Fractured clavicle

Have you broken your shoulder? In 2010, I broke my clavicle in a mountain bike crash. I looked on the internet to find out how long it would take to heal, but I didn’t find much useful information (with the notable exception of this page). So, I decided to keep a web diary of the key dates and details of my recovery to help other who find themselves in a similar predicament.

The short version is:

By “active”, I mean you can ride a bicycle, throw a frisbee, drive a car or motorbike, go jogging and do a little bit of rock climbing.

During the month one (May, for me) your arm will be in a sling. During month two (June), you’ll be doing physio to regain range of motion. Finally, during month three (July), you’ll be doing physio to regain strength.

Note: ‘fractured clavicle’ covers a huge range of ailments. Some people have a minor crack in their bone. Other times, the bone is completely broken but remains nicely lined up. My break was at the bad end – the two sides of the break were displaced pretty far apart. So, when people say “oh, I broke my clavicle and I was cycling again in two weeks” they’re not necessarily talking about the same severity of injury.

The accident – Sunday 2nd May

I was heading out on a mountain bike training ride. Near the start of the ride, there’s a small tree stump. It’s small enough to act as a takeoff ramp for a small jump and, since I cycle this way to work, I’ve jumped it many times without problems. But this time I was going faster than normal and evidentally not paying enough attention.

My front wheel cleared the obstacle but my rear wheel clipped it hard, shooting the back of the bike up into the air. The bike landed on the front wheel only and became a high-speed unicycle. My momentum carried me along on one wheel for a while, teetering on the edge of going over the handlebars. I thought “oh, not good” but stayed with it, trying to ride it out.

I didn’t manage to ride it out. I went all the way over the front and, with my hands still on the bars and the bike moving at about 20mph, I crunched onto my right shoulder and bounced along the ground.

Straight away, I knew I’d hurt my shoulder – maybe a torn muscle? It was certainly sore, but not a terrible pain. It got more serious when I put my hand onto my right shoulder. I discovered it was now shaped like a triangular wedge. Uhh, really very not good.

I decided to cease my adhoc medical investigations, and decided to focus on getting help. From previous incidents (Jeremy!) I knew I had about 20 minutes of adrenaline/endorphines before things would start getting really really sore.

There was no mobile phone reception where I crashed, so I had to get back on my bike and cycle for half a mile with one hand. Once I got some reception, I phoned a friend who took me to the hospital.

Stuff I learned:

Hospital, A&E – 1 hour after crash

I spent an hour at the nearby Minor Injuries clinic. They looked at my shoulder, and it was clear that my clavicle was now pointing the wrong way. An xray confirmed that it was broken rather than dislocated, and so I got an appointment with a specialist for the following day.

The nurses explained that clavicle fractures are usually “managed conservatively” – meaning, no surgery – because the human body is pretty good at keeping everything in alignment while the bones heal. Looking at the bone sticking up out of my shoulder, this seemed rather far fetched.

Remember the adrenaline? I was still feeling good and making jokes. Then suddenly I was feeling very not good. I guess all the happy chemicals wore off, and shock set in. The nurses quickly got me to lie on my back with legs in the air. That got the blood back into my head, and worked wonders.

The nurse gave me a sling to support my arm and strong painkillers to take away – 60mg codine + 1000mg paracetomol every 4 hours. They suggested propping myself up on 3 pillows to sleep at night. In fact, I slept reasonably well that night; codine is potent stuff.

This was the first time in my life that I heard the word “acromion”. It’s the name for the protrusion that goes round the outside from the shoulder blade, and connects to the clavicle. Previously, I knew that I had a clavicle and a scapula, but I had no idea how they joined up. Over the next few weeks, I learned a lot about shoulder anatomy …. mostly from reading The Principles of Anatomy and Physiology.

Hospital, shoulder specialist – 1 day after crash

The specialist took one look at my shoulder and said it needed surgery. The bone was displaced too far, he said, and there was no way it would heal in the right place.

In surgeon-speak, this would be an ORIF, meaning:

Specifically, they were going to drill holes through my clavicle and another nearby bone. They’d put some ‘surgical string’ through the holes, pull the bones together, and tie it off above and below with two ‘endobuttons’. They also ended up screwing the two fractured ends of the clavicle together.

The specialist enumerated the risks of surgery:

Day surgery – May 4, two days after crash

I stayed overnight in hospital – nil-by-mouth from midnight. I had a chat with the surgeon at about 9am, and was knocked out by a general anaesthetic soon after.

I came round in the recovery room at noon with an oxygen mask on and a drip in my arm. A nurse was taking my blood pressure. Despite everyone telling me that modern general anaesthetics are so much better than they used to be, I still felt sick and promptly threw up. I was still super dozy from the anaesthetic and was quite happy to go back to sleep and keep doing that for the rest of the afternoon.

