The (broken) Collarbone

Thursday, 5 April 2012

Sleutelbeen

Think of a crash in a bike race and it’s easy to imagine leg injuries given the sport is associated with the leg muscles and the exposed skin. But when it comes to broken bones, it seems riders seem to break and fracture their collarbones all the time.

Off the top of my head, from men’s pro cycling Fabian Cancellara, David Millar, Filippo Pozzato, Sebastian Langeveld, Wouter Mol, Carlos Quintero have done it this season, and there must be several more. Even the UCI’s Alain Rumpf  too. Get well soon.

Here’s a quick look at this bone which turns out to be unique.

Description
The clavicle is the formal medical name, from clavicula in Latin meaning “small key”. You might see it in other languages as the sleutelbeen in Dutch, again “key bone” or clavicule and clavicola in French and Italian.

Clavicule

Still in one piece

The bone itself is horizontal on your shoulder, from the front of the next out towards the top of your shoulder. You have one on each side and you can feel it. It’s job is to act as a support for your arm, to help hold the arm in place when the shoulder moves. A support strut if you like.

It’s also special in several ways according to Wikipedia:

  • The clavicle is the first bone to begin the process of ossification (laying down of minerals onto a preformed matrix) during development of the embryo.
  • It is one of the last bones to finish ossification at about 21–25 years of age.
  • Even though it is classified as a long bone, normally the clavicle has no bone marrow cavity like other long bones.
  • The most commonly broken bone is the clavicle, accounting for 5% of all fractures seen in hospital emergency admissions

Why do cyclists break their collarbones?
Breaks and fractures occur when there’s a sudden force to the bone and a bike crash is an almost perfect example. When you go done there’s a tendency to break the fall by putting your arm out. If you haven’t done it yourself you’ve probably seen the TV slow-motion of a rider with the arm outstretched about to confront the tarmac. But the arm just sends the force of the impact up your arm to the collarbone. Snap.

Similarly if you don’t deliberately put the arm out then you can land on the elbow and crack the bone too.

TV diagnosis
X-ray is the normal diagnosis but the radiowaves of TV offer a cheap alternative. If you watch a race on TV and see a rider go down and then get up, only to start holding their arm in a bid to take the weight of it then chances are the collarbone is in trouble. Just look at the picture above and the rider – Pozzato – is grabbing his arm and shoulder. The injury will swell and there’s local pain. Normally a sling is given. If you leave the race, don’t try to carry your suitcase.

Prognosis
All sorts of breaks and fractures can occur. If there’s no displacement, meaning the bone is fractured but still in the right place then typically surgery isn’t performed. If the bone is broken and in pieces – like Cancellara’s X-ray above – then surgery puts things in place. In Cancellara’s case he got an “intramedullary fixation device” which is a fancy word for a pin that’s like a kebab skewer on which the broken pieces were slotted back together. If you want more on the surgery and process, see the cyclingtips blog for a useful explainer.

Recovery is one of those “piece of string” responses, it is very dependent on the injury and the medical support too. For a normal break it means four weeks off the bike and then a gradual return. But often healthy athletes recover faster and some can resume work on an indoor trainer within a few days. The most extreme example of recovery must go to Pozzato who broke his bone during the Tour of Qatar in February (pictured clutching his shoulder above). He tells his tale in a good interview with Daniel Freibe on cyclingnews.com:

“The doctor told me to stay off the bike for a month, to give the bone time to calcify. The problem was that I couldn’t do anything for 40 days. I got angry with the doctor. I came back from Qatar on the Friday night, went into hospital on Saturday morning and told him to operate straight away. He said that was impossible, that I had to wait for 10 hours. I told him that I couldn’t wait ten hours, that I needed to be aback on my bike in three days and racing at the weekend. He asked me whether I was mad. My girlfriend said I was mad, too, but it was such a crucial point of the season. Even [Farnese Vini-Selle Italia directeur sportif Luca] Scinto didn’t want me to race. I said that I’d put my balls on the line and I wanted to give this everything. I told him that this was my decision. I didn’t want to lose anything, even psychologically – you know that after a week off the bike you start to lose your condition. In the end I was back on the bike after four days. I think I made the right decision.”

