Clavicle Fracture: Open Reduction Internal Fixation (ORIF)

Physical Therapy Protocol

General Considerations

• Post-operative goals:
  • Restore shoulder function.
  • Protect the surgical site.
  • Prevent complications such as frozen shoulder or muscle atrophy.
• Precautions:
  • Avoid lifting, pushing, or pulling heavy objects for the first 6 weeks.
  • Avoid excessive ROM, especially internal rotation and adduction during early stages.
  • Protect the surgical site and prevent excessive strain on the clavicle during early phases.
• Initial Management:
  • Sling use: The patient should wear a sling for comfort and support for the first 1-2 weeks post-op.
  • Non-weight-bearing: The affected arm should remain non-weight-bearing for the first 4–6 weeks.
  • Pain management and edema control:
    • Apply ice and elevate the arm to control swelling.
    • Use NSAIDs as prescribed for pain management.
    • Continue with gentle, passive exercises for circulation and pain control.

Phase I: Day 1 to Two Weeks After Surgery

• Goals:
  • Protect the fracture site.
  • Begin gentle exercises to promote circulation and prevent stiffness.
  • Initiate pain management and reduce swelling.
• Interventions:
  • Sling: Wear sling for comfort.
  • Elbow, wrist, and hand exercises:
    • Straightening and flexion of the elbow.
    • Open and closure of the hand.
    • Squeezing a soft ball.
    • Bending of the wrist forward, backward, and in a circular motion.
    • Movement of an open hand from side to side.
  • Pendulum exercises: Gentle pendulum swings to help reduce swelling and improve circulation.
  • Scapular stabilization exercises: Gentle scapular retraction, protraction, and elevation exercises to promote early shoulder stability.
• Criteria for Progression:
  • No significant pain or swelling.
  • Maintain passive movement in distal joints (elbow, wrist, hand).
  • Tolerates scapular stabilization exercises without discomfort.

Phase II: Two to Six Weeks After Surgery

• Goals:
  • Gradually restore passive and assisted range of motion (ROM).
  • Avoid excessive loading on the clavicle.
  • Initiate scapular stabilization exercises.
• Interventions:
  • Pendulum exercises can continue when pain subsides.
  • Passive and assisted ROM:
    • Start gentle external and internal rotation.
    • Begin flexion exercises with arm on the table.
    • Perform flexion with the ball on the wall.
  • Isometric strengthening exercises (sub-maximal):
    • Internal rotation.
    • External rotation.
    • Abduction and extension.
  • Aerobic exercises:
    • Low-impact activities such as walking or stationary cycling (avoiding use of the affected arm).
• Criteria for Progression:
  • Gradual improvement in ROM.
  • No pain during gentle shoulder movements.
  • Tolerates isometric strengthening exercises and aerobic activities.

Phase III: Six to Twelve Weeks After Surgery

• Goals:
  • Initiate weight-bearing exercises as tolerated.
  • Continue progression of ROM and strengthening.
  • Begin returning to functional activities.
• Interventions:
  • Active-assisted range of motion (AAROM):
    • Gradual progression of external rotation, internal rotation, and flexion.
  • Isometric strengthening with focus on:
    • Internal rotation.
    • External rotation.
    • Abduction and extension.
  • Weight-bearing exercises:
    • Light weight-bearing activities with arm supported in neutral position.
    • Begin gentle active shoulder exercises like overhead lifting once cleared by the surgeon.
  • Functional mobility exercises:
    • Reaching, lifting, and carrying with the affected arm to begin reintegration into daily activities.
• Criteria for Progression:
  • Increased ROM without pain.
  • Tolerates light strengthening and weight-bearing exercises.
  • Clear from any complications (e.g., swelling, stiffness).

Phase IV: Twelve Weeks to Six Months After Surgery

• Goals:
  • Full functional return.
  • Rebuild strength and endurance.
  • Begin return to activity.
• Interventions:
  • Progressive strengthening:
    • Continue strengthening the shoulder using light resistance.
    • Add weights and resistance bands for shoulder muscles.
  • Functional exercises:
    • Begin more complex exercises like shoulder presses, rows, and overhead motions.
    • Return to activities like light lifting or carrying.
  • Functional tests to assess readiness for more strenuous activities (e.g., sports-specific tests).
• Criteria for Progression:
  • Strength and ROM are close to baseline levels.
  • No pain or discomfort with functional exercises.
  • Able to perform lifting, carrying, and sports-specific activities safely.

Phase V: Six Months and Beyond

• Goals:
  • Full return to work and sports activities.
  • Advanced strengthening.
  • Prevention of re-injury.
• Interventions:
  • Return to full activity: Gradual return to work, recreational activities, and sports as tolerated.
  • Heavy strengthening: Full progression to resistance training for all shoulder muscles.
  • High-level functional exercises: Full return to sports and more strenuous activities like running, swimming, and lifting heavy objects.
• Criteria for Full Return:
  • Pain-free shoulder function.
  • Strength comparable to the uninjured side.
  • Able to perform all activities with no discomfort.

Patient Education and Red Flags

• Key Reminders:
  • Follow-up with the surgeon regularly for radiographs and clinical evaluations.
  • Report any persistent pain, swelling, or difficulty with motion to your therapist or surgeon.
  • Avoid excessive overhead movements or heavy lifting until cleared by the surgeon.
• Red Flags:
  • Persistent or increasing pain after performing prescribed exercises.
  • Swelling or bruising that doesn’t improve with rest or cryotherapy.
  • Difficulty moving the arm or shoulder without significant discomfort.