What is the best treatment for a broken (fractured) and/or dislocated collarbone (clavicle)?
Whether you ride a bike, a horse, or take part in contact sports, you must read this!
Bicycles and broken and/or dislocated collarbones go together like a horse and carriage
(or so the song goes!)
We do not recommend going over your horse's handlebars!
If you are a cyclist, or horse rider, the odds are that you may fall some time, land on your collarbone and either break it, dislocate it, or both. I did both in an instant, falling off a bike, many years ago.
This article deals mostly with the fracture kind. However, there is often a dislocation suffered along with the fracture, usually involving avulsing the ligaments that secure the acromioclavicular joint (AC Joint). If the AC ligaments have been fully or partially ruptured, the collarbone will appear to be "floating" above the shoulder. Please refer to Christian's Story later in this article. Christian suffered a nasty fracture of his collarbone and rupture of the AC joint. If the ligaments of the AC joint are not repaired, then the "floating" will be permanent. While we may consider it of not much consequence, I differ. Floating collarbones, other than being unsightly, can cause a lifetime of complications that may only get worse as the years become decades:
Disturbed sleep when sleeping on the previously injured side.
Pain and dysfunction with many physical activities, such as throwing and serving in tennis.
Protective muscle spasms in the shoulder and neck because of irritation and inflammation of the AC joint. These can lead to neck problems, migraines and even numbness radiating down the arm because of nerve and blood vessel impingement.
Gradual arthritic degeneration of the joint.
Collarbone injuries are so common that the seriousness of their impact on the victim - short and long term - is often overlooked.
Collarbone injuries cause weeks, if not months of sleepless misery and may cause long-term disability, including chronic pain, if not treated properly from Day One.
These injuries are horrible because it is almost impossible to sleep well during the weeks it takes for the bones and ligaments to knit securely. Attempting to roll over in bed is an agonising effort and unhelpful for the cause of uninterrupted healing. I'm talking from experience here, folks!
Think of the shoulder and collarbone acting like a car bumper during a crash. As you land on your shoulder, the collarbone crumples, absorbing some impact that might otherwise transfer to the central core of the body, shattering ribs, bruising and tearing vital organs; injuries that may be life threatening, if it was not for the crumpling of the shoulder. Not that this thought is any great comfort after suffering a shattered shoulder!
Clavicle fracture treatment
Clavicle Ligament Injuries
What is the best treatment for you? Get the best advice and make it timely!
From viewing these videos one can conclude that these injuries can be complex and there are risks involved in both conservative and surgical treatment options, including nerve damage. The extent of a collarbone injury may not initially be apparent; hence the need for a close examination by an experienced senior doctor and not just a trainee Accident and Emergency Department doctor. The decision as to the best treatment for you must be with the input of an experienced shoulder surgeon - in consultation with you - taking account all factors, including your lifestyle aspirations.
"Breaking my collar bone was nothing new to me as I had done it twice in the past. The first time the bones though broken were aligned and left to heal on their own. The second they were so far apart that surgery was the only option. I had some complications with the surgery in that the plate separated and another had to be fitted. Given this complication it still healed faster than the first time.
12 months ago I broke a collar bone again, third time! The xray was clear, the bones were miles apart.
The registrar suggested we leave it for a few weeks and see if the bones would realign. Given my job requires the use of my arms and I was keen to get back onto the bike this was not what I wanted to hear.
I contacted Gary Moller, he offered me great advice and introduced me to Marco who had been in a similar situation. I argued my case with the registrar pointing out that if left to heal on its own with a bump as often it does I would be back getting it fixed properly so lets plate it now and avoid extra costs in the future. He agreed and two weeks after the break I had a plate fitted."
It's almost impossible to immobilise a shattered shoulder
Because of the complex structure and mechanics of the shoulder (It's a four joint structure: scapulothoracic joint, glenohumeral joint, acromioclavicular joint and the sternoclavicular joint), it is almost impossible to stabilise the fracture or dislocation with any kind of strapping or sling, no matter how fancy. Unless we immobilise the damaged bones and ligaments, recovery will be slow and they will not knit well. This is especially true for the AC joint ligaments. Unless we hold the joint in place for several weeks, the ligaments will either not knit back together, or they may remain permanently apart, or lax.
