broken clavicle...surgery or not?

[hesibudifabla]

Here's an interesting bit of information for everyone. I work with a guy (he's an ironworker) who broke his clavicle years ago, like 10 years ago. He's big and muscular and it never healed. He shows it to people all the time by making it poke up. He swings hammers and pushes on heavy stuff all day long. He does have a droop on that side however. He was able to compensate for the lack of a clavicle by building muscle in that area. He's like a walking freak show. I still have the plate in that was installed back in Feb 2011. Someday I'll get it taken out but for now I hardly notice it being there unless I throw a strap over that shoulder. Lesson here is if you're a big muscular dude you'll still look like a freak show if you don't get your clavicle fixed.

 

[pnkcoral]

Sorry about all the repeat messages..

All the fractures, bruised bones, ribs, etc. seem to be healing up nicely. Thanks. They were all pretty serious..for instance someone told me that I was lucky that the sternum didn't punch through and shear off the aorta to my heart. Yikes! The pain level on those are down from what they were originally. But, they all still hurt alot should I roll on them, bump into one, or in the case of the knees, walk to much. Subsequently, the clavicle seemed a lot better today too. I walked a quit a bit and then I do these easy exercises I made up that simulate the various swimming strokes.

Now, what I have been looking into with the clavicle situation was first trying to find out if my AC and CC ligaments are still attached. It was hard to believe that with two CT scans, two MRI's, and ten portable and stationary x-rays that nobody got an MRI that showed those two ligaments. Then I was also wondering that if the two broken pieces of collarbone can displace themselves..then is there any chance that they could straignten themselves back up. I think someone said on this thread that there is a channel of muscle, nerves, etc. that has formed around them, originally. If that was the case you would think that they could be manipulated back into place?

However, I feel that I am flying by the seat of my pants on this broken clavicle deal. First, since I was a trauma patient I was funneled into a situation with various assigned doctors. The Ortho Doc litterally walks into my room at the hopital and was more interested in operating on the knee than the clavicle. Primarily, because the clavicle wasn't displaced at that time. He spends about 30 seconds and says, "Well call me next week and we will make an appointment." The cost of this appearance which was billed as fracture treatment was a mere $3400! So, you see I really didn't get a warm and fuzzy feeling from him to later do the plate and screws..especially when he gives me a nebulous price range on that operation as $20K-$40K.

Therefore, I started phoning around to different surgeons in the area. There is probably 20-25 who do the plate operations in the Valley here. However, they will not touch anyone who has been in an auto accident. At first I could not believe it and thought that it was just that particular type of office. But, phoned about 10-15 more and they would not touch it with a ten foot pole. It did not matter if it was an insurance claim, health care provider, or even cash. When I would push the point a couple of them even hung-up on me. The reasoning behind their noncompliance is there is just to much paper work, chance for lawsuits, and long wait times for their money. That is why I just concentrated on a settlement and figured I would take some cash, go to an experienced surgeon for the operation, and tell him that I fell off my roof or something. All I have to say is that our medical system must really be screwed up if you have to lie in order to get an operation and not become a cripple.

Sideways..

 

[willy81]

hesibudifabla, it is well known that nothing can substitute for surgery. some people believe that growing muscles will compensate but it never works. pnkcoral, sorry to hear that there is so much bureaucracy, it seems that your biggest problem is not the fractured bones of yours but to find a doctor, it seems that your knees heel also fine, use ICE 4 times a day, it is one of the best ways to relieve pain, do not underestimate this method, ICE is probably the best treatment. AC and CC ligaments usually stay unharmed in a typical Collar bone fracture. we have a doctor here on the forum, read message #1262 http://www.cyclingforums.com/t/133419/broken-clavicle-surgery-or-not/1260#post_4065798 you probably would like to contact him Why the doctors you called so far do not undertake an auto accident patient? I am a little unaware of those matters so please explain. Is it a matter of money?

 

[pnkcoral]

***** 81,

Yes, ICE has saved me time and time again. I have this big pack with a felt type case. I can get the clavicle and the sternum in one shot. Then I move to the ribs and lastly I hit the knees. Actually, started on the ice this morning. I did to much yesterday, had a bad night, and had a hard time even getting out of bed this morning. Recovery with multi-injuries never just goes up in a straight line..set backs happen.

