I.

INTRODUCTION
What is ORIF Surgery?
An open reduction internal fixation (ORIF) refers to a surgical procedure
to fix a severe bone fracture, or break. Open reduction means surgery is
needed to realign the bone fracture into the normal position.
Internal fixation refers to the steel rods, screws, or plates used to keep the
bone fracture stable in order to heal the right way and to help prevent
infection.
Open reduction internal fixation can also refer to the surgical repair of a joint,
such as a hip or knee replacement.
The surgical procedure is performed by a doctor who specializes in
orthopedics, which is a branch of medicine concerning the musculoskeletal
structure of the body. Under general anesthesia, an incision is made at the
site of the break or injury, and the fracture is carefully re-aligned or the joint
replaced. The hardware is installed, and the incision is closed with staples or
stitches. The steel rods, screws, or plates can be permanent, or temporary
and removed when healing takes place.
Once the open reduction internal fixation is performed, a cast is usually
applied. In the case of an ankle fracture, for instance, the first cast is a nonweight bearing cast, and crutches can be used to help keep weight off the
healing bones. Later, when the healing has progressed, this cast will be
replaced with one that can bear weight. Eventually, after a period of some
weeks, the cast will be removed entirely.

II. ANATOMY AND LOCATION

The femur is the only bone in the thigh. It is classed as a long bone, and is in
fact the longest bone in the body. The main function of the femur is to
transmit forces from the tibia to the hip joint.
It acts as the place of origin and attachment of many muscles and ligaments
so we shall split it into three areas; proximal, shaft and distal.
Proximal
The proximal area of the femur forms the hip joint with the pelvis. It consists
of a head and neck, and two bony processes called trochanters. There are
also two bony ridges connecting the two trochanters
Head Has a smooth surface with a depression on the medial surface this
is for the attachment of the ligament of the head. At the hip joint, it
articulates with the acetabulum of the pelvis.
Neck Connects the head of the femur with the shaft. It is cylindrical,
projecting in a superior and medial direction this angle of projection allows
for an increased range of movement at the hip joint
Greater trochanter this is a projection of bone that originates from the
anterior shaft, just lateral to where the neck joins. It is angled superiorly and
posteriorly, and can be found on both the anterior and posterior sides of the
femur. It is the site of attachment of the abductor and lateral rotator muscles
of the leg

Lesser trochanter much smaller than the greater trochanter. It projects

from the posteromedial side of the side, just inferior to the neck-shaft
junction. The psoas major and iliacus muscles attach here.
Intertrochanteric line a ridge of bone that runs in a inferomedial
direction on the anterior surface of the femur, connecting the two
trochanters together. The iliofemoral ligament attaches here a very strong
ligament of the hip joint. After it passes the lesser trochanter on the posterior
surface, it is known as the pectineal line.
Intertrochanteric crest similar to the intertrochanteric line, this is a ridge
of bone that connects the two trochanters together. It is located on the
posterior surface of the femur. There is a rounded tubercle on its superior
half, this is called the quadrate tubercle, which is where the quadratus
femoris attaches.

TeachMeAnatomy.com

Fig 1.1 Bony landmarks of the

posterior, proximal femur
Fig 1.0 Bony landmarks of the anterior,
proximal femur.

Clinical Relevance: Proximal Femur Fractures

Fractures of the femoral neck are a very good predictor of mortality within
a year 1/3 of people with a hip fracture will die.
Clinically, these fractures can be classified into two main groups:
Intracapsular Fracture
By Ralf Puls [CC-BY-3.0-de], via Wikimedia Commons

Fig 1.2 Fracture of the femoral neck, fixed

with a dynamic hip screw.
Intracapsular fractures are more common in
the elderly, especially women. They are a
result of a minor trip or stumble. This fracture
occurs within the capsule of the hip joint. It
can damage the medial femoral circumflex
artery and cause avascular necrosis of the
femoral head.
The distal fragment is pulled upwards and
rotated laterally. This manifests clinically as
a shorter leg length, with the toes pointing
laterally
Extracapsular Fractures
Extracapsular fractures are more common in
young and middle aged people. In these
fractures, the blood supply to the head of
femur is intact, and so no avascular necrosis
can occur. Like the subcapital fracture, the leg
is shortened and laterally rotated.