If you want to restore the AC joint to as close to it original state, the best option may be surgical repair and plating, and it is best done promptly and not a month or longer after the injury.
Painkillers, sleeping and anti-inflammatory medications
Pain is there to remind you not to move, so that the bones and ligaments can knit securely. If painkillers allow excessive movement, such as when sleeping, then you risk ending up with a non-union healing of the fracture and/or an unsightly deformity of the collarbone and a biomechanically weak shoulder. We must hold together the bones and joints. Pain helps you do that. There is advice about pain management later in this article.
I have seen a few cases of non-union bone and many floating AC joint over the years. The only solution for those with the bone non-union is surgery, often years after the original injury. For those with an old floating AC joint that is giving them trouble, I'm afraid the only option, as far as I know, is palliative treatment using anti-inflammatory medications, or the occasional surgical intervention.
Anti-inflammatory medications may interfere with the healing processes. While their use may cause a marginally quicker recovery, this may be a false recovery, since the structure may be less than 100% integrity. Please refer to my blog article about anti-inflammatory medications:
Is surgery for a fractured and/or dislocated collarbone the best treatment?
"I broke my collarbone at the shoulder joint this week and have been to ED last night where they told me they would just let it knit while I wear an arm sling."
In 30+ years of working in sports medicine and rehabilitation, and seeing many fractured collarbones, I have never seen a complication from the surgical plating of these fractures. I have seen many cases of slow and painful healing, non-union of fractures, unsightly deformed collarbones, lop-sided shoulders and permanent biomechanical weaknesses; all because of the patient being given a sling, a pile of drugs and being told to go home.
These injuries can signal the end of your time as a high performance athlete, if you are one. The gloss may be permanently off your peak performance if not treated properly.
The time it takes for return to work and for resumption of near normal activities is usually less than half the time of merely leaving most of these injuries in a sling.
Even if the fracture is extreme, you may still be told that surgical plating of a broken or dislocated collarbone is not an option. This is a polite fib - but it is the norm statement nowadays. Why?
Perhaps some emergency medical room doctors do not know the difference between the treatment for a fractured collarbone versus a dislocated one.
The extent of the injury may not be obvious on first assessment.
Surgery to the collarbone area can be complex and is not without risk.
There is a view that a complete rupture of the AC joint results in little lasting disability; whereas a partial rupture may be more disabling over the long term. By extension of this, surgical repair of an AC rupture may cause the bone ends of the AC joint, which were well apart, to be too close, such that they may grind against each other, because of the ligaments being too lax. My answer to this line of reasoning is this: "Do a good repair job in the first place and make it timely!"
Perhaps the medics have seen so many of these injuries that there is no longer a sense of concern or urgency.
Limited funding and busy operating schedules may delay surgery for weeks, by which time healing is well on its way (more about this later).
Frustration turning to anger as the days become weeks
"Hi Gary, Not too good. Very condescending ortho, now thinking of another tack if possible. What really irks is that no Dr has even looked at my X-ray.
Thoroughly pissed off. Treated me like some old lady, well I am, but a bolshy one who still likes to ride descents fast."
The Hospital Emergency Department doctor may tell you to go home, take lots of painkillers, and wear a sling for several weeks. This is usually far from good enough.
The optimum window for doing the surgery is 10-14 days post-injury while the shattered and ragged ends are still fresh.
Not offering surgery may be partly because of it taking too long for funding to come through for the operation. ACC and other insurers have a history of being reluctant to pay for surgery on injuries that may not keep a person away from work for more than a few weeks.
Important to know!
The orthopaedic department at your hospital may meet only once every two weeks to review cases that may require treatment outside of standard procedures and budget.
Ask when the next review meeting is and insist on being included, otherwise delays will drag out into weeks and you will lose the opportunity for a nice and quick repair job.
If you are in a job, such as a mechanic, which depends on you having strong and functional shoulders and if the injury is preventing you from returning to work quickly and it looks like dragging on for weeks and maybe months. Hopefully, you will be into surgery within a week (More about this later). Money talks with agencies like ACC, which explains why a worker unable to work due to an injury will have faster and better treatment than, say, the proverbial "Little Old Lady".
Another very frustrated patient
I'm still waiting...aaargh!
