Collarbone Surgery

On August 25, 2006, at the age of 51, while biking, I broke my collarbone. I was on my way to an outing of fellow grad students. It was going to be great fun. I saw pictures of the event later. It *was* fun. It just wasn’t fun for me.

What happened, I think, was that the gear slipped on my old bike. Moral of the story: if you find that your chain slips because the derailleur needs to be cleaned, or is getting old, or otherwise doesn’t function properly, attend to it right away. When the chain slipped, there was no resistance, so my foot went down instantly. That threw off my balance, and I crashed onto my right shoulder.

It was kind of a funny coincidence. The previous day, I had been biking around. I stopped to take a look at a nearby event going on. There were other people standing there looking too. After watching for a moment, I got back on my bike. I pedaled once or twice and — bam! — suddenly I was falling onto (you guessed it) my right shoulder. It seems one of the other bystanders had a huge dog; that dog spotted a Chihuahua a short distance away; the huge dog took off on a beeline for that little Chihuahua; and in the process he ran right through my front wheel, turning it sideways and putting me on the ground. I wondered, later, whether that first crash softened me up for a break the next day.

And what a break it was. First of all, I was lucky to survive. When the chain slipped and I lost my balance, I went careening off on a sharp left-hand 90-degree turn, right out into traffic on a busy street. Fortunately, I fell within my own lane. If I had kept my balance enough to go into the oncoming lane, I’d probably have been run over. Even in my own lane, I fell between two cars, but the guy in back was able to stop before he hit me.

I landed hard. Both days, my head hit the pavement. Moral No. 2: wear your helmet. It felt like it hit hard, but it didn’t seem to compress the helmet’s styrofoam any, or even to scratch the plastic cover. What was obvious was that I had broken my collarbone. I broke it once before, in more or less the same place, on November 26, 1967. I was 12. We were playing football. I tried to tackle John Deetz, a big farm boy who was probably about 16. My method of tackling him was to stand in front of him with my arms outstretched. Someone else jumped on his back at just the right moment. They both fell on me. John’s left knee went into my right shoulder. And there you are. So much for the belief that a broken bone heals stronger. Or maybe it did, but that doesn’t mean it becomes bulletproof.

This time, the collarbone broke into three pieces. I knew the kind of pain, and the sort of sickening feeling of being suddenly vulnerable in a spot that wasn’t vulnerable before; that’s how I knew it was broken. But if there had been any doubt, a quick finger inspection would have dispelled it. Instead of that nice, smooth line across your shoulder, you have this nasty gap, with a sharp, pointy thing sticking out (not through the skin, fortunately) on one side.

I didn’t put my fingers up there right away: the first mission was to grab the bike with my left hand and get us out of the street. But once I was able to get over and lean against a wall, hurting with every motion, my fingers told the story. A couple of drivers got out of their cars and came over. I said to one of them, “Want to feel something weird?” I was going to let his fingers trace the fracture. He got a kind of freaked-out look on his face and said, No, with just a trace of disgust, like, Oooh, I’m sorry, but that is just too icky. He was young.

A bus driver called the paramedics. I had two acquaintances on that bus. They were headed for the outing. They got there and reported to everyone that I had been hit by a car. We were sort of a loose-knit group, there in the Ph.D. program in Recreation, Parks & Tourism (RPTS) at Indiana University – Bloomington; few of us were close friends with one another. I didn’t expect anyone to come looking for me that night, other than the two whom I called, later in the evening; and none did. I hadn’t really thought about that until this moment, when I am doing this writeup; but as I think of it now, I guess it’s a reflection on me, and perhaps also on the RPTS department and/or on the type of person who seeks a Ph.D. I’ll have to think about that some more.

The paramedics stuck an injection in me. They felt that they needed to sit there until the I.U. police showed up. I’m not sure why. It wasn’t really a vehicular accident. But the IUPD could not be rushed. After waiting for about 15 minutes, the paramedics said to hell with it and just loaded my bike next to me in the EMS ambulance, and we took off for Bloomington Hospital.

The paramedics were good people. But I think it was a mistake to take that ride with them. I should have just rolled my bike home, about a half-mile away; or maybe I could have gotten a ride. At the hospital, I sat for three hours while nothing happened. My bone was not going to get any more broken. At home, meanwhile, I had some painkillers left over from when I got hit by a Bloomington bus back in January. I could have gotten through the night; and then, the next day, I could have walked or caught a ride over to the IU Health Center, where they probably would have been done with me within an hour. They didn’t do anything other than take X-rays and prescribe some medication at the hospital; I am sure the Health Center would have done likewise. But I guess that evening in the hospital was a good learning experience. I now have a somewhat more informed sense of what it is like to be alone, in pain, shivering from cold or shock, sitting on the floor of a hospital space because it hurts less than sitting in a chair. Much more educational than just watching episodes of “E.R.” until the painkillers knocked me out.

