"Stepping" in collar bone?

[darkest9999]

Hi.
I broke my collar bone about 11 weeks ago in a rugby injury and after visiting the hospital again they have told me that my shoulder has not healed correctly. They mentioned there is "stepping" when I move my arm around (it feels like the bone is grinding inside) and that there is a 2.5cm gap at the joint. They have booked me in for physiotherapy but im just doubtful this will fix the problem. Does anyone know more information on this problem and what treatments are normally perscribed?
Thanks

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[Judith Mollet]

Treatment depends on the seriousness of injury. The clavicle can be damaged / broken in proximal, middle or distal (thats towards the arm end) parts. With distal injuries the ligaments to the coracoid and acromion (which belong to the shoulder blade) can be involved in various severities causing more or less displacement and potential instability. Often the bone heals despite not being completely together leaving a lump or step in it which doesn't have to cause problems. It's not quite clear from your information what it is that hasn't healed properly, none union of bone is possible and also if there's been inadequate rest for the arm and too much attempted movement the ligaments can be involved. The types of acromioclavicular ligamentous injuries with displacement are classified and up to type III conservative treatment possible. For active rugby players and young people other rules may apply. Somtimes an operation is neccesary for vertical stability (so the clavicle doesn't displace upwards and distal end) but I'd only go to a surgeon who does lots of sports injuries successfully and not all local hospitals have that. I would advise you to get your exact diagnosis and X-rays before going to the physio. If you have just been seen briefly at fracture clinic and not by doctors experienced in rugby injuries consider a second opinion. Ask the physio to explain everything about the anatomy and function of what has been damaged if it's not clear to you. I guess you with want to return to rugby and you need to get good recovery and repair and advice before joining the next scrum. Physio can fix a number of problems but not all if the gap is too big. Wish yyou luck. JM

[darkest9999]

Hi, Thanks for your reply
At the fracture clinic, I was seen by a top consultant and when writing his review notes I saw he had written "approx 2.5cm gap at AC joint". After researching on the internet I think the AC joint refers to the Acromioclavicular joint which is where the Clavicle and Acromion joint together. So I reckon there is a large gap there which should either be smaller or non existing. Does anyone know any more informaton on this?

[Judith Mollet]

A space at your AC joint indicates that the joint is not together as it should be but again this information isn't telling us in which direction displacement is and the extent of ligament damage. Does not sound like Type I which has no displacement. The best person to ask is really your consultant. He should explain the situation, risks etc with the type of injury he reckons it is, long term instability problems possible, if surgery would be better, his estimates on recovery. If I wrote out all the scenarios possible in the handbook it would just get you worried more, I can't say for definite if it's Type III IV or whatever, (there are V and VI as well)the Consultant should. What were you told immediately after the first time in hospital? How much rest/ sling/ advice did you get? How long do you expect to wait for physio?

[physiobob]

Hi, Thanks for your reply
At the fracture clinic, I was seen by a top consultant and when writing his review notes I saw he had written "approx 2.5cm gap at AC joint". After researching on the internet I think the AC joint refers to the Acromioclavicular joint which is where the Clavicle and Acromion joint together. So I reckon there is a large gap there which should either be smaller or non existing. Does anyone know any more informaton on this?

We need to know if the clavicle is intact itself or if it has a fracture. The AC jt is on thing but an un-united fracture is another. Physio can assist a little with the AC jt. especially in education and in bracing if that is required for sport. However the best solution to return to overhead activities is a stabilisation of that gap.

The majority of AC jt ruptures are left as gaps. This is perhaps due to poor surgical options in the past. These days one should consider what surgical options are available although this is likely to be minimal in the UK healthcare environment

There's a few article here:

Acromioclavicular Joint Separations

Acromioclavicular Joint Dislocations

ACJ Stabilisation

A complete AC joint dislocation that is still painful after about 6 months is usually an indication for stabilization of the joint. However, some acute dislocations that are very displaced are stabilized soon after the injury.
The most widely performed procedure, with the best results has been the Weaver-Dunn procedure and modifications of this.

The procedure involves 3 main steps:

1. Removal of about 1cm of the end of the collarbone, as this is deformed and diseased.
2. Transfer of the coraco-acromial ligament to hold the collarbone down to the shoulder blade.
3. Reinforcement of the transfer with a suture or screw.