I met with the surgeon last Wednesday...he thought surgery would be required but at the last minute asked me to wear the sling for one more week!"
"A few years ago I broke my collarbone MTB racing in Nelson going OTB. On the way home on the Ferry 2 guys asked about my arm in a sling, so I explained what happened. They said they were orthopaedic surgeons and told me to push very hard for surgery. They explained the shoulder drops when the collar bone breaks. The sling does not raise the arm back up to the correct position. Bone growth will eventually grow across the gap and rejoin, but you will always be lop-sided or misaligned. If you wear a pack, the raised bone will dig into the pack strap and rub. Health Board budgets are such that very few operations are done. They will send you home with a Disprin for a long recovery.
So I pleaded my case that I was a top NZ Masters Champion and wore a pack every day commuting/training. After 5 days, they agreed to do an op. They put in a stainless steel plate and 4 screws and I was riding 5 days later on the road on MTB with comfy tyres.
1 week later I did Karapoti but had to walk the steep stuff. Without the op, I would have been out of action for 3 months on ACC. With the op I was back at work in 10 days saving on ACC costs. The plate will likely stay there forever and I can’t feel it. Once Jorge Lorenzo MotoGP Champ broke his collarbone on a Thursday. They flew him to Spain to be screwed together and that Sunday he finished 5th. Amazing, because the braking and turning loads on the upper body a motorcycle are extremely high.
So it’s a pity that Health Boards save money by sending you home, but ACC costs become higher with a longer recovery!"
Always insist on getting the Presidential Treatment
When a person seeks my advice following a collarbone injury, I may ask them the following question:
"If you were the President of the United States, would your treatment be any different?"
I asked my brother-in-law, Ioasa, this question the other day while we were out riding. I know him for his wit and he replied:
"For a start, one of my bodyguards would have taken the fall!"
If you were our Head of State and without the services of a bodyguard, a specialist would assess you and possibly be straight into surgery that day, or soon after. We are still be an egalitarian society, so demand the Presidential Treatment.
Insist on surgical repair as the first treatment option - not the last
Insist on a thorough assessment, if you are an active person, regardless of age, recreation or occupation.
Surgical repair is the usual Presidential Treatment: insist on being thoroughly assessed and insist on surgery, if your injury qualifies! This will ensure an uncomplicated recovery and full return to an active lifestyle. Cost, or lack of funding should never come into it when we are dealing with your precious and irreplaceable body.
Remember, if there is to be surgical plating to secure a ruptured AC joint, the plate may have to be removed so as to allow restoration of normal shoulder function (refer to Christian and Ash's Stories below). For plating of collarbone fractures, removal of the plate after healing is complete is usually also recommended; but go with the surgeon's recommendations on these matters - of course!
"My story was that a car turned in front of me while i was road racing (individual time trial). I was going about 50 kph and had no time to react, but avoided a head-on collision by sliding my bike sideways into the car. I impacted with my left shoulder just behind the drivers door.
I flipped over the front of the car and landed on my hip. When I was able to check myself over, the only injury i found was a lump in the top of my shoulder. I knew I probably broke my collarbone. Luckily i had no other injuries and my bike didn't have a scratch on it.
Xrays taken in Samoa showed a fractured left clavicle (collarbone) near the shoulder joint.
A NZ physio who was also in the race referred my xray to a NZ orthopedic surgeon who recommended i have surgery as soon as possible, and preferably no later than 10-14 days after the accident.
I returned to NZ as soon as I could get on the next flight and presented myself and my xrays to ED at Christchurch hospital.
I was put in a sling and given an appointment with an orthopedic surgeon 5 days later.
The surgeon initially suggested that surgery would likely be necessary, but then advised me to wear my arm in a tighter sling and he would re-assess me 1 week later. At this point I stressed that I wanted surgery asap, that i was a commuter cyclist carrying backpacks every day, and an elite cyclist and triathlete. This seemed to have little effect on his decision.
In the meantime I sent my xrays to a 2nd orthopedic surgeon who also recommended surgery.
I followed the hospital instructions and returned 1 week later. I had new xrays, which showed the bones had started to overlap but only by 10%, and not the 50% overlap required to support continuation of a conservative treatment protocol (sling only / no surgery).