As far as why so many surgeons will not operate on auto-accident victims I can only really guess. The front desk people who I talked to were reluctant to get into the specifics. My guess is the slow process that is involved an auto crash. Normally, if you had a regular injury you just go in give them your health provider and your good to go. However, that is not the case with a vehicle accident. First, it has to be determined who was at fault. A partial fault accident would probably be more problematic. So, once the at fault insurance company gets involved everything has to be funneled through them. That means even if your health provider picked up the tab they would have to be reimbursed by the at fault insurance company. But, that all gets slowed down because it takes time to put everything together for the settlement. And, as the settlement nears the at fault insurance co. then goes and negociates with the hospitals, docs. radiologist, etc to try and knock the price of medical bill down. So, that is just some of the pitfalls. But, the way everybody reacted when I said that I was in an auto accident, lead me to believe that it would be like saying your on Medicare with a hundred pre-existing conditions.

My settlement is pretty much a done deal because there was no question the other person was at fault, they disclose their liability limits, my claim was probably double their limits, and the hospital looks like they want to play ball. See the hospital et al jack their prices way up to 100% or 200% over the real cost and then you have to barter them down. So, I told them that I cannot sign off on the settlement until they discount down the $40k bill. And, we would be willing to wait the two year statute limit for a lawsuit. And, they do not want to go to court because it then comes out that they charged $10 for an aspirin. The whole deal is called a pro-rata one and it centers around the ratio of your claim and the at fautl persons liability limits. This per centage is then used to discount the medical bills. However, the reason the will not operate does not really concern me. What concerns me is that fact they have limited the pool of surgeons. And, it then appears to me that the only ones that will do it are the ones tied into the trauma centers. Then you have to ask yourself are these surgeons any good? They have to wait for ever to get paid. They put a lien on your settlement, but, that really doesn't mean that they would get paid. I can personally think of a lot of ways to get around that...

 

[bsbs1876]

Originally Posted by hesibudifabla .

Here's an interesting bit of information for everyone. I work with a guy (he's an ironworker) who broke his clavicle years ago, like 10 years ago. He's big and muscular and it never healed. He shows it to people all the time by making it poke up. He swings hammers and pushes on heavy stuff all day long. He does have a droop on that side however. He was able to compensate for the lack of a clavicle by building muscle in that area. He's like a walking freak show. I still have the plate in that was installed back in Feb 2011. Someday I'll get it taken out but for now I hardly notice it being there unless I throw a strap over that shoulder. Lesson here is if you're a big muscular dude you'll still look like a freak show if you don't get your clavicle fixed.

Hahaha. This is a funny story. My clavicle was like this before I got surgery. I'm a rather thin guy though so it was probably even more prominent. I could push my shoulder forward and the bone would pop right up like a spike almost. It had rotated back and was pushed in closer to my neck all the time too which made my posture look kinda weird. All of that is slowly becoming more normal now that I am 6 weeks post op (I had a bit of a set back with my incision but is all good now) but I still have some odd sensations and numbness going on around the area. I hope the nerves will eventually settle down a bit.

I've yet to throw anything over that shoulder but I would imagine this plate is gonna bug me in the long run. I'm not looking forward to another 6 weeks of letting those screw holes fill in but you gotta think about the future, especially if you're young.

 

[pnkcoral]

Sidebar..

Hmm.. with all the particulars and financials of my injuries I kind of forgot what I wanted to say. First, I really like this board and I think it is a great venue for discussion. I would have to disagree with Alienator that everything should be discussed with your Doc. Yes, in a perfect world..but we all know or should know that this is not a perfect medical world. What I have walked away with so far from reading all the posts is that there is probably a better or hopefully better method of surgery, tools and products for each individuals broken clavicle. Now, having said that it is kind of up to each person to research his individual situation to check his options and then make an appointment and go see a good surgeon.

I find it kind of fascinating but normal that 80% of the collarbone breaks happen in around the middle of the bone. And, this is right where it is thin and (i think) rotates a bit. So, it doesn't surprise me that so many non-displaced breaks heal up in this section with most likely with a thicker bone than the original. However, with displacement and the plate system (in this area) I can see how all these problems can arise..as discussed on this board. And, if you do not get a union with the plate you then are really in hot soup. That is why I am tending toward a closed plate system or an internal nail. But, I really will not know what avenue to take until the settlement, i talk to a good experenced surgeon, and there is no chance of it healing on its own.

