ORIF - open reduction internal fixation - isn't a single operation. It's a category of surgical techniques that describes two steps: the bone is physically repositioned (open reduction) and then held in place with hardware (internal fixation). The hardware might be plates and screws, a single lag screw, an intramedullary nail, or wires, depending on where the fracture is and how it broke.
This distinction matters when you're reading an operative report or talking through options with a surgeon, because the specific hardware choice affects recovery timelines, weight-bearing restrictions, and hardware removal decisions in ways that vary considerably by fracture type.
Why "open" reduction
Not all fractures require surgery. Many break cleanly, stay aligned, and heal with casting. ORIF is reserved for fractures that can't be kept in alignment without surgical fixation, or that are displaced enough that conservative management would result in poor function.
"Open" refers to the incision. The surgeon cuts down to the bone to reposition the fragments under direct vision. This contrasts with closed reduction, where bones are repositioned without cutting - typically done in an emergency department for fractures like a Colles' wrist fracture that can be held in a cast. Some fractures get percutaneous fixation - screws placed through small stab incisions guided by fluoroscopy - which splits the difference between open and closed.
The fixation hardware
The type of hardware is chosen based on fracture location, how the bone broke, and how much of the repair needs to share load with the bone during healing.
Plates and screws are used when multiple fragments need holding, when the fracture crosses a joint, or when structural support is needed along the bone's length. Ankle fractures are the most common example - a bimalleolar fracture, where both the fibula and medial malleolus break, typically gets a plate on the lateral side and one or two screws medially.
Intramedullary nails thread into the hollow central canal of long bones and lock with screws at both ends. They're the standard approach for femur, tibia, and humerus shaft fractures because they distribute load along the bone rather than concentrating it at a plate, and they allow earlier weight bearing.
Cannulated screws - hollow screws that slide over a guide wire - work well for fractures where point compression is what's needed: scaphoid fractures, femoral neck fractures in younger patients, isolated medial malleolus fractures.
Tension band wiring handles small bony prominences that are pulled apart under load rather than compressed. The olecranon, the bony point at the back of the elbow, is the classic example.
Why weight-bearing restrictions still apply after hardware is in
This is the question most ORIF patients ask within a few days of surgery. The operation happened. The hardware is in. Why does the surgeon still want weeks of non-weight bearing?
Hardware holds bone fragments in alignment so they can heal, but it doesn't replace the healing itself. Bone heals through callus formation - new bone bridges the fracture gap over weeks. Until that callus matures, the hardware is doing the mechanical work alone.
Hardware can fail under those conditions. Plates bend or break. Screws pull out of osteoporotic bone. An intramedullary nail can crack the cortex at the locking screw site if the bone is loaded before early consolidation. Weight-bearing restrictions aren't excessive caution - they protect the repair from forces it can't yet distribute. Most lower extremity ORIF repairs follow a phased protocol: non-weight bearing or toe-touch for several weeks, then partial weight bearing with a walker or crutches, then full weight bearing once callus formation is confirmed on X-ray.
The two failure modes
If an ORIF doesn't heal as expected, the fracture typically fails one of two ways.
Nonunion is when the bone doesn't heal. The fragments stay separate - either fibrous tissue fills the gap, or the bone ends become rounded and sclerotic without bridging. This happens in roughly 5-10% of fractures depending on location, blood supply to the area, and patient health factors. Nonunions often require revision surgery, sometimes with bone graft.
Malunion is when the bone heals in the wrong position - either inadequately reduced at surgery or shifted during healing. Clinically significant malunions cause joint dysfunction, abnormal gait mechanics, or chronic pain. Whether to treat a malunion surgically depends on how far off the alignment is and which bone was affected.
Both are more common in patients who smoke, have diabetes, or had significant soft tissue damage around the fracture. These factors don't change whether ORIF is needed - often it's the only option - but your surgeon should account for them when discussing expected recovery.
Common fractures that require ORIF
Distal radius fractures are the most common orthopedic fracture in adults under 65 - a fall on an outstretched hand. Whether it needs ORIF depends on alignment: a fracture that loses more than 10-20 degrees of dorsal tilt or breaks into multiple pieces will lose function if held in a cast.
Bimalleolar and trimalleolar ankle fractures involve both or all three bony prominences of the ankle. An unstable ankle fracture that can't be held in alignment with a boot needs plates and screws. The medial malleolus alone often requires only a lag screw or two.
Tibial plateau fractures affect the top of the tibia where the knee joint sits - high-energy injuries common in motor vehicle accidents and falls from height. Fixation aims to restore the joint surface before load bearing resumes.
Proximal humerus fractures are shoulder fractures in older adults, often from falls. Four-part fractures, where the humeral head, greater tuberosity, lesser tuberosity, and shaft all separate, are debated. Some get ORIF, others get shoulder replacement - the decision depends on patient age and bone quality.
Femoral neck fractures follow a different logic. Younger patients with good bone quality get screw fixation; older patients with osteoporosis typically get partial or total hip replacement, because screw fixation fails at higher rates in low-density bone.
Calcaneal fractures, involving the heel bone, are high-energy injuries with more variable ORIF outcomes than most fractures. Complication rates are higher because of limited soft tissue coverage around the heel, and the decision to operate is debated more than with most fracture types.
When hardware comes out
Most internal fixation hardware stays in permanently. The body tolerates titanium and stainless steel implants well, and a second operation to remove hardware adds risk without adding benefit in most cases.
There are clear exceptions. Hardware that becomes symptomatic - a plate rubbing under a tendon, a prominent screw causing joint impingement, an IT band catching on the end of a lateral femoral plate - is worth removing after healing is confirmed. Hardware crossing a growth plate in a child has to come out to avoid tethering bone growth. An infected implant usually can't be sterilized with antibiotics alone. Some anatomical locations, like the clavicle, have higher rates of symptomatic hardware that surgeons remove routinely in younger patients.
If you're wondering whether your hardware should come out and no one has mentioned it, asking directly is reasonable. The default is that it stays. The exceptions above are when it doesn't.