The aims are to stabilise and reduce the dislocation.

This is usually performed by open surgery, but can be performed through keyhole surgery (Arthroscopy) nowadays in a few centres.
We perform the arthroscopic technique in certain indications (acute injuries and mobile, reducable dislocations) and the modified Weaver-Dunn using the LARS ligament.

[darkest9999]

Hi,
The consultant did not mention any information on resting the arm and as for the physio, they should have phoned me the next day to arrange an appointment. As its already been a week since the visit Im will phone the hospital to speed things up.

[Judith Mollet]

Wait a minute, I meant 11 weeks ago when the event occured playing rugby, what advice were you given then about resting / what not to do or physio? Nothing? Did you move the arm and shoulder during these 11 weeks or were you somehow part-immobilized? I'm thinking of physiobobs comments as to "..........in the UK healthcare environment" Sad but true, although there are lots of excellent actors in the NHS show patients are often left under assessed, under informed under treated.
Do see if you can speed up the physio appointment. You have some good links to look at from physiobob. Swot up a bit on relevant parts of your shoulder so you understand what's involved and ask all the questions that are bothering you. Let us know what happens.

[darkest9999]

Hi,
When I orginally broke, different doctors looked at the x-ray and agreed that if I had been older they would have operated (Im 16) but there is a high chance it will heal correctly in 6 weeks. I was given a sling to wear but not any information on how long this was neccesary for (about 3 weeks in I abandoned the sling but kept it to minimal movement).

When I went to the check up 6 weeks later the consultant looked at the new x-ray and said I cannot particapte in physical sports for another 4 weeks but gave the go-ahead to play tennis.

When I went back a few weeks ago a different consultant looked at the recent x-ray and asked if I had any "stepping" at the shoulder. I mentioned that it feels like its grinding inside at the joint. After examining the shoulder he said I would need physio and to come back in another 6 weeks. He also mentioned no physical sports but I forgot to ask him about playing tennis (as I have pain in the shoulder and a dead sensation down the arm when I play).

[Judith Mollet]

I suppose by physical sports you thought of contact sports like rugby where someone is going to flatten you. Can't think what the doctor was thinking about. Please stop playing tennis!! At least for a while. It's too much for the shoulder area at present. Get a good assessment first and I hope a / the "top consultant" will be prepared to take some time explaining. As you are 16 I hope some sensible adult is involved somewhere regarding your outpatients appointments. Either parent, or do you have some involved sport trainer? There are physios who are good generalists but there are also specialists in sports injuries, orthopädics etc. I don't know where you are or which place you've been to and I am no longer UK based.
Can someone UK based help out some more? Physiobob?
As you are young I would hope for a good recovery, will maybe take some time to get it sorted out. Good luck

[physiobob]

Sounds like a typical 'fobbing off' job. Tennnis is crazy. Have you got a recent x-ray to show us? The NHS love the old rest it in a collar and cuff sling and it will be alright. That is, you'll be left with a permanently non-united fracture. As 16 I would say a fixation is almost more beneficial than in an older patient who may not be wanting to pursue overhead activities (although that does include sleeping!).

Where in the UK are you based?

[darkest9999]

Hi, I live in St.Albans, Hertfordshire and have Been attending the Queen Elizabeth 2 hospital in Welwyn. I booked my apppointment at the physio for Friday and will let you know what happens.

[darkest9999]

Hi, Just went to the physio therapy today. He examined me and told me the treatments they could provide. This included an Ultrasound, Heat Friction and taping. I had the heat fricion today which invovled gel substance applied round the area then a machine device rubbed onto it. Now its a bit more sore then usual so hopefully its doing the trick but he said it will take a few weeks to see an improvement.

[Judith Mollet]

Were there any other treatments explained to you apart from those you just mentioned? Did you only get "heat friction" today or was the time also spent in taking an assessment of your movemant, pain, pain behaviour and so-on. (now I know I'm ancient and I know what frictions are but heat friction?) Any movement advice, explanation. do's and don'ts? Was the 2.5 cm gap discussed? When will taping be a factor to reckon with? Have you any idea what exactly was written by the doctor on your referral to physiotherapy and the exact aims you and the physio have in the treatment? How often are you going to get treatment and what improvement is the physio aiming at?
Don't panic at the questions, I don't expect all of them to be answered after one session but it would be nice to have an idea. Physios should, and maybe this one has, inform the patient about what he's doing and why. Physiobobs referral to "non united problem" is what I am thinking about. I doubt if Ultrasound and heat friction will help the gap but may assist pain and local metabolism/healing problems in soft tissue. Keep us informed.