Thanks for all the information..

 

[hesibudifabla]

That guy with the floating clavicle has been like that for 11 years now. He said it doesn't bother him but we all know better.

When I busted mine I posted on this forum (over 2 years ago!!) and I'm glad to see the thread still cruising along. This thread is the best source of information on the interwebs regarding clavicle fractures. The real bottom line with clavicle fractures is this:

Get it plated as soon as humanly possible, no exceptions. I don't like seeing all the mis-information floating around (on other sites) about letting it heal on it's own or using weird pins to seal the deal. The answer to the broken clavicle is surgery with a screwed plate. Period. If a doctor recommends a sling and taking it easy for a few months then you need to kick him in the shin and go to another doctor! Did Lance Armstrong let his clavicle heal on it's own? So why would you (you being the newly fractured clavicle victim reading this)? It's a proven, solid, repeatable, low-risk solution to fixing bones. Don't be like my ironworker buddy and be a freakshow. He's going to have a lower quality of life as he gets older. I couldn't imagine.

I kinda like my plate, it's neat to show people the scar and then thrust my shoulder forward so they can see the outline of it. I actually have several friends with similar plates and we **** with each other all the time. Get a plate, be a part of an elite class of humanity.

 

[josephyu]

Originally Posted by willy81 .

hesibudifabla,
it is well known that nothing can substitute for surgery.
some people believe that growing muscles will compensate but it never works.


pnkcoral,

sorry to hear that there is so much bureaucracy,
it seems that your biggest problem is not the fractured bones of yours but to find a doctor,
it seems that your knees heel also fine, use ICE 4 times a day, it is one of the best ways to relieve pain, do not underestimate this method, ICE is probably the best treatment.
AC and CC ligaments usually stay unharmed in a typical Collar bone fracture.


we have a doctor here on the forum, read message #1262
http://www.cyclingforums.com/t/133419/broken-clavicle-surgery-or-not/1260#post_4065798
you probably would like to contact him

Why the doctors you called so far do not undertake an auto accident patient? I am a little unaware of those matters so please explain. Is it a matter of money?

Hi pnkcoral and willy81.


I'll add my 2 cents.
There are a couple reasons physicians don't take auto accident patients. Although auto insurances are good payers, fault may not be established. If the person with no car insurance is at fault, the surgeon may be left with no payment. Most surgeons will take auto insurances or liens that have been screened. Unfortunately, with an acute clavicle fracture, there is not enough time to properly assess if payment will be rendered. You also have to put yourself in the surgeon's shoes. Would you do the surgery if you could get sued for $1 million and not get paid? Even with health insurance, most insurances only pay a surgeon $764.55 for fixing a clavicle (although the surgeon bills $10,000). Sorry to include money in the discussion.


You are right about the CC and AC ligaments. In mid-shaft clavicle fractures, nearly all CC and AC ligaments are still intact. Distal third clavicle fractures can tear the CC ligaments while the AC ligaments are usually intact.

 

[willy81]

pnkcoral, then, you better find a way to circumvent all this bureaucratic mess, pay for it and bring the bills to the insurance company when the final decision is made. You can't wait for long. Number one priority is to get back to your normal life. keep us updated and post your x-rays if you like. hesibudifabla, I agree with every single letter of your post. Plate/screws is the only proven method for fixing clavicles. I feel sorry for this freakshow friend of yours and if it is a close friend why don't you encourage him to go for the surgery? Some people are in constant denial of the reality, it is unreasonable. I don't know how soon you had the operation but I had it in less than 24 hours after my accident. July 2nd around 17:00 the accident happened and July 3rd 13:00 got the anesthesia for the surgery. Do you plan to have the plate/screws removed? Post an X-ray, if you please! babs, after the plate removal we must be quite cautious for 6-8 weeks until the holes mend but I would not mind to slow down a little, besides I will choose to have them removed in a rather inactive period of the year.

