What are the postoperative guidelines for Open Reduction Internal Fixation (ORIF) of the clavicle?

Postoperative Guidelines for ORIF Clavicle

Following ORIF of the clavicle, immobilize in a sling for comfort (not a figure-of-eight brace), begin early passive range of motion within the first 1-2 weeks, progress to active motion by 4 weeks, discontinue the sling by 4 weeks for routine activities while avoiding lifting/pushing/pulling, and allow full weight-bearing activities at 8-12 weeks based on radiographic healing. 1

Immediate Postoperative Period (0-2 Weeks)

Immobilization

• Use a sling as the preferred immobilization method rather than a figure-of-eight brace, as recommended by the American Academy of Orthopaedic Surgeons 2, 1
• The sling provides comfort and protection during the initial healing phase 1

Early Mobilization

• Begin gentle passive range of motion exercises within the first 1-2 weeks to prevent adhesive capsulitis 3
• Adhesive capsulitis or stiffness occurs in approximately 20% of patients in the early postoperative period and requires physiotherapy intervention 3

Imaging

• Routine postoperative chest radiography is unnecessary following ORIF of clavicle fractures, as the rate of iatrogenic pneumothorax is extremely low (0% in a series of 101 patients) 4
• Standard clavicle radiographs should be obtained to confirm hardware position and fracture alignment 1

Intermediate Recovery (2-4 Weeks)

Progressive Range of Motion

• Advance to active-assisted range of motion exercises during this period 1
• Continue to wear the sling for comfort, particularly when outside the home or during sleep 1

Activity Restrictions

• Avoid lifting, pushing, or pulling with the affected arm 1
• No overhead activities or heavy lifting 1

Advanced Recovery (4-8 Weeks)

Sling Discontinuation

• By 4 weeks, most patients can discontinue sling use entirely for routine activities but should continue to avoid lifting, pushing, or pulling with the affected arm 1

Strengthening

• Begin muscle strengthening exercises once adequate healing is demonstrated 1
• Focus on scapular stabilization and rotator cuff strengthening 1

Return to Full Activity (8-12 Weeks)

Weight-Bearing Progression

• Full weight-bearing activities are typically allowed between 8-12 weeks, depending on radiographic evidence of healing and clinical examination 1
• Obtain follow-up radiographs to confirm union before clearing for unrestricted activity 1

Return to Sport

• For athletes, return to sport occurs at a mean of 211 days (approximately 7 months) post-surgery 5
• 44% of professional athletes can return within the same season as their injury 5

Common Complications and Monitoring

Expected Complications

• Overall complication rate is 23.7%, with 9.1% requiring reoperation 6
• One in four patients (24.6%) undergoes at least one clavicle reoperation within two years 7

Specific Complications to Monitor

Hardware-Related Issues:

• Isolated implant removal is the most common reoperation (18.8%), occurring at a median of 12 months postoperatively 7
• Females are at highest risk for implant removal (odds ratio 1.7) 7
• Symptomatic hardware is a common indication for reoperation 6

Adhesive Capsulitis:

• Occurs in 20% of patients and requires aggressive physiotherapy 3
• Monitor for shoulder stiffness and implement early range of motion exercises 3

Sensory Changes:

• Paresthesia over the surgical site and anterior chest develops in 13.3% of patients 3
• This is typically self-limited but should be documented 3

Infection:

• Superficial infection occurs in 3.3% of cases 3
• Deep infection requiring irrigation and debridement occurs in 2.6% at a median of 5 months 7
• Surgeons with fewer years in practice have slightly higher infection rates 7

Nonunion:

• Occurs in 2.6% of patients at a median of 6 months 7
• Risk factors include female sex (odds ratio 2.2), high comorbidity score (odds ratio 2.8), smoking, and transverse or Z-type fractures 7, 6

Malunion:

• Occurs in 1.1% of patients at a median of 14 months 7

High-Risk Patient Considerations

Smoking

• Smoking increases nonunion rates and leads to inferior clinical outcomes 2
• Smokers with transverse/Z-type fractures are at highest risk of reoperation with single plating 6
• Strongly counsel smoking cessation 2

Obesity

• Obesity is a significant prognostic factor for overall complication risk 6
• Consider this when counseling patients about expected outcomes 6

Fracture Pattern

• Transverse or Z-type fractures are predictive of major complications requiring reoperation 6
• These fracture patterns had significantly higher complication rates compared to oblique fractures 6

Patient Education Priorities

• Educate about pain management strategies during the recovery period 1
• Emphasize the importance of long-term continuation of appropriate exercises to maintain shoulder function 1
• Counsel about signs of complications requiring medical attention, including increasing pain, wound drainage, fever, or progressive stiffness 1
• Inform patients that while surgical treatment provides higher union rates and better early patient-reported outcomes, long-term outcomes at 1-2 years are similar to nonsurgical treatment 2, 1

Pitfalls to Avoid

• Do not use figure-of-eight bracing as it is not the preferred immobilization method 2, 1
• Do not delay early passive range of motion beyond 2 weeks, as this increases risk of adhesive capsulitis 3
• Do not order routine postoperative chest radiographs as they are unnecessary and expose patients to radiation without clinical benefit 4
• Do not clear patients for full activity before 8 weeks without radiographic confirmation of healing 1