What Is ORIF?
Bone fractures due to trauma or osteoporosis are often comminuted in nature and require surgical intervention. Open reduction and internal fixation are made to gain stability and anatomical reconstruction of the fractured bone. It is a two-stage process carried out in one step. The first stage repositions the broken bones, and in the second stage, the broken bones are held together using metal implants.
If untreated, the body tries to stabilize the bone fractures by pain-inducing contractions of the surrounding muscles, resulting in bone shortening.
Why Do I Need an ORIF?
It is often the preferred surgical procedure to overcome limitations encountered with skeletal traction or cast immobilization. It is indicated as follows;
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Open Fracture- Also known as a compound fracture, where the skin underlying the fracture is open.
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Floating Elbow- An injury pattern involving the fracture of the humerus and forearm.
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Bilateral Humerus Fractures- Humerus bones on both hands get fractured.
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Fractures Associated with Vascular Injury- Fracture of the bone involving blood supply.
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Fractures in Polytrauma Patients- Patients who are severely injured.
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Radial Nerve Dysfunction After Fracture Manipulation- Radial nerve travels from the armpit down the back of the arm of the hand. Sometimes in closed fixation, this nerve gets impinged, causing dysfunction.
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Pathological Fractures- Occur in patients with benign or malignant tumors and in osteoporosis due to altered skeletal physiology.
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Nonunion- No union of bones occasionally happens after closed fixation.
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Unacceptable Malunion- Irregular union of bones.
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No Compliance, Uncooperative patient- Trauma often puts the patient in a state of shock and confusion; this reduces patient cooperation during conservative fracture fixation.
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Failure of Conservative Treatment- Happens due to insufficient closed reduction leading to nonunion or malunion of fractured bones.
An early ORIF is contraindicated in severe high-grade open fractures, with soft tissue loss and cross-contamination.
What Are the Tests Done Prior to ORIF?
Multiple imaging tests are done prior to ORIF; the usual ones are-
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X-rays.
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Magnetic resonance imaging (MRI).
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Computed tomography scan (CT).
How Is ORIF Done?
Most of the time, ORIF is an emergency procedure due to the nature of the fracture incidence; however, some of them can be scheduled. The chronology of ORIF is as follows-
- Anesthesia- General anesthesia, along with a nerve block, is the standard protocol. Recently, wide-awake local anesthesia with no tourniquet (WALANT) has been providing a simple and safe alternative to conventional anesthetic techniques.
- Incision- Often, ORIF requires multiple incisions; the first one is always done to identify the location of the fracture, and the subsequent ones are done to gain better access to screw the implants.
- Reduction of the Bone- The key to the successful reduction of a comminuted fracture is to convert multiple parts of the fracture into one part. For example, in a three-part proximal humeral fracture, the procedure starts with traction sutures at the junction of the cuff and tuberosities. This allows mobilization of the fractured fragments, sutures in lesser tuberosity are pulled laterally to correct retroversion, and sutures in greater tuberosity are pulled in a downward direction to correct varus deformity.This aligns the humeral head with the tuberosities. A k-wire is used for temporary fixation of the reduced 2-part fracture of the head with the aid of suture-traction. Next is aligning the humeral shaft with the humeral head with a proximal humeral locking plate, finally reducing the entire fracture to 1-part.
- Internal Fixation- This is done with the help of implants. Numerous devices are used depending on the type of fracture. Wires, pins and screws, plates, intramedullary nails, or rods are extensively used; however, staples and clamps are occasionally used for osteotomy.
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Pins- They are used for the temporary fixation of the fracture fragments during reduction. Kirschner wires and Steinman pins are commonly used.
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Wires- These are used in conjunction with pins and screws to create a tension band for a compression effect at the fracture site.
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Screws- They are used to provide anchorage and function as a fixed-angle device in a minimally invasive technique.
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Plates- They are used to achieve stability and reduce strain at the fracture site. This aids indirect healing without callus formation.
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Intramedullary Nails And Rods- Intramedullary rods and nails are the standard treatment for diaphyseal fractures of the femur and tibia. They provide optimal biomechanical positioning to resist torsion and bending.
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Suturing And Recovery- The incision is closed with sutures followed by a cast or a splint to protect the repair as it heals. The patient is released once the post-op circulation, sensation, and movements are satisfactory.
Are Bone Grafts Used in ORIF?
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Bone grafts are used in comminuted fracture with bone loss or bone defect. Also they are frequently used in severely displaced fractures. They are indicated in fracture augmentation, vertebroplasty, fracture nonunion, and osteomyelitis. They are used in conjunction with implants. Autogenous bone grafts are the standard but not always available, allografts, though available, are usually not the immediate choice due to their disease transmission and high cost.
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This leaves commercially manufactured bone grafts as a viable substitute. Some of them are demineralized allograft bone matrix, ceramics and ceramic composites, a composite graft of collagen and mineral, coralline hydroxyapatite, bioactive glass, calcium phosphate cement, and calcium sulfate.
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For infected fracture sites, antibiotic beads composed of polymethylmethacrylate cement are packed at the site of infection.
What Are the Potential Risks and Complications of ORIF?
Apart from the bleeding and anesthesia allergy, a few complications are specific to ORIF; they are:
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Acute Compartment Syndrome- This is due to the increased pressure in the fractured joint, leading to muscle and tissue damage.
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Malunion- Irregular union of bones.
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Nonunion- No union of bones.
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Infection- Often caused due to the implants used for fixation and is seen in patients with predisposing conditions like diabetes, rheumatoid arthritis, and liver diseases.
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Other Internal Damage- To nerves, blood vessels, tendons, and ligaments.
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Implant failure.
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Intra operative fracture
What Can I Expect After ORIF Surgery?
The surgery takes several hours, depending on the extent of the injury, followed by recovery, which is usually between 3 to12 months. The orthopedic surgeon will prescribe anti-inflammatories to reduce the post-op pain, and a physical therapist will help the patient regain strength and motion.
How Do I Take Care of Myself at Home?
Although ORIF is a multi-disciplinary surgery with guidance along every step to recovery, there are a few things the patient can do for better results; they are-
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Keep your incision clean with regular dressing.
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Do not put any weight or pressure on the fractured bone.
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Inform all your healthcare providers, even the dentist, about the implants. They may suggest prophylactic antibiotics to prevent infection.
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Call your doctor if you have active bleeding from the surgical site.
Conclusion:
ORIF is an emergency procedure. It is suitable for patients with fractures due to trauma or osteoporosis. Fractures due to trauma are often associated with other injuries and are often life-threatening; the patient might not be aware of the surgery they had. Nevertheless, ORIF has a high success rate, and communicating with the respective surgeon will guide the patient along the long road to recovery.