Overview
Open reduction and internal fixation (ORIF) of the clavicle realigns a broken collarbone and holds it with a contoured plate and screws so that it heals at its correct length. The clavicle is the strut that holds the shoulder away from the chest; when it heals short or crooked, the shoulder blade sits forward and the rotator cuff works at a disadvantage, which is why a badly displaced fracture treated in a sling can heal solidly and still leave a weak, easily fatigued shoulder. Fixation restores that length, lets shoulder motion begin within days, and makes healing more predictable.
The expected result is a collarbone of normal length, full shoulder motion, and return to contact sport at about three to four months once the bone has united. Surgery is outpatient at Bayside Surgery Center in Coconut Grove.
Who It's For
Dr. O'Donnell recommends fixation for a mid-shaft fracture that is displaced by more than a full bone width with no contact between the fragments, or shortened by more than about 2 cm, because those fractures fail to heal or heal in a poor position often enough that fixation gives a better outcome. Surgery is also advised for open fractures, for skin tenting that threatens to break through, for fractures in multiple fragments, for distal-third fractures in which the ligaments no longer hold the outer fragment, and for fractures that have not united after three to four months in a sling. Athletes, cyclists and manual workers who need a reliable early return are often in this group.
Most clavicle fractures do not need surgery. A fracture with the fragments still touching, with little shortening and intact skin, heals reliably in a sling over six weeks, and in children and adolescents the bone remodels so well that surgery is rarely considered. A distal fracture with torn coracoclavicular ligaments may be treated as an AC joint reconstruction rather than a plate.
Displacement on the X-ray is not on its own the reason to plate a collarbone. Dr. O'Donnell recommends fixation when the measured shortening or separation, the state of the skin, and the patient's demands together favor it, and a fracture that is healing acceptably in a sling is left alone. The clavicle fracture page sets out how the X-ray is measured and read.
What the Procedure Involves
Surgery is performed under general anesthesia, usually with a nerve block for pain control. An incision is made along the line of the clavicle, and the small sensory nerves that cross the bone are identified and protected. The fracture is cleaned of clot and early scar, and the fragments are restored to their original length and alignment; a butterfly fragment is held with a small lag screw.
A pre-contoured titanium or stainless-steel plate is placed on the top (superior) surface of the clavicle for most mid-shaft fractures, or on the front (anteroinferior) surface, which keeps drill trajectories away from the vessels beneath the bone and leaves the plate less prominent. Screws are placed in at least three holes on each side of the fracture. For distal fractures close to the AC joint, a hook plate or a locking plate with a coracoclavicular suture-button augment is used because the outer fragment is too small for standard screws. An intramedullary pin is an alternative for simple two-part fractures in thin patients who want a smaller scar. X-rays are taken in the operating room to confirm alignment and screw position.
The operation takes about 60 to 90 minutes. The wound is closed with a dissolving stitch, the arm goes into a sling for comfort, and patients go home the same day.
Risks & How They Are Minimized
Two problems are specific to this operation. The first is numbness below the incision from the supraclavicular nerves, common enough that every patient is warned; it is reduced by protecting the branches and shrinks over months. The second is prominent hardware, because the clavicle sits directly under thin skin. Low-profile plates and anterior placement reduce it, and a plate that irritates a strap or seatbelt can be removed once the bone has healed, usually after a year.
Nonunion after plating is uncommon; risk is reduced by stable fixation and by delaying strengthening until X-rays show healing at about six weeks. Infection is rare and is guarded against with preoperative antibiotics and careful wound closure; smokers are asked to stop, since smoking impairs bone and wound healing. The subclavian vessels and lung lie just below the bone, and drilling is done with protection behind the bone at every hole. Blood clots are rare after upper-limb surgery; patients walk the same day and take aspirin if they have risk factors.
Recovery & Rehabilitation
Dr. O'Donnell's clavicle ORIF protocol restores motion in the first six weeks and holds strengthening until union is confirmed on X-ray.
| Phase | Timing | What happens |
|---|---|---|
| Protected motion | Weeks 0–2 | Sling except for exercise. Pendulums, passive and active-assisted flexion and scaption limited to 90°, scapular setting, ice. No lifting or overhead activity. |
| Motion | Weeks 2–6 | Sling weaned by 2–4 weeks. Active motion progressed to full in all planes, gentle scapular and cuff isometrics late in the phase, posture work. No resisted strengthening or lifting until X-rays show healing. |
| Strengthening | Weeks 6–12 | Begins once Dr. O'Donnell confirms healing. Progressive rotator cuff, deltoid and periscapular strengthening, overhead loading as tolerated, endurance work. Advance at radiographic union and 80% strength. |
| Return to activity | Months 3–6 | Advanced strengthening and plyometrics, sport- or job-specific progression. Contact and collision sport typically about 3–4 months with confirmed union. |
Desk work is possible within a few days, driving at two to four weeks once the sling is off, stationary cycling and running from about six weeks, and road cycling, contact sport and heavy lifting at three to four months once union is confirmed.
Protocol summary
The sling is for comfort and is worn for about two to four weeks. Passive and active-assisted elevation is limited to 90° for the first two to four weeks, overhead activity is avoided early, and there is no lifting, pushing or weight bearing through the arm until union is confirmed at about six weeks.
Progression from Phase I requires controlled pain and improving motion; from Phase II, full active motion and X-rays showing healing. Strengthening starts only after the surgeon confirms healing, and return to contact sport requires radiographic union and symmetric strength, typically at three to four months.
Physical Therapy Protocol
Clavicle Fracture — Open Reduction & Internal Fixation PDF ↗Frequently Asked Questions
Does a broken collarbone need surgery?
Most do not. A fracture with the ends still in contact and less than about 2 cm of shortening heals in a sling over six weeks. Dr. O'Donnell recommends a plate when the fragments are completely displaced or shortened by more than 2 cm, when the skin is threatened, when the fracture is in several pieces, or when a distal fracture has lost its ligament support.
How long does a plated clavicle take to heal?
The bone usually shows healing on X-ray at about six weeks, which is when strengthening begins. Full union that allows contact sport and heavy lifting is typically confirmed at three to four months. Motion begins within days of surgery, so stiffness is rarely a problem.
When can I drive after clavicle surgery?
Usually at two to four weeks, once the sling is discontinued, you can move the arm comfortably and you are off prescription pain medication. Be aware of the seatbelt crossing the incision; a small pad under the belt helps in the first weeks.
When can I cycle or play contact sport after clavicle fixation?
Stationary cycling and running from about six weeks once healing is seen on X-ray. Road cycling, mountain biking, contact sport and heavy lifting at about three to four months with confirmed union and symmetric strength. The phase criteria are in the clavicle ORIF protocol.
Will I need the plate removed?
Not routinely. The plate can stay for life. About one in five patients find it prominent under the skin or irritating with a strap or seatbelt; in that case it is removed as a short outpatient procedure once the bone has been solidly healed for a year.
This page is for general education and is not a substitute for a medical evaluation. The right procedure depends on your individual diagnosis, anatomy, and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.