Pozzato has every right to claim the right decision given his second place in the recent Tour of Flanders. But I suspect elements of the medical profession will be horrified by his attitude, it worked this time but he could just as easily have got problems.

However some can ride with a broken collarbone. Tyler Hamilton rode the 2003 Tour de France with a fractured collarbone and a lot of pain. Thanks to taping and bravery he stayed in the race. The year before that he’d broken his shoulder yet carried on in the Giro d’Italia, gritting his teeth so hard that he needed dental work once the race was over.

Magni grits his teeth

Fiorenzo Magni was a champion cyclist with three wins in the Giro and three in the Tour of Flanders too but he’s also remembered for breaking his collarbone and being unable to hold the bars properly, so his mechanics tied some rubber tubing to the handlebars for him to bite on for a time trial stage. Unorthodox and sadly he crashed again and broke his arm.

Wrist next
After the collarbone, the wrist is next for the cyclist as it too takes the impact on a crash. Carlos Barredo and Yukiya Arashiro are two out of action with this injury today.

Summary
Surprisingly the most frequently broken bone for everyone, it’s also very common for cyclists as they’re likely to land on their arms in a fall. From a small hairline fracture to the Cancellara bone wreck X-ray above, the pain and recovery period can vary. The next time you see someone clutching their arm after a crash in a race, chances are its the collarbone that’s gone.

Pin It

{ 29 comments }

a different ben April 5, 2012 at 9:05 am

chicks break collarbones too: http://www.emmajohansson.com/2012/01/24/rehab/

dislocatedMTB April 5, 2012 at 9:22 am

And guys! Before and after pics. Mine was similar to Cancellara’s, but my floating middle piece didn’t split in too. I was on the track and a good friend of mine managed to slide down the banking and take me out. I’m pretty sure I kept my hands on the bars too but as they say… it all happened so fast… and in slow motion.

http://www.dislocatedmtb.com/2011/01/full-circle-part-2the-aftermath.html
http://www.dislocatedmtb.com/2011/03/i-am-bionic.html

vincent April 5, 2012 at 9:58 am

I considered myself a real cyclist once I had fractured my clavicle fracture.

Chrismurphy101 April 5, 2012 at 9:59 am

Putting your arms out in a crash is definitely a good self-preservation instinct to break.

I broke a rib instead but it was much less painful than a collarbone.

I heard a story that in Japan they teach the juniors not to put their arms out by pushing them over onto grass repeatedly, until the ‘drop and roll’ kinda technique is the natural reflex. I am not saying it’s a fact, but it makes sense

The Inner Ring April 5, 2012 at 10:13 am

Chrismurphy101: I don’t know it it’s true either but martial arts, like some used in Japan, can teach you how to fall. The basic idea is to roll rather than smack the ground, to slowly take the force out of falling.

One additional thing is that when you fall you can tense up for obvious reasons but this can make the injury worse.

Nick Rearden April 5, 2012 at 10:20 am

I remembered reading in Cycling Weekly years ago about the promising young Irish cyclist Sean Kelly practising crashing and sure enough when I met him recently he confirmed that, sure, enough, that was a part of his regime before he went off to live and race in Belgium. He reckoned it was as much about building confidence for the rough and tumble of field sprints as for preservation of his clavicles. Of course, if I was any good I’d have asked him if he’d ever broken them but surely INRNG will know that?

bikecellar April 5, 2012 at 10:26 am

It seems to be the bigger guys (in cycling terms) who break the bones, over the years I have crashed in and out of competition scores of times, with no breakages, my thinking has always been “I bounce” at sub 60 kg I must be at the bottom end of the weight scale. I suppose the adage “The bigger they are the harder they fall” seems to apply.

The Inner Ring April 5, 2012 at 10:31 am

Nick Rearden: yes and I almost put a picture of Kelly holding his shoulder on here from 1987 but it turned out he ruptured shoulder ligaments instead but he still left the Tour de France. He did break it later in 1991.

daniel alpin April 5, 2012 at 11:18 am

i’ve done it its no fun believe me

ave April 5, 2012 at 12:03 pm

Pozzato broke his left clavicle, no? He has operation marks on his left shoulder, that’s for sure.

