Although none of the editors of InsideSurgery.com are participating in the care of bike racing champion Lance Armstrong, we have noted with interest the reports coming out of Spain today that Armstrong has suffered a broken right collarbone or clavicle.
He reportedly was riding in the Castilla and Leon bike race when he went down in a pile-up of 20 riders and was treated and released from a local Spanish hospital with his right arm in a sling. He will reportedly seek medical advice in the United States.
Clavicle or collarbone fractures are very common in falls. They can occur from a direct blow to the clavicle (e.g., being struck be a bat or from a seat belt deploying), a fall on an outstretched hand, and a fall onto the point of the shoulder (e.g. a fall onto the patient’s side).
Clavicle fractures are often associated with scapula fractures and rib fractures, as well injuries to the lungs (e.g., pulmonary contusion) and mediastinum (area deep in the chest and around the heart.)
The fractured ends of the bone can injure the underlying subclavian vein and artery, as well as the brachial plexus (a large nerve structure that controls the arms’s motor and sensory functions.) In addition, injuries to the axillary artery (main artery in the armpit area) have been reported.
Clinically, the fractured clavicle is easy to detect. Patients always report pain and there is usually an obvious deformity as the bone is superficial (close to the skin). The part of the bone proximal (closest to the center of the body) to the fracture is usually elevated due to the traction of the sternocleidomastoid bone (the big muscle in the side of the neck).
Fracture of the middle clavicle with elevation of the proximal bone.
On examination, the arm on the broken side usually hangs forward and downward.
Radiographic (X-ray) workup usually includes plain films (an anterior-posterior view of the clavicle, a lateral axillary view of the clavicle, and a transcapsular lateral view of the clavicle) and/or CT and MRI of the clavicle/shoulder area.
Fractures of the collarbone are classified by the location of the fracture – proximal, middle, or distal third of the bone. The most common fracture site is the middle (80%).
Five percent of clavicle fractures occur in the proximal part and are usually associated with disruptions in the ligaments connecting the clavicle and the sternum (breastbone).
Distal clavicle fractures occur about 15% of the time and are commonly associated with disruptions to the shoulder ligaments.
Most clavicle fractures are treated non-operatively. The patient’s arm is partially immobilized in a sling or figure-of-eight dressing and oral pain medications are prescribed.
Surgery is reserved for open fractures (bone breaks the skin), injury to an underlying artery or vein, and severe displacement of the bone ends that can not be reduced with manual pressure and splinting.
The operative procedure to repair a fractured clavicle is not difficult for an experienced orthopedic surgeon and mostly commonly uses a plate and screws.
Patients usually start physical therapy/rehab at about four weeks and have some weakness and loss of function initially with motions that mimic pulling light weights on a pully. Patients commonly complain of significant pain and discomfort with these fractures.
Initial reports on Armstrong’s injury place him out of training for three to four weeks. This would be considered a quick return for everybody but perhaps a highly conditioned athlete.
Risks of a too early return to physical activity include nonunion or malunion (the bone is not able to heal and becomes chronically weak). Generally, hairline and non-displaced fractures allow an earlier return to physical activity.
Although the exact nature of Armstrong’s injury is unclear, the fact that he was seen and released in a relatively short time makes it unlikely he had any underlying vascular injuries, which can be life-threatening.
Arterial injuries are best detected in a trauma setting via computed tomography angiography (CT angio) that uses dye placed in the veins to visualize arteries. Injury to the subclavian vein under the clavicle can be seen on chest radiograph (chest X-ray) or non-contrast chest CT.
It is also unlikely that he had any scapula or rib fractures as this usually requires an admission to the hospital for intravenous pain control. He most likely had a non or slightly displaced fracture in the middle third of the clavicle.
Although it is unclear what tests he was given in the hospital where he received treatment, in most Level 1 trauma centers in the United States, a history of a high-speed bicycle crash with clavicle tenderness being worked up by a trauma surgeon would result in a chest x-ray, head CT, c-spine CT, abdomen and pelvis CT, and studies imaging his clavicle and shoulder as requested by orthopedic surgery.