Prinsip ORIF (Open Reduction Internal Fixation) Sejarah Retak Pengobatan Imobilisasi dengan cara casting, bracing, atau splinting sendi di atas dan di bawah rekahan itu digunakan untuk patah tulang yang paling panjang, dengan pengecualian femur, yang traksi adalah pengobatan utama.Dalam, patah tulang terbuka dan luka masa lalu balistik dengan fraktur tulang panjang tidak setuju untuk merawat fraktur standar karena cedera jaringan lunak yang terkait dan kesulitan dalam mencegah sepsis; sehingga, mereka biasanya mengakibatkan amputasi, khususnya selama Perang Sipil AS.

Meskipun konsep fiksasi internal tanggal kembali ke pertengahan 1800-an, Lister memperkenalkan pengurangan terbuka, fiksasi internal (ORIF) dari patella patah tulang pada 1860-an.Penggunaan pelat, sekrup, dan kabel pertama kali didokumentasikan pada tahun 1880-an dan 1890-an.Awal fiksasi bedah awalnya rumit oleh banyak hambatan, seperti infeksi, implan kurang dipahami dan teknik, alergi logam, dan pemahaman yang terbatas dari biologi dan mekanika penyembuhan fraktur. Selama tahun 1950-an, Danis dan Muller mulai menetapkan prinsip-prinsip dan teknik fiksasi internal. Selama 40 tahun terakhir, kemajuan dalam ilmu biologi dan mekanik telah memunculkan teori-teori dan teknik fiksasi kontemporer.

Perbaikan fraktur Biologi Gangguan suplai darah endosteal dan periosteal terjadi dengan trauma awal, dan mempertahankan pasokan darah yang memadai ke situs fraktur sangat penting untuk penyembuhan. Hunter menggambarkan klasik 4 tahap perbaikan tulang alami: peradangan, lembut kalus, kalus keras, dan penataan kembali. Tahap inflamasi dimulai segera setelah cedera dan muncul secara klinis sebagai pembengkakan, nyeri, eritema, dan panas. vaskular pasokan terganggu lokal di lokasi hematoma cedera menciptakan dan mendorong migrasi sel inflamasi, yang merangsang angiogenesis dan proliferasi sel. Setelah tahap awal inflamasi, tahap kalus lunak dimulai dengan suatu infiltrasi dari jaringan berserat dan sekitarnya kondroblas situs fraktur. Penggantian hematoma oleh jaringan struktural menambahkan stabilitas ke situs fraktur.

Soft kalus ini kemudian diubah menjadi tulang kaku, tahap kalus keras, oleh osifikasi enchondral dan pembentukan tulang intramembranous. Setelah fraktur telah bersatu, proses renovasi dimulai. tulang berserat pada akhirnya digantikan oleh tulang pipih.Walaupun proses ini telah disebut tulang serikat fraktur sekunder atau perbaikan tidak langsung, ini adalah cara alami dan diharapkan menyembuhkan patah tulang. Fraktur dengan kurang dari pengurangan anatomi dan kurang kaku fiksasi (yaitu, orang-orang dengan celah besar dan strain rendah melalui fixator eksternal, casting, dan intramedulla [IM] dipaku) menyembuhkan dengan pembentukan berperasaan atau penyembuhan sekunder dengan kemajuan melalui beberapa jenis jaringan yang berbeda dan akhirnya renovasi.

pengurangan Anatomi dan stabilisasi fraktur mutlak dengan fiksasi internal mengubah biologi penyembuhan fraktur dengan strain berkurang (gaya elongasi) pada penyembuhan jaringan patah di situs. Absolute stabilitas tanpa kesenjangan fraktur (misalnya, melalui ORIF menggunakan kompresi interfragmental dan pelapisan) menyajikan strain rendah dan hasil dalam penyembuhan primer (kerucut memotong) tanpa produksi kalus. Dalam model ini, kepala pemotong dari osteons mencapai fraktur dan salib itu di mana tulang-ke-tulang kontak ada. Hal ini menghasilkan serikat oleh interdigitation osteons ini baru dibentuk menjembatani jurang. Celah kecil antara fragmen mengisi dengan tulang bermembran, yang remodels ke tulang kortikal selama strain diterapkan pada jaringan tersebut tidak menyebabkan gangguan berlebihan dan mengembangkan jaringan fibrosa (serikat buruh). Metode penyembuhan tulang dikenal sebagai penyembuhan tulang langsung atau serikat tulang primer. Pada dasarnya, proses renovasi tulang memungkinkan tulang untuk menanggapi tekanan untuk yang mempengaruhinya.

