In partial fullfillment in NCM 107n

Area:OPERATING ROOM

Submitted by: Warren Dango SNJPIICD

Submitted to:

Introduction

Open Reduction Internal Fixation (ORIF) involves the implementation of implants to guide the healing

process of a bone, as well as the open reduction, or setting, of the bone itself. Open reduction refers

to open surgery to set bones, as is necessary for some fractures. Internal fixation refers to fixation of

screws and/or plates, intramedullary bone nails (femur, tibia, humerus) to enable or facilitate healing.

Rigid fixation prevents micro-motion across lines of fracture to enable healing and prevent infection, which

happens when implants such as plates (e.g. dynamic compression plate) are used. Open Reduction

Internal Fixation techniques are often used in cases involving serious fractures such as comminuted or

displaced fractures or in cases where the bone would otherwise not heal correctly with casting or splinting

alone.

Risks and complications can include bacterial colonization of the bone, infection, stiffness and loss of

range of motion, non-union, mal-union, damage to the muscles, nerve damage and

palsy, arthritis, tendonitis, chronic pain associated with plates, screws, and pins, compartment

syndrome,deformity, audible popping and snapping, and possible future surgeries to remove the

hardware.

Anatomy and physiology

The diaphysis, or shaft, is the long tubular portion of long bones. It is composed of compact bone tissue. The epiphysis (plural, epiphyses) is the expanded end of a long bone. It is in the epiphyses where red blood

cells are formed. The metaphysis is the area where the diaphysis meets the epiphysis. It includes the epiphyseal line, a

remnant of cartilage from growing bones. The medullary cavity, or marrow cavity, is the open area within the diaphysis. The adipose tissue inside the

cavity stores lipids and forms the yellow marrow. Articular cartilage covers the epiphysis where joints occur. The periosteum is the membrane covering the outside of the diaphysis (and epiphyses where articular

cartilage is absent). It contains osteoblasts (bone-forming cells), osteoclasts (bone-destroying cells), nerve fibers, and blood and lymphatic vessels. Ligaments and tendons attach to the periosteum.

The endosteum is the membrane that lines the marrow cavity.

Here are the main features of short, flat, and irregular bones:

In short and irregular bones, spongy bone tissue is encircled by a thin layer of compact bone tissue. In flat bones, the spongy bone tissue is sandwiched between two layers of compact bone tissue. The spongy

bone tissue is called the diploë. The periosteum covers the outside layer of compact bone tissue. The endosteum covers the trabeculae that fill the inside of the bone.

In certain bones (ribs, vertebrae, hip bones, sternum), the spaces between the trabeculae contain red marrow, which is active in hematopoiesis.

Objectives

• Assess the anatomy, physiology, and pathophysiology of the ORIF.

• Analyze the diagnostic and surgical interventions for a patient undergoing an ORIF.

• Plan the intraoperative course for a patient undergoing ORIF.

• Assemble supplies, equipment, and instrumentation needed for the procedure.

• Choose the appropriate patient position

• Identify the incision used for the procedure

• Analyze the procedural steps for ORIF.

• Describe the care of the specimen

• Discuss the postoperative considerations for a patient undergoing ORIF.

Definition/Purpose of Procedure

• Realignment and fixation of a fracture of the femur through an operative incision

• Goal: solid union of bone in perfect alignment, to return joints and muscles to normal position, to prevent or repair vascular trauma, and to rehabilitate the pt as early as possible

Pathophysiology

• Classifications of fractures

– Traumatic

• Closed (Simple)

• Open (Compound)

– Pathologic

• Oblique (45 degree angle to bone)

• Spiral (curves around bone)

• Avulsed (fracture pulls bone & other tissues away from the point of attachment.

– Comminuted (bone breaks in many pieces)

– Compressed (bone is crushed)

– Impacted (broken bone ends are forced into each other)

– Depressed (broken bone is forced inward)

• Complete vs Incomplete

• Stable vs Unstable

Internal Fixation

• Screws, Plates, Nails

• Intermedullary nailing

– Advantages: increase and evenly spread load sharing of the bone, reduced scarring, minimal blood loss, low infection rate, fracture hematoma preserved at fracture site.

– Type of nail Fixation of a short oblique fracture using a plate and screws above and below the fracture

Diagnostics• Exams

– X-ray• Preoperative Testing

Surgical Intervention: Special Considerations• Patient Factors• Room Set-up

– Position sterile tables on the affected side• Etc

– Have x-rays in room– Some surgeons prefer to double-glove and remove the first pair

following completion of draping– Observe x-ray precautions; notify radiology dept when pt is being

positioned for preliminary films; intraop x-ray will be used (either via portable machine or C-Arm flouroscopic image intensification)

– Wear protective goggles

Surgical Intervention: Anesthesia• Method: General or epidural • Equipment

– Upper body Bair hugger available Surgical Intervention: Positioning

• Position during procedure– Lateral position on Fracture Table or without; might be supine

• Supplies and equipment – If no FX Table, may use a leg holder and pillow placed between legs

and clear adhesive drape used to drape perineum out of field before skin prep

– Wide adhesive to stabilize patient at shoulders in addition to safety strap over the unaffected thigh

• Special considerations: high risk areas– Arm on unaffected side on armboard, other arm either flexed across

chest or postioned on pillow on Mayo stand– Padding around feet, ankles, bony prominences

Surgical Intervention: Skin Prep• Method of hair removal: wet prep• Anatomic perimeters

– Begin over fracture site extending from umbilicus to below the knee, well beyond midline anteriorly, and down table posteriorly. If no FX Table, leg and foot are completely prepared.

