I broke my collarbone, left side, last Monday. I’ve been off the bike since then. I am going to set my trainer up on Saturday for some indoor spinning. Do you have any ideas on how to make things heal any faster? Any advice would be a great help.
Bob Cozzetti.

Dear Bob,
Since the clavicle ("collarbone") is the most commonly broken bone in the human body, your question is a good one for us to take a look atin detail. It's such a common injury for cyclists that I think we tendto not give it the attention it deserves.

Certainly, it has had Tyler Hamilton's attention the past few days.I won't speculate on any details about Tyler's clavicle, but suffice itto say that even if his fracture is the tiniest of all possible fractures(which it probably isn't), his performance Sunday on L'Alpe d'Huez wasimpressive.

Anatomy
To talk about clavicle fractures in any detail, it will be necessary to take a quick anatomy lesson.

The relevant structures are the bones (figure 1), joints (figure2), ligaments (figure 3), and neurovascular structures (figure4).

The clavicle is a fairly fine and narrow bone charged with the responsibilityof anchoring the entire upper extremity (a.k.a., the “arm”) to the restof the body. It links the sternum ("breast bone") to the scapula ("shoulderblade"), which then connects to the humerus, the bone of the upper arm.(Feel free to break into song here.)

Two areas on the scapula that are worth mentioning here are theacromion and glenoid fossae. It's also important to notice that the firstrib passes just beneath the clavicle. Realize also that all bones havean outer layer called the periosteum, which is responsible for growth andmaintenance of the bone; this layer, being somewhat strong and sheath-like,also provides some structural support. Here is a nice X-ray view of the bones in an uninjured shoulder, which shouldgive you an idea of what is should look like. Anatomicdiagram, X-rays of normal and fractured clavicles

The relevant joints (Figure 2) are the sternoclavicular jointbetween the sternum and clavicle and the acromioclavicular joint betweenthe clavicle and the acromian, which is simply a raised-up area on thescapula. These small joints are true joints in an anatomic sense as eachcontain a joint capsule, joint fluid, and a small meniscus. This setupis in every way similar to the more-familiar knee joint. These tiny jointsafford a remarkable amount of movement to the shoulder, but are (like theclavicle itself) very vulnerable to injury. Without diverging too much,it is a sprain of the acromioclavicular joint that is commonly referredto as a "shoulder separation". This injury is not to be confused (as itcommonly is) with a shoulder dislocation, which is when the humerus popsout of the glenoid fossa on the scapula.

In Figure 3, the all-important ligaments that hold the wholething together are pointed out. Take a look. I won't go into detail heresince we're talking about fractures, not sprains (i.e., injuries to ligaments).

Finally, and perhaps most importantly, in Figure 4 are shownthe neurovascular elements, the subclavian artery, subclavian vein andthe brachial plexus. These provide the blood supply, sensation and movementcontrol of the arm.

Fracture terminology
It's necessary at this point to be clear on some of the terminologythat we use to talk about fractures. This is good information for all fractures,not just fractured clavicles.

The most critical point about any fracture is whether it is "open" or"closed." An open fracture is one in which the skin over the broken boneis cut, thus exposing the bone pieces to the elements (i.e., dirt andbacteria). This obviously is a bad thing, but very rarely relevant in claviclefractures. A closed fracture is one where the skin overlying the fractureis uninjured.

The second critical distinction is whether a fracture is "displaced"or "non-displaced." A displaced fracture is one in which the two brokenpieces have come out of place so that the two ends don't line up like theydid before the break occurred. A non-displaced fracture is one where thebone is broken but the pieces are still more or less lined up normally.

A third distinction is between an "angulated" and "non-angulated" fracture.This describes whether or not the two bone pieces are lined up straightor at an angle to each other.

Finally a "comminuted" fracture is one that is broken into several pieces, while a "non-comminuted" fracture is one where the break results in justtwo pieces.

I should also point out here that the term "compound," as in "compoundfracture," is a non-medical term that has no precise meaning for us medicaltypes.

