Distal Collar Bone (Clavicle) FractureTHE INJURYOn December 25th, 2007 (Christmas day) when I was out for a walk with my fiancee's family, we were tossing a football around in a large open grassy field. While running full force and leaping in the air to catch a football thrown beyond my reach, I found myself landing off balance on one foot with the momentum of my body continuing to carry it at a high rate of speed toward the rock-hard frozen ground. I knew I was going to fall to the ground so I decided to tuck in my arms and roll through it to help absorb the shock. But when I hit the ground, my left shoulder took a direct impact and I heard a muffled "crunch" as my body rolled over the grass and came to a stop. At first it felt like my shoulder joint had popped out of the socket because I didn't hear a distinct "snap". I reached over the my left shoulder with my right hand and felt that it was out of place. I remember asking someone nearby if they could look at it and snap it back into place. But when people looked at it and said "Eww...that doesn't look good at all", I started to get worried. I reached back and could feel my shoulder was deformed and there was a firm bump on the back of my trapezius (neck-to-shoulder muscle). I think at that moment I realized that my collar bone was broken and pushing out against my trapzius muscle at the back of my shoulder. That's when the body automatically goes into a mild form of shock; when people are telling you "Eww...that looks serious" and "We'd better get you to the hospital". I could feel the blood begin to drain out of my face as I tried to remain calm. The pain was minimal at this point; about the same as having rammed my shoulder against a concrete wall without breaking anything. My stomach was getting a little queezy at the thought of the bone tearing its way through the muscle of my upper back. I could feel that I was pale in the face, and the pain was slowly starting to creep in. I remember being surprised at 1) how easily the bone broke and with almost no "cracking" sound at all, and 2) that the broken bone really didn't hurt that much. The pain was mainly coming from the torn tissue around the bone. So my fiancee's family ran home to get the car and took me to the emergency room at the Hospital. When I arrived, the pain was increasing quite rapidly. The nurses asked me at what pain level I was at on a scale from 1 to 10, and I told them about a 4. They proceeded to cut my shirt off since I couldn't lift my arm. They took me to the X-ray room and took two X-rays of my shoulder from the front, and one from slightly off to the left side. The X-rays from the front are angled downward so that the rib cage doesn't overlap the clavicle. The X-ray technician told me right away, "Yup, it's definitely broken. And it's a pretty big break." The doctor came in aagain then to tell me that I had broken my collar bone toward the distal (lateral or outside) end. He went on to say that clavicle fractures are normally left to heal on their own without surgical intervention, but that I should follow up with an orthopedic specialist when I returned back to my hometown after the holidays. I asked the doc if he was implying that I just leave the bone to heal itself, and he told me that the majority of collar bone fractures heel by themselves. He said that the muscles which are attached to the broken parts of the bone will pull at the bone and pull it back close to its original alignment. He said it might leave a big bony knot where the bone heals, but that I shoulder be able to use my left arm again normally after a few months. I guess the old saying goes "As long as the two ends of the bone are in the same room, they'll find each other and reunite." So I took is advice, had my arm put into a sling, asked for a hardcopy (CD-ROM) of my X-rays, got some pain killers, and went home. By the time I was leaving the hospital, my pain had increaed to a level 8. Every bump and turn on the way home caused me to clench my teeth and brought tears to my eyes. I could feel the broken end of my clavicle poking and tearing at the muscles and tissue of posterior shoulder when my body made any sort of movement. Once we were back at the house, I sat down on a couch and propped my elbow on a pillow to rest. I waited for the pain killers to kick in. At this point I was definitely up to a pain level of 9. My overall shoulder felt like it had been kicked in by a horse; it had an dull but extremely sore and bruised feeling to it. In contrast to this, the area where my broken clavicle was protruding into the muscle of my posterior shoulder had an extreme sharp burning sensation. It was as if someoone had taken a fireplace poker and heated it up redhot in the fire and then drove it into my posterior shoulder. It was a combination of these two pains working together that would make life miserable for then next several days. THE FINAL DIAGNOSIS Two days after the clavicle fracture happened I went to see a local orthopedic specialist to get another evaluation/opinion of my condition. He took a look at the CD-ROM of my X-rays and said that I had a severe type 2 (displaced fracture with torn CC ligaments) distal clavicular fracture. He told me I had three options. 