Shoulder > Collarbone Fracture > Treatments

    Open Reduction and Internal Fixation

You may be a candidate for open reduction and internal fixation to repair your fractured collarbone if the fracture occurred in the outer (distal) third of the bone, closer to your acromioclavicular (AC) joint. You may also need this surgery if your fracture did not heal properly during immobilization. In this procedure, the fracture is fixed in place by wires and sutures or plates and screws.

The decisions you make and the actions you take before surgery can be every bit as important as the procedure itself in ensuring a healthy recovery. Getting a second opinion from another qualified surgeon is often advisable, particularly in rare or unique cases.

   Make sure you have received any equipment you will need when you get home from the hospital. This may include a shoulder sling, ice packs or coolers, or heating pads. You should receive prescriptions for any of these from your doctor when your surgery is scheduled.

   Learn the potential risks and benefits of the surgery by asking your surgeon any questions that will help you better understand the procedure. It can also help to talk to others who have undergone the same surgery.

   Any physical problems, such as a fever or infection, should be reported to your surgeon, and you should notify your surgeon of any medication you are taking.

   If possible, discontinue the use of any anti–inflammatory medicine, especially aspirin, a week prior to surgery, to prevent excessive bleeding during the procedure.

   To reduce the risk of infection, improve healing, and decrease complications, try to quit smoking or decrease the amount you smoke. In general, smokers have a higher infection and overall complication rate.

   To check if the orthopedist performing the surgery is board-certified or eligible, call the American Board of Orthopaedic Surgery at 919-929-7103.

At most medical centers, you will go to "patient admissions" to check in for your open reduction and internal fixation of your collarbone fracture. There may be separate check-in areas for ambulatory outpatient (patients who go home the same day after surgery) and for overnight inpatient surgery, so be sure to ask your physician or an assistant about this. After you have checked in to the hospital or clinic, you will go to a holding area where the final preparations are made. The paperwork is completed and your shoulder may be shaved, though this is not always necessary. You will wear a hospital gown and, if applicable, remove your watch, glasses, dentures, and jewelry. You will have the opportunity to speak with your orthopedic surgeon or an assistant, and meet the anesthesiologist or anesthetist (a nurse who has done graduate training to provide anesthesia under the supervision of an anesthesiologist). Then, you will walk or ride on a stretcher to the operating room. Most patients are not sedated until they go into the operating room. Here are some important steps to remember for the day of your surgery:

   You will probably be told not to eat or drink anything after midnight on the night before your surgery. This will reduce the risk of vomiting while you are under anesthesia.

   Because you may be unable to drive, arrange for someone to help take you out of the hospital and drive you home when you are released.

   Wear a soft, comfortable shirt that will not irritate your skin when worn under a shoulder sling.

   Take it easy. Keeping a good frame of mind can help ease any nerves or anxiety about undergoing surgery. Distractions such as reading, watching television, chatting with visitors, or talking on the telephone can also help.

Open reduction and internal fixation of your fractured collarbone can take between one and two hours to perform.

   After arriving in the operating room, the anesthesiologist will begin intravenous sedation and often a regional anesthetic will be given. The patient may then be given a general anesthetic, depending on what pre-surgery decisions have been made.

   An incision is made to access the fractured part of the collarbone.

   The surgeon will use plates and either screws or sutures to fixate the broken bone, depending on the pattern of the fracture.

   The incision is then closed and the patient is taken to the recovery room.

When you awaken in the recovery room following open reduction and internal fixation of your collarbone fracture, your shoulder usually is wrapped in gauze, immobilized in a sling, and covered with an ice pack. You may feel a moderate amount of pain. You usually stay in the recovery room for at least two hours while the anesthetic wears off. General anesthesia wears off in about an hour and regional anesthesia may take about two hours to wear off. You should try to move your fingers while you are in the recovery room to improve circulation. Moving your wrist may be painful, and you usually should not try to move your elbow. Your temperature, blood pressure, and heartbeat will be monitored by a nurse, who, with the assistance of the doctor, will determine when you are ready to leave the hospital or, if necessary, be admitted for an overnight stay.

