Portrait of the Clavicle
as a Young Bone

I shut myself in the bathroom and face the mirror. Even though the room is cold I remove my shirt and bra. I want to get an unobstructed view of it, of them.

They rest at each side of the suprasternal notch, that hollow in the neck that Ralph Fiennes termed the "Almasy Bosphorous" in the film The English Patient.

They lie almost horizontally, almost perpendicular to my spine, just above my uppermost ribs. The inner end of the right one--the end that's closest to the middle of my body--sticks out, a knob stretching the skin, a mysterious shy thing five inches long. The outer end sticks out less. This end appears to fade gently into my skin, a secret tunnel to my shoulder.

The left one is different. This one is five and a half inches long. Its inner end sticks out slightly, but not as much as the inner end of the right one. The left one does no subtle fading. No graceful blending here. Toward the middle the bone sticks out, the biggest sticking-out knob of the pair. Moving toward the outer end it does fade, but who notices with this bump in the middle hogging all the attention.

These are my collarbones, my clavicles. It is obvious that the two are not the same. Not in the least. With the exception of some internal organs, isn't the human body supposed to be symmetrical? If you fold someone in half leg over leg, arm over arm, aren't the two halves supposed to fit?

If I woke up one day and found them like this, not knowing how they got this way and suspecting they're supposed to be identical, I don't think I'd know which one was in its original, unaltered state. Who ever pays attention to their collarbones? The collarbone is kind of like the middle child, lost and ignored between the mythic breasts and the dramatic yet practical face.

Clavicle. Clavicle. Say it with me. "Clavicle." Rhymes with pickle. Fun to say, fun to hear. Let's use it in a sentence. During high school Katie fractured her clavicle.

The day was a fall one, cold and windy. A game day, one of hundreds. I wore the polyester, stripes-down-the-sleeves soccer jersey, the one embalmed in a sampling of sweat passed down through the years. The details of the game escape me. You'd think I'd remember the team we played or the final score, but I don't.

Even the details of the injury itself escape me now. It was all quite undramatic. At some point I was tripped by a member of the other team. Or maybe I tripped over her, I don't quite remember--it's nicer to think the whole thing wasn't the fruit of my own lack of grace. I fell over the enemy cleat, probably outstretched my arms to cushion the fall, and lay sprawled in the grass for a fraction of a second. Then I scrambled to my feet and ran to catch up with the action of the game.

I continued to play but noticed a slight throbbing pain in my shoulder. The throb didn't hurt all too bad, though I do remember feeling, for lack of a better word, weird. There was something about the way the nerve endings in my right shoulder pulsed, something that told me this throb was different.

Eventually I was subbed off the field. I plopped on the bench next to my teammates, out of breath, sweating and cold at the same time, that weird mix that comes with strenuous exercise in chilled October air. I put on my jacket, shoulder still throbbing, an odd, painless throb. After a while Mr. Geysen, my coach, told me to go back in. I attempted to remove my jacket, the pullover kind where both arms and head must travel through the neckhole for the jacket to be successfully removed. But I couldn't maneuver my arm through the hole--my left shoulder refused to let my arm move freely. The shoulder was still throbbing but the pain was worse now--numb yet throbbing with a muffled but strong pain. A whole contradiction of nerves. I somehow knew if I tried to move my shoulder, it would hurt terribly bad.

"Coach, I can't go in."

"Why not?"

"I can't get my jacket off. I think I hurt my shoulder."

"And you're just realizing this?" but already off to plan B, "Meghan, you're in, right wing."

What followed is as typical as a trip to the emergency room can be. The ride to Leonard Morse Hospital in my dad's truck, trying not to move my shoulder, the pain getting worse with the miles, each bump in the road excruciating. The mandatory hour in the ER waiting room. Sitting on a gurney while the police read the guy in the next bed his rights, the guy screaming and swearing and struggling to free himself from the restraints (oooh, just like TV!). Removing my shirt and bra in front of the nurse so she could examine the locus of the pain. Staring at the ceiling in radiology as the bones in my torso absorbed invisible X rays. The diagnosis: "Your clavicle is fractured."

"My clavicle?"

"Your collarbone."

My first thought was of the immediate future. "When will I be able to play soccer? Will I be able to drive?"