1) I let it heal by itself and live with a big bony knot and impaired mobility of my shoulder. 2) I elect to have surgery (Open Reduction and Internal Fixation) to realign the bone and have a metal plate screwed ontop of it hold it together. 3) I have surgery without the plate and just tie the broken clavicle back down to the cricoid process where the ligaments were torn. In either case, the orthopedic specialist strongly recommended surgery because the bone was severely displaced and impaled in the muscle of my posterior shoulder. I told him I was from out of town and he suggested that I have the surgery down in my hometown since I will need to come back for a postoperative review a few weeks after surgery. So my fiancee and I packed up our bags and drove the 8-hour trip back to our hometown for a surgical consult with an orthopedic surgeon. That orthopedic surgeon agreed with the diagnosis of the severe type 2 (Neer) distal clavicular fracture, and he said there is no chance of it healing on its own. The distance of separation between the factured ends along with the tearing of the CC ligaments and the impalement of the clavicle in my trapezius muscle all indicated that surgery was necessary. There was no way that the clavicle would rejoin by itself and there was tissue caught between the two broken ends of the collar bone. So I was scheduled for surgery in a week (because of conflict with the New Years holiday). The procedure that was recommended was an ORIF (Open Reduction and Internal Fixation) where they would make an incision across the top of my shoulder and dislodge the bone from my muscle and pull it back to the front. They then planned on putting a metal plate with screws across the fracture site and tying down the construct (plate) to the cricoid process with a thick "shoestring-type suture" to help reestablish the torn CC ligaments. THE TREATMENT OPTIONS Let me begin by saying that I most adamantly did not want to have surgery. I was not fond of the idea of having an incision (and subsequent scar) on my shoulder, and the idea of having metal plates and screws along with "shoestrings" in my body made my stomach crawl. I imagined being able to run my fingers over my fixed clavicle and feeling the plate and screws under my skin. So I began doing some research as to the pros and cons of my treatment options. Here is what I found. Please keep in mind that this should not be taken as medical advice, and you should consult your orthopedic specialist and strongly consider his expert advice to your specific injury before making any medical decisions. I am not a medical expert.
THE SURGERY I was scheduled for outpatient surgery to have my clavicle fixed. I had talked over my options with the surgeon befor the operation. My concern was, after looking at the X-rays, that there wasn't enough bone left on the distal (outside) end of my clavicle for the screws to securely fasten to. My break occurred about 1.5 cm from the end of the clavicle, and I felt that 1.5 cm wasn't enough to put screws into without splitting the bone. And furthermore, I preferred not to have a plate put in because I didn't want the uncomforts of a plate, and I preferred having the bone heal more solidly on its own. After discussing it, we decided that he would try to put in an IM pin as Plan A, and if that didn't work, then he would use the plate and screws as Plan B. I was okay with that. I arrived at the outpatient surgery center and waited in the waiting room to have my name called. Then they took me to the "prep" room where a nice nurse asked me questions about allergies and past history, etc. They then had me change into a hospital gown and the had me mark an "X" on the correct shoulder that was going to be operated on. Then another nurse can in and inserted an IV into my wrist. Apparently, there are several locations that they can insert an IV into, including the elbow, back of hand, bottom of wrist, and side of wrist. You can elect to have a small local anesthetic injected at the site of entry to help numb the skin for the insertion of the IV. The anesthitic injection hurts like a bee sting; you can't really feel the