Email excerpt from an increasingly desperate and frustrated Christian Wengler to the orthopaedic surgeon:
"I'm concerned a collarbone left to knit by itself without surgery could leave me unbalanced, due to a shorter/lower shoulder, and cause issues down the track through my spine, pelvis, and knees, as well as issues with heavy backpacks on my regular commute. - I'm an extremely fit and competitive age group cyclist and triathlete (43yrs old). I win multiple races every year - I commute to work every day by bike (30k round trip + 20k-50k extra training per day) - Some days I commute by running to and from work - I carry a backpack with work papers/laptop/groceries on most days - I regularly travel for work and carry a laptop with me in a shoulder bag - I'm training to qualify for the work age group triathlon champs in either Canada or Netherlands - I train up to 20-25 hrs per week (cycling, swimming, and running) - I'm entered for a triathlon in Australia in 6 weeks. I'm worried that I'm not going to have this injury treated properly (given my circumstances), and I just don't know what I can do to get a second opinion, or what I should do to help me to get the surgery as soon as possible, so I can start rehab, and get back to work quicker."
"The surgeon and registrar met in private, and then the surgeon advised me that he would recommend surgery in my case. I was admitted to the ward with the hour, and less than 1 hour after that i was wheeled into surgery it took about 2 hours.
Because of the location of the fracture, the surgeon inserted a hook plate into the shoulder to connect the main collarbone to the fractured portion and that was connected to the shoulder. The plate will need to be removed after 3 months.
I stayed in hospital overnight (24 hrs) and was discharged the next afternoon with a prescription of Tramadol and Paracetamol, some light exercises prescribed by the physio, and some occupational therapy tools to help me in the kitchen at home. I have a follow up consultation in 2 weeks, and i have a medical certificate allowing 6 weeks off work.
I am taking natural healing supplements as recommended by Gary Moller. I'm feeling very tired, but am improving quickly. The surgery was a success and my recovery will progress quickly."
How to get the Presidential Treatment
Christian, Mark, and Marco's stories show the way to go forward. Present a convincing case for getting the best treatment, otherwise you will receive the "lowly citizen's treatment" which is painkillers and a sling and out the door!
If you have fractured or dislocated a collarbone:
Prepare a one page, point-by-point case, arguing why you require the Presidential Treatment and hand this to the medical team at the earliest opportunity. The points to make are if:
Your job requires you to have brawny arms and shoulders. Nurse, mechanic, drain layer, builder?
You commute to work with a heavy backpack which contains your work tools such as a computer.
If you carry a shoulder bag at work, when visiting clients.
Plating the injury will have you back at work much sooner and save ACC income related costs.
You are physically active and place great value on an active lifestyle. Think hiking with a heavy backpack. Perhaps you do judo? Volunteer coach?
You are a swimmer, cyclist, martial artist, tennis player, or triathlete, and especially if training for a national or international championship or similar. Maybe there is a tight deadline?
You are caring for someone at home who has mobility and other issues that require you to be strong and mobile.
You have private insurance. If not, tell them you will pay no matter the cost (of course that offer will not be accepted; but you are sending the message that your long-term health is very important to you).
You are getting stomach pain and serious discomfort from taking even small amounts of the pain medications to the extent you must stop. If you have any diseases of the digestive tract, such as Crohn's, prolonged use of pain medications may not be safe.
You are in extreme pain despite the medications and could not sleep at all to the extent your suffering is making you mentally unstable and extremely fragile (if you have a history of mental issues such as depression or suicide ideation, then let them know).
Be honest about what you say - no fibs please - but be to the point and assertive.
"The politely squeaky wheel will get the oil"
If you sense you are getting nowhere ask for a second opinion. I do not know how successful this ploy is. It seems to work; other times maybe all it does is antagonise an already arrogant person on whom you so desperately rely.
Be respectfully tolerant of your orthopaedic surgeon
"Gary, I saw XXX, not very nice at all; usual condescending surgeon".
Why do some surgeons come across as being arrogant?
Historically, orthopaedic surgeons are notorious for their arrogance and lack of bedside manner. This has been the case for over a hundred years. I got to witness some shocking examples when working in the rehabilitation department of Dunedin Hospital during the 1970s.