OT notes · Orthopaedics

ORIF shoulder girdle fractures (clavicle plating, proximal humerus)

Usual anaesthesia
General anaesthesia
Position
Clavicle: supine with head and trunk slightly raised, arm draped free. Proximal humerus: beach chair, patient moved to the edge of the table, C-arm from behind the shoulder
Setting
urgent

Operative note template for plate fixation of a displaced midshaft clavicle fracture or open reduction and internal fixation of a proximal humerus fracture, with a filled example for superior plating of a displaced comminuted midshaft clavicle fracture.

Download printable PDFFree. Just log in with your Google (Gmail) account.

Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • numbness below the scar from supraclavicular nerve injury (clavicle)
  • prominent plate needing later removal
  • non-union, malunion or loss of fixation
  • infection and wound problems
  • injury to subclavian vessels, brachial plexus or lung (clavicle, rare)
  • axillary nerve injury (proximal humerus)
  • avascular necrosis of the humeral head
  • screw cutting out into the shoulder joint
  • shoulder stiffness
  • conversion to shoulder replacement if the head cannot be fixed

Pre-operative details for this operation

  1. FractureMidshaft clavicleLateral clavicleProximal humerus, 2-partProximal humerus, 3-partProximal humerus, 4-partIsolated greater tuberosityside, date and mechanism of injury, displacement, shortening, comminution
  2. Neurovascular status before surgeryaxillary nerve (deltoid), brachial plexus, radial pulse
  3. Skintenting, abrasions over the clavicle
  4. Imagingclavicle AP and cephalic tilt view; shoulder AP, scapular Y and axillary views; CT if pattern unclear
  5. Implants available3.5 mm LC-DCP / precontoured clavicle plate; proximal humerus locking plate; cannulated screws, suture anchors; arthroplasty set as back-up for proximal humerus

Anaesthesia and position

  1. AnaesthesiaGeneralGeneral with brachial plexus block
  2. PositionSupine, head and trunk raised (clavicle)Beach chair (proximal humerus)
  3. C-armposition; full fracture seen on image before prepping

Operative findings

  1. Fracture pattern at surgerynumber of fragments, butterfly fragment, comminution, bone quality
  2. Supraclavicular nervesseen and preserved / divided
  3. Proximal humerus: tuberosities, head and calcardisplacement of greater and lesser tuberosity, medial calcar comminution, head split
  4. Rotator cuff and long head of bicepsintact / torn
  5. Reduction achievedanatomic / acceptable; length and alignment restored

Procedure (steps)

  1. IncisionClavicle: along and just below the clavicleDeltopectoral, from above the coracoid distallyDeltoid split from acromion (not more than 5 cm)length; dilute adrenaline infiltration if used
  2. Nerve protectionsupraclavicular nerves (clavicle); axillary nerve (proximal humerus)
  3. Deep exposureclavicle: periosteum and muscle attachments kept; deltopectoral: cephalic vein mobilised, clavipectoral fascia incised lateral to conjoined tendon
  4. Fracture cleaned of haematoma and reducedreduction tools; traction sutures in cuff tendons for tuberosities; small distractor
  5. Provisional fixationK-wires, clamps, lag screw
  6. Plate positionSuperior clavicle plateAnterior (anteroinferior) clavicle plateProximal humerus plate lateral to biceps grooveplate height checked on image (proximal humerus)
  7. Screwsclavicle: at least 3 bicortical screws each main fragment, interfragmentary screw; humerus: head locking screws first, calcar screw, then shaft screws
  8. Supplementary suture fixationcuff sutures tied to plate (proximal humerus)
  9. Final image and screw checkshoulder taken through range on image; no screw in the joint
  10. Bone graftNot neededIliac crest cancellous graft

Closure, drains and dressing

  1. Irrigation
  2. Deep layerplatysma closed over clavicle plate / rotator interval and deltoid repaired
  3. Subcutaneous tissue and skinsuture used; subcuticular
  4. DrainNoneSuction drain
  5. Dressing and slingArm sling
  6. Distal neurovascular status at end

Specimens and implants

  1. Platetype, number of holes, make, batch/lot, sticker pasted
  2. Screwsnumber, type (cortical / locking / lag), lengths
  3. Other implantsK-wires left, suture anchors, heavy sutures
  4. SpecimensNone

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Neurovascular observationradial pulse, hand sensation and movement; deltoid once block wears off
  2. Slingfor comfort; duration
  3. Clavicle: activityuse the hand at the side from day 1; no shoulder abduction or lifting over about 7 kg until early healing
  4. Proximal humerus: physiotherapyif fixation stable: pendulum, passive forward flexion to 130 degrees and external rotation to 30 degrees from POD 1; active motion at 6 to 8 weeks; strengthening at 10 to 12 weeks
  5. Analgesiadrug, dose, frequency
  6. Check X-raysclavicle AP and cephalic tilt; shoulder AP and axillary
  7. Follow-upwound check and suture removal at 2 weeks; X-ray for union at 6 weeks

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. A.K., 32 years, two-wheeler rider, fall on the right shoulder 3 days ago. X-ray: displaced comminuted midshaft right clavicle fracture with a vertical butterfly fragment, no overlap contact, 2 cm shortening. Neurovascular status normal.

