The Procedure
An Open Reduction Internal Fixation (ORIF) is a surgical procedure to repair broken bones. When relating to the shoulder, the surgery is performed to repair a fractured humerus (upper arm bone), scapula (shoulder blade) or clavicle (collarbone) where conservative treatment, or letting the bones heal naturally, is unsuitable. The procedure typically involves realigning the broken bones and stabilising them with metal plates and screws.
The procedure is usually performed as an open procedure. I will normally book about 2 hours of theatre time, depending on the severity of the injury.
Pre Op
Whilst you wait for your surgery date, there are a few things to do:
- Speak to your health fund to confirm if the hospital fee for your surgery is covered on your policy
- Speak to your anaesthetist to confirm their fees
- Register your details with the hospital
- Read through, complete and return your paperwork to my office
- Plan your transport to and from the hospital. You won’t be able to drive yourself home after the surgery, so make sure you have a travel plan in place
- If required, arrange any recommended pre op physio appointments
- If required, get any pre op pathology tests (e.g., blood tests)
- Use benzoyl peroxide 5% wash on your shoulder for 5 applications: twice a day for two days, and then again on the morning of the surgery. This will help reduce your risk of infection from Cutibacterium acnes.
- Pack a bag for your hospital stay including regular medications in the original packaging, a loose button-up shirt to wear after surgery, nightwear, personal items including toiletries. If you have sleep apnoea, you must bring your CPAP machine.
- If you are on any blood thinners, ring my office and confirm when to stop taking them before the operation.
- If you are on any diabetic tablet medications, ring your anaesthetist and confirm whether you need to stop taking them before the operation.
- Confirm your admission details with my office one to two business days prior to surgery
Though this can seem overwhelming, you will be provided with detailed instructions on what needs to be done so your surgery journey can be as smooth as possible.
Complications
General risks of surgery include:
- Bruising & haematoma: this will vary for each patient. Bruising is a normal side effect of surgery and usually resolves in a short time. Haematoma may rarely require a return to theatre for drainage.
- Infection: infection is a rare but possible risk and is usually treated with antibiotics.
- DVT and PE: deep vein thrombosis and pulmonary embolism are blood clots that form in either the lower limbs or your lungs. If left untreated, DVT and PE can have serious effects, however if treated promptly, the risks are significantly lowered. More information can be found here
- Anaesthetic risks: as RTSR is performed under a general anaesthetic (GA), there are the usual risks associated with this. In Australia, the risk of mortality from GA is around 1 in 100,000. Fortunately, Australia is one of the safest places to undergo a GA. For context, the risk of death in a car accident in Queensland is around 1 in 10,000.
- Wound issues: some superficial issues can develop on the wounds after surgery, however most will require a small intervention to resolve the problem.
Some of the risks and complications specific to ORIF procedures include:
- Delayed healing or non-union: the bones may fail to unite, which could require another surgery.
- Joint stiffness: , joint stiffness is uncommon following clavicle and scapula ORIFs, hHowever , joint stiffness is almost universal following ORIF of the proximal humerus. It takes at least 6 months for the movement to return to the shoulder following a proximal humerus ORIF with it often taking 12 months to return. Fortunately, permanent stiffness is not usual.
- Frozen shoulder: frozen shoulder can occur after any surgery around the shoulder joint. It resolves with time. You will still get a good result from the surgery once the frozen shoulder has resolved, however it can make the rehab prolonged and miserable if the frozen shoulder is severe.
- Hardware issues: the metal plates and screws may cause complications, which may require another surgery.
- Nerve damage is a rare but recognised complication.
- Avascular Necrosis (AVN) where the head of the humerus loses its blood supply and then collapses and becomes arthritic is a well-recognised complication of proximal humeral fractures due to disruption of the blood supply to the humeral head caused by the fracture disrupting the blood vessels. Avascular Necrosis sometimes occurs following surgical treatment of proximal humeral fractures.
Day of Surgery
Your admission details will be confirmed one to two business days prior to surgery. You will need to make note of your admission time and your fasting time. Your admission time may be as early as 6am. If you aren’t local to Brisbane, it is usually recommended that you stay the night before in case your admission is early.
When you arrive at the hospital, you will go through the admissions process and then be taken through to the surgical waiting area. Your anaesthetist will have a short consultation with you before you go into theatre and under general anaesthetic. I will say hi to you before the surgery in the anaesthetic bay of the operating theatre and mark your operation site with you.