Berdasarkan lingkungan mekanik patah seperti didikte oleh pilihan bedah fiksasi internal dan pola fraktur, 2 pola stabilitas dapat hasil yang menentukan jenis penyembuhan tulang yang akan terjadi. Absolute stabilitas (yaitu, tidak ada gerakan antara fragmen fraktur) hasil dalam penyembuhan tulang langsung atau primer (Renovasi). Relatif stabilitas (yaitu, sejumlah fragmen gerakan) dengan serikat pekerja menyembuhkan tulang sekunder atau tidak langsung.

Pins and wires Pin dan kabel

kawat Kirschner (K-kabel, 0,6-3,0 mm) dan pin Steinmann (3-6 mm) memiliki berbagai penggunaan, dari traksi skeletal untuk fiksasi fraktur sementara dan definitif. Ketahanan terhadap lentur dengan kawat adalah minimal, sehingga mereka biasanya dilengkapi dengan metode stabilisasi lain bila digunakan untuk fiksasi fraktur, tetapi paling sering, kabel yang digunakan sebagai fiksasi sementara sebelum fiksasi definitif dengan perangkat yang lebih kuat. traksi skeletal dengan K-kawat adalah mungkin dengan penggunaan tensioner K-kawat, yang, dengan aplikasi, menegang kawat dan memungkinkan untuk menahan beban lentur.

K-kabel dan pin Steinmann dapat memberikan fiksasi sementara untuk rekonstruksi patah sementara tulang minimal dan menimbulkan kerusakan jaringan lunak dan meninggalkan ruang untuk penempatan perangkat keras tambahan. penempatan pin Perencanaan ini penting untuk menghindari perangkat fiksasi akhirnya permanen, dan jika mungkin, pin harus ditempatkan sejajar dengan sekrup yang digunakan untuk kompresi fraktur.Tergantung pada diameter, pin juga dapat digunakan sebagai guidewires untuk fiksasi sekrup cannulated.

Pilihan fiksasi permanen termasuk patah tulang di mana muat minimal atau stabilisasi dilindungi dengan perangkat lain, seperti fixators eksternal, piring, dan kawat gigi. Pin atau kawat fiksasi sering digunakan untuk fraktur falang, metakarpal, metatarsal, humeri proksimal, dan pergelangan tangan. . K-kawat kawat umumnya suplemen ketegangan-band konstruksi di olekranon, patella, dan patah tulang maleolus medial.

K-kawat dapat sepenuhnya berulir atau nonthreaded dan baik diamond atau poin trocar yang sederhana dalam desain dan memiliki kemampuan terbatas untuk memotong tulang keras, sebuah proses yang dapat menyebabkan overheating. Untuk alasan ini, mereka harus dimasukkan perlahan-lahan saat peralatan listrik digunakan, untuk menghindari nekrosis termal. penguat Gambar sering digunakan untuk penentuan posisi optimal fiksasi, terutama dengan penyisipan perkutan dikombinasikan dengan teknik pengurangan tertutup. Mungkin pin poin di kedua ujungnya, memfasilitasi teknik fiksasi antegrade-mundur, namun, mereka adalah potensi bahaya dan harus digunakan dengan hati-hati.

pin Steinmann lebih besar, mungkin ulir atau unthreaded, dan saat ini digunakan terutama untuk traksi tulang panjang dalam hubungannya dengan sanggurdi traksi Bhler.Awal teknik pengobatan fraktur terdiri dari pin untuk traksi tulang dan penggabungan ke dalam gips itu penuh dengan infeksi pin, melonggarkan, dan hilangnya pengurangan. Teknik ini telah diganti dengan yang lebih canggih perangkat fiksasi eksternal, metode fiksasi internal, dan plating invasif minimal dan perangkat IM.

Sekrup cannulated Guidewires untuk dipekerjakan di kali untuk fiksasi definitif, karena mereka tersembuhkan ulir, yang memungkinkan untuk fiksasi pada korteks berlawanan.Contoh ini akan menjadi pengurangan tertutup dan teknik perkutan pinning untuk fraktur humerus proksimal.