• Solution options: Betadine, Duraprep, Hibiclens Surgical Intervention: Draping/Incision

• Types of drapes– Folded towels and sterile, plastic adhesive drape. fenestrated sheet

covers the field• Order of draping

– Four sheets may be draped around perimeter of site; • Special considerations• State/Describe incision: at fracture site

Surgical Intervention: Supplies• General

– Basin set, Suction tubing, ESU pencil/holder, needle magnet or counter, asepto or bulb syringe, graduated cylinder, 6 “ tube or impervious stockinette (if FX Table is not used)

• Specific

– Sterile plastic adhesive U-drapes (2) (perineum and operative site)– Suture & Blades: Blades (2) # 10– Medications on field (name & purpose)– Catheters & Drains

Surgical Intervention: Instruments• General

– Basic orthopedic procedures tray• Specific

– AO femoral nail instrumentation set– Hip retractor tray– Bone holding instruments tray– Drill bits, including ¼ “ gauge– Power reamer and drill and cords, long guide wires, Extra guide pins,

screw set– Fixation device: Rods or nails (eg. Hanson-Street, Kuntscher, Rush)

or compression set and instrumentation particular to that device– 13-mm calibrated drill bit, Large reverse awl, tissue protector,

radiographic ruler, a guide rod for cannulated nails, calibrated wire guide

Surgical Intervention: Equipment• General

– Suction, ESU, Power Source for drill• Specific

– Fracture Table or leg holder (optional)Surgical Intervention: Procedure Steps

• Phases of fracture treatment– Reduction– Immobilization– Rehabilitation

Surgical Intervention: Procedure Steps• Surgeon confirms nail length with flouroscopy • Obtains AP view of proximal femur • Ruler is held along the lateral side of the thigh and placed until the top is

level with tip of greater trochanter, skin marked at this level• AP view of distal femur is taken• Proximal end of the ruler is placed at the skin mark and nail length is read

from the ruler• Surgeon makes a longitudinal incision proximal to the greater trochanter

thru the gluteus medius and maximus

• The 3.2 calibrated guidewire is placed using the power drill. It is placed in the medullary canal to a depth of 100 mm at the entry point where the nail will be placed.

• The 13-mm cannulated drill bit with tissue protector is placed over the guidewire and drilled to a depth of 100 mm. This opening will allow for insertion of 9 to 12 mm nails.

• For 13- to 15- mm nails, the broach is used instead to enlarge the opening. The drill bit is removed after the opening has been created.

• STSR assembles insertion instruments• Use of cannulated screws:• The correct connecting screw is placed into the insertion handle and

secured to the nail with the ball hexagonal screwdriver.• The driving cap is screwed onto the insertion handle. This serves as the

striking point when the hammer is used.• STSR hands the assembly to the surgeon, who manually inserts the nail

into the femoral opening as far as possible.• For cannulated nails, the nail is inserted over the guidewire, which passes

thru an opening in the side of the insertion handle• Next: the surgeon is given the hammer to drive the nail into the distal

metaphysis. The guidewire is removed.• Next: the proximal locking bolts are placed:• The standard aiming arm is attached to the insertion handle. The STSR

assembles the triple trocar assembly, 11.0/8.0 mm protection sleeve, 8.0/4.0 mm drill sleeve, and 4.00 mm trocar.

• The STSR loads the 4.0-mm calibrated drill bit onto the power drill and hands it to the surgeon, who drills thru both cortices until the drill sleeve presses against the cortex.

• The locking bolt length is read from the calibrated drill and communicated by the surgeon to the STSR.

• The STSR hands the surgeon the locking bolt, protection sleeve, and screwdriver to insert the locking bolt. This step is repeated for the second proximal locking bolt.

• Next: distal locking bolt is placed with the use of flouroscopy: C-Arm is placed to show the most distal hole in the femoral nail

• A stab incision is made over the site of the distal hole with a # 10 knife blade

• STSR hands surgeon the power drill w/4.0 mm drill bit, which is placed in the distal hole and drilled thru both cortices.

• Using a depth gauge, the surgeon measures the length of the locking bolt.

• STSR should remind surgeon to add 2-4 mm to the reading to make sure the thread of the bolt engages far into the cortex.

• STSR hands the surgeon the correct size bolt, holding sleeve, and screwdriver for insertion of the bolt

• Next: insertion instruments are removed.• STSR hands the surgeon the hexagonal screwdriver and end cap to be

threaded onto the proximal end of the nail.• STSR should be prepared to hand the surgeon the ratchet wrench to

tighten the end cap.• Surgeon closes the stab incisions, places dressings, and pt taken to PACU.

Counts• Initial: Sponges and sharps• First closing• Final closing

– Sponges– Sharps– Instruments

Dressing, Casting, Immobilizers, Etc.• Type of tape or method of securing heavy gauze pad and tape of choice—

foam or silk tape

Postoperative Care

• Destination

– PACU

• Expected prognosis (Good, Depends on Dx)

• Potential complications

– Hemorrhage

– Infection

– Other: Damage to….

– Surgical wound classification: Class I, unless traumatic injury with visible debris

Resources/ Reference Bibliography

• Alexander’s pp. 880-882

• Berry & Kohn p. 751- 755

• Goldman pp. 330-332

• Lemone & Burke pp. 1193-1203

• MAVCC Info Sheets Unit 10

• STST pp. 851-853.