Open reduction and internal fixation, usually shortened to ORIF, is the surgical repair of a broken bone. Around the shoulder it is used for fractures of the humerus (upper arm bone), the scapula (shoulder blade) and the clavicle (collarbone) where treating the fracture without surgery is not suitable.
The two parts of the name describe the two parts of the operation: the broken bone is realigned, and it is then held in that position with plates and screws while it heals.
The procedure
ORIF is usually carried out as an open procedure, through an incision that gives direct access to the fracture. The fragments are brought back into alignment and fixed with plates and screws. About two hours of operating theatre time is booked, although this depends on the severity of the injury.
Risks and complications
All surgery carries risk. The risks that are relevant to you are discussed with you in consultation before any decision about surgery is made.
General surgical risks
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Bruising and haematoma. The amount of bruising varies from patient to patient. A haematoma, which is a collection of blood under the wound, rarely needs to be drained in theatre.
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Infection. Infection is rare but possible, and is usually treated with antibiotics.
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Deep vein thrombosis (DVT) and pulmonary embolism (PE). Blood clots can form in the veins of the leg and can travel to the lungs. These are serious conditions, but the risk of lasting harm is significantly reduced when they are recognised and treated promptly.
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Anaesthetic risks. These are discussed with your anaesthetist before surgery. In Australia the risk of death from a general anaesthetic is around 1 in 100,000.
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Wound problems. Superficial wound problems can occur, and most need a small intervention.
Risks specific to this procedure
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Delayed healing or non-union. The bone may be slow to heal, or may fail to heal. This may require further surgery.
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Joint stiffness. Stiffness is uncommon after ORIF of the clavicle and the scapula, but it is almost universal after ORIF of the proximal humerus. Movement can take at least six months to return, and often around twelve months. Permanent stiffness is not the usual outcome.
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Frozen shoulder. This can follow any shoulder surgery. It resolves with time and the result of the surgery itself is generally unaffected, but if it is severe, rehabilitation can be prolonged and difficult.
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Hardware problems. The plates and screws can cause problems, and may need to be addressed with further surgery.
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Nerve damage. Rare, but a recognised risk.
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Avascular necrosis (AVN). Loss of the blood supply to the head of the humerus, which can lead to collapse of the bone and arthritis. AVN is well recognised after fractures of the proximal humerus and sometimes occurs following surgical treatment of these fractures.
Before surgery
There are a number of things to work through before your surgery. You will be given detailed written instructions covering all of this.
- Confirm with your health fund that the hospital fee is covered.
- Confirm your anaesthetist’s fees.
- Register your details with the hospital.
- Read, complete and return your paperwork to the rooms.
- Plan your transport to and from hospital. You cannot drive yourself home.
- Attend any pre-operative physiotherapy that has been recommended.
- Complete any pre-operative pathology, such as blood tests, if it has been requested.
- Wash the shoulder with benzoyl peroxide 5% wash, twice daily for two days, and then once more on the morning of surgery, five applications in total. This reduces the risk of infection with Cutibacterium acnes, a bacterium that lives in the skin.
- Pack your hospital bag: your regular medications in their original packaging, a loose button-up shirt, nightwear and toiletries. Bring your CPAP machine if you have sleep apnoea.
- If you take blood thinners, phone the rooms to confirm when to stop them.
- If you take tablets for diabetes, phone your anaesthetist to confirm whether to stop them.
- Confirm your admission details with the rooms one to two business days before surgery.
The day of surgery
- Your admission details are confirmed one to two business days beforehand. Make a note of your admission time, which may be as early as 6am, and the time from which you must fast.
- If you do not live in Brisbane, staying in the city the night before is usually recommended.
- After the admissions process you wait in the surgical waiting area. Your anaesthetist will see you for a brief consultation before you go through to theatre.
- Dr Cutbush will greet you in the anaesthetic bay and mark the operation site. You are then given the general anaesthetic.
- The usual stay is one night. Discharge is generally around 10am, after Dr Cutbush has reviewed you.
- You will be given a folder containing your post-operative pack: a letter describing what was found and what was done, together with your rehabilitation and post-operative care information.
- Arrange for someone to take you home.
Recovery and healing
Recovery after ORIF requires a significant period of rest. A sling is usually needed for about six weeks to immobilise the shoulder and support the bone as it heals. There is no driving and no high-intensity physical activity during this period.
Physiotherapy starts immediately after surgery. Full recovery typically takes between six and twelve months. You will be reviewed by Dr Cutbush at around six weeks, and the timing of later reviews depends on how you are progressing.
Rehabilitation
The goals of rehabilitation after ORIF are to promote healing of the bone, to reduce pain and inflammation, and to improve mobility. The programme differs depending on which bone was fixed, so the two main protocols are set out separately below. Follow the protocol that matches your operation, as confirmed in your post-operative pack.
Clavicle ORIF: day one
Before you leave hospital the physiotherapist will fit your sling and show you how to manage eating, showering and dressing in it. Make sure you can do these things before you are discharged.
The goals on day one are to protect the healing bone, to manage pain and inflammation, and to minimise stiffness in the glenohumeral joint. Early passive elevation is limited to less than 90 degrees and external rotation to between neutral and 45 degrees.
The sling is worn for up to six weeks. Dr Cutbush confirms the exact duration after surgery.
Day one exercises:
- Gentle active range of motion for the cervical spine. The neck is often tender and limited after a clavicle fracture.
- Active range of motion for the elbow, wrist and hand.
- Gentle scapular neutral exercises and postural advice. No large scapular rolls.
- Shoulder: passive pendulum below 90 degrees, and active or passive external rotation from neutral to 30 to 45 degrees.
Pain management: positioning, a correctly fitted sling, and cryotherapy for 20 minutes every two to three hours for the first three days. After that, heat may be more helpful.
Follow-up: physiotherapy at week two, and review at week six with Dr Cutbush and a shoulder physiotherapist.
Humeral ORIF: day one
Education on day one covers the healing timeframes and the precautions: no weight bearing through the arm, avoid torsional forces (external and internal rotation), and no active range of motion.
The sling is worn for four to six weeks, according to the operation notes. You should be able to put it on and take it off independently.
Day one exercises:
- Active range of motion for the cervical spine, elbow, wrist and hand.
- Gentle scapular neutral exercises and postural advice.
- Shoulder: passive or circular pendulum, aiming for a minimum drop of 70 to 80 degrees; supported forward lean to 90 to 120 degrees, according to the operation notes; passive external rotation to neutral unless otherwise stated; and passive movement where there is greater or lesser tuberosity involvement.
- Exercise videos are available through Extend Rehab and on this website.
Pain management: positioning, a correctly fitted sling, and cryotherapy for 20 minutes every two to three hours for the first five days. After that, heat may be more helpful.
Swelling: swelling of the upper limb is common after humeral ORIF and may need specific attention. Ice, effleurage and an oedema glove where appropriate are all used to control it.
Daily activities: light use of the hand within the sling is encouraged.
Follow-up: local physiotherapy at week one to two, and review at week six with Dr Cutbush and a shoulder physiotherapist.
Results after surgery
Where surgery is indicated, ORIF generally has good outcomes, particularly in terms of pain and range of motion compared with treating the fracture without surgery. Some patients need further treatment because of one of the complications described above, and how often that happens varies with the injury. Individual results vary.
Next steps
This page is general information about a surgical procedure and is not a recommendation that you have it. Whether surgery is appropriate for you can only be determined after assessment. All surgery carries risk; the risks relevant to you are discussed in consultation before any decision is made.