Screws Sekrup

sekrup Bone adalah bagian dasar dari fiksasi internal modern. Mereka dapat digunakan secara terpisah atau dalam kombinasi dengan jenis tertentu implan. TRancangan umum sekrup (lihat Gambar 1-2 ) terdiri dari tip, poros, benang, dan kepala. Tip sekrup putaran membutuhkan pretapping, sedangkan ujung sekrup bergalur self-tapping. Poros ulir terletak antara kepala dan bagian dari sekrup Thread. T Benang sekrup didefinisikan oleh perusahaan besar atau di luar (diameter benang) dan minor atau akar (diameter batang) diameter, pitch, memimpin, dan jumlah benang. The distance between adjacent threads is the pitch. Jarak antara benang yang berdekatan adalah lapangan.

PengobatanTerapi Medis

Tujuan umum dari manajemen fraktur awal adalah untuk mengendalikan perdarahan, memberikan penghilang rasa sakit, mencegah cedera reperfusi iskemia-, dan menghapus sumber potensial kontaminasi (benda asing dan jaringan nonviable). Setelah ini dilakukan, fraktur harus dikurangi dan pengurangan harus dipertahankan, yang akan mengoptimalkan kondisi untuk serikat patah tulang dan meminimalkan komplikasi potensial.

Tujuan dalam mengelola patah tulang adalah untuk memastikan bahwa segmen anggota badan yang terlibat, ketika sembuh, telah kembali berfungsi maksimal mungkin. Hal ini dilakukan dengan mendapatkan dan kemudian mempertahankan pengurangan fraktur dengan teknik imobilisasi yang memungkinkan untuk menyembuhkan patah dan, pada saat yang sama, menyediakan pasien dengan aftercare fungsional. Entah berarti nonoperative atau bedah dapat digunakan.

Nonoperative (tertutup) terapi terdiri dari casting dan traksi (kulit dan traksi tulang)CastingClosed reduction should be performed initially for any fracture that is displaced, shortened, or angulated. This is achieved by applying traction to the long axis of the injured limb and then reversing the mechanism of injury/fracture, followed by subsequent immobilization through casting or splinting. Splints and casts can be made from fiberglass or plaster of Paris. Barriers to accomplishing reduction include soft-tissue interposition and hematoma formation that create tension in the soft tissues.Closed reduction is contraindicated under the following conditions29 : Undisplaced fractures If displacement exists but is not relevant (eg, humeral shaft fracture) If reduction is impossible (severely comminuted fracture) If the reduction, when achieved, cannot be maintained If the fracture has been produced by traction forces (eg, displaced patellar fracture)TractionFor hundreds of years, traction has been used for the management of fractures and dislocations that are not able to be treated by casting. With the advancement of orthopedic implant technology and operative techniques, traction is rarely used for definitive fracture/dislocation management. Two types of traction exist: skin traction and skeletal traction.In skin traction, traction tapes are attached to the skin of the limb segment that is below the fracture. When applying skin traction, or Buck traction, usually 10% of the patient's body weight (up to a maximum of 10 lb) is recommended.40 At weights greater than 10 lb, superficial skin layers are disrupted and irritated. Because most of the forces created by skin traction are lost and dissipated in the soft-tissue structures, skin traction is rarely used as definitive therapy in adults; rather, it is commonly used as a temporary measure until definitive therapy is achieved.

In skeletal traction, a pin (eg, Steinmann pin) is placed through a bone distal to the fracture. Weights are applied to this pin, and the patient is placed in an apparatus to facilitate traction and nursing care. Skeletal traction is most commonly used in femur fractures: A pin is placed in the distal femur (see image below) or proximal tibia 1-2 cm posterior to the tibial tuberosity. Once the pin is placed, a Thomas splint is used to achieve balanced suspension.

Femur fracture managed with skeletal traction and use of a Steinmann pin in the distal femur.

Femur fracture managed with skeletal traction and use of a Steinmann pin in the distal femur.