[325867]

Hi,
I saw a woman who had a very similar injury post - MVA (motor vehicle accident.) With a program of graduated ROM exercises and scapular/ glenohumeral mobilizations she regained almost full pain free ROM of her shoulder. Her repeat x-ray showed callous formation ultimately reunited the 2 fragments even thought they were 2.5 cm apart.
Don't feel discouraged !
325867

[darkest9999]

Hi,
The physio did not mention any exercises I should be doing or about the 2.5cm gap but reccomended when I play tennis to take ibuprofen before and use ibuprofen gel on the shoulder as well and also to ice the shoulder 3 times after playing to reduce the swelling. I was initially assesed by peforming movements with the arm but only had the "heat friction" treatment when I visited. I also read that having an ultrasound allows him to understand the type of seperation there is (there are 7 different ones in total) and from that he could persue the best treatment. As to having the taping , I reckon that will be another option if this does not resolve the issue. Ill keep you posted.

[m.nowara]

Dear Darkest

i actually had a lot of patients in my center i follow ,dont be scare its easy case because your Doctor didnt discharge you to attend to take a few sessions of physiotherapy unless your bone is great with complete heal dont worry when you fell a stepping or grindling or heald incorrectely in your shoulder or around, it'll be improve in physiotherapy ,but wait a wile and look at your shoulder after 10 sessionsand it depends on the severity of the sighns and symptoms

your treatment must be as follows

*in the time you have a pain and swelling on shoulder you have to rest your shoulder and wait untill the swelling and pain disapear with using these modalities
1.cold application for 40 min and more twise a day
2.ultrasound (pulsated application) for 1.6 Hz intensity for 5 min once daily
3.scabular passive moblization
4.shoulder passive mobilization
5.Interfarantial electro therapy application around shoulder
6.stretchening EXCs
\\\\\this program takes 6 to 10 days or untill the symptoms (pain,and swelling ) dysapear\\\\\\\\\\\\\\\\\\\\\\\\

after that you have to start your actual work and take a real forword step in physiotherapy as follows

1.active strengthening excersises for the muscles around shoulder ,we prefair to start in pendolum excercises the PNF ACTIVE EXCs
2.then progressive resistive PNF EXCs
3.every EXCs must be followd by Ice application around shoulder for 40 min
\\\\\\\\\\\\\\this last program must taken in the physiotherapy center and at home\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\

sorry i didnt answer you before because today is my 1st day to me in this site


good luck and have a nice day

[joshvv]

Hi.
I broke my collar bone about 11 weeks ago in a rugby injury and after visiting the hospital again they have told me that my shoulder has not healed correctly. They mentioned there is "stepping" when I move my arm around (it feels like the bone is grinding inside) and that there is a 2.5cm gap at the joint. They have booked me in for physiotherapy but im just doubtful this will fix the problem. Does anyone know more information on this problem and what treatments are normally perscribed?
Thanks

i broke my collar bone on last monday it still hurts a little but the doc told me just gave it time and it will get better what did they gave you for pain meds because they gave me oxys

reply when you have time

josh

[physiobob]

i broke my collar bone on last monday it still hurts a little but the doc told me just gave it time and it will get better what did they gave you for pain meds because they gave me oxys

Any chance you can upload a copy of your x-ray images? You can of course treat some fractured clavicles conservatively but then there are a lot that also benefit from surgery. Depends on the extent and position of the fracture, how many breaks, what the position post fracture is.....

[estherderu]

I was recently in touch with the person who is conducting a RCT into using kinesio taping and Sling vv sling with mid-clavicular fractures.
I was informed that the group of patients wasn't as big as they had hoped and that they will be publishing in the near future.
The results must be positive for kinesiotape (elastic therapeutic taping) because thay have decided to use the tape for every person with a mid-clav fracture coming into the hospital from now on.

Putting a piece of elastic therapeutic tape on a fractured clavicle does have a painlessening effect at the very least.
This month an article on this subject will be published in a Spanish tape Newsletter.
If anyone is interested I can send them the english version.

Esther