Case details

Date: 04/09/2026. Urgent ORIF right clavicle. OT 3.

In OT 10:00. Incision 10:35. Closure completed 11:45.

Surgeon: Dr A. (3rd-year resident, orthopaedics), under supervision of Dr B. (consultant, scrubbed). Assistant: Dr C. (1st-year resident). Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: completely displaced and comminuted midshaft clavicle fracture with shortening, at higher risk of non-union. Patient chose fixation after sling treatment was also explained.

Skin intact, no tenting. Distal pulses and brachial plexus function normal.

Consent: general, procedure-specific and anaesthesia consent in Hindi from patient. Numb skin below the scar, plate prominence and later removal explained.

Right side marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 10:20.

Anaesthesia and position

General anaesthesia.

Supine, head and trunk raised about 30 degrees, right arm draped free. Parts painted with chlorhexidine-alcohol and draped. C-arm from the opposite side.

Procedure

Incision 10 cm along and just below the clavicle after infiltration with dilute adrenaline.

Two supraclavicular nerve branches crossing the fracture site identified and preserved.

Findings: midshaft fracture with a 2 cm vertical butterfly fragment, no soft-tissue interposition. Good bone quality.

Haematoma cleared. Muscle and periosteum on the fragments kept. Butterfly fragment reduced to the medial fragment and fixed with an interfragmentary lag screw. Main fragments reduced and held with clamps; length restored.

7-hole 3.5 mm precontoured superior clavicle plate applied. Oscillating drill used to limit risk to nerves. Three bicortical screws in each main fragment.

C-arm AP and cephalic tilt: reduction and plate position satisfactory, screw lengths correct.

No bone graft needed.

Closure

Wound irrigated with normal saline. Platysma closed over the plate with absorbable suture. Skin closed with subcuticular suture. No drain.

Dressing and arm sling. Radial pulse present, hand sensation normal.

Specimens and implants

7-hole 3.5 mm precontoured superior clavicle plate with six 3.5 mm screws; one lag screw (size as used). Make, batch and lot recorded; stickers pasted.

No specimen.

End of procedure

Estimated blood loss 100 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to recovery in stable condition. Pulse 82/min, BP 126/78 mmHg, SpO2 99 percent.

Post-op orders

Radial pulse, hand sensation and movement checked regularly till fully recovered from anaesthesia.

Sling for comfort. Use the hand for light tasks at the side from today. No shoulder abduction exercises and no lifting over about 7 kg till early healing.

Check X-ray right clavicle AP and cephalic tilt on POD 1.

Wound check and suture removal at 2 weeks. X-ray for union at 6 weeks.

Signature

Dr A., JR-3, Orthopaedics. Reg. no. ________. 04/09/2026, 12:00. Seen by Dr B.

Must document for this operation

  • Supraclavicular nerves seen and preserved, or divided. Numbness below the scar is the commonest complaint after clavicle plating, and the note shows whether it was expected.
  • Plate position and the number of screws in each fragment. Fewer than three good screws each side is linked to loosening, and the plate position guides later removal.
  • For the proximal humerus: tuberosity handling, calcar screw and plate height. Varus collapse, impingement and tuberosity displacement are the usual failures, and the revision surgeon plans from these details.
  • Final image check that no screw enters the joint. A screw in the glenohumeral joint damages the glenoid, and the record must show it was checked in several planes.
  • Implant stickers. Needed for implant removal and recall.
  • Allowed movement and lifting limits. The physiotherapist and the patient act on what is written, and early loading risks loss of fixation.

Common mistakes in these notes

  • Writing 'plating done' without plate position (superior or anterior) or hole count.
  • No mention of the supraclavicular or axillary nerve.
  • Not recording a pre-op neurovascular examination.
  • Proximal humerus: not recording whether the calcar was supported or how the tuberosities were fixed.
  • Leaving out the movement plan.

Indian practice and paperwork

  • Record the batch and serial number of the plate and screws in the case sheet; NABH also expects them in the OT implant master logbook and the discharge summary. (NABH Hospital Standards 5th ed., MOM.10(d))
  • If the plate is removed later, the explanted metal goes in the blue puncture-proof container for metallic body implants, not the yellow bag. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Tornetta P III, ed; Wiesel SW, editor-in-chief. Operative Techniques in Orthopaedic Trauma Surgery. 2nd ed. Wolters Kluwer, Ch 16, Plate fixation of clavicle fractures (Ring D, Jupiter JB); Ch 19, Open reduction and internal fixation of proximal humerus fractures (Dillon MT, Torres S, Gilotra M, Glaser DL), pp. e-book markers P.153-P.155; P.176-P.183.
  • Saghieh S, et al., eds. Operative Dictations in Orthopedic Surgery. Springer; 2013, Ch 77, ORIF three-part proximal humerus fracture (Wolf BR); Ch 78, Closed reduction and pinning of two-part proximal humerus fracture (Frangie R), pp. 279-284.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; recommended for internal fixation devices; redose after 4 h. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

This page cannot be printed from the browser. Use the Download printable PDF button on the page.