"You'll be out for about six weeks if all goes well."

Six weeks. The soccer season ended in about six weeks. All that training, a week of hell under the August sun called "soccer practice," all this to sit out the second half of the season? And I couldn't drive? To a 16 year old who had gotten her license less than two weeks earlier, this qualified as a devastating turn of affairs.

At the hospital they gave me a brace, which I vaguely remember as being a cushiony foam contraption that traveled around both my shoulders and wasn't too uncomfortable or conspicuous to wear. The brace, along with a sling, stabilized the fracture. Having grown to associate broken bones with casts, I was surprised to find that this is how they treat a clavicle fracture--leave it alone and hope for the best.

I went to school the next day, brace, sling, and all, and with the codeine and Tylenol they'd given me, I felt fine.

But the day after that it was like the pain had been slacking off and all of a sudden decided to show up for work. Pain yes, school no. To make me feel better, someone, probably my mom or dad, bought me a bag of Riesen chocolate chews. This made me happy. This is what I remember most about breaking my collarbone. A bag of Riesen chocolate chews.

There I was, the day after the day after it happened, immobilized on the pull-out couch in the den, sharp pain shooting from my shoulder to points beyond. This pain was different from the initial muffled throbbing pain. This new pain was all knives and arrows, sharp, shooting, distinct, ruthless. All of this weaponry did not bring out my best side. I couldn't reach the bag of Riesens on the floor--to move would bring more knives, moving = knives, knives = bad.

"Mom, Daddy, Chris, anyone," I simultaneously yelled and whined.

My brother arrived, annoyed at being disturbed. "What?"

"Can you get me a Riesen. I can't reach them." After teasing me with the candy, holding it just out of my reach, he tossed me the bag. To this day he mocks me with this line, this whine, with the whining exaggerated for full effect.

It was a run-of-the-mill adolescent injury. Everyone breaks an arm or leg or collarbone sometime during his or her youth in some klutzy freak accident, right? It's a good story to tell when you're older. I was allowed to drive again about a month after the fracture and got to practice with my team a few times before the season ended. At that point it appeared the fracture would spawn no life-changing repercussions. Life carried on as usual.

Though now when I walked or ran for long periods of time my clavicle would start to ache. It was as if it was tired of being ignored, as if it missed the attention I had given it during the injury and recovery. My clavicle had tasted the sweet nectar of recognition and wanted more. And would do anything to get it. If I throb just slightly, it figured, she'll have to think about me. And it's not like I'm incapacitating her. She can do all the things she did before. Only now she'll think about me every so often, acknowledge my presence in her skeleton, cursing me but acknowledging me just the same. You know that song that kids sing to learn about different body parts, the one that goes: "The hip bone's connected to the thigh bone. The thigh bone's connected to the knee bone. . . ." Well it's time to add a new line: "The clavicle's connected to the sternum."

So it was, my collarbone had a mind of its own. But still the inconvenience was minimal. Every so often when I'd go hiking, or shopping at the mall, or skiing, or did any activity that required me to walk or stand for long periods of time, my collarbone would ache and throb. An ache I'd call annoying and inconvenient. Not fun but bearable. During high school and college I did none of these activities regularly, though, so my clavicle was kind of like my period. It visited a few days each month, during which time it posed a minor inconvenience. The rest of the month it was gone and forgotten.

Back then it appeared the biggest impact of my injury would be cosmetic, in the form of a hard bump in the middle of my collarbone that had not been there before. How did this bump come to be? It seems that when the bone first breaks, both the bone itself and the surrounding tissue bleed like crazy. Bleeding is the bone's initial reaction to this sudden destruction. After a couple of weeks have passed, the site of the break stiffens, and a construction crew of bone-making cells called osteoblasts moves in. The osteoblasts create a sort of scaffolding made of collagen that surrounds the point of fracture the way a croissant surrounds a cocktail wiener in that classic hors d'oeuvre, pig-in-a-blanket. This new tissue is called a soft callus. In a picture of this process the bone looks so snug and cozy in its new bone home. But this new tissue is not strong: the stiff coziness is deceptive.

