Fractures > Treatments
Open Reduction and Internal Fixation
Preparing for Surgery
The decisions you make and the
actions you take before your surgery can be every bit
as important as the procedure itself in ensuring ahealthy
recovery. Getting a second opinion from a surgeon who
is as qualified as the surgeon who gave the initial
diagnosis is advisable, especially in rare cases.
to arrange for someone to take home any equipment you
will need when you get home from the hospital. This
may include a walker, crutches, ice packs or coolers,
or household items to make movement around the house
easier. You should receive prescriptions for any of
these from your doctor when your surgery is scheduled.
the potential risks and benefits of the surgery, and
ask your surgeon any questions that will help you better
understand the procedure. It can also help to talk to
someone else who has undergone the same surgery.
physical problems, such as a fever or infection, should
be reported to your surgeon, and you should notify your
surgeon of any medication you are taking.
possible, discontinue the use of any anti–inflammatory
medicine, especially aspirin, a week prior to surgery,
to prevent excessive bleeding during the procedure.
reduce the risk of infection, try to refrain from smoking
for at least a week prior to surgery.
sure the orthopedist performing the surgery is board–certified,
which can be determined by calling the American Board
of Orthopaedic Surgery at 919-929-7103.
to ask the doctor
to take to the hospital
At most medical centers, you will
go to "patient admissions" to check in for
your open reduction–internal fixation surgery.
There may be a separate department for overnight inpatient
surgery check–in, so be sure to ask your doctor.
In the trauma setting you will go directly to the emergency
room. After you have checked in to the hospital or clinic,
or in the case of a traumatic injury, after you leave
the emergency room, you will go to a holding area where
the final preparations are made. The paperwork is completed
and your hip and thigh area may be shaved (this is not
always necessary). You will wear a hospital gown and
remove all of your jewelry. You will meet the anesthesiologist
or nurse anesthetist (a nurse who has done graduate
training to provide anesthesia under the supervision
of an anesthesiologist). Then, you will walk or ride
on a stretcher to the operating room. Most patients
are not sedated until they go into the operating room.
Here are some important steps to remember for the day
of your surgery:
will probably be told not to eat or drink anything after
midnight on the night before your surgery. In general,
you should not eat for eight hours before surgery. This
will reduce the risk of vomiting while you are under
a loose pair of shorts or sweatpants that will fit comfortably
over your hip bandage when you leave the hospital.
it easy. Keeping a good frame of mind can help ease
any nerves or anxiety about undergoing surgery. Distractions
such as reading, watching television, chatting with
visitors, or talking on the telephone can also help.
to take to the hospital
When an open reduction and internal
fixation is performed:
six to ten inch incision is made over the top of the
thighbone, called the greater trochanter. The incision
usually is curved in a boomerang or banana shape.
cartilage and loose bone chips are removed.
femoral neck and head are properly positioned (reduction)
in the socket joint of your hipbone to ensure smooth
neck of your femur, which may have fractured along various
lines and in multiple pieces, is reconstructed. The
fractured bones are fixed in place with small nails,
pins, or screws, restoring the original straight shape
to the branch on the inside of your thighbone.
damaged soft tissues, including the joint capsule that
surrounds the hip joint, are sewn together tightly to
help hold the hip joint in place.
are closed with 30 to 40 staples, a bandage is placed
over the incisions, and the patient is taken to the
surgery, there is a small risk of avascular necrosis
(destruction of the femoral head) and of post-traumatic
arthritis. Both of these may lead to more surgery, including
total hip replacement.
After surgery to repair your stress
fracture, you usually will stay in the recovery room
for at least two hours while the anesthetic wears off.
Your hip will be bandaged with white gauze pads and
tape and may have ice on it. You may have lost a significant
amount of blood during surgery and there may be a small
amount of bleeding afterward. Depending on your age
and the volume of red blood cells in your blood stream,
blood may need to be replaced in the recovery room through
an IV. You will be given adequate pain medicine, either
orally or through an IV (intravenous) line, as well
as instructions for what to do over the next couple
of days. Antibiotics and blood thinners (anticoagulants)
also may be administered to help avoid infection and
blood clots. You should try to move your feet, ankles,
and knees while you are in the recovery room to improve
circulation. Your temperature, blood pressure, and heartbeat
will be monitored by a nurse, who, with the assistance
of the doctor, will determine when you are ready to
leave the recovery room and be admitted for a three
to five night stay.
Post-op in Hospital
After surgery to repair an intertrochanteric
fracture, some patients remain in the hospital for as
long as five days. Some patients may have to stay longer
and in rare cases may need to be transferred to rehabilitation
centers or nursing homes. Nurses typically apply a fresh
bandage two days after surgery. The bandage may need
to be replaced once or twice while at home and the nurses
can teach you to change the bandage yourself. You may
be instructed to use a wedge-shaped foam pillow called
a hip abduction pillow that help keeps your legs spread
apart and held in a proper position. There will likely
be pain, and you can expect to be given pain medication
as needed. Be sure to ask for medication as soon as
you feel pain coming on, because pain medication works
best on pain that is building rather than on pain that
is already present. The nurses will not give you more
than your doctor has prescribed and what is considered
to be safe. Though physicians generally limit bearing
weight on your leg, you will be instructed to sit up
and move around to help circulate blood. Beginning in
the hospital, you probably will need to use a walker
or crutches while the fractured bones heal for between
three and 12 months. Your physician, nurse, or a physical
therapist will teach you to use your walker or crutches
and begin gentle rehabilitation exercises to avoid muscle
atrophy. Your physician usually takes X-rays of your
hip before you leave the hospital. In addition, you
will be given an appointment to return for a checkiup
and more X-rays every eight to 12 weeks until your hip
heals. Most patients receive a prescription for pain
medication. You will be unable to drive a car, so be
sure to have arranged a ride home.
