When does a fracture need surgery?

Most upper-limb fractures heal in a sling or cast. Surgery is reserved for fractures that are displaced beyond what the bone will tolerate, intra-articular fractures that need anatomic reduction to preserve joint surface, unstable patterns that will lose position in a sling, and high-energy or open fractures with associated soft-tissue or neurovascular injury. The decision is fracture-specific and depends on the pattern, displacement, the patient, and the goals of treatment.

ORIF stands for open reduction and internal fixation. The fracture is exposed through a surgical incision (open), the bone fragments are realigned (reduction), and the fracture is held in place with implants such as plates and screws or an intramedullary nail (internal fixation). The aim is to restore anatomy and provide enough stability to allow early movement while the bone heals.

How long until the bone is healed?

Most upper-limb fractures unite radiographically by twelve weeks, although clinical comfort and functional recovery often run ahead of x-ray healing. Older patients, smokers, diabetics, and high-energy injuries can take longer. The treating surgeon follows progress with serial x-rays at intervals through the recovery and adjusts activity restrictions accordingly.

Will the metalwork need to be removed?

In most cases the plates, screws, and nails stay in permanently. Modern low-profile titanium implants are usually well tolerated and do not need to come out. Removal is considered if the hardware causes prominence under the skin, irritation, or pain, which is more common after clavicle and elbow procedures where the plate sits subcutaneously and is easily felt, particularly in slim patients. Removal is a small day-case operation once the bone has fully healed, usually no earlier than six months after the original surgery.

Where does Dr Piper operate on fractures?

Private cases are treated at Lakeview Private Hospital in Norwest. Public and complex trauma cases are operated at Westmead Hospital, where Dr Piper has been a Visiting Medical Officer since 2015 and where the full multidisciplinary trauma team is available. The choice of facility depends on the fracture, the patient, and any associated injuries.

Procedure

Open reduction and internal fixation of fractures

Open reduction and internal fixation (ORIF) is the surgical realignment of a fractured bone followed by internal stabilisation using plates, screws, or intramedullary nails. Used for displaced, unstable, intra-articular, or high-energy upper-limb fractures that will not heal well in a sling or cast.

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Indications

When fixation is the right operation

Most upper-limb fractures heal in a sling or cast. Surgery is reserved for fractures where non-operative treatment will leave a poor result. The decision is individual and depends on the fracture pattern, the patient, and the goals of treatment. Common indications include:

Significant displacement. A fracture displaced beyond what the bone will tolerate without a functional deficit. The threshold differs by bone: a clavicle shortened by more than two centimetres, a proximal humerus with an angulated head, or a distal radius with loss of radial length and tilt.
Intra-articular fractures. Fractures that extend into a joint surface need anatomic reduction to preserve the cartilage and reduce the risk of post-traumatic arthritis. Even small step-offs in a joint surface are poorly tolerated.
Unstable fracture patterns. Fractures that hold position poorly in a sling or cast. Spiral or comminuted patterns, segmental fractures, and fractures with significant muscle pull on the fragments often need internal fixation to maintain alignment during healing.
Open fractures. Fractures where the bone has broken through the skin. These need urgent washout and stabilisation to reduce the risk of infection and to allow soft-tissue healing.
Associated neurovascular or soft-tissue injury. Fractures with nerve or blood-vessel involvement, or with major soft-tissue damage, often need fixation to allow the soft tissues to heal alongside the bone.
Polytrauma and floating segments. In multi-system trauma, fixing fractures early allows mobility, reduces complications, and lets the patient participate in rehabilitation for other injuries.

Fracture patterns

Upper-limb fractures Dr Piper treats

Dr Piper operates on the full range of upper-limb fractures from shoulder girdle to forearm. Modern fixation uses pre-contoured plates and locking screws designed for specific anatomic sites, allowing rigid fixation with minimal soft-tissue stripping.

Clavicle fractures. Mid-shaft fractures with significant displacement or shortening are commonly fixed with a pre-contoured clavicle plate. See the clavicle fracture page for the operative-versus-non-operative decision and what recovery looks like.
Proximal humerus fractures. Three- and four-part fractures of the top of the humerus, often in older patients after a fall. Fixed with locking plates and screws designed for the proximal humerus. In older patients with very comminuted patterns or poor bone, a reverse shoulder replacement is sometimes a better option than fixation.
Humeral shaft fractures. Many heal in a functional brace, but unstable patterns, segmental fractures, and fractures with radial nerve injury often benefit from plating or intramedullary nailing.
Distal humerus fractures. Intra-articular fractures of the elbow end of the humerus. These are technically demanding and need anatomic reduction with dual plating to restore the joint surface.
Olecranon fractures. Fractures of the bony tip of the elbow. Commonly fixed with tension-band wiring or a small plate, depending on the pattern.
Complex elbow injuries. Terrible-triad injuries (elbow dislocation with radial head and coronoid fractures), Monteggia injuries, and other complex elbow trauma. These need a coordinated approach addressing bony fixation, ligament repair, and stability.
Radial head fractures. Some are stable and treated non-operatively. Displaced or unstable fractures are fixed with small screws or plates, or in comminuted patterns the radial head may be replaced.