Four to eight weeks after the injury, new bone begins to form, surrounding the break where the soft callus came before. After eight to 12 weeks have passed, this bony bridge breaches the gap. This new bone is hard and can be seen on an X ray; ideally it is as strong as the original. Finally, starting eight to 12 weeks after the break and lasting up to several years, the site corrects itself, fixing any deformities that remain. This lengthy process is called remodeling; like the remodeling done on a house, this process takes its time and has no definite end. I wondered, did my osteoblasts go on strike before the job was complete? My doctor assured me, however, that the remodeling process is not perfect. Most collarbone fractures heal with a bump like mine, evidence of the new bone that has filled in the break. He told me the occasional pain I experienced meant the fracture probably did not heal 100 percent correctly; unfortunately the only way to reverse such an imperfection would be to re-break the bone, a process involving costly and painful surgery. I figured I could deal with the pain and left it at that. Thinking that this bump and occasional pain were the main aftereffects of my clavicular fracture, I could not complain.

And then I decided to go hiking for seven months.

For a variety of vague reasons loosely related to my love of the mountains, fresh air, and hiking, I decided to walk the length of the Appalachian Trail, from Georgia to Maine. This meant carrying a 30- to 40-pound pack eight hours a day for seven months for a total of 2,172.6 miles. A pack whose straps rested directly on top of my collarbone. Did I consider the effect this reality would have on my friendly left collarbone? To be honest, I don't remember. I think I worried that my clavicle would hurt, but I guess I didn't worry enough not to hike.

So I hiked.

It's kind of funny. By the time I was a month into the hike, my period had all but disappeared. It would last one day per month instead of its usual six and I no longer experienced cramps. It was wonderful! I wasn't worried--I assumed my body probably wasn't getting enough nutrients and calories for me to get pregnant. A hiker is supposed to ingest upwards of 5,000 calories every day and take in a balanced load of carbohydrates, protein, and fat, not an easy feat when you're carrying your entire menu on your back. I'd heard that female athletes often don't get their periods and figured it would resume once I stopped hiking. My collarbone did not take a similar backseat role. Instead of bothering me every few weeks, my clavicle used my hike as an excuse to become a permanent fixture in my life.

I say goodbye to the three-sided shelter and am off and moving. Judging by the position of the sun, it's about nine or ten in the morning, a late start by hiker standards. I've got a liter of water, enough to get me to the next water source. My belly is full of the pop tarts, instant breakfast, and coffee I consumed before starting out. Bowels and bladder have been emptied. My bodily needs have been met for the moment, it's time to lose myself in the walking. And in the dirt and rocks below, the trees around, the ever changing sky above. Starting out, I think about the distances to today's landmarks. Today there are two roads and a waterfall. I must walk 1.2 miles to reach Va. 608, 6.5 miles to reach Va. 606, and 7.8 miles before I pass Dismal Creek Falls. Where will I end up for the day? We'll see, it depends. Out here plans are rarely made and even more rarely followed.

This is the wonderful goulash of hiking. Always walking, no matter what, always walking. Always walking. Wake up, eat, get water, pack up camp, walk, snack, walk, lunch, get water, walk, snack, walk, set up camp, get water, dinner, sleep, repeat, repeat, repeat. Every six days or so visit a town for variety and food, sometimes a bed. A routine threads through the hike. But the routine is oh-so-loose and vague! Every day is different, lushly varied by the changing landscape and views, the people I meet, the streams I get water from or skinny-dip in, the three-sided shelters I stay in, the vehicles I accept rides from at road crossings on my way into town.

At the moment I am alone.

Somewhere behind me is Valley Girl, the guy I've been hiking with more or less since Erwin, Tennessee. "Valley Girl?" "Guy?" No, this is not a typo. On the trail most everyone adopts a trail name, a pseudonym that fully completes the removal from society that comes with thru-hiking. Valley Girl, who answers to Kevin in the so-called real world, happens to have a stellar valley girl accent, chock full of the phrases "oh my God," "like," and "no way," despite the fact that he hails from Raleigh, North Carolina. Along the way someone commented on this odd vernacular habit and, despite his fervent protests, Valley Girl he became. Somewhere in front of me are Good Indian and Lexan, who also stayed at the shelter last night along with Valley and me. Good Indian is a 20-something car-and-wine-loving computer programmer from Atlanta, Georgia--his last name is Bonsavage, French for Good Indian; Lexan is a sarcastic gal from somewhere in the Midwest--her name derives from the heavy-duty, lightweight lexan plastic from which the fork that she carries was made. These three are just a drop in the bucket of the hundreds of people I've met along the trail. At the moment, however, it's just me and the birds; there are no people in sight.

