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common injury in cycling due to falls on the shoulder and relative high speed,
is clavicle fractures. Although any part of the clavicle can be broken, they
most commonly occur in the middle of the clavicle.
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. During
its movement via a frontal axis, it follows the movement of the shoulder and rotates forward and backward.
With respect
to characterizing clavicle fractures we tend to divide the bone into thirds
with a medial, middle and lateral portions.
Fractures to
the sterno-medial third of the clavicle are rare and make up less than 5
percent of breaks, while the acromio-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). (Fig
1)
Fig.1 Two
broken clavicles
What's
the typical diagnosis and prognosis for return to cycling?
Diagnosing clavicle fractures is usually not too
difficult given the usual deformity that results from the injury. X-rays of
clavicle fractures can look alarming due to how angulated the fractures can
appear and there can also be multiple fracture pieces.
In pro cyclists, there are often stories of riders
getting their clavicles surgically repaired and returning rapidly to the pro
peloton. In 2012, Pippo Pozzato broke his clavicle in the early season, but was
back on his bike within days after clavicle surgery and went on to place 2nd
over the cobbles of Flanders weeks later.
Fortunately,
despite how bad clavicle fractures may appear on x-ray, most clavicle fractures
usually heal on their own without surgery. Once the fracture heals, there is
usually a cosmetic deformity of the clavicle, but there are typically no
deficits in terms of any shoulder function, motion or strength. Therefore, the
initial management of clavicle fractures is mainly symptomatic with analgesic
medication and supporting the arm with a sling. (Fig.2)
Fig.2 Type
‘’8’’ sling
There are only
a few absolute indications to have a clavicle fracture surgically treated, such
as a break or severe tenting of the skin and secondary nerve or blood vessel
injury. Relative indications for surgery are significant shortening of the
clavicle and for cosmetic reasons.
Surgical
treatment of clavicle fractures does probably allow for an earlier return to
sport activity. However, one often requires a second surgery to remove the
surgical hardware as the area of surgical fixation can become easily irritated
since the skin is quite thin lying over the clavicle.
It takes
about 6-8 weeks for clavicle fractures to heal, but it may take up to three
months for the strength of the fracture site to normalize. So avoiding sports
activities in which falling may be a risk is recommended for about three
months.
Although
non-operative management of clavicle fractures is usually recommended, the
circumstances of a clavicle fracture can vary between individuals. Therefore,
it is important to have a frank discussion with a medical physician and/or
orthopedic surgeon to determine how best to manage this injury.
Haralambos Haralambakis
Physiotherapist
Sources:
1)http://www.active.com/cycling/articles/how-cyclists-bounce-back-from-a-broken-collarbone
2) http://velonews.competitor.com/2011/07/news/training-center-what-cyclists-should-do-when-they-break-their-collarbone_186486
3) Clavicle fractures : How to fix them Stamatis Kottakis, Dimitris Anagnostopoulos, Nikolaos Mpolanos, Kyriakos Kalogerakos, Nikos Mpaltagiannis Ε.Α.Ν Peiraia ‘’Μetaxa’’