The procedure

What happens in the operating theatre

The specific approach depends on the fracture, but the general principles are common to all upper-limb ORIF. Surgery is performed under general anaesthetic, often with a regional nerve block to help with pain control after surgery.

The patient is positioned for the operative site. The fracture is approached through a surgical incision placed to protect the surrounding nerves and blood vessels. The fragments are identified, freed up, and reduced into anatomic alignment under direct vision and with image-intensifier guidance.

Fixation is then applied. For most upper-limb fractures this means a pre-contoured locking plate placed against the bone with locking and non-locking screws to compress the fragments and resist deforming forces. Some fractures are better suited to an intramedullary nail, where a long rod is passed through the inside of the bone and locked at each end. Intra-articular fragments are fixed first to restore the joint surface, then the metaphysis and shaft are reduced and stabilised.

The wound is closed in layers with absorbable sutures. A dressing and a sling are applied at the end of the procedure. Most upper-limb ORIF cases are an overnight stay or a day case, depending on the fracture and the patient.

Recovery

What recovery looks like

Recovery is fracture-specific. The general pattern is a sling for two to four weeks for comfort, with early supervised range of motion starting within the first one to two weeks under physiotherapy guidance. Wrist fractures usually require a cast or removable splint. The aim is to maintain joint mobility while the fixation protects the fracture from displacing.

Active strengthening starts once early bone healing is visible on x-ray, typically around six weeks. Heavy lifting and contact sport are usually deferred until x-ray shows fracture union, typically at twelve weeks. Older patients, smokers, and high-energy injuries can take longer to unite.

Most patients return to office work within two to four weeks. Driving is usually possible by four to six weeks, once out of the sling and with safe two-handed control of the steering wheel. Manual work and sport are cleared at six to twelve weeks depending on the fracture and the demands of the activity.

X-ray follow-up tracks healing. Visits are typically at two weeks for wound check, six weeks for early union, and twelve weeks for return to full activity. Further follow-up is arranged if healing is slower than expected.

Complications and risks

What can go wrong

Fracture fixation is a well-established procedure with generally good outcomes. The specific risks include (but are not limited to):

Non-union. Failure of the bone to heal across the fracture line. More common in smokers, older patients, high-energy injuries, and fractures with poor blood supply. May require further surgery with bone grafting.
Mal-union. Healing in a non-anatomic position. Modern internal fixation aims to prevent this; revision is occasionally needed for significant deformity affecting function.
Infection. Uncommon in closed fractures, more common after open injuries or contaminated wounds. Antibiotics are given at induction. Deep infection of a fixed fracture may require return to theatre.
Hardware prominence. Plates and screws can be palpable or irritating under thin soft tissues, particularly in the clavicle. Removal is a small day-case operation once the fracture has united.
Nerve injury. The nerves around each fracture are at some risk during surgical exposure. Careful technique and image guidance minimise this risk. Most nerve issues recover spontaneously.
Complex regional pain syndrome (CRPS). A rare condition that causes pain and stiffness in the hand.
Stiffness. Joint stiffness after a peri-articular fracture is the commonest functional issue. Early supervised motion and physiotherapy reduce the risk.
Anaesthetic and medical complications. Discussed separately by the anaesthetist before surgery. The risk of DVT is low for upper-limb surgery.

FAQ

Frequently asked questions

When does a fracture need surgery?: Most upper-limb fractures heal in a sling or cast. Surgery is reserved for fractures that are displaced beyond what the bone will tolerate, intra-articular fractures that need anatomic reduction to preserve joint surface, unstable patterns that will lose position in a sling, and high-energy or open fractures with associated soft-tissue or neurovascular injury. The decision is fracture-specific and depends on the pattern, displacement, the patient, and the goals of treatment.
What is ORIF?: ORIF stands for open reduction and internal fixation. The fracture is exposed through a surgical incision (open), the bone fragments are realigned (reduction), and the fracture is held in place with implants such as plates and screws or an intramedullary nail (internal fixation). The aim is to restore anatomy and provide enough stability to allow early movement while the bone heals.
How long until the bone is healed?: Most upper-limb fractures unite radiographically by twelve weeks, although clinical comfort and functional recovery often run ahead of x-ray healing. Older patients, smokers, diabetics, and high-energy injuries can take longer. The treating surgeon follows progress with serial x-rays at intervals through the recovery and adjusts activity restrictions accordingly.
Will the metalwork need to be removed?: In most cases the plates, screws, and nails stay in permanently. Modern low-profile titanium implants are usually well tolerated and do not need to come out. Removal is considered if the hardware causes prominence under the skin, irritation, or pain, which is more common after clavicle and elbow procedures where the plate sits subcutaneously and is easily felt, particularly in slim patients. Removal is a small day-case operation once the bone has fully healed, usually no earlier than six months after the original surgery.
Where does Dr Piper operate on fractures?: Private cases are treated at Lakeview Private Hospital in Norwest. Public and complex trauma cases are operated at Westmead Hospital, where Dr Piper has been a Visiting Medical Officer since 2015 and where the full multidisciplinary trauma team is available. The choice of facility depends on the fracture, the patient, and any associated injuries.

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