 

[bsbs1876]

I love how you guys are killing this guy a "freakshow". He's not a monster! He just broke his clavicle like the rest of us, haha. I guess I was a freakshow for 3 years. I actually know a few guys who have malunited collar bones and they genuinely say it does not bother them. I think it depends on the person and the break.

*****, last time I saw my surgeon he says it's pretty obvious the plate is coming out. The end of the plate closest to my chest is prominent and is almost like sticking to the skin. I think it's the screw head that you can see and feel. I cannot move my skin around in that area. It is like stuck to the plate. Truthfully I cannot wait to have the plate removed already and it has only been 2 months. The surgeon says it all depends on the MRIs and Xrays when it can come out - "It could be 6 months, 8 months, 9 months. We will have to see." he says. The bone just needs to be fully bonded.

 

[willy81]

Dr. josephyu thanks for explaining. Bsbs well, some people take a very complicated (freakshow) approach to a very simple problem, yeah, we will have the plate out when it is time, I believe it is better to leave it for at least 15 months, this is what I plan to do. Muscles will never bond with the CB normally if the plate stays in. How are you doing?

 

[bsbs1876]

*****,

I'm doing pretty good. Using the arm for everything normally as I would but not lifting anything heavy. I will be back to see my surgeon on the 14th of May for a CT scan so he can get a good look at how much bone growth there is and will advise on what I am allowed to do from there.
It's kinda funny how doctors have different opinions on the same subject... my surgeon seems to think the plate can come out a lot sooner than 15 months just as long as the bone is healed right up.

 

[willy81]

if you remember, initially my Doctor's assistant told me that I could had it out in 9 months, then a few weeks later the Doctor told me 16-18 months, then last time I saw him after Christmas he said that I was doing very well so in 15 months post op it could be removed. I think it depends on the progress, or the deposition of Calcium. The screws slow down the progress pretty much, remember, we must be very cautious for 6-8 weeks after it has been removed, I suppose now you can go riding if there is no snow, it has gone right?

 

[bsbs1876]

The snow is gone here but it is still damn cold outside for the next few days. I am actually not much of a cyclist. I am more of a runner and enjoy hockey and golf. I only came to this website because of all the info on the injury which I did to myself on my ATV up north. I will surely be back out on that thing this summer though. Nothing can hold me back from that machine.

 

[bsbs1876]

I've started running outside sometimes lately but I noticed my shoulder cramps up quite a bit after like 3 miles. I've decided to stop and just use the indoor trainer for another few weeks or a month because it feels very awkward. Any runners out there can comment on their return to outdoor running after surgery?

 

[josephyu]

Hi Friends,

I wanted to toss out my views on a couple of the questions:
1. Why do surgeons disagree on which clavicle fractures need treatment? There is still a large group of ortho docs who feel that nearly all clavicle fractures should be treated without surgery. In the past, scientific studies rated a patient as having a good outcome if she had decent shoulder motion and a healed fracture. Newer studies are looking at a LOT more parameters and saying that patients are NOT doing as well as we thought. I would not necessarily say one group of doctors is right or wrong because each patient is individualized and you must consider the risks of surgery. Also, a surgeon may not feel comfortable with that particular procedure. When a surgeon says you don't need surgery, he may be saying he doesn't feel comfortable doing the surgery.
2. When does the plate come out? No good answer. Based on orthopedic wisdom that has been passed down generations, that length of time is typically 1 year. However, as the long as the bone is radiographically healed, IMHO the plate can be removed. This differs from patient to patient. I assess radiographic healing by looking at 2 orthogonal views of the clavicle bone and I look at bridging callous.
3. Which middle third clavicle fractures need surgery? Most don't need surgery. The ones that do are the following: (1) fractures that don't make contact (displaced by more than 100%), (2) fractures shortened by 1.5 cm, (3) severely comminuted fractures. I did a video explaining this... http://www.totalsportsmedicine.com/#!clavicle-fractures/c3gx
4. When is the best time to get surgery? Ideally, within 2 weeks. The surgery is just easier. After 4 weeks, bone has started to form and you are often chipping away a partially healed clavicle fracture.
5. When can fractures be pinned? You need two conditions: (1) a displaced fracture which is not too comminuted (2) surgeon that pins clavicle fractures. Only 5-10% of surgeons pin or plate. Most plate.
6. Is my recovery normal? Tough question to answer because "recovery" means different things to everyone. Most people get numbness outside the skin incision. Superficial skin nerves are cut during surgery. Cramping in the first few weeks are normal. Cold insensitivity is common because the plate is so superficial and conducts cold.