I walk, cross Route 608 after about a mile and after a few miles am on a ridge. But even before that, about 15 minutes after I start hiking, it wakes up and says hello.

"I know you hoped deep down, not expecting it but hoping just the same, that somehow I'd be gone today, that I wouldn't visit, that I'd get tired of this hiking stuff and go away for good," it pipes in. "Nope. I'm here, don't forget it. I'm as regular as each step. As constant as the white blazes that mark this trail. As long as you walk, I'll be here, humming that same tune o' pain, keeping you company, making sure you don't get too comfortable."

It, of course, is my left clavicle.

My clavicle starts to ache almost as soon as I start walking in the morning. I continue to walk, and the ache and throb increase until the pain compels me to stop, take off my pack, and rest my bone. Isn't it silly, isn't it absurd? Other hikers complain of knee, foot, or ankle problems, perfectly logical injuries when you're using those body parts to walk 15 miles a day. The guys all complain about heat rash, a result of certain body parts chafing in the humidity. But me, I've got a cranky little collarbone. My legs will walk all day with no complaints. Lacking that frequently chafed male body part, I've got no chafing to speak of. But I've got to break seven or more times a day because of a five-inch bone.

Over time the pain wore on me physically and mentally. The aching would get worse by the day, requiring more frequent breaks, until the pain would get so bad I'd have to take a few days off to rest the bone. It got to the point where I'd often dread the day's hike simply because I dreaded the collarbone pain that came with it. I loved hiking with my entire body--except my collarbone. The ache was always just bad enough to notice. It didn't stop me from hiking, just made the process slightly but continuously annoying and uncomfortable.

I tried a variety of methods to ease the pain--adjusting the straps on my pack, packing my backpack differently, making my pack as light as possible. Nothing worked, not in the long run. In the end I resorted to consuming lots and lots of ibuprofen. I averaged six or seven a day--the maximum amount you should ingest daily according to another hiker whose dad was a doctor--and prayed the onslaught of pills would be kind to the rest of my insides.

During my hike, as the pain got worse, I often thought about the surgery my doctor had spoken of earlier, re-breaking my bone to give it a chance to heal correctly. If I ever do another long-distance hike, I thought, I will seriously consider having the process performed. The temporary pain of the surgery would be well worth the relief of constant pain that accompanied my structurally infirm clavicle as I hiked.

My collarbone wasn't all spilled milk though. I came to use it to measure how far I'd hiked. When it started to hurt so bad that I needed to stop and take my pack off, I knew I had walked about two miles. I sent my watch home after a few weeks; my collarbone performed the role of timekeeper just fine. My day was broken down into these clavicle segments. I could walk two miles in one clavicle segment. In between segments I stopped to eat a snack, or get water, or eat lunch, or take in a view, or just sit and look at the dirt. My days were usually made up of seven to nine segments. Most people didn't stop this often; my progress was slower because of my collarbone. This slowness thankfully did not leave me without companions. Although some hikers left me in their dust, there were plenty who dilly-dallied and took as many breaks as I.

My clavicle forced me to stop and smell the roses. Or in my case, stop and smell the pine sap and rotting leaves. I am grateful for this necessity. During these breaks I would stop and take in my surroundings. I appreciated and pondered rocks, trees, views, dirt roads, streams, and pieces of litter that I otherwise would've passed without a second thought. I stopped for every shelter, cooler of trail magic (the name for any kind of treat, often a calorific can of soda, left at the side of the trail or road for hikers to consume), and every other non-wilderness oddity that crossed my path. A restaurant a couple miles off the trail in North Carolina? I'm there. A free ride on the gondola at Killington Ski Resort in Vermont? Count me in. A few days off in New York City? Hell yeah. A side trip to Cooter's Garage, home of the world-famous Dukes of Hazzard car General Lee? Do you even have to ask? Breaks like this were fun of course, but they also meant a rest for my collarbone, an always enticing bonus. I'm a sprinter at heart; my nature is to go full throttle until the task at hand is complete. My clavicle was the ever-mindful presence reminding me to take it easy. "Slow down, the experience is in the journey, not the destination!"

