What is the process for open reduction internal fixation (ORIF) of a fracture?

Open Reduction Internal Fixation (ORIF): Surgical Process

ORIF is a surgical procedure that restores normal anatomical alignment of fractured bone fragments through direct surgical exposure, followed by stabilization with internal hardware such as plates, screws, or pins to maintain reduction while healing occurs. 1

Core Surgical Steps

Pre-operative Assessment and Planning

• Obtain appropriate imaging to confirm fracture pattern and plan surgical approach, typically starting with standard 3-view radiographs of the affected area 2
• Consider CT imaging if initial radiographs are equivocal or to better characterize complex fracture patterns and joint involvement for surgical planning 3
• Perform computer-assisted virtual surgical planning for complex fractures (particularly distal femoral and intra-articular fractures), which reduces operative time, blood loss, and fluoroscopy exposure compared to conventional planning 4

Surgical Technique

• Achieve surgical exposure through appropriate incision and approach based on fracture location (e.g., posterior Judet approach for scapular fractures, volar approach for distal radius fractures) 5
• Apply traction and distraction to disimpact fracture fragments, which may require substantial force—specialized multi-degree-of-freedom traction devices can reduce required force by up to 80% 1
• Perform direct visualization and manipulation of fracture fragments under fluoroscopic guidance to achieve anatomical reduction 1, 4
• Achieve articular surface restoration to less than 2mm step-off for intra-articular fractures to prevent long-term complications like post-traumatic arthritis 2
• Apply internal fixation hardware (plates, screws, pins) to maintain reduction while monitoring alignment with fluoroscopy 1, 5
• Consider bone grafting for fractures with bone loss or significant comminution 3

Wound Closure and Post-operative Care

• Irrigate the surgical wound thoroughly before closure 3
• Close the wound in anatomical layers with careful attention to repairing detached muscle origins (e.g., deltoid reattachment to scapular spine) 3, 5
• Apply sterile dressing and appropriate splinting 3
• Administer antibiotic prophylaxis for closed fractures according to standard protocols 3

Critical Timing Considerations

When Open Reduction is Indicated

• Perform open reduction when closed reduction fails due to fracture pattern, soft-tissue interposition, or technical factors, though this may result in increased elbow stiffness compared to successful closed reduction 2
• Consider early surgery (within 12 hours) for displaced pediatric supracondylar fractures to reduce the need for open reduction, as delays beyond 12 hours significantly increase the likelihood of requiring open technique 2
• Perform emergent reduction for fractures with vascular compromise to restore perfusion 2

Surgical Timing and Outcomes

• Delayed ORIF (beyond 14 days) does not significantly increase wound complications or impair functional outcomes for ankle fractures, with wound complication rates of 5% for early surgery versus 11.8% for delayed surgery (not statistically significant) 6
• Typical timing for elective ORIF is several days to weeks after injury for ambulatory procedures 6

Special Populations and Considerations

Pediatric Fractures

• Establish prompt urinary drainage when managing pelvic fracture-associated injuries before addressing orthopedic fixation 2
• Avoid prolonged attempts at reduction that may worsen injury severity or delay other necessary interventions 2

Elderly Patients

• Pay special attention to bone quality and modify fixation methods accordingly 3
• Consider that distal radius fractures account for up to 18% of fractures in elderly patients, with increasing use of internal fixation despite higher costs 2

Open Fractures

• Perform thorough debridement and provide appropriate antibiotic coverage beyond standard prophylaxis 3
• Avoid suprapubic tube placement concerns during pelvic ORIF, as no evidence indicates increased risk of hardware infection 2

Common Pitfalls to Avoid

• Placing incisions too medially (e.g., in scapular approaches) limits lateral exposure and glenohumeral joint access 5
• Inadequate soft tissue handling increases risk of wound-healing complications, particularly with extensive surgical approaches 5
• Accepting suboptimal articular reduction (>2mm step-off) leads to post-traumatic arthritis 2
• Repeated failed attempts at closed reduction before converting to open technique increases injury severity and complications 2

Expected Functional Outcomes

• Excellent functional outcomes (DASH scores 98-100) achieved in 81.7% of clavicle ORIF patients at 6 months 7
• High bone union rates with early pain relief and effective anatomical restoration 7
• Adhesive capsulitis or stiffness occurs in approximately 20% of patients in early postoperative period, manageable with physiotherapy 7
• No significant difference in long-term functional scores between early and delayed surgery for ankle fractures 6