What is the postoperative plan for a patient who has undergone an Open Reduction Internal Fixation (ORIF) of the clavicle?

Postoperative Management After ORIF of Clavicle Fracture

Initiate immediate mobilization with sling immobilization for comfort only, begin pendulum exercises within the first week, and progress to active range of motion and strengthening exercises by 4-6 weeks, with full weight-bearing activities permitted at 8-12 weeks based on radiographic healing. 1

Immediate Postoperative Period (0-2 Weeks)

Immobilization

• Use a sling for comfort and support, not rigid immobilization 1
• The sling serves primarily for pain control and protection during the early healing phase
• Patients may remove the sling for gentle activities as tolerated within the first week

Early Mobilization

• Begin pendulum exercises and passive range of motion within the first postoperative week 1
• Early mobilization is critical to prevent stiffness and adhesive capsulitis, which occurs in 20% of patients if not addressed 2
• Avoid lifting, pushing, or pulling with the affected arm during this phase 1

Pain Management

• Apply cryotherapy immediately postoperatively and continue through the first week 3
• Monitor for signs of infection (occurs in 2.6-3.3% of cases): increased warmth, erythema, purulent drainage 2, 4
• Address paresthesia over the surgical site, which develops in 13.3% of patients and typically resolves spontaneously 2

Early Rehabilitation Phase (2-6 Weeks)

Progressive Range of Motion

• Advance to active-assisted range of motion exercises by 2-4 weeks 1
• Focus on restoring full shoulder elevation and rotation
• Monitor for development of adhesive capsulitis—the most common complication requiring physiotherapy intervention 2

Sling Discontinuation

• Discontinue sling use entirely by 4 weeks for routine activities 1
• Continue to avoid lifting, pushing, or pulling with the affected arm until 6-8 weeks 1

Strengthening Initiation

• Begin isometric strengthening exercises for the shoulder girdle muscles by 4-6 weeks 1
• Start with non-weight-bearing exercises
• Progress based on pain tolerance and clinical examination findings

Intermediate Phase (6-12 Weeks)

Progressive Strengthening

• Advance to concentric and eccentric strengthening exercises in closed kinetic chain patterns 1
• Combine strength training with neuromuscular control exercises 3
• Focus on scapular stabilization and rotator cuff strengthening

Weight-Bearing Progression

• Allow full weight-bearing activities between 8-12 weeks based on radiographic evidence of healing 1
• Obtain follow-up radiographs at 6-8 weeks to assess fracture union
• Clinical examination should demonstrate no tenderness at the fracture site and stable hardware

Return to Activity (3-6 Months)

Functional Testing

• Assess shoulder strength with isokinetic testing showing >90% symmetry before return to heavy labor or contact sports 3
• Evaluate patient-reported outcomes using DASH score (81.7% of patients achieve excellent scores of 98-100 by 6 months) 2
• Confirm full range of motion without pain or compensatory patterns

Activity Clearance

• Clear patients for unrestricted activities at 3-6 months when radiographic union is complete and functional testing is satisfactory 1
• Earlier return to work is possible for sedentary occupations (typically 6-8 weeks)
• Manual laborers require longer recovery (12+ weeks) 5

Critical Monitoring and Complications

High-Risk Patients Requiring Closer Follow-Up

• Smokers have significantly higher nonunion rates (2.2-fold increased risk) and should be counseled on cessation 5
• Obese patients demonstrate increased overall complication rates 5
• Patients with transverse or Z-type fractures have higher reoperation rates 5

Reoperation Considerations

• Overall reoperation rate is 24.6%, with isolated hardware removal being most common (18.8%) at median 12 months 4
• Nonunion occurs in 2.6% of cases at median 6 months—higher in female patients and those with comorbidities 4
• Deep infection requiring irrigation and debridement occurs in 2.6% at median 5 months 4
• Symptomatic malunion requiring osteotomy is rare (1.1%) but occurs at median 14 months 4

Warning Signs Requiring Urgent Evaluation

• Persistent pain beyond 3 months with lack of radiographic healing progression (suggests nonunion) 1
• Progressive deformity or hardware prominence causing symptoms 4
• Signs of deep infection: persistent fever, wound drainage, increasing pain after initial improvement 2, 4
• Pneumothorax symptoms (rare at 1.2% but potentially serious): sudden chest pain, shortness of breath 4

Key Pitfalls to Avoid

• Do not delay early mobilization—adhesive capsulitis develops in 20% of patients with prolonged immobilization 2
• Do not advance weight-bearing activities before radiographic confirmation of healing—nonunion risk increases with premature loading 1, 6
• Do not ignore persistent pain beyond 12 weeks—this indicates potential nonunion requiring surgical consultation 1
• Do not assume all hardware will remain asymptomatic—counsel patients that 1 in 5 will require eventual hardware removal 4