what you can expect and how you can cope while recovering
at home from open reduction-internal fixation surgery:
this procedure, there is usually pain and discomfort
for about two weeks. If needed, take pain medication
as instructed. The pain tends to decrease each day after
surgery. Check with your doctor if unexpected pain arises.
are usually removed about two to three weeks after surgery.
You may need to change your bandage yourself once or
twice during the first week at home after surgery as
instructed by the nurses in the hospital. You can normally
stop using bandages when the wound is dry.
your staples dry. Depending on your surgeon's
advice, the time you are instructed to keep the incision
dry varies, usually from two to three weeks.
move your toes, ankles, and knees as much as possible
to help circulate blood.
balanced diet, iron supplements, and proper hydration
may help restore healthy tissue.
fractured hip can make it difficult to move around your
house and perform even simple household tasks like cooking,
bathing, and laundry. Try to have friends or family
members available to visit you once or twice a day for
several weeks. If you live alone, your insurance company
decides whether you qualify for a nurse. Otherwise,
you can hire help through a social worker at the hospital
who can put you in contact with nursing and therapy
agencies in your area.
to begin range of motion and walking exercises within
two days of surgery. You should not remain sedentary
because you run the risk of developing blood clots and
bedsores. Your physician usually refers you to a physical
therapist who can help you learn to walk after surgery.
This usually takes three to six weeks.
some people can regain strength without supervised physical
therapy, your physician will evaluate your ability to
walk and prescribe further physical therapy as needed.
to call the doctor after surgery
Physical therapy may be helpful during
the first three to six weeks after surgery as you learn
to use your walker or crutches. Many patients prefer
easier–to–use walkers or "quad–canes"
– devices consisting of four canes connected by
handles. Range of motion is extremely important. Movement
may be painful at first, but it is important to avoid
stiffening in your hip. For the first few weeks, your
physical therapist may help you move your hip in different
directions to stretch out the joint. Partial weight
bearing can begin as soon as possible after surgery.
Full weight bearing is generally delayed until an X-ray
shows that your femoral neck has healed and an MRI confirms
you have not developed avascular necrosis, a dangerous
loss of blood supply. This may not occur for three to
12 months. However, you should move around with the
aid of a walker as much as possible. You usually also
practice stair climbing using handrails to support your
weight. Rehab may progress to resistive exercises –
those involving weights – to keep the muscles
around your hip strong. You may continue visiting a
physical therapist or you may be able to strengthen
your hip on your own, depending on your physician's
advice. In some cases, general cardiovascular exercise
may adequately strengthen hip muscles. Typical hip strengthening
exercising involve leg exercises while sitting or laying
down that do not involve bending the hip or taking steps
with extra weight on your arms or torso. Patients under
age 65 should eventually be able to resume functional
activities like stair climbing, single leg support,
swimming, and driving. You may be able to begin more
vigorous activities as your hipbone heals and your leg
gets stronger. Patients over age 65 may have more difficulty
returning to activities and restoring full health to
their hip after a fracture.
Once your hip stress fracture has
healed, building muscle strength around your hip can
help you avoid further injury. You also may consider
training with a physical therapist or coach to increase
your balance and coordination, which can help decrease
the chances of accidental falls. If your physician feels
you are at risk for future femoral neck fractures, you
may be instructed to cut back or avoid repetitive stress
activities like long distance running. Physicians generally
recommend cross–training after a stress fracture
to avoid putting the same type of stress on your hips
every day. You should alternate your running workouts
with cycling, swimming, or other cardiovascular activities.
Slowly increase the intensity and duration of your workouts.
Try to avoid drastic increases in your athletic activities.
Another way to help prevent further hip injuries is
to avoid stressing your hip during daily activities.
After a hip stress fracture, take it easy on your hips
whenever possible during the day to save them for activities
and exercise. Avoid stairs when there is an elevator,
take the shortest path when walking, and consider wearing
athletic shoes designed to absorb shock. In general,
you should avoid participating in activities in old,
worn–out shoes. Running shoes typically wear out
after 250 to 300 miles of running. Running on softer
surfaces, like grass or cushioned tracks, may also decrease
your risk or recurring hip stress fractures. If your
stress fracture was caused by anatomical problems, like
differences in your leg length or twisting in your shinbone,
your physician may prescribe orthotic devices to wear
in your shoes. Orthotics can help properly transfer
weight through your hips and provide you with a more
| Treatment Introduction
Stress fractures in your femoral neck,
the branch on the inside of your upper thighbone that
runs from the femoral head at the hip joint to the top
of the thighbone, may require surgery if the bone is
at risk of further damage. The surgery usually is performed
as soon as possible after the stress fracture is diagnosed.
Small pins or screws are used to reinforce weakened