needle at all, but the anesthetic stings and burns for a few seconds. The IV tube is inserted into your vein and taped down to your skin to prevent it from being pulled out. They will then use the IV to administer liquids, electrolytes, medication, and the general anesthetic. It is a good idea to go to the bathroom one last time before they take you into surgery. Once I was ready to go to surgery they walked me into the operating room and had me lie down on the operating table. They stretched my good arm out to the side so that they could have access to the IV, and they put a pillow under my head. They asked me what had happened to my broken collar bone and I began to tell them the story............. ........and the next thing I new I was opening my eyes in the recovery room. I was dazed; completely "out of it". I closed my eyes again and woke up again a few minutes later. A nurse was standing next to me adjusting my IV. I was sedated on pain killers and my shoulder was wrapped in soft foam padding. It took me about 30 minutes to get up and start putting my clothes on. The nurses took the IV out and gave me some oral pain killers and sent me home. I later found out what went on during my surgery, of which I have absolutely no recollection. The surgeons opened the incision over my shoulder and found that the distal (outside) fragment of my clavicle was shattered. This meant that they go not do Plan A nor Plan B since there wasn't much bone left to attach anything to. They ended up removing the shattered pieces of bone from the end of the clavicle and then repositioning the clavicle into correct anatomical position and tying it down to surrounding bone. To tie it down, they drilled two holes through the clavicle through which to pass the tie-downs. Since both of my CC (coracoclavicular) ligaments were torn, they had to reconstruct both of them. They began by using a heavy suture tape (like a shoestring) to loop under the coracoid process of the scapula. This suture tape was threaded through the proximal (near) hole in the clavicle and tied. Then they took the coracoacromial ligament, cut it off of the acromion, and threaded it through the distal (far) hole in the clavicle. These two reconstructed ligaments kept the clavicle tied to the coracoid and held it in the correct position. THE PAIN AND HEALING PROCESS Immediately after the surgery the pain was fairly intense. I was on oxycontin for pain and it helped take away my awareness of the pain. Put it also made me very drowsy and disoriented/confused. I found that I needed to take the oxycontin once every 4 hours to keep the pain manageable. I'd say the majority of the pain came from the disrupted muscles and the intense swelling over my shoulder and upper back. They say that ice packs will help ease the swelling, but I didn't use any. Some side effects of the anesthesia showed up the first few days after surgery. My stomach was upset (I think that was due to the oxycontin), and my sense of taste for sweet things disappeared for a week or two. I had a sore throat for a few days, which I think is from the endotracheal tube they place in your airway during the surgery. i think this tube is also possibly responsible for the loss of taste, as it compresses on nerves in your throat. But the lack of taste may also be your body just telling you that it craves protein rather than sugar. For the healing process, avoid alcoholic drinks and sodas. These disrupt the blood supply to the healing area and impede the healing process. Smoking also impedes healing. Eat lots of protein, calcium and vitamins and minerals. Your body needs good nutrition in order to heal. For example, it can't utilize calcium to rebuild bones without having vitamin D. The pain during the healing process is quite noticeable and decreases by a miniscule rate degree each day. I'd say my pain during the first few days was a 9 out of 10, with it dropping down to a 7 while I rested, a 9 when I tried to walk around, and a 4 when fully medicated with oxycontin. The swelling and torn internal tissues seem to cause the most pain for the first few days. It is extremely painful to get up, sit down, or especially to lay down or get up from a reclined position. It seems every muscle in your body pulls on your thorax which then pulls on your shoulder and chest muslces. The pain causes you to hold your upper body in an abnormal position, which in turn causes your back to ache. Since your arm is in a sling, your upper back and neck muscles spasm and atrophy (dissolve) which then makes your entire neck, back, and spine hurt. With medication, the first few days are tolerable during rest. Walking around made my shoulder hurt really bad and