From the hospital, I called a friend. He came over, waited 45 minutes for them to release me, and drove me home. Two more friends met me there. Interestingly, two of these three friends, Chun Chieh Wang and Chunyun Wang (no relation), were Chinese. (The third was Katie Finch, a master’s student.) This reminded me of a time in my master’s studies in Missouri, when all my American friends were too busy with other things to help me move some stuff — one was going rock-climbing; one didn’t return my call — but three Chinese grad students (Tao Zhu, Dong Xiaodan, and Yuhua Bi) were prepared to drop everything and help me. In these and other experiences, it has seemed to me that Chinese students in America, especially from the mainland (even those who hail from big cities like Beijing), have a work ethic more like that of my parents’ generation, when (in my rural upbringing) there were still times when the neighbors would all get together to help one another.

We stayed up a while at my place, talking about the outing that I had missed, and about my accident. I had an appointment with an orthopedist, a well-known practitioner there in Bloomington. He advised that I could just let the collarbone heal on its own. An alternative, he said, would be to have a plate installed. Without the plate, there would basically be these two separate pieces of bone on the right and left ends of what used to be my collarbone. The third fragment, he said, which had sharp ends and was pointed vertically, would eventually be surrounded by fibrous material, so that it would no longer be a danger. I wasn’t sure whether it would be a lifelong lump or would ultimately be dissolved. He said I might lose some strength if I didn’t have an intact collarbone, but that it would probably not be a big deal unless I made my living as a laborer or professional weightlifter.

I gave it a week, and then decided on surgery.  I’m glad I did.  I have subsequently met someone who had a collarbone fracture and now has not only weakness, but a permanent kind of grating experience when he moves his arm a certain way.  He said he wished he had had surgery too.  I did not want to be losing strength, and I was concerned about my shoulder sagging as time went on.

At the time, I was especially concerned with the pain.  I think if I had been in less pain, I might not have bothered with it. I say that because, when the time for surgery did come around, about three weeks after the accident, I was in much less pain and was actually wondering whether the surgery was necessary.

On the other side of the coin, I had never had a significant surgery. It seemed like there really wasn’t much to lose. The surgeon said that the plate they would use was form-fitted to the bone and would not be very obtrusive, and that, once it was in, it would be “along for the ride.” He said that he had done a number of these surgeries, and that people rarely bothered to remove the plates, though I could do that later if I wanted. I said I was a little concerned that there would be this piece of metal in my shoulder, pointed at my heart and/or my throat; I was afraid of what might happen if I again fell onto that shoulder and drove that piece of metal to the left. He said that it was always possible to dream up chance scenarios, but he did not seem to think that was a serious concern.

On the day of surgery, I went to the hospital and got prepped. I was lying on an operating table, shortly before I would be given general anesthesia to knock me out. He stopped by to talk to me, which I appreciated. He said I would have a scar. Well, of course I knew I would have a scar. The gesture he made with his hands, though, was wide enough to be scary. I had known women who had had breast implants, and their scars from those surgeries varied from tiny to large, depending upon the skill of the surgeon and how much time s/he was inclined to take to avoid scarring. So when he made a longish gesture, I thought, Oh, no, I’ve got myself a cut-’em-up kind of surgeon. He also said that I would experience numbness in my upper chest because some nerves would be damaged or destroyed in the surgery. This was not something I had at all anticipated.

It suddenly seemed like I had to rethink this decision, at this very awkward time — like (of course) I should have gotten a second opinion, or should now get one. But, you know, bailing out on a surgery, when you’re not sure if insurance will cover what you’ve done so far, or if they will cover a second go-round — these were the thoughts that came to mind. There was also some inertia, some helplessness. You’re lying there; you have put yourself in their care; and now you try to wonder if maybe that was a mistake. Quitting at that point would have been both hard and questionable, and in the few moments I had between then and being knocked out, I was mostly being wheeled around, asked questions, and being spoken to. It was not the best situation for deep thought.  So I didn’t decide to bail out.