I was a day surgery case, and normally that means you go home at around 7pm. However, I was still groggy at 7pm and hadn’t managed to eat any food. So I stayed in overnight. At about 10pm I managed to eat some food, and around midnight I managed to stand up. The next morning, I got to go home. Oh boy, I felt every tiny bump in the road on the drive home.

The hospital gave me a fabric sling to wear, and wound dressings which needed changed daily. The stitches they’d used on the surgical incision were the dissolving kind and didn’t require any further attention.

Tips:

Coping – week one.

The first week involved adapting my lift to one-handed living, since my bad arm was in a sling. Things like:

Pain-wise, week one was not good. I was still on mega-strong codine. My shoulder itself wasn’t that sore, but my forearm and wrist had bad throbbing pain which kept me awake at night. The nerves in the wrist pass through the shoulder, and so post-surgery swelling was messing them up. One night, I had to get up and sit up for two hours waiting for the pain to subside.

Each day, I had to change the dressing on the surgery wound. Fortunately, it all healed up really well and there was never any sign of infection. After a week, I was told to leave it uncovered.

I found it easiest to sleep on the sofa rather than a bed. A few days after getting home, I was able to roll slightly onto my good side and support by back against the back of the sofa via strategically placed cushions.

Adapting – week two

Week two was all about adapting my life. I’m a big computer user so I tried various alternative input methods. Voice recognition wasn’t great; the accuracy was tolerable, but editing and making corrections was tedious. Chord keyboards were better. I’d bought a Twiddler years ago and suddenly it became very useful. It was great to be back on the internet, but it was frustrating to be so slow at everything.

During week two, I stopped taking the super-strong hospital codine and went down to over-the-counter strength cocodamol.

Random tips:

Back at work – week three

I went back to work at the start of week three. I was able to talk and write emails very slowly, but I couldn’t do any real programming. I was able to get the bus and train, and sometimes got a lift in a friend’s car. Other days, I worked from home.

During week three I decided to stop taking codine. I was still a bit sore, but I was beginning to think that taking painkillers was becoming more of a psychological crutch rather than a necessity so I just stopped taking them.

Frustration – week four

Week four was full of frustration. I knew I had an x-ray appointment the following week and it couldn’t come soon enough – I wanted to know if the surgery had went well or not. I was trying to do more and more activities and that was causing me lots of aches.

Your neck gets really sore when you walk around with your arm bouncing in a sling. The top of my back and my neck felt like it was tied in knots and caused me more pain than my shoulder. For four consecutive days, I had hot baths after work and that worked wonders.

No sling, no movement – month two

My hospital appointment was 4 weeks after the surgery. I was expecting to get an x-ray but they didn’t do one. Instead, the surgeon just checked my shoulder by hand. It was good news. The wound had healed up really well and I could stop using the sling.

The surgeon explained that he’d screwed the ends of the bone together, and consequently there wasn’t any risk of it coming undone. Actually he said, “once we had the bones lined up, we looked at it and thought that we couldn’t not put a screw in .. a bit ‘belts and braces’ though”.

I was pretty pleased to find the ends had been screwed together because I’d been worried about dislodging the bone over the last few days.

With my arm out of the sling, I suddenly discovered what immobility does to your joints. My elbow had seized up and my muscles had wasted away badly during the last four weeks. My elbow wouldn’t straighten out – it felt like the blood vessels or nerves in my elbow were too short and being tugged on. It would be two days until my elbow would go straight.

Worse, I couldn’t lift my arm more than a few inches away from my body. It was a real shock. I tried to move my arm and it just wouldn’t move. I tried really hard to move my arm and it moved only an inch. My arm looked thin and emaciated. The muscles I used to have from years of rock climbing had vanished due to four weeks of immobiltiy. My arm had never been this weak before, and it was weird to experience my body in this state.

Being scientifically minded, I later calibrated the effort it took to move my arm. I picked up some weights with my good arm, and estimated that a straight-arm lift of 8kg was comparable to the effort it took to lift my unladen bad arm by itself.

When the surgeon explained what he’d done, he used a big stream of jargon which, because I’d been reading lots on the internet, I mostly understood. The key phrases were:

I also knew that normally you have two ligaments between your clavicle and the coracoid process. I assumed those had been torn, and I asked if he’d “fixed them”. His answer was a bit vague (to my ears), but it amounted to this:

“Those ligaments have been torn and are gone forever. Your body will fill that area with scar tissue. This scar tissue will hold all the bits together pretty well”

After seeing the surgeon, I saw a physiotherapist. She gave me some gentle exercises – pendulum swings, arm-straightening stretches and assisted lifts. The surgeon had said it’d be 2 months before I could drive a car, but the physio said two weeks (and the physio was spot on!).

