Collarbone 101

Introduction


Most of you saw the photo album I posted of my hiking trip to Death Valley, DogTown, Zion National Park and Salt Lake City. Originally I intended to include the pictures of the NYC Five Boro Bike Tour that I was supposed to ride in on May 3 but I had a small complication. On April 16, at mile 20 of a 30 mile training ride, I had a cycling accident and fractured my collarbone. So no Five Boro Bike Tour for me this year but I thought I would at least post the story of my fractured collarbone in this Blog. I recognize that this is probably more information than you could possibly want about collarbones but, nonetheless, here we go.



The Emergency Room


I ended up at the Morristown Memorial Hospital emergency room. I knew that I had done something really bad to my left shoulder but had not a clue what: perhaps a dislocation, perhaps a broken bone, perhaps -- because hope springs eternal -- just a bad bruise. But it hurt like hell and I had an odd bump on the top of my left shoulder so I just kept my left arm close to my chest at at 90 degree angle and hoped for the best.

The consensus of the admitting nursing staff was that I had a dislocated shoulder but I knew that the real diagnosis awaited an x-ray. I was amazed had how efficient and fast the hospital was in admitting me and getting me into an individual emergency waiting room. However, my amazement ended when I then waited almost two hours to see a doctor who obviously was not going to do anything but send me to the hospital lab for an x-ray.

Now think back to the time at which you incurred your most severe pain -- ever. Unfortunately for me, my accident established my new pain high-water mark. No, not the pain at the time of the accident and not the pain as my shoulder swelled up but pain as a result of going to get the x-ray of my shoulder. But, you ask, how could an x-ray cause pain? Read on.

As I was wheeled down the hospital hallways, I got passed off several times from a nurse to an orderly to an x-ray technician. My shoulder pain was somewhat under control as I continued to keep my left arm close to my chest at a 90 degree angle. For my first x-ray, the technician wanted a side shot so she asked me to stand perpendicular to the x-ray screen, which I did. She then decides that she wants me repositioned and instead of just asking me to move forward a bit -- and in a moment of her forgetting why I was there for an x-ray in the first place -- she comes up behind me and slams her two hands down on top of my shoulders to reposition me herself. Remember the bump on the top of my shoulder I mentioned which made the nurses think the shoulder was dislocated? Well, it turns out that the bump was one end of the broken collarbone which was sticking up at a 45 degree angle. As the technician's hand came down on that bone stub, I saw stars, felt faint, nauchous and broke out in a cold sweat. They had to take the remaining x-rays while I was seated as I could not stand. Now I will readily admit that I do not know what the distinctive competencies are for an x-ray technician but I do believe that the ability to remember what injured body part is causing the need for an x-ray ought to be one of those competencies.

Still sweaty, nauchous and feeling faint, I get back to the waiting room and eventually the doctor comes in to tell me my collarbone is broken and I need to see my orthopedist. So in total, I spend about 5 hours at the hospital to get an x-ray.

The Clavicle


The collarbone, more formally known as the clavicle, is the bone over the top of your chest, between your breastbone (sternum) and shoulder blade (scapula). It is easy to feel the clavicle, because unlike other bones which are covered with muscle, only skin covers a large part of the collarbone. Clavicle fractures are extremely common. Broken collarbones occur in babies (usually during birth), to children and adolescents (because the clavicle does not completely ossify, or develop, until the late teens), to athletes (because of the risks of being hit or falling), to idiots like me, and to people during many types of accidents and falls. Cycling accidents where several riders pile up usually results in one or more broken collarbones. I think professional cyclists view broken collarbones as an occupational hazard.

Collarbone fractures can occur in a number of ways from a simple break to a compound fracture and the treatment will depend on the position of the fracture in relation to the end of the bone and many other factors. Clavicles fractures are also classified according to where the break occurs and , not surprisingly, most fractures occur around the middle of the bone as illustrated below.

A broken clavicle cannot be fixed in the same way as a leg or arm by surrounding the limb in a plaster cast. This is practical with limbs because a limb bone is normally held by the muscles in compression along its axis. The clavicle is subject to all sorts of forces and torque, and the geometry is much more complex. Even if the whole shoulder could be encased in plaster, it would be unlikely to hold the bone in position.

Be that as it may, it seems that the various muscles surrounding the clavicle generally do a pretty good job of keeping the bone in place and the broken fragments in contact. Indeed, in about 95% of the cases a fractured clavicle will form a good union without any surgery and this natural repair is often stronger than the original.

Soon after the break, the ends of the bone "bleed" and gradually a fibrous tissue builds up around the end of each break. These tissue formations act as part of the mechanism to restore a blood supply to the site of the fracture and typically after 14 days, they intermingle and bridge the gap. Once the bones are held together by the fibrous tissue, the tissue starts to calcify (i.e., turn into bone). Even if the two ends do not butt up perfectly, the calcification seems to build up in such a way that, after healing, a good cross-section is maintained along the bone. The surplus fibrous tissue dissolves away over the subsequent years.

After about 2 to 3 months, the fracture should be completely healed, although there is rarely perfect alignment of the broken sections which often results in a "knot" or a bump on the collarbone.

The normal treatment for a broken clavicle is simply to keep the arm in a sling or an elastic figure 8 type restraint for 2 to 3 weeks. For most patients the sling is more comfortable and statistically, just as likely to foster a good union.

In some cases, the two ends of the bone join up in some awkward way. Perhaps a sharp end is protruding, perhaps the geometry is all wrong such that the two ends of the bone never get close enough to allow the bridge of fibrous tissue to form. This is termed a "non-union."

