Question

What is an open reduction with internal fixation (ORIF)?

What would be your priority assessment?

How would this impact their daily living?

List some focus points for patient teaching.

List 5 things for each patient that you would want to know in the morning report.

Answer 1

1 .

ORIF is surgery to fix a broken bone. Open reduction means that the bone is moved back into the right place with surgery. Internal fixation means that hardware (such as screws, rods, or pins) is used to hold the broken bones together.

Open reduction internal fixation (ORIF) is a surgery to fix severely broken bones.

It’s only used for serious fractures that can’t be treated with a cast or splint. These injuries are usually fractures that are displaced, unstable, or those that involve the joint.

“Open reduction” means a surgeon makes an incision to re-align the bone. “Internal fixation” means the bones are held together with hardware like metal pins, plates, rods, or screws. After the bone heals, this hardware isn’t removed.

Generally, ORIF is an urgent surgery. Your doctor might recommend ORIF if your bone:

• breaks in multiple places
• moves out of position
• sticks out through the skin

ORIF may also help if the bone was previously re-aligned without an incision — known as closed reduction — but didn’t heal properly.

The surgery should help reduce pain and restore mobility by helping the bone heal in the right position.

Despite the increasing success rate of ORIF, recovery depends on your:

• age
• health condition
• post-surgery rehabilitation
• severity and location of the fracture

ORIF surgery

ORIF is performed by an orthopedic surgeon.

The surgery is used to fix fractures in the arms and legs, including bones in the shoulder, elbow, wrist, hip, knee, and ankle.

Depending on your fracture and risk for complications, your procedure might be done immediately or scheduled in advance. If you have a scheduled surgery, you may have to fast and stop taking certain medications first.

Before surgery, you might receive a:

• physical exam
• blood test
• X-ray
• CT scan
• MRI scan

These tests will allow the doctor to examine your broken bone.

ORIF is a two-part procedure. The surgery can take several hours, depending on the fracture.

An anesthesiologist will give you general anesthesia. This will put you in a deep sleep during the surgery so you won’t feel any pain. You might be put on a breathing tube to help you breathe properly.

The first part is open reduction. The surgeon will cut the skin and move the bone back into the normal position.

The second part is internal fixation. The surgeon will attach metal rods, screws, plates, or pins to the bone to hold it together. The type of hardware used depends on the location and type of fracture.

Finally, the surgeon will close the incision with stitches or staples, apply a bandage, and may put the limb in a cast or splint depending on the location and type of fracture.

What to expect following the procedure

After ORIF, doctors and nurses will monitor your blood pressure, breathing, and pulse. They’ll also check the nerves near the broken bone.

Depending on your surgery, you may go home that day or you might stay in the hospital for one to several days.

If you have an arm fracture, you may go home later that day. If you have a leg fracture, you might have to stay longer.

ORIF surgery recovery time

Generally, recovery takes 3 to 12 months.

Every surgery is different. Complete recovery depends on the type, severity, and location of your fracture. Recovery can take longer if you develop complications after surgery.

Once your bones begin to heal, your doctor may have you do physical or occupational therapy.

A physical or occupational therapist can show you specific rehabilitation exercises. These moves will help you regain strength and movement in the area.

For a smooth recovery, here’s what you can do at home:

• Take pain medication. You might need to take over-the-counter or prescription pain medication, or both. Follow your doctor’s instructions.
• Make sure your incision stays clean. Keep it covered and wash your hands often. Ask your doctor how to properly change the bandage.
• Lift the limb. After ORIF, your doctor might tell you to elevate the limb and apply ice to decrease swelling.
• Don’t apply pressure. Your limb may need to stay immobile for a while. If you were given a sling, wheelchair, or crutches, use them as directed.
• Continue physical therapy. If your physical therapist taught you home exercises and stretches, do them regularly.

It’s important to attend all your checkups after surgery. This will let your doctor monitor your healing process.

Walking after ORIF ankle surgery

After ORIF ankle surgery, you won’t be able to walk for some time.

You can use a knee scooter, seated scooter, or crutches. Staying off your ankle will prevent complications and help the bone and incision heal.

Your doctor will tell you when you can apply weight on the ankle. The time will vary from fracture to fracture.

Risks and side effects from ORIF surgery

As with any surgery, there are potential risks and side effects associated with ORIF.

These include:

• bacterial infection, either from the hardware or incision
• bleeding
• blood clot
• allergic reaction to anesthesia
• nerve or blood vessel damage
• tendon or ligament damage
• incomplete or abnormal bone healing
• metal hardware moving out of place
• reduced or lost mobility
• muscle spasms or damage
• arthritis
• tendonitis
• audible popping and snapping
• chronic pain due to hardware
• compartment syndrome, which occurs when there’s increased pressure in the arm or leg

If the hardware gets infected, it might need to be removed.

You may also need to repeat the surgery if the fracture doesn’t heal properly.