Fast-forward to November. At this point, the collarbone had not yet healed, despite the plate. On this particular visit to the doctor’s office, his assistant seemed to be taking a very long time to deal with me. It definitely was not the in-and-out experience of other visits. I got the impression that mine had become a complicated situation, and that she needed to take care of some other people first, as she said, so that she could sit down and talk to me about my case. This was not reassuring.

I should mention, at this point, that I had become acquainted with the surgeon’s wife, from whom he was then separated.  She was not a friend.  She was just someone with whom I had had a few brief conversations in the course of a workday project.  I didn’t even know they were related; at this point, I can’t remember if she was using his last name.  But given the way he botched the job, I did wonder if he did it deliberately.  It wouldn’t seem likely, but who knows?  Maybe he had a good sense of what he could get away with, without being very liable for a malpractice suit.  With or without deliberate intent, obviously, I could not be very pleased with the quality of his work.

When the assistant did come back into the room in which I was seated, she informed me that the bone was not healing. She started talking to me about the possibility that I might need to wear a device that would deliver electrical stimulation to the bone, in order to stimulate bone growth. This concept took me by surprise. It seemed to me that, if you’ve joined the segments of bone together, they naturally tend to grow together. But now, as I looked at the X-rays, it seemed that the bone segments had not been tightly fitted together before the surgeon inserted the screws. Worse, as I looked at the X-rays, it appeared that the surgeon had not screwed the screws all the way into the plate. That seemed to explain why I was still sometimes experiencing excruciating pain when I would put on a backpack, or when my girlfriend would absentmindedly grab me on the shoulder: the screw head was poking up under my skin. Finally, although I was not an expert in reading X-rays, I will report that I was shocked at how the plate appeared on the X-ray. This was not a contoured piece; it looked like a flat, rectangular steel plate.

2006-09-07 Collarbone Surgery -- X-Rays_Page_2

That was my last visit to that orthopedist’s office.  At this point, I visited another specialist. He said that he assumed the screw was sticking out because the first guy couldn’t get it all the way in. He corrected the assistant’s claim that I had worked the screw loose by using the arm too much; these were locking screws, he said, and once inserted they would not come loose. This specialist said that, in ten years of practice, he had inserted only one collarbone plate. He recommended against it because of the risks of surgery. When I asked what risks he had in mind in particular, he said that one was, of course, the risk of infection, and another was that the lung was nearby and there was the possibility of significant complications in that regard. Also, he said, even if collarbone fragments are quite separated, they tend to form a fibrous connection that, for practical purposes, will function as well as if the bone were still intact. It occurred to me, at this moment, that it might have made sense to have surgery, without plate insertion, solely for the purpose of lining up the bone fragments, so that they would heal into bone or at least into fiber. (See the WebMD article cited below for a tape-and-wire technique that had achieved good results.) Now, of course, it was too late for that.

Without my asking, this other surgeon anticipated that I might indeed want to have the plate removed. He said he wouldn’t even think about it, though, for a year. At a certain point, he said, the scar would turn from red to white, and after that, and after a year had passed, he would consider it appropriate to look into it.

That brings me up to the present. One thing the first guy was right about was the nerve damage. A year later, I still had numbness extending down about a hand’s width from the collarbone. Maybe a little more. At some times, I didn’t feel numb at all; at other times, it was distinctly uncomfortable. Here’s how I wrote it up, in notes that I made some two or three months after the surgery:

The numbness that I experience includes a tingling, pins-and-needles sensation when the area is touched. At best, it is like the unpleasant feeling in your lip, after the dentist injects novocaine into your jaw. The area sometimes also itches. Numbness and tingling combine to make it unpleasant to touch the area. The area affected by this numbness and tingling is about six inches wide and five inches high. This has ramifications for a variety of things. For instance, I told the doctor’s assistant that it was now unpleasant for my girlfriend to hug me and put her head on that side. (She said my girlfriend would just have to hug me on the other side.) Moreover, pressure on the site causes pain that goes beyond tingling. A grip of someone’s hand on my shoulder in that area is very unpleasant. For instance, when a friend gripped my shoulders from behind in an attempt to give me a momentary shoulder rub, I flinched and pulled away. The pain from that experience continued for some time.

One year after surgery, the scar had partly changed from red to white.  It formed a curve about five inches long. It was not closed tightly after the incision, and it did not heal well initially – there was, in fact, a small pocket of infection – but it had improved since then. The screwhead was still painful; I still got sharp pains when someone or something hit it the wrong way. The plate was no longer so obviously present when I would moved, but I could still feel it when I climbed stairs, for example, or used exercise machines. My concern about it being pointed at my throat was still there; I was still interested in having it removed. I was hoping that, with it gone, there would be less of a lump in my shoulder, possibly less nerve irritation, no more pain from the screw under my skin, and no more risk of having a piece of metal pointed at my throat.