 

[bsbs1876]

Originally Posted by josephyu .

Hi Friends,

I wanted to toss out my views on a couple of the questions:
1. Why do surgeons disagree on which clavicle fractures need treatment? There is still a large group of ortho docs who feel that nearly all clavicle fractures should be treated without surgery. In the past, scientific studies rated a patient as having a good outcome if she had decent shoulder motion and a healed fracture. Newer studies are looking at a LOT more parameters and saying that patients are NOT doing as well as we thought. I would not necessarily say one group of doctors is right or wrong because each patient is individualized and you must consider the risks of surgery. Also, a surgeon may not feel comfortable with that particular procedure. When a surgeon says you don't need surgery, he may be saying he doesn't feel comfortable doing the surgery.
2. When does the plate come out? No good answer. Based on orthopedic wisdom that has been passed down generations, that length of time is typically 1 year. However, as the long as the bone is radiographically healed, IMHO the plate can be removed. This differs from patient to patient. I assess radiographic healing by looking at 2 orthogonal views of the clavicle bone and I look at bridging callous.
3. Which middle third clavicle fractures need surgery? Most don't need surgery. The ones that do are the following: (1) fractures that don't make contact (displaced by more than 100%), (2) fractures shortened by 1.5 cm, (3) severely comminuted fractures. I did a video explaining this... http://www.totalsportsmedicine.com/#!clavicle-fractures/c3gx
4. When is the best time to get surgery? Ideally, within 2 weeks. The surgery is just easier. After 4 weeks, bone has started to form and you are often chipping away a partially healed clavicle fracture.
5. When can fractures be pinned? You need two conditions: (1) a displaced fracture which is not too comminuted (2) surgeon that pins clavicle fractures. Only 5-10% of surgeons pin or plate. Most plate.
6. Is my recovery normal? Tough question to answer because "recovery" means different things to everyone. Most people get numbness outside the skin incision. Superficial skin nerves are cut during surgery. Cramping in the first few weeks are normal. Cold insensitivity is common because the plate is so superficial and conducts cold.

Thanks for your detailed write up, Dr. Yu.

I agree with everything you have stated in your message. When I initially broke my clavicle back in 2009 all of the orthopedic surgeons I saw did not want to do the surgery. I personally think this was because they were uncomfortable with it and just wanted to wait and see how it all turns out. I had ~1-5-2cm of shortening but was not displaced. My fracture ends were touching but at a very bad angle which caused a malunion with shortening. This caused my shoulder to push in closer to my torso and did not allow my trapezius or pectoral muscles to develop properly through exercise. This was not just due to weakening. This was due to the fact that the bone was in a position that simply did not allow the muscle to grow in the right spots. All of this also resulted in pain, especially after physical activity.

I am now almost 2 months post op from surgery. I have not hit the gym yet because of course we are supposed to hold off on lifting for 3-4 months but I still feel that this was the right decision. My isometric exercises are slowly building the muscles back and I can see/feel that they are in more of a right spot. I am still not perfectly symmetrical but I truly believe that in the long run things will all come into place now. The bone was lengthened and straightened during the operation which makes my body look and feel more anatomically correct.

I am also a prime example of this surgery not being without risks. 2 weeks after my operation I had complications of the incision resulting in an aggressive intervention to re-open the site and flush it to remove/prevent infection. This was successful and I am doing well now. It set me back a bit but seemed like it was necessary at the time. The plate on my clavicle will also need to be removed when possible because of my thin frame. It is not joining with the skin properly and is noticeable in a few spots. It also seems to be causing aches with weather changes, particularly cold and rain. My doctor works the same way as Dr. Yu in that he does not give a set time as to when the plate will come out. He will do CT scans until he sees that the bone is fully healed and then it is safe to remove. I will be doing this as soon as it is possible because I want to be done with surgeries, gone with the hardware, and get on with living my life.

