What is the recommended post-operative recovery and return to sport protocol for an adult or adolescent patient with no significant comorbidities after open reduction internal fixation (ORIF) of a mid shaft clavicle fracture?

Post-Operative Recovery and Return to Sport After ORIF of Midshaft Clavicle Fracture

Patients can safely return to sport as early as 6 weeks post-ORIF for midshaft clavicle fractures, though most athletes return between 6-12 weeks, with progression based on clinical healing, pain-free range of motion, and functional strength rather than time alone.

Immediate Post-Operative Phase (0-2 Weeks)

Immobilization and Protection

• Use a simple sling for comfort and protection during the first 2-4 weeks, discontinuing when pain allows 1
• Avoid lifting, pushing, or pulling with the affected arm during this period 1
• Begin gentle pendulum exercises and passive range of motion immediately as tolerated 1

Pain Management

• Expect significant pain reduction within the first 2 weeks, with pain scores typically dropping from 3.6 to 1.0 on a 10-point scale 2
• Cryotherapy may be applied during the first postoperative weeks to manage pain and swelling 1

Early Rehabilitation Phase (2-6 Weeks)

Range of Motion Progression

• Discontinue sling use by 4 weeks for routine activities 1
• Progress active-assisted range of motion exercises, advancing to active range of motion as pain permits 1
• Achieve near-full range of motion by 6 weeks in most cases 2

Strengthening Initiation

• Begin isometric strengthening exercises at 2-4 weeks 1
• Progress to light resistance exercises at 4-6 weeks, focusing on scapular stabilization and rotator cuff strengthening 1
• Prioritize closed kinetic chain exercises over open kinetic chain exercises during early strengthening 1

Functional Milestones

• Expect QuickDASH scores to improve from approximately 33 pre-operatively to 21.5 at 2 weeks and 16.1 at 4 weeks 2
• By 4 weeks, 93% of elite cyclists are training outdoors, demonstrating the potential for rapid functional recovery in motivated athletes 2

Advanced Rehabilitation Phase (6-12 Weeks)

Progressive Loading

• Full weight-bearing activities are typically allowed between 8-12 weeks, depending on radiographic evidence of healing 1
• Advance resistance training progressively, ensuring pain-free execution of exercises 1
• Incorporate sport-specific movements and neuromuscular training 1

Return to Sport Criteria

Return to sport should be based on objective criteria rather than time alone, including:

• Radiographic evidence of fracture union (typically by 8-12 weeks) 1, 3
• Pain-free full range of motion in all planes 1
• No tenderness over the fracture site 4
• Strength symmetry >90% compared to the contralateral side 1
• Completion of sport-specific training without pain or functional limitations 1

Return to Sport Timeline

• Early return (≤6 weeks): Possible in 23% of athletes, particularly in non-contact sports or training activities 4
• Standard return (6-12 weeks): Achieved by 67% of athletes by 12 weeks 4
• Competition return: 56% of cyclists and 57% of motocross riders return to competition by 6 weeks 2
• Mean return to play: 83 days (approximately 12 weeks) across all sports 4

Long-Term Outcomes and Monitoring (3-6 Months)

Expected Functional Recovery

• QuickDASH scores typically reach near-perfect levels (0.8-0.94 out of 100) by 12 weeks, indicating minimal disability 3, 4
• All patients should achieve fracture union with proper surgical technique 3
• Patient satisfaction rates approach 100% with appropriate rehabilitation 4

Complication Monitoring

Be vigilant for complications that occur in approximately 24-27% of cases:

• Hardware irritation (24%): Most common complication, may require eventual hardware removal 3
• Peri-incisional dysesthesia (17%): Usually resolves over time 3
• Adhesive capsulitis/stiffness (20%): Requires aggressive physiotherapy 5
• Superficial infection (3%): Treat with antibiotics 5
• Nonunion (<1%): Rare with proper fixation 3

Risk Factors for Complications

• Smoking increases complication risk 2.7-fold and significantly predicts reoperation 1, 6
• Obesity increases overall complication risk 6
• Transverse or Z-type fracture patterns have higher complication rates 6
• Manual laborers have higher rates of minor complications 6

Critical Pitfalls to Avoid

Premature Loading

• Do not allow heavy lifting, pushing, or pulling before 4 weeks, as this risks hardware failure or delayed union 1
• Avoid contact sports or high-risk activities before radiographic union is confirmed 4

Inadequate Rehabilitation

• Failure to address scapular dyskinesis and rotator cuff weakness leads to persistent dysfunction 5
• Neglecting sport-specific training before return to competition increases reinjury risk 1

Ignoring Red Flags

• Persistent pain beyond 6 weeks warrants radiographic evaluation for nonunion or hardware complications 3
• Progressive loss of motion suggests adhesive capsulitis requiring intensive physiotherapy 5
• Wound drainage or systemic symptoms indicate possible deep infection requiring urgent evaluation 3

Special Considerations for Athletes

Elite/High-Level Athletes

• More aggressive rehabilitation protocols are safe and effective in motivated athletes 2
• Early return to training (outdoor cycling by 4 weeks) is achievable with proper surgical fixation 2
• Competition return by 6 weeks is realistic for non-contact or individual sports 2, 4

Contact Sport Athletes

• Require complete radiographic union before return to contact 4
• May benefit from protective padding during initial return to competition 4
• Typically require 12+ weeks before unrestricted competition 4