These thoughts prompted me to look into surgery again.  In my initial browsing online, I saw another concern that also argued in favor of removing the plate. I realized already that the bone was weaker where the screws were drilled into it — that there was less bone in those places. I was particularly concerned about the last screw, on either end of the plate. In the middle of the plate, there would be little chance of re-breaking the bone; the plate would hold it securely. But on the ends, where the plate ended, there would be just that weakened bone with the screw hole in it. I noticed, now, that other patients were discussing this possibility online.

But the new concern, raised in a Medscape article, was that osteoporosis (bone loss) also takes place under the plate. Once again, it seemed, it was a case of use it or lose it. The body evidently senses that the steel plate is doing the job, so the bone itself wastes away. Not the desired outcome! A photo of an X-ray in that Medscape article looked much like my own X-ray.  Incidentally, in describing the procedure used in that case, the article said that the authors of a study found that this method achieved bone union (i.e., the bone grew back together) in every case in which that procedure was used. So clearly something unusual happened in my case.

The article also cited an instance when that plate was removed 54 weeks after surgery. So the second surgeon’s advice to wait a year seemed on target. This second surgeon was younger; I had a feeling that I was experiencing what they say, which is that doctors nowadays are best trained when they emerge from medical school, and that the older ones tend to rely on beliefs that may not be supported by the latest research. Yet that interpretation does not entirely mesh with the words of a WebMD article, which seems to imply that even an older orthopedist would customarily be inclined not to operate: “Traditionally, clavicle fractures have been treated nonoperatively, and the consensus was that they all heal.” That article, like the other one, also reported that use of a plate resulted in “bony union” in all cases in one study, but it sounded like the ordinary recommendation would be to remove the plate. One layman’s opinion said, sensibly, that the plate could be removed “if problems develop,” posing the question of what degree of problem I should experience before removing the plate (or wishing I had done so). A bike rider said his doctor recommended removing the plate before returning to riding.

The next question was, who should do this surgery? I had moved to Indianapolis, which was reputed to have some top-quality doctors. This time, I wanted to get someone good — within the limits of my health insurance, of course, which had its own slate of approved docs.

Following the link at Medline Plus, I tried using the lookup page of the American Academy of Orthopaedic Surgeons. (Why did I just know, even before checking the spelling, that of course the Academy would use the more pretentious spelling of “orthopedic”?) This gave me a list of more than a hundred specialists; but as I verified by checking a few of the results, it did not provide me with the ability to compare them for, say, their area of specialty (e.g., adult or child, neck or knee). The same was true for the search page at the American Board of Medical Specialties. These were both useful in the sense of making sure you weren’t dealing with a total quack, perhaps, but they did not provide guidance beyond that. So I did my own mass search for specialists in clavicles.  The basic idea of my search was that I wanted to find someone from the list who had published an article that demonstrated some knowledge of the collarbone in particular.

I wound up choosing James Bicos.  It was a good choice.  He cut along the same line as before.  He didn’t seem to do any new permanent or semi-permanent damage, beyond the scar itself.  The plate came out, and the concerns mentioned above largely went away.

Here’s how it stands in December 2009, a little more than three years after the plate was inserted and about two years after Bicos removed the plate.  The scar from Bicos’s surgery is thin and white.  You can see the larger scar from the original surgery underneath; part of that scar is still red.  Once in a while I notice numbness.  It is always there, but rarely obtrusive; it is much less pronounced than it had been.  I suspect that the plate tended to obtrude on nerves, or for whatever reason that the plate aggravated the situation.  There are still some tender spots.  I haven’t carried a really heavy backpack since then, so I’m not sure about that, but I can say that a full daypack doesn’t bother me, at least not when I bike to school and carry it around campus.  If someone grabs me on the shoulder, it’s still unpleasant; I can’t say whether a really hard grip would be truly painful.  If I walked into a door or had some other impact right on that spot, I think that would be pretty nasty.

What I think happened is that the original doctor cut away more than he needed to, and I therefore lost some cushioning or gained some sensitivity that wouldn’t have been there if I had chosen a different surgeon.  I don’t know; that’s just how it feels.  One of these days, I’ll have an excuse to look at another X-ray of that area, and then I’ll know more about how it has all shaped up.

(This post was moved here from another blog.)

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