Treatment

What treatments should I consider?

With such a wide variety of injuries to the shoulder girdle it is not surprising that the treatment options are widely variable also. Several fractures can be treated symptomatically only, while others require closed reduction or open reduction. A few fractures of the proximal humerus and fracture dislocations of the shoulder are treated primarily with shoulder replacement because of concerns about the blood supply of the fracture fragments. Any open fracture requires surgery to clean up the wound and remove all dirty or dead tissue. The fracture is often stabilized by ORIF once the wound is cleaned up.

Non-surgical treatment is employed commonly. Nearly all fractures of the sternum, the collarbone, the blade of the scapula, the acromion and coracoid processes and the neck of the glenoid are treated without attempting to improve the position of the fracture or fix it. Symptomatic treatment usually includes using a sling to limit movement of the shoulder and prevent the weight of the arm dragging on the painful part. Most slings are suspended round the neck, which can get uncomfortable. An arm immobilizer is available in some hospitals; this goes round the chest and supports the forearm and the arm just above the elbow.

Within a few days the pain from the fracture site settles to the point where immobilizing the shoulder is not necessary for pain relief. Movement of the forearm and elbow is encouraged and pendulum (or circus) movements of the shoulder may be possible. The patient leans forward or to the side, letting the arm hang clear of the chest and the elbow is then moved in small circles to prevent scar formation in the joints. This type of rehabilitation activity can gradually increase as the fracture heals. Where this is the treatment plan, consultation with an orthopaedic surgeon may not be necessary.

In some cases a closed reduction is needed followed by splinting. Under anesthetic, but without opening up the fracture site, the fracture (or dislocation) is manipulated into a better position and alignment. This is typical treatment for glenohumeral dislocation. Avoiding excessive shoulder motion for a period of weeks should allow the ligaments to heal without being stretched and may reduce the chance of recurrent dislocation in the future. Displaced clavicle fractures are often treated in a figure eight brace which braces both shoulders back and may improve the position of the fracture. Some humeral neck fractures are angulated initially and may be treated by a closed reduction to improve the position followed by splinting in a sling.

In some fractures of the humeral neck, the fracture is unstable - meaning that it is at high risk to displace again after closed reduction. This can be prevented by inserting pins through the skin and across the fracture under x-ray control. When the fracture has partly healed, these pins can be removed without the need for an anesthetic.

The usual reason for treating a fracture by surgery is that the results of nonoperative treatment would not be satisfactory. Residual deformity, irregularity of the joint surface or bone fragments likely to interfere with movement are the most common reasons for this decision. In most situations the surgeon chooses to open up the fracture site to replace the fragments back in the correct position. This is called an open reduction. The position is then secured by fixation with metal implants such as plates, screws, pins and wire. This is called internal fixation. Together, this is commonly referred to as ORIF - meaning open reduction and internal fixation.

Open reduction and internal fixation (ORIF) is often employed for glenoid rim fractures, fractures of the outer end of the clavicle, for displaced fractures of the neck of the humerus, for fracture dislocations of the shoulder and for fracture dislocations of the sterno-clavicular joint. ORIF is used less often for fractures of the shaft of the collarbone, or glenoid neck or displaced avulsion fractures of the acromion, coracoid process, distal pole of the scapula or greater tuberosity. A more complex form of ORIF, intramedullary (IM) rod fixation is sometimes used for unstable fractures of the neck of the humerus. External fixation is not commonly used in North America for fractures in the shoulder girdle. After most forms of fixation of shoulder fractures, a sling is used for a few weeks to help with pain control and reduce the load on the healing area.

In severely shattered fractures of the neck of the humerus the blood supply of the head of the humerus is lost and the bone supporting the joint surface will die. In this situation a decision to do an artificial joint operation may be made. The head fragment is removed and replaced with a metal implant that is fixed inside the shaft of the humerus and has a rounded "head" the same size and shape as the natural one. The remaining fragments are fixed back to the implant and the shaft of the humerus. When this heals the shoulder should be free from pain and have an acceptable range of movement.

Percutaneous pins (and external fixation devices) are always removed as soon as possible. This can be done without a general anesthetic. Other implants are removed at a secondary operation of "hardware removal" only if they are causing symptoms. If the screws or plates are under the skin or can be felt, they may be uncomfortable. The prospect of an operation for implant removal is worrying to patients who fear that it will be as painful as the original fracture treatment. Much of the pain from the original fracture comes from torn muscles, broken bones, and bleeding. Since the bone and muscle damage have both healed, the discomfort after hardware removal is much less and recovery is rapid. The operation does need an anesthetic but can often be done as outpatient, or day surgery.