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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.

Pengobatan
Terapi 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)
Casting
Closed 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 conditions
29
:
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)
Traction
For 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 Therapy
In 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 demands
3. Preservation of blood supply to the injured area of the extremity
4. Active, pain-free mobilization of adjacent muscles and joints to prevent the development of
fracture disease
Open 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 wires
Kirschner 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 screws
Plates 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 exist
12
:
Buttress (antiglide) plates
Compression plates
Protection plates
Tension band plate
Bridge plates
Buttress 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 nails
The 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 fixation
In 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 nonunion
The 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 Details
Detecting 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 Details
C-arm fluoroscopy is valuable and often necessary in the operating room to provide for and to
evaluate the results of internal fixation before the patient leaves the surgical suite. Alternatively,
portable radiography can be used if multiple radiographic images are not anticipated to be
necessary.
Postoperative Details
Postoperatively, appropriate wound care and suture or staple removal is 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-up
Consultation 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. Rehabilitation services 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.
Complications
Complications 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
o 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.
o 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
o 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.
o 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.
o 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
o 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.
o 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.
o 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 Guide
Updated December 06, 2008
About.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, MD
Definition: 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).
4,5
Pada 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).
20
Debridemen 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.