Surgical TherapyIn 1958, the Association for the Study of Internal Fixation (ASIF) created 4 treatment goals for surgical fracture management.12 To date, these goals have not changed and are as follows:1. Anatomic reduction of the fracture fragments: For the diaphysis, anatomic alignment ensuring that length, angulation, and rotation are corrected is required, whereas intra-articular fractures demand an anatomic reduction of all fragments.2. Stable internal fixation to fulfill biomechanical demands3. Preservation of blood supply to the injured area of the extremity4. Active, pain-free mobilization of adjacent muscles and joints to prevent the development of fracture diseaseOpen reduction and internal fixation (ORIF)The objectives of ORIF include adequately exposing the fracture site and obtaining a reduction of the fracture. Once a reduction is achieved, it must be stabilized and maintained.Kirschner wiresKirschner wires, or K-wires, are commonly used for temporary and definitive treatment of fractures. However, K-wires resist only changes in alignment; They do not resist rotation, and they have poor resistance to torque and bending forces. K-wires are commonly used as adjunctive fixation for screws or plates and screws that involve fractures around joints.When K-wires are used as the sole form of fixation, casting or splinting is used in conjunction. The wires can be placed percutaneously or through a mini-open mechanism. As stated by Canale, K-wire fixation " is adequate for small fragments in metaphyseal and epiphyseal regions, especially in fractures of the distal foot, wrist, and hand, such as Colles fractures, and in displaced metacarpal and phalangeal fractures after closed reduction."14 K-wires are also commonly used as adjunctive therapy for many fractures, including patellar fractures, proximal humerus fractures, olecranon fractures, and calcaneus fractures.Plates and screwsPlates and screws are commonly used in the management of articular fractures. This use demands an anatomic reduction of the fracture fragments and allows for early ROM of the injured extremity. Plates provide strength and stability to neutralize the forces on the injured limb for functional postoperative aftercare (see images below).

Preoperative radiographs showing a type B ankle fracture.[ CLOSE WINDOW ]

Preoperative radiographs showing a type B ankle fracture.

Ankle fracture radiograph after open reduction and internal fixation.[ CLOSE WINDOW ]

Ankle fracture radiograph after open reduction and internal fixation.

Plate designs vary, depending on the anatomic region and size of the bone the plate is used for. All plates should be applied with minimal stripping of the soft tissue.Five main plate designs exist12 : Buttress (antiglide) plates Compression plates Protection plates Tension band plate Bridge platesButtress plates counteract the compression and shear forces that commonly occur with fractures that involve the metaphysis and epiphysis. These plates are commonly used with interfragmentary screw fixation. The buttress plate is always fixed to the larger main fracture fragment but does not necessarily require fixation through the smaller fragment, because the plate buttresses the small fragment into the larger fragment. To achieve this function requires appropriate plate contouring for adequate fixation and support.Compression plates counteract bending, shear, and torsional forces by providing compression across the fracture site via the eccentrically loaded holes in the plate. Compression plates are commonly used in the long bones, especially the fibula, radius, and ulna, and in nonunion or malunion surgery.Protection plates are used in combination with interfragmentary screw fixation. The interfragmentary compression screws provide compression at the fracture site. This plate function neutralizes bending, shear, and torsional forces on the lag screw fixation, as well as increases the stability of the construct. Protection plates are commonly used for fractures involving the fibula, radius, ulna, and humerus.Bridge plates are useful in the management of multifragmented diaphyseal and metaphyseal fractures. Achieving adequate reduction and stability without disrupting the soft-tissue attachments to the bone fragments may be difficult and requires skill in the use of indirect reduction techniques.A tension band plate technique converts tension forces into compressive forces, thereby providing absolute stability. An example of this technique is when a tension band plate is used for an oblique olecranon fracture.

A locking plate acts like an internal fixator.41 There is no need to anatomically contour the plate onto the bone, thus reducing bone necrosis and allowing for a minimally invasive technique. Locking screws directly anchor and lock onto the plate, thereby providing angular and axial stability. These screws are incapable of toggling, sliding, or becoming dislodged, thus reducing the possibility of a secondary loss of reduction, as well as eliminating the possibility of intraoperative overtightening of the screws. The locking plate is indicated for osteoporotic fractures, for short and metaphyseal segment fractures, and for bridging comminuted areas. These plates are also appropriate for metaphyseal areas where subsidence may occur or prostheses are involved.42 Intramedullary nailsThe use of intramedullary nails over the past half century has been widely accepted. These nails operate like an internal splint that shares the load with the bone and can be flexible or rigid, locked or unlocked, and reamed or unreamed.

Locked intramedullary nails provide relative stability to maintain bone alignment and length and to limit rotation. Ideally, the intramedullary nail allows for compressive forces at the fracture site, which stimulates bone healing. Intramedullary nails are commonly used for femoral and tibial diaphyseal fractures (see image below) and, occasionally, humeral diaphyseal fractures. The advantages of intramedullary nails include minimally invasive procedures, early postoperative ambulation, and early ROM.

