Introduction Open reduction internal fixation (ORIF) is an orthopedic surgical procedure which is utilized to treat severe fractures.

It is usually done in a sterile operating environment by an orthopedic surgeon with a support team which includes an anesthesiologist to manage the patient along with scrub nurses, circulating nurses, maintenance of a sterile environment, and positioning the patient. There are two separate components to an ORIF procedure. The first is the open reduction part, which refers to using open surgery to set the bones. Open surgery may be required when a fracture is complex or there are many pieces of bone. The surgeon makes an incision in the area of the break to access the involved bone or bones, and manipulates them back into place, checking with an x-ray machine to confirm that the fracture has been fully addressed. The internal fixation involves the use of pins, plates, and screws to hold the bones in place. This is done because the bones cannot heal with casting or splinting alone. The internal fixators hold the bones together as they begin to heal. Sometimes they are simply left in place, and in other instances, they may be removed when healing is complete. Healing is monitored with the assistance of medical imaging to confirm that the bones are knitting, healing evenly, and healing correctly. Overview Open reduction and internal fixation (ORIF) is a commonly used treatment for fractures throughout the body, including the distal femur. Supracondylar nonphyseal femur fractures are rare in the pediatric population. Although the exact definition of the supracondylar region of the femur is unclear in the pediatric patient, it is often determined by measuring the width of the distal femoral physis, then using that distance to measure proximal to the physis to create a square. This region has been dubbed the supracondylar region of the femur. Various studies have described the incidence of distal femur fractures to be from 7-12%.These injuries are usually the result of direct trauma to the thigh or knee. It is very important to assess for other associated injuries when presented with a supracondylar femur fracture. Often, patients who sustain these injuries may have pathologic bone from diseases such as osteogenesis imperfect or presence of neuromuscular disease. Also, of utmost importance, with a supracondylar femur fracture in a child less than 1 year of age, the physician should be suspicious of child abuse

Anatomy and Physiology

The skeletal system comprises of 206 bones and provides four basic functions:

Support for tissues and muscle Protection for vital organs Movement through bones and attached muscles Storage for minerals and immature blood cells

1. Support Bones and cartilage that make up the skeleton are the only rigid materials in the body. The 206bones of the skeleton provide a framework and points of attachment for many of the soft tissues of the body. The five main classifications of bones are: Long (e.g. femur), Short (e.g. tarsal bones of the foot), Flat (e.g. frontal bone of the skull), Irregular (e.g. vertebrae) and Sesamoid (e.g. knee cap) 2. Protection These structures protect some of the vital tissues and functional organs of the body. Typical examples are: Skull - protects the brain Vertebrae - protects the spinal cord Thoracic cage - protects the heart and lungs

3. Movement Bones act as levers during movement and provide solid structures to which muscles are attached. The joints allow movement between bones and these movements are directly related to the type of joint and range of motion. Joints fall into one of three categories: Fixed fibrous or Synarthroses (e.g. bones of the skull), Slightly moveable or Amphiarthroses (e.g. symphysis pubis) and Freely movable or Diarthroses. Freely Movable joints comprises of four main groups: Ball and Socket (e.g. hip), Hinge (e.g. elbow), Pivot (e.g. radius and ulna) and Gliding (e.g. carpal joint of the wrist)

Two kinds of bone tissue: 1. Compact bone The hard material that makes up the shaft of long bones and the outside surface sof other bones. Compact bone consists of cylindrical units called osteons (Haversian systems). Each osteon contains concentric lamellae (layers) of hard, calcified matrix with osteocytes (bone cells) lodged in lacunae (spaces) between the lamellae. Smaller canals, or canaliculi, radiate outward from a central canal (Haversian canal), which contains blood vessels and nerve fibers. Osteocytes within an osteon are connected to each other and to the central canal by fine cellular extensions. Through these cellular extensions, nutrients and wastes are exchanged between the osteocytes and the bloodvessels. Perforating canals (Volkmann's canals) provide channels that allow the blood vessels that run through the central canals to connect to the blood vessels in the periosteum that surrounds the bone.

Spongy bone consists of thin, irregularly shaped plates called trabeculae, arranged in a lattice work network. Trabeculae are similar to osteons in that both have osteocytes in lacunae that lie between calcified lamellae. As in osteons, canaliculi present in trabeculae provide connections between osteocytes. However, since each trabecula is only a few cell layers think, each osteocyte is able to exchange nutrients with nearby blood vessels. Thus, no central canal is necessary.

Main features of a long bone: 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. 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 thecavity 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.

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 diploe. Periosteum covers the outside layer of compact bone tissue. 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.

Component parts of a synovial joint A fibrous capsule surrounds the joint and is strengthened by ligaments. The stability of these joints is dictated by the shape of articulating surfaces, their surrounding ligaments and muscles. For example, the knee is given great strength from 2 cruciate and 2 collateral ligaments.

rticular or hyaline cartilage covers and protects the ends of bones which meet to form a joint and therefore allows freedom of movement. It is a very hard, smooth material which does not repair itself when damaged.