Larry T. April 5, 2012 at 12:18 pm

Back-in-the-day the coaches used to ride us around on grass and “crash” us in an attempt to teach us how to fall off without breaking anything. I had plenty of practice falling off as a motorcycle racer as well so (so far anyway) have managed to avoid breaking any bones in my two-wheeled life. I’ve fallen off enough times to instinctively “assume the position” (as in the fetal one) as soon as possible. Of course I’ve probably now jinxed myself and will be joining the broken clavicle ranks soon enough! Best wishes for a speedy recovery to Spartacus, just looking at the x-ray gives me phantom pain.

Gerrald April 5, 2012 at 12:22 pm

Excellent piece again. I wondered how cyclists should deal with this. Inrng, do you know whether crashing lessons ever became part of the exercising routine in any team?
Given the number of occurences, and the possible impact on the season, would riders consider the bionic approach of replacing the clavicle with a metal counterpart? If so, would this count as doping?

Andy Raff April 5, 2012 at 1:08 pm

A few years back I fell and cracked a bone in my elbow, ouch.

I have fallen a couple of times recently, but more due to my own stupidity and not clicking out of pedals in time when the chain has dropped etc.

But each time I just braced myself and kept my arms close to my side.

Sore on the hips and side, but I guess it lowers the risk of breaks to wrist/collar bone etc.

But no idea what I’d do at high speed.
Having said that, I rarely hit high speeds unless going downhill!

vincent April 5, 2012 at 1:11 pm

Chris Murphy101 and InnerRing The martial arts practice of Ukemi is where you tuck your head and roll taking the fall on your upper back and rolling out. It is practiced until it becomes habitual.
A good example of it being used. Watch J.A.Flecha hit the tarmac when he was hit by the car in the 2011 TDF

miles April 5, 2012 at 1:44 pm

I broke my collerbone in a race in San Louis in 1983 and reading articles like this make it hurt again!

zalamanda April 5, 2012 at 1:47 pm

sometimes crashes take you by surprise. Even though I’m used to riding in the wet, I pranged in a race; thin tyres in heavy rain aren’t good friends and I hit the ground hard. I didn’t realise I’d broken my elbow until I’d finish. Do you reckon Joseba Beloki could have predicted his tyre rolling off his rim while decending the Cote de La Rochette?

alanjay April 5, 2012 at 2:15 pm

Broke my right collarbone 4 times but funnily enough never cycling! It is very wonky now!

Ken April 5, 2012 at 2:59 pm

In the Tour a couple of years ago, both Frank Schleck and Lance Armstrong took similar falls in the early stages. Frank suffered the classic collar bone break. For Lance, it was clear from the tears on the BACK of his jersey that he had the athletic grace to roll with the fall … and ride on.

Jaas April 5, 2012 at 5:24 pm

at the end of last year i crashed at 25mph in road race. as i was writhing on the ground i was pretty sure i broke the clavicle. but it turned out not to be. I did not stick out my arm. I just held on to the drops and road it into the ground. then got fetal as soon as possible because i was mid pack with 40 more guys behind me. Maybe thats what saved the collar bone. It happened so fast that i didnt have time to stick an arm out.

The Inner Ring April 5, 2012 at 5:41 pm

Sometimes the higher the speed, the safer the crash. It’s relative but when you fall at speed you tend to slide. If you go over slow, or into an obstacle, then you topple sideways and go down hard. Of course you can get horrific injuries from a high speed crash but sometimes, especially when wet, you go down better at 40km/h and slide, instead of crunching at 20km/h.

Stephen April 5, 2012 at 5:57 pm

I was taught and have followed the practice to ensure multiple points of contact with the ground upon a fall from a bike. It’s better to have a sore elbow, hip and knee than to take all the force onto one of those body parts because then the chance of breaking a bone is greater. As Ken mentioned with Lance, rolling is goal.

Jim April 5, 2012 at 7:29 pm

Years ago I took a judo class. In judo blows are not exchanged rather one attempts to take their opponent down to the mat. The first lessons we beginners received consisted of how to fall down– “judo-rolls”– rolls both forward and backward inwhich you learned how to tuck ones head and shoulder and present broad areas of the torso and legs to the mat to absorb the energy. I found the same principle worked when crashing on the bike.