Midshaft femur fracture managed with open reduction and internal fixation performed with use of an intramedullary nail.[ CLOSE WINDOW ]

Midshaft femur fracture managed with open reduction and internal fixation performed with use of an intramedullary nail.

External fixationIn 1907, European physician Albin Lambotte developed the technique of external fixation for the management of fractures.43 External fixation provides fracture stabilization at a distance from the fracture sitewithout interfering with the soft-tissue structures that are near the fracture. This technique not only provides stability for the extremity and maintains bone length, alignment, and rotation without requiring casting, but it also allows for inspection of the soft-tissue structures that are vital for fracture healing.Indications for external fixation (temporarily or as definitive care) are as follows: Open fractures that have significant soft-tissue disruption (eg, type II or III open fractures) Soft-tissue injury (eg, burns) Pelvic fractures (see image below)

Pelvic fracture managed with external fixation.[ CLOSE WINDOW ]

Pelvic fracture managed with external fixation. Severely comminuted and unstable fractures Fractures that are associated with bony deficits Limb-lengthening procedures (see image below)

Ilizarov fixator.[ CLOSE WINDOW ]

Ilizarov fixator. Fractures associated with infection or nonunionThe polytrauma patient: Early total care vs damage-control orthopedics

Soft-tissue injuries and potential open wounds are inflammatory foci that behave much like an endocrine organ by releasing mediators and cytokines both locally and systemically, leading to a systemic inflammatory response. Further surgical insult (ie, femoral nailing for a femur fracture) can aggravate this mediator response, resulting in a further immunologic response, known as the "second hit" phenomenon.44 This, in turn, may exacerbate the patients clinical status and can lead to further morbidity as well as mortality.

Early total care is important; several studies have documented the advantages of early fixation of long-bone fractures, especially femur fractures.44,45 These advantages include early mobilization with improved pulmonary function, shorter time on a ventilator, reduced morbidity and mortality, and easier nursing care.

Early definitive surgical care should only be considered in stable patients who have been adequately resuscitated, whereas those who are unstable should undergo damage-control orthopedics (DCO). This concept refers to an early debridement of surgical wounds, with temporary external fixation of long-bone fractures and dislocations. The pins should be placed outside the zone of injury and should avoid sites of planned future incisions.

Damage-control surgery should be considered in patients who are hemodynamically unstable or those with hypothermia, an abnormal base deficit, or blood-clotting abnormalities/pulmonary complications. No single test is available yet to determine which patients are at risk for a major systemic inflammatory response following trauma.12 Preoperative DetailsDetecting and adequately addressing all other injuries, including comorbidities and preexisting medical conditions, is essential. If patients have multiple medical problems, consult an internal medicine specialist before performing any operative intervention.Prophylactic antibiotics (cefazolin, 1 g) should be administered. If the patient is allergic to penicillin, clindamycin can be administered. Patients with open fractures should be given appropriate antibiotic prophylaxis (see Management of open fractures).Intraoperative DetailsC-arm fluoroscopy is valuable and often necessary in the operating room to provide for and to evaluate the results of internal fixationbefore the patient leaves the surgical suite. Alternatively, portable radiography can be used if multiple radiographic images are not anticipated to be necessary.Postoperative DetailsPostoperatively, appropriate wound care and suture or staple removalis performed as directed by the physician. Depending on the type of fracture sustained by the patient, he or she may be immobilized in a splint or cast. Postoperatively, patients are examined at follow-up visits, usually within 1-2 weeks after their surgery, and periodically until the fracture has healed and functioning has returned. Weight-bearing status is dependent upon stability of the fracture or osteosynthesis construct.Follow-upConsultation with rehabilitation specialists can be useful in helping inpatients to ambulate with the aid of crutches or a walker and, ultimately, to decrease postoperative morbidity and expedite patients' discharge planning. Rehabilitationservices can be invaluable for many individuals in regaining their ROM and strength once the fracture has healed.The need for physiotherapy depends on the nature of the injury and the patient's motivation, educational level, and abilities. Physiotherapists aid in helping patients to recover from joint stiffness and to maintain and restore ROM. These therapists can provide appropriate guidance with respect to exercises and activities that aid in the patient's healing process.The timetable for follow-up visits varies, depending on the nature of the injury. All patients must be monitored closely for potential complications (see Complications). At the time of discharge after the initial care of the fracture, the patient should be made aware of all the follow-up requirements specified by the treating physician.ComplicationsComplications of casts

Complications of casts include the development of pressure ulcers, thermal burns during plaster hardening, and thrombophlebitis. The AO ASIF group commented that prolonged cast immobilization, or cast disease, can be responsible for creating circulatory disturbances, inflammation, and bone disease that result in osteoporosis, chronic edema, soft-tissue atrophy, and joint stiffness.12 These problems may be avoided by providing functional aftercare.