Tendons connect muscle tissue to bone and although more elastic than ligaments, have a far greater tensile strength than muscle. Synovial membrane lines the joint cavity and covers the tendons and ligaments which pass through it. The membrane produces synovial fluid which lubricates the joints Ligaments are tough fibrous bands of tissue which connect bone to bone and help stabilise a joint, the strongest ligament in the body being situated at the front of the hip capsule, preventing excessive backward movement of the legs. Ligaments, although stronger than muscle tissue, have fewer nerve endings and less blood supply , and therefore take longer to repair when damaged. Whilst these strong fibrous bands offer great stability to a joint in preventing excessive movement, if they are stretched or torn through injury, they do not necessarily return to their former length and therefore may remain stretched, therefore offering reduced stability to that particular joint. A bursa is a small sac formed in connective tissue lined by a synovial membrane and containing a small amount of synovial fluid. It is situated between moving parts, often between tendon and bone, to prevent rubbing.

Surgical Instruments A Deaver retractor (manual) is used to retract deep abdominal or chest incisions. Available in various widths. A Richardson retractor (manual) is used to retract deep abdominal or chest incisions An Army-Navy retractor (manual) is used to retract shallow or superficial incisions. Other names: USA, US Army. A malleable or ribbon retractor (manual) is used to retract deep wounds. May be bent to various shapes. Cutting and Dissecting Instruments Straight Mayo scissors - Used to cut suture and supplies. Also known as: Suture scissors. Curved Mayo scissors - Used to cut heavy tissue (fascia, muscle, uterus, and breast). Available in regular and long sizes. Metzenbaum scissors (A) - Used to cut delicate tissue. Available in regular and long sizes.

Clamping and Occluding Instruments A hemostat is used to clamp blood vessels or tag sutures. Its jaws may be straight or curved.

Other names: crile, snap or stat. A mosquito is used to clamp small blood vessels. Its jaws may be straight or curved. A Kelly is used to clamp larger vessels and tissue. Available in short and long sizes. Other names: Rochester Pean. A burlisher is used to clamp deep blood vessels. Burlishers have two closed finger rings. Burlishers with an open finger ring are called tonsil hemostats. Other names: Schnidt tonsil forcep, Adson forcep. A right angle is used to clamp hard-to-reach vessels and to place sutures behind or around a vessel. A right angle with a suture attached is called a "tie on a passer." Other names: Mixter. A hemoclip applier with hemoclips applies metal clips onto blood vessels and ducts which will remain occluded.

Grasping and Holding Instruments Are used to hold tissue, drapes or sponges. An Allis is used to grasp tissue. Available in short and long sizes. A "Judd-Allis" holds intestinal tissue; a "heavy allis" holds breast tissue. A Babcock is used to grasp delicate tissue (intestine, fallopian tube, ovary). Available in short and long sizes. A Kocher is used to grasp heavy tissue. May also be used as a clamp. The jaws may be straight or curved. Other names: Ochsner. A Foerster sponge stick is used to grasp sponges. Other names: sponge forcep. A dissector is used to hold a peanut. A Backhaus towel clip is used to hold towels and drapes in place. Other name: towel clip. Pick ups, thumb forceps and tissue forceps are available in various lengths, with or without teeth, and smooth or serrated jaws. Russian tissue forceps are used to grasp tissue. DeBakey forceps are used to grasp delicate tissue, particularly in cardiovascular surgery.

Adson pick ups are either smooth: used to grasp delicate tissue; or with teeth: used to grasp the skin. Other names: Dura forceps. Bone file- smoothing bone Parkes rasp-cutting bone Mini-Liston bone cutting forceps- cutting bone

SURGICAL PROCEDURE

Pre-operative antibiotics, +/- interscalene block General endotracheal anesthesia Modified beach-chair position. All bony prominences well padded. Examination under anesthesia of affected shoulder. Prep and drape in standard sterile fashion. Have a well-padded height adjustable Mayo stand or shoulder positioner available to hold the arm during the case. Deltopectoral incision from just medial to AC joint to just lateral to the proximal edge of the biceps muscle belly. Identify deltopectoral interval (interval can be found by palpating medial edge of deltoid insertion into clavicle or finding fat layer in interval surrounding cephalic vein.) Preserve cephalic vein by ligating any branches to deltoid and taking the cephalic vein and its surrounding tissues medially. Incise clavipectoral fascia adjacent to the conjoined tendon up to the coracoacromial ligament. Release upper 1/3 of pectoralis tendon if needed for exposure. Ensure the anterior humeral circumflex vessels are protected and preserved. Identify the long head of the biceps tendon and ensure that it is preserved thoughtout the case. Identify the fracture fragments. The key to identifying the various components is the long head of the biceps tendon. The lesser tuberosity and subacapularis tendon are medial to the long head tendon. The greater tuberosity and supraspinatus are lateral. Generally splinting the rotator interval between the tuberosities provides adequate exposure to the proximal humerus. Mobilize the tuberosity fragments. Tag them with suture as needed. Gently identify the humeral head fragment, being careful to avoid any neurovascular injury. Confirm that the head fragment is not split or impacted and the cartilage is intact. Reduce that fragments into anatomic position. The humeral head can usually be reduced by externally rotation the arm and gentle pushing and rotating the head into its anatomic position.