The Shaft
The shaft descends in a slight medial direction. This brings the knees closer
to the bodys center of gravity, increasing stability.
On the posterior surface of the femoral shaft, there are roughened ridges of
bone, these are called the linea aspera (Latin for rough line)
Proximally, the medial border of the linea aspera becomes the pectineal
line. The lateral border becomes the gluteal tuberosity, where the gluteus
maximus attaches.
Distally, the linea aspera widens and forms the floor of
the popliteal fossa, the medial and lateral borders form
the the medial and lateral supracondylar lines. The
medial supracondyle line stops at the adductor
tubercle, where the adductor magnus attaches.

Fig 1.3 Posterior surface of the femoral shaft,

showing the linea aspera.

Clinical Relevance: Fractures of the Femoral Shaft

By Nevit Dilmen [CC-BY-SA-3.0], via Wikimedia Commons

Fig 1.4 Mid-shaft fracture of the femur.

Fractures of the shaft are relatively
uncommon, and require a lot of force.
Such fractures are usually a consequence
of a traumatic injury, such as a vehicular
accident.
One particular classification is
the spiral fracture this can present with
leg shortening. The loss of leg length is
due the fragments overriding, pulled by
the attached muscles.
As the method of injury is typically high
energy, the surrounding soft tissues may
also be damaged. One possible sequelae
of a femoral shaft fracture is femoral
nerve palsy. It is also important to ensure
the blood supply from the femoral
artery hasnt been compromised, as it
supplies the remainder of the lower limb.

III. OPEN REDUCTION INTERNAL FIXATION

PROCEDURES
( What is it and why do I need it?
Open reduction and internal fixation (ORIF) is surgery to repair a broken
bone. Open reduction means the doctor makes an incision (cut) to reach the
bones and move them back into their normal position. Internal fixation
means metal screws, plates, sutures, or rods are placed on the bone to
keep it in place while it heals. The internal fixation will not be removed.
Why do I need it? )
This surgery is done on an arm or a leg to repair fractures that would not
heal properly with a cast or splint alone.
Your surgeon may recommend ORIF if:
The bone is broken into many pieces
The bone is sticking out of the skin
The bone is not lined up correctly
A closed reduction (without opening the skin) was done before and it didnt
heal properly
A joint is dislocated
This surgery should allow your bone to heal properly. When it does, you will
have less pain and be better able to move and use your arm or leg.
Potential benefits
ORIF surgery may:
Decrease pain and
help
your broken arm or leg
heal correctly

Risks and potential

Alternatives
complications
Risks associated with ORIF is usually done only
any surgery: Bleeding
when the break is so
severe that it is the
that would require a
only option. If the break
blood transfusion;
is not severe, your
infection; allergic

 Restore the bone to

its
normal function
Prevent further injury

reaction to anesthesia
Risks associated with
ORIF: Nerve damage
that reduces feeling in
the arm or leg
Hardware in the arm
or leg moving out of
place
Pain, swelling, or
trouble moving the arm
or leg
Incomplete healing of
the bone
Increased pressure in
the arm or leg
(compartment
syndrome) which can
damage muscles and
tissue
Blood clot, possibly
traveling to the heart
(pulmonary embolism)
Muscle spasms

doctor may be able to

move the bones back
into place, or maintain
the position of the
bones with a cast or a
brace while it heals.

IV. PREOPERATIVE CARE

PRIOR TO PROCEDURE:

Since broken bones are usually caused by trauma or an accident, an

ORIF surgery is typically an emergency procedure. Before your surgery,
you may have:
o Physical examto check your blood circulation and nerves
affected by the broken bone
o X-ray , CT scan , or MRI scan to evaluate the broken bone and
surrounding structures
o Blood tests
o Tetanus shot depending on the type of fracture and if your
immunization is not current

An anesthesiologist will talk to you about anesthesia for your surgery.

If your surgery is urgent, you may not have time to fast beforehand;
make sure to tell your doctor and the anesthesiologist when you last
ate and drank.