Complications of traction Complications of traction include the development of pressure ulcers, pulmonary/urinary infections, permanent footdrop contractures (if the foot is positioned in equinus), peroneal nerve palsy, pin tract infection, and thromboembolic events (eg, deep venous thrombosis [DVT], pulmonary embolism). These complications stem from a lack of patient mobility, muscle atrophy, weakness, and stiffness that result from a fracture.Complications of external fixation Complications of external fixation include pin tract infection, pin loosening or breakage, interference with joint motion, neurovascular damage when pins are placed, malalignment caused by poor placement of the fixator, delayed union, and malunion.Complications of fractures and surgical management Complications of fractures and surgical management include neurologic and/or vascular injury, CS, infection, thromboembolic events, avascular necrosis, and posttraumatic arthritis. Neurologic and vascular injury Neurologic and vascular injuries can occur in any fracture and are more likely in cases with increasing fracture deformity. Peripheral nerve injury is suspected if a patient experiences motor or sensory deficiencies. Management of neurologic injury involves immediate reduction of the fracture and possible nerve exploration, with subsequent follow-up to assess whether or not neurologic function returns. Arterial injury is suspected if the patients pulses are diminished or absent in the affected limb. If there is evidence of arterial injury, immediate realignment of the limb is performed, and the pulses and perfusion are checked again. If the pulses do not return, angiography is indicated, with concomitant involvement of vascular surgeons. Arterial injuries are especially prevalent in cases of knee dislocations, proximal tibial fractures, and supracondylar humerus fractures. Compartment syndrome CS, initially reported by von Volkmann in 1872,46 is a potentially limb- and life-threatening condition. CS occurs when tissue pressure exceeds perfusion pressure in a closed anatomic space. This condition can occur in any compartment, such as the hand, forearm, upper arm, abdomen, buttock, thigh, and leg, but it most commonly occurs in the anterior compartment of the leg. The natural history of CS involves tissue necrosis, functional limb impairment, and renal failure secondary to rhabdomyolysis, which may lead to death if untreated. CS can occur after traumatic injury to an extremity, after ischemia (eg, after hemorrhage or thromboembolic event), and, in rare cases, with exercise. Clinically, patients experience pain that is out of proportion to the degree of injury and pain with passive stretching of the involved muscles, as well as pallor, paresthesia, and poikilothermia. Pulselessness, however, is a late finding of CS. Compartment pressures can be objectively measured. Intracompartmental pressures greater than 30 mm Hg or a diastolic blood pressure minus intracompartmental pressure that is greater than 30 mm Hg is an indication for surgical intervention. Definitive therapy consists of surgical fasciotomy of the affected compartments. Infection: Complications of surgical intervention include local infection in the form of cellulitis or osteomyelitis and systemic infection in the form of sepsis. Early recognition of a local infection may prevent the development of sepsis and, thus, decrease patient morbidity. The most common pathogen is Staphylococcus aureus. Other pathogens include group A streptococci, coagulase-negative staphylococci, and enterococci. Appropriate antibiotics should be administered if an infection is suspected. Serial C-reactive protein and erythrocyte sedimentation rate measurements should be obtained and may be used to assess treatment response to antibiotics. If infection cannot be eradicated with antibiotics, I&D of the surgical wound may be necessary, with removal of orthopedic hardware, but only if the hardware is not performing its role. Thromboembolic events: Thromboembolic events may occur after orthopedic trauma with prolonged patient immobilization. Patients with significant fractures who are immobile for 10 days or longer have a 67% incidence of thrombosis.14 Prophylaxis is effective in decreasing the incidence of DVT in the immobilized extremity,47 but it has not been shown to be effective in decreasing the incidence of fatal pulmonary embolism. In addition, prophylactic anticoagulation carries with it its own set of serious and life-threatening complications, such as bleeding. Before using DVT prophylaxis, the risks and benefits of such therapy must be thoroughly explained to the patient. Avascular necrosis: Avascular necrosis (AVN) is caused by disruption of the blood supply to a region of bone. Revascularization of the avascular bone can lead to nonunion, bone collapse, or degenerative changes. AVN is most commonly associated with fractures of the femoral head and neck, scaphoid, talar neck and body, and proximal humerus. Posttraumatic arthritis: Posttraumatic arthritis is common in intra-articular fractures, particularly in intra-articular fractures that are not adequately reduced. Management of posttraumatic arthritis depends on the joint involved and can include arthroscopic debridement, osteotomy, arthroplasty, or arthrodesis. Complications of bone healing Delayed union is defined as a fracture that has not healed after a reasonable time period (the time in which it was expected to heal) has passed. Nonunion is defined as a fracture with no possible chance of healing, no matter how long the initial treatment is carried out. Risk factors for nonunion are summarized in the Table. Management consists of treatment of the cause of the nonunion and can include eradication of infection,48 stabilization of the fracture, removal of interfering soft tissues, bone grafting,49 and medical/nutritional modifications of comorbidities. Malunion is defined as healing of bone in an unacceptable position in any plane, which leads to a disability for the patient, cosmesis, or the potential for the development of posttraumatic arthritis. Treatment involves surgical correction of the anatomic abnormality.

