do need surgery. However, in many fractures there is a choice; one can treat it in a sling or elect to have surgery.

Treatment with a sling avoids all the risks associated with surgery like infection, scars, future irritation from the plate, time in hospital and it cost much less. But it will mean being in a sling fulltime for between three and six week before you can start moving your arm. During this time there may be considerable pain and motion of the broken bone ends(doesn’t make sense?). In most cases it is too sore to drive, cycle or work during this time.

Surgery involves a general anaesthetic and, most often, a night in hospital. The severity of the break and the quality of the fixation will determine the time you spend in the sling and when you can start using the arm. This is usually between one and three weeks.

Although the speed of bone healing and return to sports is quicker in the surgically treated patients, this must be weighed against the risks of surgery. If all goes well, it can be a comparatively rapid recovery compared to other fractured bones. The downside is that once the bone is healed the plate may bother you sufficiently that it needs to be removed; this is done once the bone has healed.

Although I sincerely hope that you are never faced with this decision, here are some variables to bear in mind when deciding how to treat your fracture.

Work: Being in a sling for an extended period means you may not be able to complete your commitments. You will manage clerical activities one-handed, but if you are self-employed and/or need to do physical work, surgery may be advisable.

Driving: This is possible roughly two to three weeks following surgery. If treated in a sling you will be relying on family, friends and Uber for lifts for between six and eight weeks.

Social and cycling commitments: These feature highly on the minds of cyclists I meet in an emergency unit. Your injury affects not only you, but your family and your riding partner. (It is considered bad form to let your Epic partner know of your injury before your spouse!) Think about the timing of upcoming holidays and events. But do not allow these short term interests to completely dictate your decision making.

People have varied views about surgery; some are vehemently against it and would avoid it at all cost, while others will more readily entertain the thought of it. Be sure that you convey your perceptions to your surgeon and discuss this with them.

Any injury is a setback, but hopefully this information helps to prepare you if you, or someone you know, get into this unfortunate position.

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