If your surgery is scheduled, you may be asked to stop taking certain

medications up to a week in advance.

Anesthesia
General anesthesia may be used. It will block any pain and keep you asleep
during the surgery. In some cases, a spinal anesthetic, or more rarely a local
block, may be used to numb only the area where the surgery will be done.
This will depend on where the fracture is located and the time it will take to
perform the procedure.

DURING THE PROCEDURE:

Description of Procedure
Each ORIF surgery differs based on the location and type of fracture. In
general, a breathing tube may be placed to help you breathe while you are
asleep. Then, the surgeon will wash your skin with an antiseptic and make an
incision. Next, the broken bone will be put back into place. Next, a plate with
screws, a pin, or a rod that goes through the bone will be attached to the
bone to hold the broken parts together. The incision will be closed with
staples or stitches. A dressing and/or cast will then be applied.
Open Reduction and Internal Fixation Surgery of the Ankle

Copyright Nucleus Medical Media, Inc.

IMMEDIATELY AFTER THE PROCEDURE:

After your surgery, you will be taken to the recovery room for observation.
Your blood pressure and breathing will be monitored until you are awake and
doing well. Your pulse and the nerves close to the broken bone will also be
checked. Most patients with an arm fracture go home the day of surgery.
Patients with a leg fracture sometimes stay longer.
How Long Will It Take?
An ORIF surgery can take several hours depending on the fracture and the
bone involved.

How Much Will It Hurt?

Anesthesia prevents pain during surgery. Pain and discomfort after the
surgery can be managed with medications.
Average Hospital Stay
This procedure is done in a hospital setting. Your length of stay will depend
on your surgery. You may be in the hospital for 1-7 days.
POST-PROCEDURE CARE:
At the Hospital

After surgery, patient will be given nutrition through an IV until you are
able to eat and drink.

Patient will be asked to get out of bed and walk 2-3 times a day to
prevent complications.

Patient will begin physical therapy to learn how to move. You will also
be shown exercises to regain muscle strength and range of motion.

Patient will learn how to properly use any assisted devices, such as a a
wheelchair or crutches.

Patient will be asked to cough and breathe deeply to prevent lung

problems.

Patient affected limb will be elevated above your heart to decrease

swelling.

During patient stay, the hospital staff will take steps to reduce your chance
of infection such as:

Washing their hands

Wearing gloves or masks

Keeping your incisions covered

There are also steps you can take to reduce your chances of infection such
as:

Washing your hands often and reminding visitors and healthcare

providers to do the same

Reminding your healthcare providers to wear gloves or masks

Not allowing others to touch your incisions

At Home
Complete recovery usually takes 3 to 12 months. How long it takes depends
on how severe your fracture was, and whether nerves and blood vessels
were damaged.
Your doctor may recommend physical therapy during your recovery. A
physical therapist can teach you exercises to help you regain strength and
motion in your limb. These exercises may be necessary for you to be able to
use your arm or leg the way you used to.

Before you leave the hospital, you will need to arrange for a ride home.
Arrange to get help at home from friends and family until you can manage
on your own.
When you return home, do the following to help ensure a smooth recovery:

Take care of the bandage or dressing to prevent infection.

Check your affected limb often for sense of feeling.

Get up and walk several times a day.

Continue to do exercises prescribed by your physical therapist.

Elevate the affected limb above the level of your heart for the first 48
hours. You may also be instructed to use ice to reduce swelling.

Ask your doctor when its okay for you to bathe or shower, and when
the dressing will be changed.

Call the physician

It is important for you to monitor your recovery after you leave the hospital.
Alert your doctor to any problems right away. If any of the following occur,
call your doctor:

Signs of infection, including fever and chills

Redness, swelling, increasing pain in the affected limb

A lot of bleeding or any discharge from the incision site

Loss of feeling in the affected limb

Swelling or pain in the muscles around the broken bone

Pain cannot be controlled with the medications you were given

Cough , shortness of breath, or chest pain

Joint pain, fatigue, stiffness, rash, or other new symptoms.

If you think you have an emergency, call for medical help right away.