Operative treatment
The two main options for fixation are a nail or a plate. The pattern of your fracture will dictate which you are offered. A nail is a titanium rod (see x-ray to the right) which is 8mm thick and about 15cm long is inserted through a small cut on the corner of your shoulder at the top and pushed down through the centre of the bone towards the elbow. There are 2 or 3 other small cuts to insert locking screws which stop the nail twisting inside the bone. The other method is plating (see lower image on the right) which is where a stainless steel plate, shaped a little like a tennis racquet, is attached to the bone with 7 or 8 screws. In hospital this may be referred to as ORIF (open reduction and internal fixation). Routinely, metalwork is left in-situ even though once the fracture has healed, the metalwork is redundant. To have the metalwork removed would be another operation which is another anaesthetic and further surgery which would be yet another opportunity to pick-up a complication and metalwork doesn’t usually provide any long-standing issues by being left in the body. Yes, you may set off alarms at airports but you’ll be able to provide a simple explanation ! Of course, sometimes it is necessary to remove metalwork if, for example, it works loose, is prominent or gets infected.
These fractures are best treated with surgery, if that is the chosen treatment, within the first 3 weeks. After that the fracture is healing to an extent where the surgeon has to breakdown that healing in order to realign the fragments. This is hard work and makes the surgery longer and much more complex. Usually we would be able to arrange your surgery within 3 weeks of your injury date. You should be aware that not all orthopaedic surgeons perform such surgery so you may be waiting for a specific surgeon to have a place on his or her operating list in order to be able to get it done. This is easier said than done with pressures on our health services the way they are.
You will usually come to the hospital on the day of your surgery and meet the surgeon and anaesthetist. They will re-explain the surgery and can answer any questions that you may have. The anaesthetist may offer you a ‘nerve-block’, in addition to a general anaesthetic, to assist with post-operative pain relief.
The surgery usually takes between 1 and 2 hours and then you will spend some time in the ‘recovery’ area of theatres before returning to the ward. It would be usually for the operating surgeon or a member of the team to see you after the surgery to explain what went on. You may be discharged the same day or perhaps the next day, most often depending on your own home circumstances.
You should wear the sling as directed, day and night but it can be removed under certain circumstances and this is not detrimental to your surgery. You can remove it to get washed or showered. You may need help. Keep your arm in the position that it would be if it were in a sling (forearm across your tummy) and hold the shower-head in the other hand. Shower low-down, using only a flannel near your dressing and into the armpit of the operated arm. Do not get your dressing wet. If it gets wet, it needs changing and the more a dressing is changed the more likely the wound will get infected. It is also ok to remove the sling to do some gentle exercises of the elbow to avoid stiffness and of course the hand and wrist. The physiotherapist on the ward will show you some gentle exercises to do for your shoulder also.
At about 2 weeks after your operation you will come back to the hospital to have you wound checked and any stitches trimmed or removed. After this it is common to be able to get the wound wet in the shower. Be gentle with the wound as it is still fragile. Don’t rub it vigorously with a towel but dab it dry. Be gentle with the wound for 6 weeks after the operation.
I would usually recommend a patient to use a sling for about 4 weeks after fixation of a shoulder fracture. After 4 weeks start to move your shoulder through a gentle range, initially moving the arm below the level of the shoulder and increasing to above the shoulder after a couple of weeks but the physio will advise you. All patients progress slightly differently. Some pain is to be expected.
It can be difficult for patients to know how much physio to do and what it should feel like both during and after doing the exercises. If you don’t do enough then obviously it won’t be beneficial. If you do too much then you may get a lot of pain and even do damage to the surgical repair. As a guide, you should have pain for no longer than an hour after doing your exercises. If you’re pain is lasting longer than this, you may be doing too much. The pain you experience during the exercises should not go above 5 on the pain scale (1-10, with 10 being the worst pain imaginable). If your pain does go above this level then you need some gentler exercises to work with initially before building back up.
You will be reviewed again at about the 2 month mark. By this time your pain should be under control, you should be getting well on physio. Driving is feasible at about this stage for many. Patients that drive cars with automatic gear-boxes tend to get back into driving much sooner than those with manual gearboxes, especially when it’s the left shoulder that was fractured. The DVLA just advise no plaster casts and no slings. After that it is down to the driver to declare for themselves whether they feel safe to drive.
You will be followed-up in clinic for as long as it takes to see that your injury has recovered to a satisfactory level. X-rays may be taken to check the healing position.