Clavicle ORIF (Open Reduction and Internal Fixation)

What is clavicle ORIF?

Clavicle or collarbone connects the arm to the body. Clavicle ORIF is a surgical procedure that stabilizes and helps in healing a broken collarbone. Open reduction is a surgical procedure in which the broken bones are realigned back to their normal position by opening the skin and muscles and directly approaching the bone. Internal fixation is a method of reconnecting the bones with the help of a specially designed hardware such as plates and screws.

 

What are the Indications for the procedure?

  • Open fracture
  • Skin tenting
  • Polytrauma with rib fractures
  • Displaced fractures of the outer end of clavicle
  • Injury to subclavian artery or vein
  • Floating shoulder (fracture in clavicle and scapula neck or humerus)
  • Symptomatic malunion of broken bone fragments
  • Symptomatic Non-union of broken bone fragments
  • Displaced fractures with gap or shortening of more than 2cm
  • Injury to brachial plexus
  • Athletes/labourers involving repeated overhead activities

 

What are the risks?

The surgery possesses few risks like other surgeries.

  • Infection due to hardware
  • Implant removal
  • Hardware problems like broken screws or plates
  • Damage to the localized nerve
  • Injury to artery or veins
  • Injury to lung
  • Misalignment of bone
  • Nonunion
  • Frozen shoulder/stiffness
  • Complications from anaesthesia

 

What are the benefits?

  • Pain relief
  • Good functional outcome
  • Anatomical alignment
  • Predictable fracture union
  • Reduced chances of malunion
  • Improved cosmesis – swap scar for deformity
  • Better outcomes in fractures greater than 2 cm shortening of clavicle and 100 % displacement
  • Increased strength and endurance of the shoulder

 

 How should I prepare for the procedure?

ORIF is an emergency surgery performed after an accident or injury.  You can prepare for the procedure by following steps-

  1. Before surgery, your surgeon will investigate your general condition through certain tests such as blood tests, electrocardiogram or chest X-ray to rule out any health risks. This helps to rule out any possible risks of surgery such as bleeding, heart diseases etc.
  2. It is advisable to inform your surgeon about any medications or supplements (esp. Blood thinners) you are taking. He may ask you to stop them before the surgery as they may complicate the operation.
  3. If you are a smoker, you should stop smoking at least 48 hours before the operation. Smoking increases the risk of chest and wound infection. It also affects your recovery process after the surgery by slowing it down. Some patients require help for household activities as many activities that require upper movement of the shoulder and other household activities such as bathing, dressing, laundry and cooking for few weeks nearly six weeks.
  4. Any infection in the body including common cold or a cough should be cleared up before the operation.
  5. You should also stop eating or drinking 8 hours before the operation.
  6. Positive attitude towards the operation and your condition are necessary for the success of the surgery. This will help you for better health benefits and faster recovery.

 

How is it performed?

The selection of technique/implants for clavicle ORIF depends on the severity of the injury, its location and duration after injury.

  • The operation is usually performed under general anaesthesia. In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation but he cannot feel whatever is happening in the surgical area. Your surgeon can select the combination of both local and general anaesthetic.
  • Positioning– The position of the patient during the operation is semi beach chair position
  • Procedure- a 5-10cm incision is made at the top of the shoulder and the fracture identified.
  1. Acute injuries – The surgeon will realign the bone fragments back to the position in its normal position (open reduction). He will rejoin the bone fragments with the help of pines, wires, plates and screws. In some cases with outer end fractures the stability is achieved by anchors placed in shoulder blade (coracoid) to augment the fixation.
  2. Chronic injuries – In majority of cases dead bone at the fracture site is excised packed with bone graft and stabilised with plates and screws.
  • The layers of the muscle and skin are then closed with the help of absorbable sutures. The operation may take a couple of hours.

 

What happens after surgery?

  • The local anaesthetic wears off 4-10 hrs after surgery, patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
  • Initially, the aims are the comfort and rest the arm in a sling for a couple of days.
  • Before discharge, you may see a physiotherapist, who will teach you gentle exercises of your fingers, wrist, elbow and pendulum exercises of the shoulder. You may be able to start these gentle exercises on the day of your operation and they are essential to reduce stiffness, pain and to strengthen the muscles around your shoulder.
  • You can use your arm to do light activities (writing, using keyboard etc) that don’t cause excessive pain or discomfort.
  • The patient is reviewed in clinic around 2 weeks following the operation for wound check and physiotherapy.
  • The wound should be massaged (typically after 2 weeks) using moisturising cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness, helps scar to mature).
  • You could start a gentle range of movement (ROM) exercises at 3 weeks and progress to full range of movements around 6 weeks. Between 6weeks and 3months you could start using your arm for more strenuous activities (swimming, driving, lightweights in gym etc). This will be guided by your surgeon and is based on radiographic (X-ray) and clinical union of the fracture. It is advisable to avoid contact sports or any injury to the affected area for 3 months. The duration may increase or decrease based on the personality of fracture, quality of bone and method of fixation.
  • Physical therapy plays an important role for returning back to the normal activities and its vital to work with the physiotherapists to get full function back in your shoulder.

Plates and screws are usually not removed from the bone even if the healing process is complete until they cause discomfort in the skin of the affected area. In some patients the implants below the skin may cause irritation especially when you wear a seat belt, back pack etc. In selected cases the implants are removed after complete union of fracture and might take upto a year.

Clavicle ORIF_1

  1. 25 year old gentleman had a fall during snowboarding and broke his collar bone with one of the fragments tenting the skin (Red arrow) and fracture gap. B. 6 months radiograph with fully healed clavicle after open reduction and internal fixation with plates and screws. Patient returned back to pre-injury level of activities, three months after surgery.

Clavicle ORIF_2

  1. 55 year old polytrauma patient following road traffic accident was admitted with complex lateral end clavicle fracture. B. 5 months radiograph with fully healed clavicle after open reduction and internal fixation with plates and screws augmented with anchor in coracoid (shoulder blade). Patient returned back to pre-injury level of activities, six months after surgery.

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