Your hospital stay will usually be one night. You will be discharged usually around 10am. I will see you before your discharge. I will provide you with a folder containing a detailed postoperative pack including a letter telling you what I found at surgery and exactly what I did in your operation along with information about your rehabilitation and postoperative care. Remember to have someone available to take you home from the hospital.
Post Op Recovery & Healing
The post-operative recovery for ORIF procedure requires extensive rest. A sling is required, usually for 6 weeks, to immobilise the shoulder and promote correct healing of the bone. During this time, driving and high intensity physical activities are not permitted.
Physiotherapy is started immediately after the procedure, and full recovery typically takes 6 to 12 months after surgery.
A review with Dr Cutbush is required at around 6 weeks postoperatively, and further reviews beyond this timeframe will depend on individual progress.
Rehabilitation
After ORIF surgery, rehabilitation and physiotherapy exercises aim to promote correct healing of the bone, reduce pain and inflammation, and improve shoulder mobility.
Physiotherapy Guidelines
Clavicle ORIF Day 1 Physiotherapy Guidelines
The hospital physio will demonstrate how to fit your sling and how to eat, shower & dress whilst in your sling. Please make sure you go through these things with the physio so that you get them really clear in your mind before you leave hospital.
Goals:
- Protect bony healing
- Assist in the reduction of pain and management of inflammation
- Minimise GHJ (glenohumeral joint)stiffness while allowing the fracture to heal, with early PROM (passive range of motion) limits of elevation < 90° (to limit the natural elevation &rotation of the clavicle) and external rotation at neutral to 45°
Sling:
- To be worn up to 6 weeks. I will let you know after the surgery how long you need to wear the sling for postop
- Check fit, demonstrate activities of daily living (showering, dressing etc)
Therapy Day 1:
- Instructed in precautions as per clavicle ORIF (open reduction internal fixation) and ADL (activities of daily living) modifications
- Sling don/doff and correct fit
- Day 1 exercise program:
- Gentle cervical spine AROM (active range of motion), often tender and limited
- Elbow, wrist & hand AROM (active range of motion)
- Gentle scapular neutral exercises / general posture advise *no large scapula rolls
- Shoulder: passive pendulum <90°, active / passive shoulder external rotation at neutral 30°- 45°
- Assist in the management of pain by:positioning, appropriate sling fitting, cryotherapy initially (x20 min every2-3 hours for first 3 days post-operatively), then heat may be useful
Followup:
- See physiotherapist week 2 for progression of rehab program. Week 6 with meand shoulder Physiotherapist.
Humeral ORIF Procedure Day 1 Physiotherapy Guidelines
The hospital physio will demonstrate how to fit your sling and how to eat, shower& dress whilst in your sling.
Goals:
- Protect bony healing of fracture
- Assist in the reduction of pain andmanagement of inflammation
- Minimise the development of GH (glenohumeral) joint stiffness while allowing the fracture to heal
- Passive Elevation
- Passive External rotation at neutral
Day One:
- Education and Reassurance: healing timeframes, precautions asper proximal humeral head ORIF (open reduction internal fixation) (no WB(weight bearing), torsional forces (ER and IR) (external rotation and internal rotation), no AROM (active range of motion)
- Sling: for 4-6 weeks (check surgical notes), don/doff independently and correct fit, demonstrate activities of daily living (showering, dressing etc). I will let you know after the surgery how long you need to wear the sling for postop
- Day 1 exercise program:
- Cervical spine, Elbow, Wrist and Hand AROM (active range of motion)
- Gentle scapular neutral exercises/general posture advice
- Shoulder:
- passive or circular pendulum – aim for minimum 70°/80° drop
- supported forward lean with forearm supported to 90°- 120° (check surgical notes)
- passive external rotation to neutral(unless stated otherwise)
- ensure passive if Greater tuberosity or lessor tuberosity involvement
- patient may refer to Extend Rehab orDr Cutbush’s website for exercise videos
- Pain management: positioning, appropriate sling fitting, cryotherapy initially (x20 min every 2-3 hours for first 5 days post-operatively), then heat may be useful
- Oedema control for the upper limb: ice, effleurage, oedema glove if appropriate
- ADL (activities of daily living) advice: use of hand for light function within sling
Considerations:
- Refer to surgical notes for greater understanding of fracture and surgical fixation. Swelling of upper limb common, oedema control may need specific attention
Followup:
- With local physiotherapist week 1-2 to monitor. Week 6 with me and shoulder Physiotherapist.
Results After Surgery
ORIF surgery generally has good outcomes, particularly for reducing pain and improving range of motion when compared to conservative treatment. There are risks of further treatment being required due to potential complications, however this will vary.