Clavicle fractures
The catch about discussing a fractured clavicle is that there are fracturedclavicles and then there are fractured clavicles. Imagine an open displacedangulated comminuted (yes, this is a quiz of sorts) clavicle fracture.Here you will do operating-room time, get to know an orthopedic surgeon on a first-name basis, and probably never have a perfectly functioning shoulder. Nowpicture a closed non-displaced non-angulated non-comminuted fracture ofthe clavicle. With this one, you could conceivably continue riding a grandtour (assuming you're talented, highly motivated, and one thoroughly toughson of a bitch).

Mechanism of injury
Clavicles break in one of three ways. The first and probably most commonway is to fall directly onto your shoulder. The second is to whack yourclavicle directly. In cycling, this might be thanks to the top tube, stem,or handlebars. Thirdly, it's possible to break your clavicle by puttingout your hand to catch yourself as you fall. Here the force is transferredup through the arm and dissipated as the clavicle breaks. In the thirdsituation, however, it's more common for the wrist or elbow to give wayfirst, thus sparing the clavicle.

Complications
While uncommon, clavicle fractures can result in some pretty seriouscomplications.

Look again at Figure 4 and imagine jagged bone fragments movingaround next to the brachial plexus, subclavian artery, and subclavian vein.Injuries to those structures result in loss of movement and sensation inthe arm and disruption of blood flow to the arm. Fortunately, these complicationsare quite rare.

It's also possible for a sharp fracture fragment to pass between theribs and damage the lung. Collapse of the lung, partial or complete, wouldresult. Serious bleeding can also occur.

Long-term complications include "malunion" in which the clavicle healsin a bad position, causing cosmetic and/or functional difficulties. "Non-union"is when the break never heals, resulting in chronic pain and movement difficulty.

Treatment
The treatment of all clavicle fractures includes ice and anti-inflammatorymedications like ibuprofen or naproxen. A stronger opiate pain medicationlike Tylenol/codeine or vicodin is often necessary at first.

Some displaced and/or angulated clavicle fractures require "reduction"to put the bone back into a reasonable alignment so that it can heal properly.Reduction is the medical term for manipulation to convert them to non-angulatedor non-displaced fractures.

In some cases, surgery is undertaken to realign the bone fragments and then hold themtogether with plates and screws. Obviously an orthopedicsurgeon will needed for this. This is a greater consideration for professionalcyclists who need to get back on the bike ASAP. The downside to surgicalfixation of clavicle fractures is the increased possibility of non-unionas the bone fragments depend on the hardware to do the work and don't botherto heal together.

Some nice X-rays and a surgical view:Pinned clavicle - an X-rayProgress from break to recoverySurgery in progress (Not for the weak of stomach)

Immobilization with a standard sling or figure-eight sling with beneeded depending on the type of fracture. A figure-eight sling is onethat pulls both shoulders back into the position that moms want when theyyell about slouching or bad posture.

Prognosis
How long it takes before it's okay to get back to riding (or whatever)depends on the precise details of the fracture. This can range anywherefrom the next day (on a fixed trainer with no use of the injured shoulder)to several weeks. The general rule is that you can do whatever is possiblefor you to do safely and without too much discomfort. There simply aretoo many potential variables for me to be more precise.

I hope this information answers your question to some extent. You needto be in the hands of a family physician comfortable caring for your injuryor request referral to an orthopedic surgeon.

Best wishes,
Prentice

---

Dr. Prentice Steffen, board certified in both emergency medicine and sports medicine, is serving as team doctor for the Prime Alliance Cycling team. He has served as team doctor for several teams including Mercury, Spago and U.S. Postal. Steffen has also served as medical director and event physician for major races including the Tour Du Pont, New York City Marathon and the Tour de Trump. Steffen also serves as the sports-medicine section editor for the Journal of Emergency Medicine. His services are outlined in detail at www.pdssportsmed.com Please send your sports-related medical questions to "Ask the Doctor" in care of WebLetters@7Dogs.com. We will forward a selection of questions to one of three physicians currently working with this site.Important Notice:
The information provided in the ASK THE DOCTOR column does not constitute formal medical advice. The information provided on this public web site is provided solely for general interest of the visitors to the site. The information contained in this column applies to general medical practice and may not reflect current medical developments or be interpreted as medical advice. Understand that reading the information contained in this column does not mean that you have established a doctor-patient relationship with Dr. Prentice Steffen. Readers of this column should not act upon any information contained in the web site without first seeking medical advice from their personal physician.