O.R.I.F.By Jonathan Cluett, M.D., About.com GuideUpdated December 06, 2008About.com Health's Disease and Condition content is reviewed by the Medical Review Board See More About: broken bones fracture treatment planning for surgery

Treatment of an intertrochanteric hip fracture with a metal plate and screws.X-Ray Image Jonathan Cluett, MDDefinition: O.R.I.F. is an abbreviation for Open Reduction Internal Fixation. Open reduction internal fixation is a method of surgically repairing a fractured bone. Generally, this involves either the use of plates and screws or an intramedullary (IM) rod to stabilize the bone. If you are having a broken bone treated by ORIF, you will be taken to the operating room, given anesthesia so that you will not feel the surgery, and have your bones repaired by an orthopedic surgeon. Also Known As: Open Reduction Internal Fixation, Operative Treatment, Open Treatment

Reduksi terbuka dengan fiksasi interna (ORIF=open reduction and internal fixation) diindikasikan pada kegagalan reduksi tertutup, bila dibutuhkan reduksi dan fiksasi yang lebih baik dibanding yang bisa dicapai dengan reduksi tertutup misalnya pada fraktur intra-artikuler, pada fraktur terbuka, keadaan yang membutuhkan mobilisasi cepat, bila diperlukan fiksasi rigid, dan sebagainya. Sedangkan reduksi terbuka dengan fiksasi eksterna (OREF=open reduction and external fixation) dilakukan pada fraktur terbuka dengan kerusakan jaringan lunak yang membutuhkan perbaikan vaskuler, fasiotomi, flap jaringan lunak, atau debridemen ulang. Fiksasi eksternal juga dilakukan pada politrauma, fraktur pada anak untuk menghindari fiksasi pin pada daerah lempeng pertumbuhan, fraktur dengan infeksi atau pseudoarthrosis, fraktur kominutif yang hebat, fraktur yang disertai defisit tulang, prosedur pemanjangan ekstremitas, dan pada keadaan malunion dan nonunion setelah fiksasi internal. Alat-alat yang digunakan berupa pin dan wire (Schanz screw, Steinman pin, Kirschner wire) yang kemudian dihubungkan dengan batang untuk fiksasi. Ada 3 macam fiksasi eksternal yaitu monolateral/standar uniplanar, sirkuler/ring (Ilizarov dan Taylor Spatial Frame), dan fiksator hybrid. Keuntungan fiksasi eksternal adalah memberi fiksasi yang rigid sehingga tindakan seperti skin graft/flap, bone graft, dan irigasi dapat dilakukan tanpa mengganggu posisi fraktur. Selain itu, memungkinkan pengamatan langsung mengenai kondisi luka, status neurovaskular, dan viabilitas flap dalam masa penyembuhan fraktur. Kerugian tindakan ini adalah mudah terjadi infeksi, dapat terjadi fraktur saat melepas fiksator, dan kurang baik dari segi estetikPenanganan pascaoperatif meliputi perawatan luka dan pemberian antibiotik untuk mengurangi risiko infeksi, pemeriksaan radiologik serial, darah lengkap, serta rehabilitasi. Penderita diberi antibiotik spektrum luas untuk mencegah infeksi dan dilakukan kultur pus dan tes sensitivitas. Diet yang dianjurkan tinggi kalori tinggi protein untuk menunjang proses penyembuhan.Rawat luka dilakukan setiap hari disertai nekrotomi untuk membuang jaringan nekrotik yang dapat menjadi sumber infeksi. Pada kasus ini selama follow-up ditemukan tanda-tanda infeksi jaringan lunak dan tampak nekrosis pada tibia sehingga direncanakan untuk debridemen ulang dan