Fracture Fixation Surgery Explained — Plates, Screws, Rods and Nails

When someone breaks a bone and is told they need surgery to "fix" it, the natural question is: what does that actually mean?

The word "fix" in this context is literal — the broken bone fragments are fixed in correct alignment using metal implants, holding them in place while the bone heals. These implants — plates, screws, rods, and nails — are what most people have vaguely in mind when they picture fracture surgery, but rarely understand specifically.

This guide explains how fracture fixation works, which implants are used for which fractures, and what to expect from surgery and recovery.

Why Not Just Cast It?

Not all fractures need surgery. Many fractures — including many wrist fractures, some ankle fractures, and most minor fractures in children — heal well with a plaster cast that holds the bone in position while it heals naturally.

Surgery is recommended when:

The fracture is displaced: The broken fragments have shifted out of alignment. A displaced fracture that is set (reduced) and held in a cast may re-displace because of muscle pull or gravity. Surgery provides rigid internal fixation that maintains alignment reliably throughout healing.

The fracture involves a joint surface: Even a millimetre of step-off at an articular surface leads to uneven load distribution, cartilage damage, and premature arthritis. Joint-surface fractures (intra-articular) almost always require surgery to restore the smooth joint surface.

The fracture is in a position where casting can't maintain alignment: Some fractures — particularly the femur (thigh bone), hip, and certain spine fractures — simply cannot be held in a cast. The bone is too deep or the forces acting on it are too great.

The patient needs early mobility: In elderly patients with hip fractures, prolonged immobility is often more dangerous than the surgery itself. Pneumonia, blood clots, pressure sores, and muscle wasting can develop rapidly in a bedridden older person. Surgical fixation allows mobilisation within days.

Multiple fractures (polytrauma): Early surgical stabilisation of fractures in trauma patients improves overall outcomes by allowing earlier rehabilitation and reducing systemic complications.

The Two Main Approaches: Open and Percutaneous

1. Open Reduction and Internal Fixation (ORIF)

The classic fracture surgery. "Open" means the surgeon makes an incision over the fracture site and directly visualises the broken fragments. "Reduction" means manipulating the fragments back into their correct anatomical position. "Internal fixation" means holding them there with metal implants.

ORIF is used when the fracture complexity requires direct visualisation to achieve accurate reduction — particularly for intra-articular fractures where the joint surface must be restored precisely.

2. Percutaneous (Closed) Fixation

Implants are inserted through small stab incisions, guided by X-ray imaging (fluoroscopy) rather than direct vision. The bone is not directly exposed. This is less traumatic than open surgery and is used when the fracture can be reduced by manipulation from outside (closed reduction) before fixation.

Intramedullary nailing (see below) is typically done percutaneously. K-wire fixation of certain fractures is also percutaneous.

The Implants: What Goes In and Why

1. Plates and Screws

A plate is a flat metal strip that is contoured to fit the surface of the bone. Screws pass through the plate into the bone on either side of the fracture, holding it in alignment.

Modern plates are made of titanium or stainless steel — both strong, inert, and well-tolerated by the body. Titanium is lighter, more flexible, and has better osseointegration (bone grows onto its surface), making it preferred for most modern fracture fixation.

Locking plates: Modern fracture plates are often "locking" — the screws thread into the plate holes and lock to the plate, creating a fixed-angle construct. This is particularly valuable in osteoporotic bone, where traditional screws may pull out but locking screws are anchored to the plate itself.

Plates are used for:

• Forearm and wrist fractures
• Clavicle fractures
• Complex tibial and fibular fractures
• Periarticular fractures (around the knee or elbow)
• Pelvic fractures
• Femoral and tibial shaft fractures in certain configurations

2. Intramedullary Nail (IM Nail)

For fractures of the long bones — femur (thigh), tibia (shin), and humerus (upper arm) — the most biomechanically logical fixation is internal: a nail inserted down the hollow centre of the bone (the medullary canal).

A long metal rod is inserted through a small entry point (at the knee for tibial nails, at the hip for femoral nails) and driven down the canal, spanning the fracture from above and below. Cross-screws (locking screws) are placed perpendicular to the nail at each end to prevent rotation and telescoping.

IM nailing is load-sharing rather than load-bearing — the nail shares the mechanical stress with the healing bone, rather than taking all of it. This allows early weight-bearing in many cases.

IM nailing is the standard treatment for:

• Displaced femoral shaft fractures
• Tibial shaft fractures
• Subtrochanteric femoral fractures (below the hip)
• Certain humeral shaft fractures

3. Screws Alone

Some fractures — particularly undisplaced fractures in good bone, or fractures where a single compression screw is sufficient to hold reduction — are fixed with screws alone without a plate.

Femoral neck fractures in younger adults are often fixed with cannulated screws (hollow screws through which a guide wire is first placed). Hip screws combined with a side plate (DHS — dynamic hip screw) are used for certain femoral neck and intertrochanteric fractures.

4. Kirschner Wires (K-Wires)

Thin, pointed metal wires that are drilled across fracture fragments to hold them in position. Used for smaller fractures — wrist (radial styloid), hand, fingers, ankle. They are often left partially protruding from the skin and removed in clinic after 4–6 weeks once initial healing has begun.

5. External Fixation

When fractures are severely contaminated (open fractures with wound contamination), associated with vascular injury requiring vascular surgery, or when the patient is too unstable for definitive fixation, an external fixator is used.

Pins are drilled into the bone through small skin incisions, attached to bars and clamps outside the body — stabilising the fracture without any hardware at the fracture site. The external fixator can be left in place while wound and vascular problems are dealt with, then removed and replaced with internal fixation later.

Open Fractures: A Special Situation

An open (compound) fracture is one where the bone penetrates through the skin. This is a surgical emergency for two reasons: the bone and soft tissues are contaminated with bacteria, and the soft tissue damage may compromise healing and vascularity.

Treatment priorities:

1. Thorough wound washout in the operating room
2. Debridement (removal of contaminated and dead tissue)
3. Fracture stabilisation — often with external fixation initially
4. Wound closure or coverage (may require plastic surgery input for skin grafting or flap coverage)
5. Antibiotics

Definitive internal fixation is typically delayed until the wound is clean and healing, to reduce infection risk around the implants.

What Recovery Looks Like After Fracture Surgery

Recovery varies enormously depending on which bone, which fracture type, the patient's age and bone quality, and associated injuries.

General principles

Weight-bearing: Begins early for many lower limb fractures fixed with IM nails (partial or full weight-bearing within days to weeks). Joint-surface fractures may require non-weight-bearing for 6–12 weeks while the bone heals.

Bone healing time: Long bones typically show radiological healing in 3–6 months. Wrist fractures: 6–8 weeks. Femoral shaft fractures: 3–6 months. Hip fractures in the elderly: 3–4 months, but function improves much earlier with rehabilitation.

Implant removal: Metal implants do not need to be removed in most adult patients. They are inert and well-tolerated lifelong. Removal is considered for: symptomatic prominence, infection, implant failure, or young patients who plan high-impact activity.

Physiotherapy: Essential for all fracture patients. Range of motion, muscle strengthening, and proprioception training begin as soon as the fixation and wound allow.

Fracture Surgery at Prakash Hospital, Noida

Prakash Hospital, Sector 33, Noida, has 24/7 trauma and orthopaedic emergency services. Dr. Mayank Chauhan manages both acute fracture care and planned elective fracture surgery, including complex periarticular and polytrauma cases.

Fracture patients from across Noida, Greater Noida, and the NCR region are regularly managed at Prakash Hospital.

To book a consultation or attend the emergency department, call the number listed on the website.