Even with these issues I still feel that I have made the right decision. It is still a bit early to say for sure because I have not returned to sport or weight lifting yet but I am confident that my body needed this. Sometimes I think about if my humerus or ulna were to join in a malunion, could I live with that? Of course not! My arm would be bent and obviously weak. I don't think the clavicle should be any different. Yes, the shoulder was usable but it did not ever perform to it's full extent.

Feel free to PM me if you have any questions about my experience.

 

[willy81]

Dr. Yu Many Thanks from me too. It is good you explained us what is the main reason some Doctors prefer not to operate a broken cb. I am almost 10 months post-op and I feel very strong, I follow a normal program at the gym, I play basketball without fear or hesitation to engage. Still have this numbness at the impact point, which is in front of the head of the humerus, the muscle which feels numb is the anterior deltoid. But this has nothing to do with the surgery, it feels like this because the muscle has not recovered from the impact yet. It feels better than several months ago but not as before the accident. bsbs, hahaha, you can't wait to ride your ATV again. don't try loops the first day, OK?

 

[bsbs1876]

Hey *****, I have numbness in the same spot you described ever since I got surgery. It feels like it is getting a bit better but I have a feeling it will always kinda be there. My numbness pretty much covers the area a few inches below every bit of my scar which spans probly a good 6 inches across almost from sternum to acromial. My scar is probly longer than most of yours cause he had to get everything back out to length after 3 years. It is fading some already though I think because I'm using this cream on it which seems to be helping. Who knows though since scars naturally do fade on their own anyway.

 

[pnkcoral]

Josephyu,

I wanted to get back to you on your current post and the one you wrote about auto insurance. I think you are ride on..and factual too.I have had a crash course (no pun intended) in auto wrecks, ER treatement, trauma docs, and yes a lot of broken bones..clavicle included. I was grateful to have had a rapid response team take me to the ER, treat me there as needed, then do all sorts of exams, and eventually evaluate me. However, things kind of went down hill from there. The care was poor and I do not know what I would have done if my wife did not spend the three days with me in the hospital. That included spending two nights in the extra bed. Then you had over-kill on all the CT scans, MRI's and probably some ten x-rays. I found it interesting that the minimum auto liability insurance in my state was $25K and the hospital bill came to a little over that figure. But, the real downfall of the trauma system when dealing with the insurance at-fault system is that once you are out of the woods or even still in the woods they assign you one of their trauma docs for whatever ails you. And, since you are most likely in a vulnerable state they just go ahead and do what they think is right and most likely will charge you accordingly. Nobody every said, "Say that MRI is three grand, you already had one but we want to give you another one, are you up for it." In fact, the day I was going to be discharged the departmental nurse came in and said "say Mr. G. we have to do one more MRI before I can discharge you." Well after three days of no sleep and a torso full of broken bones I hit the ceiling. NO FRIGGIN WAY LADY! They were on hunting expediation for a hairline fracture that I got 40 years ago. So, she finally relented. I will say one thing about being a trauma patient..they are thorough.

Now, I am not saying all trauma docs are substandard but I was practically being brow beated into having a plate and screw job done on my broken collar bone. The problem was that at first it was not displaced, and, then when it did get displaced about ten days after the accident I was in no condition to have it done. I just had to many serious injuries and was on my way of coming down with pnuemonia to boot. Its funny because then I was game (an old swimmer who no longer knew his limitations) but now I realize that if anything had gone wrong..like an infection (which could have been likely because my system was so weak) I would have been undone. What stopped me more than anything was the price of the surgery and not knowing how much liability insurance the at fault driver that hit me had. Technically, they(the at-fault insurance company) are supposed to tell you because if you keep running up the surgery bills and they only have $25K in liability it will eventually come out of your own pocket. However, luckily they would not tell me how much insurance they had, which is called bad faith. So, fortunatley I held off on the surgery which was the right choice for me. But, if I did not have all the other injuries and had health insurance I would most likely have gone ahead and had the operation. Lastly, I am not at liberty to say anything more about my injuriesI because I still have a substantial claim going on, but, I just went on intuition and didn't let a hungry doc do a surgery that I was not up for..physically or financially. I very rarely get myself into a postion where that little voice in my mind says, "I do not feel comfortable with this Doc but with this guy it went off big time." All is well that ends well...

Thanks, great board..