osteotomi. Untuk pemantauan selanjutnya dilakukan pemeriksaan radiologis foto femur dan cruris setelah reduksi dan imobilisasi untuk menilai reposisi yang dilakukan berhasil atau tidak. Pemeriksaan radiologis serial sebaiknya dilakukan 6 minggu, 3 bulan, 6 bulan, dan 12 bulan sesudah operasi untuk melihat perkembangan fraktur. Selain itu dilakukan pemeriksaan darah lengkap rutin.6,7,17,18 Foto kontrol setelah operasi telah dilakukan pada kasus ini, terlihat screw dan wire terpasang baik. Hasil pemeriksaan laboratorium sesudah operasi Hb 5.1 g/dL, jadi penderita ditranfusi whole blood sampai Hb 10 g/dL. Penderita juga sudah dikonsulkan untuk rehabilitasi. Pengertian rehabilitasi adalah melakukan restorasi ke arah bentuk dan fungsi yang normal setelah suatu trauma atau penyakit. medik untuk diberi latihan-latihan secara teratur dan bertahap yang sangat penting sehingga ketiga tujuan utama penanganan fraktur bisa tercapai, yakni union (penyambungan tulang secara sempurna), sembuh secara anatomis (penampakan fisik organ anggota gerak; baik, proporsional), dan sembuh secara fungsional (tidak ada kekakuan dan hambatan lain dalam melakukan gerakan).4,5Pada fraktur terbuka derajat IIIB perlu tindakan selanjutnya untuk menutup defek akibat kerusakan jaringan lunak (otot, fasia, subkutis, dan kulit) yang hebat. Penderita direncanakan untuk dilakukan muscle flap dan skin graft. Skin graft atau tandur alih kulit adalah penutupan luka dimana kulit dipindahkan dari lokasi donor dan ditransfer ke lokasi resipien. Beda flap dan graft yaitu suplai darah flap berasal dari jaringan itu sendiri sedangkan graft tidak memiliki suplai darah sendiri jadi memerlukan suplai darah dari resipien. Terdapat banyak jenis flap antara lain kutaneus (lokal), fasiokutaneus, otot, muskulokutaneus dan free flap. Local skin flap mengandung seluruh ketebalan kulit beserta fasia superfisialnya untuk menutup defek yang kecil. Muscle flap hanya menggunakan otot untuk menutup defek, digunakan pada keadaan dimana dibutuhkan jaringan lunak dengan vaskularisasi baik yang relatif resisten terhadap infeksi, membantu penyembuhan luka, dan dapat memberi vaskularisasi yang baik untuk skin graft.19 Oleh karena terdapat sebagian tulang tibia yang nekrotik , maka direncanakan untuk dilakukan osteotomi. Setelah osteotomi perlu dilakukan bone graft (tandur alih tulang). Dikenal tiga sumber jaringan tulang yang dipakai dalam tandur alih tulang yaitu autograf (berasal dari penderita sendiri-krista iliaka, kosta, femur distal, tibia proksimal atau fibula), alograft (berasal dari orang lain), dan xenograft (berasal dari spesies lain).20Debridemen berulang adalah kunci keberhasilan penanganan fraktur terbuka. Fiksasi eksternal memberikan stabilisasi fraktur yang baik serta memungkinkan pengamatan langsung mengenai kondisi luka, status neurovaskular, dan viabilitas flap dalam masa penyembuhan fraktur. Pemberian antibiotik dan perawatan luka penting dalam pencegahan infeksi yang dapat mempengaruhi penyembuhan fraktur. Klasifikasi Gustilo merupakan indikator prognosis pada fraktur terbuka.6,9,16 Semakin tinggi derajat, semakin besar risiko infeksi dan nonunion. Akan tetapi dengan, penanganan yang tepat diharapkan dapat terjadi union serta fungsi fisiologis dapat kembali seperti semula.