Fracture Fixation (ORIF)

Fracture Fixation (ORIF) is a surgical operation in which a broken bone is opened up, repositioned into its correct alignment, and held in place with metal hardware such as plates, screws, rods, or wires.

When a bone breaks, the two ends can shift out of place. ORIF — which stands for Open Reduction and Internal Fixation — corrects this in two steps. 'Open reduction' means the surgeon makes an incision (a cut through the skin) to directly see and move the bone fragments back into their natural position. 'Internal fixation' means the fragments are then locked in that position using metal implants placed inside the body. This holds the bone steady while it heals from the inside out.

ORIF is used when a broken bone cannot be treated safely with a cast or splint alone — usually because the fragments have shifted significantly or the break is too unstable to heal in the right position without surgical support.

• Displaced fractures (breaks where the bone ends have moved out of alignment) that cannot be corrected by manipulation through the skin
• Comminuted fractures (breaks where the bone has shattered into multiple pieces)
• Intra-articular fractures (breaks that extend into a joint, such as the knee, ankle, wrist, or hip) where precise alignment is critical to prevent arthritis
• Open fractures (breaks where a bone fragment has pierced through the skin), once the wound is clean
• Fractures near the hip in older adults, such as a femoral neck fracture (a break at the top of the thigh bone), where prolonged bed rest would be dangerous
• Fractures of the long bones of the arm or leg that are unstable or at risk of shortening
• Fractures that have failed to heal properly with non-surgical treatment

ORIF is generally not the first choice in certain situations. Your doctor will assess whether a different approach is safer.

• Simple, non-displaced fractures (where the bone has cracked but the ends remain in line) that heal well in a cast
• Patients with severe active infection at the fracture site, which may require the infection to be treated first
• Patients whose overall health makes general anaesthesia (being fully asleep during surgery) too risky
• Very fragile, severely osteoporotic bone (bone that has become dangerously thin and weak) that may not hold metal hardware reliably

Like all operations that involve opening the body and placing metal implants, ORIF carries recognised risks, ranging from minor and temporary to rare but serious.

• Pain and swelling around the surgical site, which is expected and usually managed with medication
• Infection at the wound or around the implant, which may require antibiotics or, in serious cases, further surgery to clean the area
• Bleeding during or after surgery, occasionally requiring a blood transfusion
• Damage to nearby nerves, which can cause numbness, tingling, or weakness in the limb
• Damage to nearby blood vessels
• Deep vein thrombosis (DVT) — a blood clot forming in a deep vein, usually in the leg — and the risk that the clot may travel to the lungs (pulmonary embolism)
• Delayed union or non-union — the bone taking much longer than expected to heal, or failing to heal together at all
• Malunion — the bone healing in a slightly incorrect position, which may affect movement or cause long-term pain
• Hardware complications, such as a screw or plate loosening, breaking, or causing irritation under the skin, sometimes requiring a second operation to remove it
• Stiffness of the nearby joint if rehabilitation is delayed or incomplete
• Scarring at the incision site
• Reactions to anaesthesia (the medications used to keep the patient asleep or numb during surgery)

Preparation for ORIF covers what you do in the days before surgery, any tests the medical team will arrange, and what to expect on the day itself. Your surgical team will give you specific instructions that may differ from what is described here.

In the days before surgery, doctors usually ask patients to stop eating and drinking for a set number of hours beforehand — typically nothing after midnight before a morning operation, though your team will confirm the exact window. Smoking slows bone healing and increases the risk of infection, so surgeons usually ask patients to stop or reduce smoking well before the procedure. Alcohol should be avoided in the days leading up to surgery. Patients taking blood thinners, anti-inflammatory medications, or certain supplements are usually asked to pause these before the operation, as they can increase bleeding — your doctor will advise which to stop and when.

The medical team will usually arrange several assessments before the operation:

• X-rays and, in some cases, a CT scan (a detailed cross-sectional scan) of the fracture, to plan exactly where and how to place the hardware
• Blood tests to check general health, clotting ability, and blood group
• An electrocardiogram (EKG), which records the heart's electrical activity, and a chest X-ray — particularly for older patients or those with heart or lung conditions
• An anaesthesia review, where the anaesthetist (the doctor who manages your sleep and pain during surgery) assesses which type of anaesthesia is safest for you

On the day of the operation, the steps usually follow this order:

• 1. Admission and identity checks — the team confirms your details, the fracture site, and the planned procedure
• 2. Marking — the surgeon marks the correct limb or site on the skin to prevent errors
• 3. Anaesthesia — general anaesthesia (fully asleep) or regional anaesthesia (the limb is numbed from a certain point downward) is given, depending on the fracture location and your health
• 4. Sterilisation and draping — the skin around the fracture is cleaned with antiseptic solution and covered with sterile drapes
• 5. Incision — the surgeon makes a precise cut over the fracture site to expose the bone
• 6. Reduction — bone fragments are carefully moved back into their correct anatomical position under direct vision, and often confirmed with a live X-ray machine (called a fluoroscope) in the operating theatre
• 7. Fixation — metal implants (plates, screws, intramedullary nails that run down the centre of the bone, or wires, depending on the fracture type and location) are secured to hold the bone in place
• 8. Wound closure — the layers of tissue are stitched closed and the wound is dressed
• 9. Recovery room — the patient is moved to a recovery area where nurses monitor breathing, blood pressure, and pain as the anaesthesia wears off

Recovery after ORIF varies considerably depending on which bone was fixed, the severity of the fracture, the patient's age and overall health, and how well rehabilitation is followed. Your surgical team is the best source of guidance for your specific situation.

• Monitoring after surgery: Most patients spend at least one night in hospital. Nurses check the operated limb regularly for circulation, sensation, and movement. Patients with more complex fractures or other health conditions may stay longer.
• Pain management: Pain is expected in the first days and is usually controlled with medication prescribed by the team. Pain typically decreases steadily over the following weeks.
• Weight-bearing restrictions: Depending on the bone and the stability of the fixation, the surgeon will specify whether the patient should avoid putting weight on the limb entirely, bear partial weight with support, or move freely. These instructions must be followed carefully to prevent hardware failure.
• Immobilisation: Some patients will wear a cast, splint, or brace over the operated area for a period after surgery, even though the hardware is already holding the bone.
• Wound care: The dressing over the incision is changed at intervals as directed by the team. The wound must be kept dry until it has healed. Signs of infection — increasing redness, warmth, swelling, discharge, or fever — should be reported to the doctor promptly.
• Physiotherapy (physical rehabilitation): Guided exercises usually begin early to prevent stiffness, maintain muscle strength, and restore joint movement. A physiotherapist will design a programme tailored to the specific fracture and hardware used.
• Blood clot prevention: In many cases, doctors prescribe blood thinners for a period after surgery to reduce the risk of deep vein thrombosis. Patients are also usually encouraged to perform gentle foot and ankle exercises even while resting in bed.
• Follow-up appointments: Regular clinic visits and X-rays are scheduled to confirm the bone is healing in the correct position and that the hardware remains secure. The number and timing of these visits will vary.
• Hardware removal: The metal implants are often left in the body permanently. In some cases — particularly in younger patients, or if hardware causes irritation or pain — a second operation to remove the implants may be planned after the bone has fully healed.
• Return to activity: The timeline for returning to work, driving, sport, or heavy lifting depends on the fracture site and the individual's progress in rehabilitation. Your surgeon will advise when each activity is safe to resume.
• Lifestyle: Adequate nutrition, particularly calcium and protein intake, supports bone healing. Continuing to avoid smoking after surgery is strongly associated with better healing outcomes.