it made me quite irritable. I couldn't sleep. I couldn't taste well, and the drugs made me sick to my stomach. So by the fourth day post-operation, I decided to go off of the narcotics. I took some Tylenol to help reduce the pain from the swelling, but I figured I could indure the pain as long as I rested. I'd say at that point I was at an 8 pain level, which dropped to about a 6 with rest. I'd say the pain came from the swelling of the tissue (it felt like a giant bruise over my entire shoulder that the swelling was pressing on) and the immobility of my upper body. My back and neck hurt really back, like when you have your neck turned to the side for a while watching TV and then you try to turn it back. It was extremely sore. By the end of the first week after surgery I was still at a pain level of about 7. I walked around very slowly with an obvious look of pain in my face. I couldn't get dressed, or shower, or use the computer, or eat very well. The TV remote control was about all i could manage. By the second week, the pain gradually came down to about a 6. But it seemed that the weather affected my pain level. As the pressure changed or the temperature changed, my bone would ache painfully. During some days when it got really cold and rainy, I had to be confined to the bed again because the pain was back to a 9. By the end of the second week I was scheduled to go see my surgeon for a post-operative consult. They took X-rays and the surgeon said everything looked okay. He exphasized again that I should keep my arm in a sling and avoid stressing it. He said I should do "pendulum" exercises where you take the sling off and let your arm hang by your side, swinging it lightly back and forth. He scheduled me for a second follow-up in another four weeks. Over the next four weeks the shoulder got slightly better each day. It takes 4-6 weeks for bone and torn muscle to heal. From my experience, the tissue heals as quickly as the hair on your chest grows back (the hair that the shave off during surgery). So you can judge the rate of healing that way. So here is a summary of my recovery: WEEK 1 Pain level: 9, decreasing to 8 Attitude: In a lot of pain, irritable, disoriented from pain killers, sleep deprived. Loss of taste for sweets. Look of pain on face. Tears once in a while. Daily living: Pretty much incapacitated. Can't dress or shower. Eating is difficult. Going to bathroom is difficult. Wearing sweatpants and button down shirt is best. Diffucult to sleep more than an hour at a time. WEEK 2 Pain level: 7 decreasing to 6, but back to 9 during weather changes. Pain similar to kicking your skin into the edge of coffee table. Hurts to cough or laugh. Attitude: In quite a bit of pain, really sore neck and back, sleep deprived. Bored. Somber, emotionless face. Daily living: Slow movements. Able to dress and shower with assistance. Able to sleep now for about 3 hours at a time. WEEK 3 Pain level: 6 decreasing to 5. Pain similar to a bad sunburn, but without the burning sensation. Attitude: In pain, really sore neck and back, sleep deprived. Smiling once in a while. Hurts to cough or laugh. Daily living: Slow movements. Back at computer doing minimal work with good hand. Able to dress and shower on my own, but it takes a really long time. Able to sleep for about 5 hours at a time. WEEK 4 Pain level: 4 decreasing to 2, biggest decrease in pain. Now feels similar to a bad tooth ache. Pain is now frustrating but manageable, like after a really hard workout at the gym when you can't move the next day. Hurts to cough or laugh. Attitude: In pain, really sore neck and back, sleep deprived. Smiling and chatting again. Daily living: Slow movements. Working full time on computer again. Able to shower and dress, but still slow with caution. Able to sleep for about 6 hours at a time. WEEK 5 Pain level: 2 decreasing to 1. Shoulder is sore, feels similar to severe arthritis. Feels "frozen". Hurts to cough. Attitude: Sore neck and back. Smiling and chatting. Daily living: Slow movements. Able to leave house for dinner or movie. Able to remove sling and exercise arm a little, but arm doesn't move very well. Able to shower and dress, but still with caution. Able to sleep through night. WEEK 6 Pain level: 1. Shoulder is sore. Feels similar to being frozen. Attitude: Smiling and socializing again. Daily living: Fairly normal movements. Able to leave house and run errands. Able to remove sling and exercise arm with rubber bands, but arm doesn't move very well. Able to shower and dress at normal pace, but limited movement of arm. Add: How bone heals. FEELINGS OF DEPRESSION/INADEQUACY irritability - provoked by pain. inability to move life changing experience |