In most non-union cases special treatment is necessary and the most common option is to perform a surgical operation to mechanically fix the two collarbone sections with a metal plate or pin. About 85% of clavicle fractures occur in the middle third of the bone and are usually repaired with a pin. The remaining 15% of fractures mostly occur in the outer third area of the bone (towards the arm) and are surgically repaired with a metal plate. Once the operation has been performed, the two ends of the bone are in good mechanical contact, and the plate is relieving some of the forces that are trying to pull the union apart. There is a 99% chance that a good union will form.



The Orthopedist

The day after the accident I saw my orthopedist, Dr. Andrew Willis, and his physician assistant (PA), Steve Storch. As I walk into the examining room with Steve I see the following x-ray of my broken collarbone on the monitor.

The x-ray shows why I had a bump on the top of my shoulder and why the x-ray technician's hand slamming down on my shoulder hurt so much.

"Steve" I said, "how is this going to mend since the two ends of my broken collarbone have different zip codes?" Steve responded, "Yes, that is a problem and Dr. Willis will be talking to you about it."

Dr. Willis then comes in and starts to look at some of the additional x-rays that had just been taken that morning at his office. These were pictures of the break from different angles, especially from the top of my shoulder looking down.

Dr. Willis then starts to talk about the injury and it is clear that he is also using my case as a teaching moment for PA Steve. Dr. Willis now becomes a bit excited and tells PA Steve that my case is very interesting and highly unusual and they hardly ever see such a case. First, the fracture is in the outer third of the collarbone and not in the normal middle third. Second, the degree of bone separation is rather large. And third, not only do the bones miss each other in the vertical orientation, but, looking at the top-down x-ray, we can see that the bones are also misaligned from front to back. In other words, the longer part of the collarbone needs to be moved both down and towards the front to be aligned with the outside section of the collarbone. At this point I am really quite thrilled that I can be contributing to the continuing education of PA Steve.

The conversation quickly turns to the need for surgery and it is scheduled for the next week at which time they will cut in, align the collarbone and screw a plate on top of the collarbone to fix it in place while it mends. Sounds like a fun day! Sometime after the bone mends Dr. Willis may go back in to, in his words, "remove the hardware." Although young, Dr. Willis seemed very competent, came highly recommended, and since he is one of the orthopedists for the NY Jets he must know what he is doing.

The Hardware


Because of the odd curvature of the collarbone they manufacture various curved plates depending upon where the clavicle break is located as shown below.

For my break they use a variant of the top plate in the above picture where the flared part with the two adjacent holes is located to the outside towards the arm to provide enough anchor support since there is not much collarbone on the outside of the break.

The illustration above shows how they use special clamps ("lobster claws") to first align the bone and then to temporarily fix the plate on the bone.

As shown above, they then predrill the holes and just screw it down. Now of course, the illustrations make it look so neat and clean but the picture below is what it really looks like in the operating room -- OUCH.

Post Operation

The operation went fine, I had a huge bandage on my shoulder, it hurt like hell but the Percocet and Vicodin helped quite a bit -- oh yeah, quite a bit. Dr. Willis used a titanium plate and nine screws. Here are the before and after x-rays to compare.

As you can see, by design they want the screws to go all the way through the bone and stick out the bottom.

I have to compliment PA Steve on his suturing because here is what a typical staple approach looks like.

But pictured below is my shoulder where he sutured inside the incision and the suture thread only comes out at the two ends with a knot in each end. Yesterday he just cut off one knot and pulled it out and I did not feel anything -- very elegant.

Next Steps

My priority now is to not do anything stupid and pull the screws out of the plate which is the main risk. I wear a sling outside of the house and try to keep the arm supported inside the house and do not lift anything heavy or over-rotate the arm. I will start some physical therapy in a few weeks and, God willing, the break will mend over the new few months.

If the titanium plate is not bothering me it can just stay in, otherwise, it is removed during another surgery. Actually, I kind of like the cyborg aspect of having a titanium plate so I hope it just stays in although I think I will need a doctor's note for airport security.

Since I will not be riding my bike (pictured below) for awhile I have not taken it to my bike shop yet for repair.

My bike has a carbon fiber frame which is incredibly strong and light but unlike metal, it does not dent on impact but instead it cracks which is very difficult to repair. I think the frame is OK although some components are damaged. I am sure my bike shop will be thrilled to know that my shoulder took the full impact of the accident and saved the bike frame from being damaged.



DogTown Follow Up


You will recall from my Death Valley photo album that my cat Felix

was pissed off that I volunteered to work at DogTown and not at Cat World. Well, he has gotten over that but he is now pissed that his petting time has been reduced due to my injury. Hey, life is tough.

You will also recall that I spent the day at DogTown volunteering with the dog Chico, pictured below.

This past Friday, the DogTown episode "Will to Survive" on the National Geographic Channel featured Chico. They rerun the DogTown episodes so you can catch it another time if you want to see Chico being trained.

When I was at DogTown they told me that Chico's problem was that he killed some chickens since as a border collie mix he has a strong instinct to pursue small prey. But what I learned in the TV episode was that after he had killed some chickens, he then killed the family Yorkshire Terrier and ended up at DogTown. In the TV episode they show the steps the trainer at DogTown went through to correct this aggressive prey-stalking behavior.

Felix would have really, really been pissed if I had adoped Chico and brought a dog into the house. However, I guess it would have been short lived since I assume Chico would have then gone about stalking and killing Felix. I'll have to remind Felix how good he has it.