What is the detailed rehabilitation protocol for a 65-year-old male with a left clavicular fracture managed non‑operatively?

Detailed Rehabilitation Protocol for Non-Operative Left Clavicle Fracture

For a 65-year-old male with a left clavicular fracture managed non-operatively, implement immediate immobilization with a sling for 3-6 weeks followed by progressive functional rehabilitation starting at 3 days to 2 weeks post-injury, with the goal of achieving full range of motion and strength by 3 months 1, 2.

Initial Immobilization Phase (Weeks 0-3 to 6)

Immobilization Method:

• Use either a simple arm sling or shoulder immobilizer (both are acceptable options per AAOS guidelines) 3
• The figure-of-eight brace is also an option, though no superior outcomes have been demonstrated 4
• Duration: Maintain strict immobilization for 3-6 weeks depending on fracture stability and pain control

During Immobilization:

• Remove sling only for hygiene and gentle pendulum exercises after initial pain subsides (typically 7-14 days)
• Avoid lifting, pushing, or pulling with the affected arm
• Keep elbow, wrist, and hand mobile with gentle active range of motion exercises to prevent stiffness

Early Rehabilitation Phase (Weeks 2-6)

Initiate physical therapy between 3 days to 2 weeks post-injury 1, 2:

• Pendulum exercises: Begin immediately once tolerated (typically within first week)
• Passive range of motion: Gentle assisted forward flexion and external rotation
• Active-assisted exercises: Progress as pain allows, typically by week 3-4
• Scapular stabilization exercises: Gentle scapular retraction and depression exercises

Key Principle: Studies without strict immobilization showed nonunion rates of 5-24% versus 3-29% with immobilization, so balance early mobilization with adequate protection 1.

Progressive Strengthening Phase (Weeks 6-12)

Once clinical and radiographic healing is evident (typically 6-8 weeks):

• Active range of motion: Full active elevation, rotation, and functional movements
• Resistance training: Begin with light resistance (1-2 lbs), progressing to functional loads
• Rotator cuff strengthening: Internal/external rotation with resistance bands
• Scapular strengthening: Rows, protraction/retraction exercises
• Functional activities: Gradually return to activities of daily living

Return to Full Function (Weeks 12+)

Expected Timeline:

• Full range of motion: Typically achieved by 3 months 5, 2
• Full strength: Equal to contralateral side by 3 months in most cases 2
• Return to work: Average 3.9 months for non-operative management 6
• Return to sport: 3.9 months average for non-operative treatment 6

Functional Outcomes to Expect:

• Studies with functional rehabilitation protocols report Constant Shoulder Scores of 87.8-96 out of 100 1
• 90% of patients achieve excellent to good results with proper rehabilitation 2
• Strength should equal the uninjured extremity in properly rehabilitated patients 2

Critical Monitoring Points

Watch for complications requiring surgical conversion:

• Nonunion risk: 3-29% with proper immobilization, up to 15% overall 3, 1
• Symptomatic malunion: May affect shoulder strength and function 3
• Persistent pain: 14-49% report some residual pain with immobilization protocols 1

Red flags for surgical referral:

• Lack of healing progression by 8-12 weeks
• Increasing displacement on follow-up radiographs
• Persistent pain limiting function beyond 3 months
• Patient dissatisfaction with cosmetic deformity

Important Caveats

Age Consideration: At 65 years old, this patient may have slightly slower healing than younger adults, but non-operative management remains highly effective. Studies show 19 of 20 floating shoulder injuries (more severe than isolated clavicle fractures) healed uneventfully with non-operative treatment 2.

Displacement Matters: While the AAOS guidelines note that surgical treatment offers higher union rates and better early outcomes for displaced fractures 3, long-term patient-reported outcomes are similar between operative and non-operative treatment, making non-operative management a valid choice.

Avoid LIPUS: Do not use low-intensity pulsed ultrasonography (bone stimulators) as it does not accelerate healing or reduce nonunion rates (Moderate recommendation) 3.

Physical Therapy Intensity: Studies including structured functional rehabilitation protocols showed better outcomes (Constant scores 87.8-96) compared to those without formal protocols (81-85) 1, emphasizing the importance of supervised rehabilitation rather than immobilization alone.