Yes, my clavicle encouraged me to hike at a more leisurely pace, though it seems the lesson could've been taught in a less painful way. As long as I'm hiking with my pack, I'm hurting. I love the feeling hiking brings me. Walking and sweating and pushing myself, using my own body to move hundreds of miles over mountains and across entire states--when I hike I am powerful and healthy and alive. But as high as I feel, the pain always remains. While on the trail I can never quite lose myself in the mountains; my clavicle always brings me back.

"Why are you so obsessed with this?"

This is my mom's response as I read about bone fractures and wonder aloud whether I might have post-traumatic arthritis in my shoulder, or maybe a malunioned fracture. Whatever the reason, I feel drawn to understand this rogue structure of tissue. I want to bone up on all there is to know about the clavicle. One need look no farther than Gray's Anatomy for a thorough description of the bone, much of it in medi-speak. Gray's most vivid tidbit is that the clavicle "is a long bone, curved somewhat like the italic letter ƒ." Like this: ƒ , only 5 inches long and horizontally oriented. I imagine my slender ƒ bones resting in their place above my ribs. My right clavicle, the healthy one, is like this, like an ƒ that hasn't been crossed; my bumpy left clavicle has no letter equivalent.

Gray gives us more than this metaphor. He describes the shape, surface, and position of the bone using words like "anterior borders" and "coracoid tuberosity"; he writes in a medical dialect of English not readily understood by the general public. I brush up on the terms I learned in college biology but have since forgotten--anterior, posterior, lateral, medial. This helps me to understand Gray's descriptions, but I still fight to maintain my attention throughout Gray's dense account of the bone's many surfaces. "The anterior border is continuous with the anterior margin of the flat portion. Its lateral part is smooth, and corresponds to the interval between the attachments of the Pectoralis major. . . ." For me this verbal picture does only so much; I want to hold an actual collarbone in my hand and run my fingers along the grooves, ridges, and rough patches of which Gray speaks.

Before getting lost in a sea of terms, I do learn a few things. The word "clavicle" comes from clavicula, Latin for "little key." The clavicle, along with the scapula, or shoulder blade, make up the shoulder girdle. The outer end of the bone is connected to the shoulder blade to form the acromion joint, while the inner end connects the shoulder girdle to the trunk of the body via the sternum, or breastbone, to form the sternal joint.

The clavicle's job is twofold. The bone is a "rigid strut" that acts as a fulcrum, a point from which muscles rotate the arm away from the body. And the bone is a shield, protecting major blood vessels, nerves, and the lungs. If the collarbone does so much, why does it remain unnoticed? Perhaps because it is not the biggest or longest or most interestingly shaped bone. Although it sticks out for everyone to see, or at least feel, it seems the collarbone is fated to be a behind-the-scenes bone, while more glamorous bones like the skull and femur soak up the bulk of osteo-attention.

According to one text, the clavicle is the most frequently broken bone in the human body because "it is much exposed to violence." This common injury is even more common in athletes, who are more likely to meet the type of violence to which the clavicle is vulnerable.

Did you know that a wishbone is made up of a bird's clavicles? In humans, the inner ends of the clavicles connect to the breastbone, but in birds the two bones are joined to form what we know as the wishbone. So much fuss is made over the wishbone that I am surprised to find that this is not common knowledge. Perhaps people are afraid of being too closely compared with birds, perhaps they are still afraid, deep down, that Darwin's discoveries that humans share structures with apes, whales, and birds means humans aren't quite as special as they imagine. Until now the wishbone-clavicle connection has been kept quiet. I will make it my duty to make this fact known. At next year's Thanksgiving dinner I will make a wish on the turkey's clavicle and remember the broken wishbone tucked in my own shoulder.

The clavicle even has a quiet place in art and culture. You will find a song, by the band Alkaline Trio, on the clavicle's resume. "I want to wake up naked next to you/ Kissing the curve in your clavicle." For me the song would have to be edited slightly, but "kissing the bump in your clavicle" doesn't have quite the same ring to it. I even found a website, "The Clavicle Page," that claims to be "a celebration of the underrated collarbone." Consisting solely of close-up photos of 20 different female clavicles--some of the women wear bras, some don necklaces, none boast shirts--it seems that the collarbone plays another more private role as fetish. And the pinnacle of the clavicle's career may very well be Alfred Stieglitz's crisp black-and-white photograph of his artist wife Georgia O'Keefe's clavicle. The simplest things are often the most beautiful; this image takes my breath away.

I still think about having corrective surgery done on my collarbone. In the future I would like to hike the Pacific Crest Trail, which travels over 2,600 miles through the western United States from Mexico to Canada; it would be wonderful to do the hike free of clavicular pain. And for now, because bitching and being bitter have their limits, I've decided to focus on the lessons my clavicle has taught. Of course, it is a lot easier to pontificate about my collarbone from my current pain-free, off-the-trail location. These lessons may sound a whole lot like clichés to you; to me they are as real as all the pain that has oozed from my clavicle.

To me, the collarbone is a reminder.

A reminder of the fragility of the human body. You never know when a freak accident will affect the remainder of your living days.

A reminder of the amazing complexity of the human body. Hundreds of parts, each with a unique form and function, each doing its job, interacting to achieve the whole. It is clear to me that no part, not even the clavicle, is insignificant.

It is my collarbone that reminds me why these truisms contain their fair shares of truth.

It is my collarbone, wrapped up in a fajita of muscle and skin, that has become a permanent fixture in the hike that is my life.

This is my clavicle, my reminder, my wishbone, my little key.

I walk through a sunny Pennsylvania morning. Glowing crowds of corn plants line each side of the trail and fill the field that unfurls to my right, creating a mosaic of greens, yellows, and sunlight. Today I have arranged for someone to take my pack up to Duncannon, the town that is a day's hike up the trail. I am hiking pack-free. Hikers call this "slackpacking" but I find nothing lazy in the process. When I slackpack, my collarbone sleeps and I am free of clavicular complaints. Today the terrain is unusually flat and I fly. My muscles collectively take off and I am a whirlwind of energy, light, and shoes. The distinct corn plants blur into a singing green tunnel. I walk the first eight miles without stopping simply because I can. I love every minute of this pack-free paradise. I try not to think about tomorrow, but I do. Tomorrow I'll carry my pack again and the pain will return. Tomorrow the pain will return and I'll try not to think about it because there's not much else I can do. Tomorrow, I'll walk.

Works Cited

Clayman, Charles, ed. The Human Body. New York: Dorling Kindersley, 1995.

Gray, Henry. Anatomy of the Human Body. 26th ed. Ed. Charles Mayo Goss. New York: Lea and Febinger, 1954.

Mosby's Medical Dictionary. 6th ed. St Louis, Missouri: Mosby, 2002.

Nelter, Frank H. Atlas of Human Anatomy. Summit, New Jersey: CIBA-Geigy Corporation, 1989.

"Safety and Environmental Health." 9 vols. MacMillan Health Encyclopedia. Vol 8. New York: MacMillan Publishing Company, 1993.

Sieg, Kay W. and Sandra P. Adams. Illustrated Essentials of Musculo-skeletal Anatomy. Gainesville, Florida: Megabooks, 2002.

Websites Cited

http://ShoulderAndCollarbone.upmc.com/ClavicleFracture/
University of Pittsburgh Medical Center, "Shoulder and Collarbone, Broken Collarbone"

http://www.hughston.com/hha/a.fracture.htm
Hughston Sports Medicine Foundation, Hughston Health Alert, "Problems that Can Occur During Fracture Healing"

http://kovacortho.com/ListOfItems.asp?IncludedPageID=1670
Michael J. Kovac, MD, "Fractures"

http://www.chw.edu.au/parents/factsheets/fracturj.htm
The Children's Hospital at Westmead, "Fractures--Bone Healing"

http://www.shoulder1.com/reference/faq10.cfm/1
Shoulder1.Com, Body1 Inc., "Reference: Frequently Asked Questions"

http://www.stayinginshape.com/3osfcorp/libv/r04.shtml
OSF Healthcare, "Bone Fractures"

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All rights reserved. Comments. Last modified Tue, Dec 9, 2003.