Recovering movement – month two

One month after breaking my shoulder, I could just about type with two hands. I had to deposit my bad hand onto the keyboard manually. It meant I could type, but it put a lot of strain onto my shoulder and was uncomfortable.

My first proper physio session was on June 3rd. I got some exercises to do which sound simple, but they required a lot of effort:

I did the exercises for thirty minutes, three times every day. It took four days of this before I could actually get my arm up to the horizontal position.

All the time, I kept thinking of one of my friends who’d smashed his elbow badly. Afterwards, he had said “I wished I’d been more diligent about doing my physio exercises”. This made me realise I basically had one chance to do this right and so I mentally committed myself to having “physio” as my main activity for the next month.

Prior to the accident, I’d been racing mountain bikes and cycling long distances. After training for that, I was used to pushing myself to the point of exhaustion and was no stranger to discomfort. I was also used to setting and achieving realistic targets. Suddenly, race training was a memory and physio was the only ‘challenge’ I had to focus my energy on. I decided that I wasn’t just going to do the physio exercises. I was going to totally nail them, so that each time I visited the physio they’d say “wow, you’ve progressed much further than we expected”. This was my goal, and it kept me focused.

I also initially had the wrong mental model for what physio achieves. Initially, I was waiting for the sore bits to “get better” by themselves and was reticent to stretch them. Then I realised that they don’t get better by themselves .. the physio exercises pull them apart. The muscles are all damaged and full of inflexible scar tissue. It needs to be physically forced to move. This wasn’t pleasant. There was a pointy bone at the top of my scapula which I could feel scraping against the inflammed muscles every time I moved. And when I’d do the hand-behind-back stretch, I was pulling and stretching the very bits that I felt I should be protecting. But you just have to do it. You need to get the joints and muscles moving, otherwise they might never move properly again. No choice.

I was still getting a lot of nerve pain. It felt like there was an overly tight elastic band stretched beneath my skin, which got tugged and pulled when I moved. That nerve pain started to go away as I started moving more and had less swelling.

By the end of week five, I could type with two hands much more comfortably. I was able to lift plates out of high cupboard, just.

As time went on, I started being able to do more tasks:

At the end of June, I had another hospital appointment. This time I did get an xray. The surgeon said it looked good. He explained that the joint was at around 30% normal strength, and that there was still a risk of re-breaking it over next 4 weeks. My forearm was still numb, although not sore. He recommended I wait six weeks before any ‘strenuous activity’. Stationary exercise bicycles were allowed. Jogging was also okay, so long as I didn’t fall over or jar my shoulder too much.

I decided to aim to do a 10k run in mid-September to give me something to focus on. On 28th June I started jogging, being very careful not to trip up.

Regaining strength and movement – month three

In July I had another physio appointment and was given some different exercises. To increase my range of motion, I had to stand under a doorway, put my hand against the top of the doorway and then move forward so that my arm was stretched backward a bit. As ever, I was told I should push far enough that it’s “uncomfortable, but not agony”.

The second exercise required a resistance band; like a big elastic band. I tied a knot in the elastic band, wedged one end into a closed door and held onto the other end with my hand. With my elbow joint at 90 degrees and my arm at a 45 degree angle to my side I had to pull against the band by rotating my upper arm, keeping everything else fixed. Oh boy, that was tough at first. It really isolates your shoulder muscles.

Some more dates:

Recovered – month four

On 3rd August, three months since my accident, I had my last physio appointment. They said I didn’t need to do any more exercises, and they were very pleased by my recovery. Two days later, I went out cycling again without any problems and also played frisbee that week. In September, I ran my 10k and in October I went ice climbing.

In November, I started doing the hundred push up challenge and after several weeks was able to do 5 sets totalling 140 pressups before winter colds brought things to a halt. This was really a psychological thing for me. I wanted to end my ‘recovery’ mindset by showing myself that I could train up and achieve something that I wasn’t able to do pre-accident.

Epilogue – a year on

It’s now a year since my accident. My shoulder healed completely, and is now stronger than it was before the accident. I still have screws and bits of titanium in my shoulder. They don’t set off airport scanners, but you can feel them under my skin. They also don’t cause problems for MRI scanners, according to the surgeon.

Looking back, I think the most important thing was to mentally commit myself to doing the physio exercises. Not in a token way, but in a “knock the ball out of the park” way. It was hard and uncomfortable work, but I had to do it for myself, and I ended up regaining full range of motion because of it.

Andrew Birkett (andy@nobugs.org), 7 May 2011.