After open reduction and internal fixation of a collarbone fracture, some patients remain in the hospital for as long as 24 hours. There will likely be pain, and you can expect to be given pain medication as needed. Be sure to ask for medication as soon as you feel pain coming on, because pain medication works best on pain that is building rather than on pain that is already present. The nurses will not give you more than your doctor has prescribed and what is considered to be safe. Ice also helps control pain and swelling. Physicians generally suggest that you immobilize your shoulder in a sling for about six to eight weeks. You will be taught how remove the sling and bend your elbow if necessary. In addition, you will be given an appointment to return and a prescription for pain medicine. You will not be able to drive, so be sure to have arranged for a ride home.

After open reduction and internal fixation of a collarbone fracture, you will need to take steps to reduce the pain and inflammation in your shoulder. Rest, icing, and anti-inflammatory painkillers such as ibuprofen or aspirin can ease pain and swelling, and immobilizing the shoulder will keep it stabilized. Here is what you can expect and how you can cope with a sling immobilizing your shoulder:

   The first concern is to monitor swelling for the first 48 hours while wearing your sling. Physicians generally prescribe ice packs to be applied for 20 minutes at a time, three or four times a day.

   There may be some minor drainage on the bandage since fluid may have accumulated during the surgery. Expect some blood to show through the bandage during the first 24 to 48 hours.

   Physicians generally recommend that you wear the sling day and night for between two and eight weeks.

   You can usually remove the gauze bandage and bathe regularly after two to seven days. Call your physician if bleeding continues. You can remove the sling for brief periods to shower, but remember to avoid moving the injured arm.

   Stitches are usually removed about two weeks after surgery.

   When your shoulder starts to heal, your physician may recommend that you remove the sling for short periods to perform some light, early-motion exercises.

   You should move your fingers and hands in the sling as much as possible to help circulate blood.

   If you develop a rash or irritated skin around your sling, call your physician.

   If you notice any abnormal wear or discomfort in the sling, contact your physician as early as possible. In general, do not try to "grin and bear it" if discomfort does not go away within a few days. The sling should not irritate your skin.

Rehabilitation can usually begin within a few weeks after surgery, but you should visit your physician a week after the injury for a check-up. Until cleared by your physician, you should keep the shoulder immobilized in the sling. The sling may make it difficult to use the hand of the injured shoulder, and you may need to take several weeks off from work, depending on how much you rely on the immobilized hand.

After about two or three weeks of immobilization, your physician usually refers you to a physical therapist to begin rehabilitation exercises. The first stage of physical therapy usually involves passive motion exercises with the assistance of your physical therapist. Most patients begin with forward motion in the shoulder. Because your arm has been held across your chest for weeks, rotating or turning the shoulder outward is usually painful when rehab begins. With the shoulder held in place, you usually begin strengthening your wrist and elbow by flexing and extending your hand and arm. After two to four weeks, you may be able to start moving your hand, arm, and shoulder without the assistance of the therapist. Usually within eight weeks, your therapist can start adding resistance to your exercises with weights or elastic bands. Non-contact sports, like tennis and swimming, can often be resumed within four months. Contact sports should usually not be resumed until at least six months. Depending on your specific situation, your physician may prescribe a modification to the above regimen.

Though injuries caused by direct trauma frequently are difficult to avoid, you can help reduce your risk of repeat collarbone injuries by making shoulder strengthening exercises part of your everyday routine. Rotator cuff strengthening helps reduce the risk of overuse problems during athletic or work activities that require repetitive overhead motions. For players in contact sports like football, hockey, or lacrosse, wearing well-fitted shoulder pads that provide more cushioning can help prevent direct-blow collarbone injuries. Indirect injuries, such as accidentally falling on your hand, are more difficult to prevent. After a collarbone injury, you should be careful to notice any pain or discomfort in your shoulder during athletics. Avoid playing through shoulder pain.