Cat4Fodder April 5, 2012 at 7:39 pm

@ The Inner Ring:

Also keep in mind, cyclists, given the lack of weight bearing impact involved in the act of cycling, have very, very brittle bones. In fact, some bones of racers are pre-osteoporosis due to the amount of leaching of calcium and other minerals from the bones during exercise.

It is also a big reason for the # of hip related injuries from falling (see Floyd Landis). It is also a contributing factor.

http://well.blogs.nytimes.com/2009/07/01/is-bicycling-bad-for-your-bones/

Roadie61 April 5, 2012 at 9:55 pm

Stephen: You hit the nail on the head. “Multiple points of contact with the ground…”

Volleyball players, football players, martial artists, skateboarders and athletes in many sports learn what we used to call the “tuck and roll.” The idea is to pull the arms in (if you have time to think, many times you don’t) to prevent a broken wrist or clavicle, and roll over the back of the shoulder.

“vincent” mentions JA Flecha in the 2011 TDF — watch the slow-mo of him after hit by the car and he does “roll” onto the tarmac; he did suffer elbow and knee lacerations, but no broken bones, amazingly.

Below is a video link of kids teaching how to jump off a roof (yes) — there are some great slow-mo shots of them rolling with arms tucked in. Great way to prevent fractured clavicles and wrists in cycling, IF one has time to think.

http://www.5min.com/Video/How-to-Land-and-Roll-172535662

I didn’t see footage of Cancellara’s fall (did a camera pick it up?) in the feed zone, but S Langeveld’s crash video shows a textbook example of how to break your clavicle, and he did. Both arms were extended when he hit the ground. It’s a natural reaction/reflex for the arms to go out to protect the ribs and vital organs in the chest and abdomen.

The joints in the shoulder girdle are the most vulnerable in the body; the glenohumeral joint (ball-and-socket joint) is a very unstable one. The head of the humerus (the ball) sits in a shallow cavity (glenoid fossa), but the humeral head is very large in comparison to the shallow, small cavity that it sits in. I’ve heard orthopedic surgeons refer to this joint as a softball sitting on a golf tee (slight exaggeration, but gives a good idea of the vulnerability). With arms extended, the glenohumeral joint is extremely unstable and vulnerable to injury. The ball is forced easily upwards with blunt trauma, often fracturing the clavicle and disrupting additional tissues above.

GRJim April 5, 2012 at 10:30 pm

This judo roll thing is only good if you a) have a save landing area and b) have time to actually react. I once surely would have been run over by a bus had I rolled. Collar bones break, then they heal, then they bother you in old age maybe. C’est la vie.

lauaxeta April 5, 2012 at 11:26 pm

Ave,

Pozzato broke his right collarbone in the Tour of Qatar, but the surgeon who operated on him also removed the plate from the left collarbone, broken the previous year in Tour of Belgium.

http://www.velonation.com/News/ID/11130/Operation-for-Filippo-Pozzato-following-Qatar-collarbone-break.aspx
In the April edition of Procycling magazine, there is an article about Pippo, and a picture showing two dressings, covering both left and right collar bones.

Kristi April 5, 2012 at 11:27 pm

I shattered my L clavicle in a fall in 2000, and the stainless steel wire they wrapped around it to hold all the pieces together is still in there 12 yrs later. I call it my mini-coat hanger. I have nerve damage at the scar/incision point. I often wonder if the wire should have come out but since my MD was also Wayne Gretsky’s ortho surgeon, I just didn’t question it.

Swan April 6, 2012 at 1:10 am

Don’t forget Hincapie did the last few days of the 2010 TdF with a broken collarbone- he was still putting in his turns in the leadout!

Felix Khanis April 13, 2012 at 2:42 am

Broke collarbone 3 weeks ago. Was going downhill,just started raining so it was slippery or something and the bike just went from under me.
Anyway there is a wonderful thing called reiki. Hard to believe but it works. It takes away the pain and promotes healing.
I got 3 packets of panadine forte for pain in the hospital. But I have not so much pain.
Same story when I broke my hip. No pain.

Comments on this entry are closed.

Previous post:

Next post: