A bone fracture is a break in the continuity of a bone. While most fractures can be treated non-operatively using a cast or splint, some require surgical intervention, known as operative fixation, to heal properly. The decision for surgery depends on the specific characteristics of the break and the potential for functional recovery. When a fracture is severe, unstable, or involves a joint, surgery offers the best opportunity to restore the original anatomy and function of the limb.
Defining When Surgery is Required
Operative management is necessary when a fracture is significantly displaced, meaning the bone fragments have shifted too far out of alignment to heal correctly. Unstable fractures, which are likely to move or redisplace even after non-surgical reduction, also require stabilization with internal hardware. A serious indication for immediate surgery is an open or compound fracture, where the broken bone penetrates the skin. These injuries require urgent cleaning and stabilization to prevent contamination and major complications.
Fractures that extend into a joint surface, known as intra-articular fractures, often necessitate surgery to achieve precise anatomical alignment and preserve long-term joint function. Even a slight misalignment can lead to chronic pain and early-onset arthritis. If a fracture fails to heal after non-operative treatment, resulting in a non-union or malunion, corrective surgery may be required to stimulate healing or reposition the bone.
Common Surgical Approaches
One of the most frequent surgical methods is Open Reduction and Internal Fixation (ORIF), which involves making an incision to directly visualize and manually realign the bone fragments. Once repositioned, they are secured using various types of internal fixation hardware. This hardware often includes metal plates contoured to the bone’s shape and attached with multiple screws to hold the pieces rigidly in place. Wires or pins are sometimes used for smaller fragments or as temporary fixation.
For fractures involving long bones, such as the femur or tibia, surgeons often perform Intramedullary Nailing. This technique involves inserting a long metal rod directly down the hollow center of the bone, known as the medullary canal. The rod acts as an internal splint, stabilizing the entire length of the bone while allowing controlled micromotion at the fracture site, which promotes healing. The rod is secured at the ends with screws, locking it into the bone and preventing rotation or shortening of the limb.
External Fixation is reserved for complex injuries, such as severe open fractures with significant soft tissue damage, or for temporary stabilization in trauma patients. This procedure involves inserting pins or wires through the skin and into the bone fragments, which are connected to a rigid frame located outside the body. The external frame holds the bones in alignment, offering stability while allowing access to the surrounding injured soft tissues for wound care. The frame may remain in place until the fracture is fully united or until soft tissues have healed enough to permit internal fixation.
Recovery and Rehabilitation Timeline
Recovery following fracture surgery begins immediately with the post-operative phase, focusing on pain management, infection prevention, and managing swelling. Patients are closely monitored for signs of nerve or blood vessel compromise. The initial healing period, where the body forms a soft callus to bridge the fracture gap, generally lasts about six weeks.
Physical therapy (PT) or occupational therapy (OT) often starts early, sometimes within days of the operation, using gentle range-of-motion exercises for nearby joints. This early mobilization prevents joint stiffness and muscle atrophy, which can hinder long-term recovery. The progression to weight-bearing activities is controlled by the orthopedic surgeon and depends on the fracture location and fixation stability. For lower extremity fractures, this transition can range from no weight-bearing for several weeks to immediate partial weight-bearing if the fixation is strong.
The bone requires several months for the soft callus to fully mineralize into a hard callus, which provides structural strength. Full bone healing can take anywhere from three to twelve months, depending on the injury severity, patient age, and overall health. Hardware is often left permanently, but if it causes irritation or pain, a second surgery may be scheduled to remove the plates, screws, or rods after the fracture is completely healed.
Addressing Potential Surgical Complications
While fracture surgery is performed to improve the outcome, it carries risks related to the procedure and the placement of foreign materials. One potential issue is infection, particularly in open fractures, where bacteria can adhere to the fixation hardware and form a protective biofilm. This can lead to a bone infection known as osteomyelitis, often requiring long-term antibiotic therapy and possible hardware removal.
Another concern is non-union, which occurs when the bone fails to heal completely within an expected timeframe (typically nine months). Conversely, malunion is a complication where the fracture heals in an incorrect or functionally poor position, causing chronic pain or altered limb mechanics. These healing problems are sometimes related to instability at the fracture site or insufficient blood supply.
The internal hardware itself can occasionally fail, with screws loosening or plates bending or breaking if the bone does not heal fast enough to bear the load. Surgery also carries a risk of damage to surrounding structures, including adjacent nerves, which could result in numbness or muscle weakness, or blood vessels, which can compromise circulation.