The fragments are then anatomically reduced and temporarily fixed using k-wires or suture. Placing a non-absorbable #5 suture in a figure-8 fashion is often beneficial to maintain the reduction during plate placement and also serves additional fixation. Place a proximal humeral plate as selected in the preoperative plan using AO technique and as instructed in the manuctures technique guide. Pack allograft bone chips / demineralized bone graft as needed to improve healing. Repair the rotator interval. Irrigate. Close in layers.

Tasks and Responsibilities of the Nurse

SCRUB NURSE Pre-operative Responsibilities 1. Assist with the preparation of the room for the designated surgical procedure, including gathering supplies for the procedure. 2. Scrub, dry hands, gown, and glove. R. To promote sterility. 3. Assist person scrubbed in first position with: a. Setting up back table, mayo, and basins b. Arrangement of instruments c. Preparation of suture and needles d. Preparation and counting sponges e. Arrangement and preparation of other necessary items f. Gowning and gloving surgeon and assistants g. Assist with draping h. Arrangement of sterile field Intra-operative Responsibilities 1. During the procedure, progress from double-scrubbed position. Train self to keep eyes on field, and learn steps of procedure.

2. Begin developing methods of anticipating needs of surgeon and assistant. 3. After closing the skin: a. Assist with care of instruments and counts if necessary b. Care of specimen c. Assist with dressing of wound Post-operative Responsibilities 1. After the completion of the Procedure: a. Assist with the gathering of all materials used during the procedure b. Discard items as necessary being careful to discard sharp items in designated places c. Return all items to respective area d. Assist with cleaning of room e. Clean the materials used properly and arrange them after drying 2. Perform any duties which will speed up the surgical procedure to follow in that room. CIRCULATING NURSE Pre-operative Responsibilities 1. Care for the patient before surgery by: a. Greeting patient and assist nurse with identification b. Checking patient's chart, preparation, etc. 2. Prepare the room by: a. Obtaining instruments, supplies, and equipment for the designated operative procedure b. Opening unsterile supplies c. Assisting in gowning d. Observing breaks in sterile technique

e. Assisting anesthesiologist as necesssary f. Assisting with skin preparation and positioning g. Assisting with forming of the sterile field 3. Count the instruments, sharps and sponges before the procedure and confirm with scrub nurse. Intra-operative Responsibilities 1. During the Procedure: a. Remain in room and dispense materials as necessary b. Observe procedure as closely as possible c. Begin establishing method of anticipating needs of surgical team d. Care of specimen as indicated e. Care of operative records as indicated 2. Before the closing of the organ or peritoneum, count all instruments, sharps and sponges and confirm with scrub nurse. 3. Inform the surgeon and assistant surgeon of a report of the instruments. Post-operative Responsibilities 1. Properly document all the necessary information on the patients chart. 2. Assist in the cleaning of the Operation Room as necessary.

Prior to operation:

A careful history and physical examination are performed to exclude the possibility of other gastrointestinal diseases that may mimic biliary colic, such as peptic ulcer disease or reflux esophagitis.

When the diagnosis of acute cholecystitis is suspected the patient should receive nothing by mouth; however, nasogastric suction usually can be reserved for patients who are vomiting or have ileus and abdominal distention.

Intravenous fluids are given to correct volume depletion and any electrolyte imbalances are measured and corrected. Monitor and regulate IVFs

The nurse instructs the patient about the need to avoid smoking to enhance pulmonary recovery postoperatively and avoid respiratory complications. It is also important to instruct the patient to avoid the use of aspirin and other agents that can alter coagulation and other biochemical process

On of the most important responsibility of the nurse is to let the patient sign an informed consent regarding the surgery.

The patient is given anaesthesia prior to surgery and the patient is under NPO.

During the operation

Monitoring the vital signs of the patient is one of the responsibilities of the nurse during the surgery.

Assisting the anesthesia care provider during induction of general anesthesia Ensuring adequate oxygenation and hydration

After the operation

After recovery, the nurse places the patient in the low fowlers position. IV fluids may be given and nasogastric suction may be given to relieve abdominal distention. Water and other fluids are given in about 24hours, and soft diet is started when bowel sounds returned.

Placing warm blankets on the patient to enhance comfort and preserve the patient's body temperature

Assessing the patient's vital signs, oxygen saturation level, level of consciousness, circulation, pain, IV site, fluid rate, and hydration status, as well as the status of the surgical site and dressing and all related monitoring equipment

The nurse helps in relieving the pain by instructing the patient regarding proper positioning.

The nurse helps in improving the respiratory status by instructing the patient regarding deep breathing exercises.

The nurse also provides skin care like cleaning the incision part and providing clean dressing following a strict aseptic technique

The nurse instructs the patient about the medications that are prescribed by the physician

Discussing recommended follow-up management with the physician and the surgeon

Open Reduction Internal Fixation

Submitted by: Ahmabelle Mara D. Abella Submitted to: Emily L. Lagura RN, MN