What is the postoperative protocol for open reduction internal fixation (ORIF) of a humeral shaft fracture?

Postoperative Protocol for ORIF Humerus Shaft Fracture

Begin immediate active range of motion exercises without restrictions on movement or force, allowing weight-bearing as tolerated from postoperative day one.

Immediate Postoperative Management (Day 0-1)

Mobilization Protocol

• No immobilization required - modern angular stable implants provide sufficient stability 1
• Immediate active motion without restrictions on movement or force 1
• Remove surgical dressings and begin shoulder/elbow exercises immediately
• Weight-bearing as tolerated on the affected extremity

Wound Management

For closed fracture ORIF, apply negative pressure wound therapy (NPWT) over the incision to reduce surgical site infection (SSI) risk and revision surgery rates 2. This represents a strong recommendation based on high-quality evidence showing NPWT mitigates SSI risk after closed fracture fixation.

Antibiotic Prophylaxis

Administer perioperative cefazolin or clindamycin as standard prophylaxis 2. This is a strong AAOS recommendation. Continue antibiotics for ≤24 hours postoperatively unless specific risk factors exist (obesity, immunosuppression, high ASA score) 3.

Pain Management

Implement multimodal analgesia including:

• Peripheral nerve blocks (consider axillary or interscalene block)
• Scheduled NSAIDs if not contraindicated
• Opioids for breakthrough pain only

Early Postoperative Period (Days 1-14)

Rehabilitation

• No restrictions on active range of motion for shoulder and elbow 1
• No sling immobilization required 1
• Begin pendulum exercises, active-assisted forward elevation, and elbow flexion/extension immediately
• Progress to active strengthening as pain allows

Activity Restrictions (Only Three)

1. No heavy lifting for 3 months
2. No exhausting physical activity for 3 months
3. No blunt force trauma to the arm for 3 months 1

VTE Prophylaxis

Prescribe pharmacologic VTE prophylaxis (enoxaparin or equivalent) for 4 weeks postoperatively 4. Use sequential compression devices while hospitalized.

Critical Monitoring Points

Radial Nerve Function

• Assess radial nerve function at every postoperative visit (wrist extension, thumb extension, finger extension)
• If iatrogenic radial nerve palsy develops (occurs in ~3% of cases), adopt expectant management - over 90% recover spontaneously 5
• Consider EMG/nerve conduction studies at 3 months if no recovery

Wound Surveillance

• Monitor for signs of SSI: erythema, warmth, drainage, fever
• Smoking and diabetes increase SSI risk - counsel patients accordingly 2
• Remove sutures at 10-14 days

Radiographic Follow-up

• First X-ray at 2 weeks: assess hardware position and early callus formation
• 6 weeks: evaluate progressive callus formation
• 12 weeks: confirm bridging callus and fracture consolidation
• Early callus formation typically visible by 4-6 weeks 6

Functional Milestones

Expected Recovery Timeline

• 6 weeks: Most patients achieve functional range of motion for activities of daily living
• 3 months: Return to light work and non-impact activities
• 6 months: Full unrestricted activity including heavy labor and contact sports
• Union rate: Expect >95% union with ORIF 7, 8

Outcome Expectations

By 24 months, patients should achieve:

• Constant Score: 77-81 points (approximately 90% of uninjured side) 1
• DASH Score: 14-16 points (minimal disability) 1
• Full or near-full range of motion in >80% of cases 9

Common Pitfalls to Avoid

Do not immobilize in a sling - this leads to prolonged rehabilitation and stiffness without improving union rates 1. The evidence clearly demonstrates that early active motion is not inferior to restrictive protocols and may improve patient satisfaction.

Do not delay mobilization - modern locking plate technology provides sufficient stability for immediate active motion, even in older patients with osteoporotic bone 1.

Do not extend antibiotic prophylaxis beyond 24 hours unless specific high-risk factors exist - prolonged antibiotics increase C. difficile risk without reducing SSI 2, 3.

Do not routinely explore radial nerve in primary radial nerve palsy - expectant management yields >90% recovery 8, 5.