These problems are rare. However, you’re more likely to develop complications if you smoke or have medical conditions such as:

• obesity
• diabetes
• liver disease
• rheumatoid arthritis
• history of blood clots

To limit your chances of complications, follow your doctor’s instructions before and after surgery.

Ideal candidates for ORIF surgery

ORIF isn’t for everyone.

You may be a candidate for ORIF if you have a serious fracture that can’t be treated with a cast or splint, or if you already had a closed reduction but the bone didn’t heal correctly.

You don’t need ORIF if you have a minor fracture. Your doctor might be able to treat the break with closed reduction or a cast or splint.

Takeaway

If you have a serious fracture, your doctor might recommend open reduction internal fixation (ORIF) surgery. An orthopedic surgeon cuts the skin, re-positions the bone, and holds it together with metal hardware like plates or screws. ORIF isn’t for minor fractures that can be healed with a cast or splint.

ORIF recovery can last 3 to 12 months. You’ll need physical or occupational therapy, pain medication, and lots of rest.

You should contact your doctor if you experience bleeding, increasing pain, or other new symptoms during recovery.

2 .,

Pre-operative assessment is required prior to the majority of elective surgical procedures, primarily to ensure that the patient is fit to undergo surgery, whilst identifying issues that may need to be dealt with by the surgical or anaesthetic teams. The post-operative management of elective surgical patients begins during the peri-operative period and involves several health professionals. Appropriate monitoring and repeated clinical assessments are required in order for the signs of surgical complications to be recognised swiftly and adequately.

This article examines the literature regarding pre-operative assessment in elective orthopaedic surgery and shoulder surgery, whilst also reviewing the essentials of peri- and post-operative care. The need to recognise common post-operative complications early and promptly is also evaluated, along with discussing thromboprophylaxis and post-operative analgesia following shoulder surgery.

Most patients undergoing elective surgery are subjected to routine history checks and clinical examinations by medical staff at the time that a decision is taken by both clinician and patient to undergo surgery. For most procedures other than those which are very minor, a formal pre-operative assessment consultation is usually led by a specialist nurse or a member of medical staff, and generally includes a review of the patient’s case notes, a detailed history and clinical examination, and additional tests and investigations.

History

Salient points in the history in patients who are presumed to be healthy is to identify any as-yet undetected illnesses which could have an adverse affect on the forthcoming surgery and peri-operative care. The history should focus on the indication for surgical procedures, allergies, and undesirable side-effects to medications or other agents, known medical problems, surgical history, major trauma, and current medications.

Common conditions which can affect peri-operative care include ischaemic heart disease, congestive cardiac failure, chronic respiratory disease, diabetes mellitus and liver or renal dysfunction [3]. As anaesthetic drugs can have pronounced adverse effects on cardiovascular and respiratory systems, it is worthwhile enquiring about chest pain, dyspnoea, ankle swelling and palpitations. The presence of a cough, sputum production and any indication of airway obstruction will provide invaluable information. An excellent indicator of cardiorespiratory function is tolerance of exercise [4]. A smoking history should also be taken as smokers are difficult to anaesthetise due to their upper airways being sensitive to the dry gases used during anaesthesia, and their risk of hypoxia is greater. Assessment and documentation of alcohol intake is required, as induction of liver enzymes by alcohol may shorten the action of anaesthetic drugs and may identify the risk of potential alcohol withdrawal. The use of recreational drugs such as intravenous opiates should also be recognised, as such patients may have poor venous access, may be at risk of septicaemia, and may pose a risk to the surgical team. Patients on long term steroids require adequate cover intra-operatively in order to avoid a hypotensive crisis [4].

In elective shoulder surgery, a detailed history is important not only in arriving at the correct diagnosis, but also in decision-making between the clinician and patient. The history may be considered one of the most valuable yet least effectively used tools in clinical medicine [5]; and poor history taking and physical examination may lead to both inappropriate diagnostic testing and surgery. Patients with shoulder pathology usually present with pain and/or loss of function, which should be explored along with the patient’s premorbid status and demands, and the likely functional demands aimed for in the future. A comprehensive interview regarding the patient’s pain and functional deficit is required, exploring components such as site, onset, duration, character and radiation of the pain, including features of neural irritation. The degree of dysfunction should also be clarified and how this impacts on the patient and their activities of daily living (ADL), especially as lower pre-operative ADL measurements have been associated with higher post-operative mortality in patients undergoing elective orthopaedic surgery [6]. Table ​11 below displays how shoulder function can be assessed [5].

Table 1.

Assessment of Shoulder Dysfunction

Which movements are limited? This can help isolate the structure

Consider the following if movements are limited by:

▪   pain: tendinopathy, impingement, sprain/strain, labral pathology

▪   mechanical block: labral pathology, frozen shoulder

▪   night pain (lying on affected shoulder): rotator cuff pathology, anterior shoulder instability, ACJ injury, neoplasm (particularly unremitting pain)

▪   sensation of ‘clicking or clunking’: labral pathology, unstable shoulder (either anterior or multidirectional instability)

▪   sensation of stiffness or instability: frozen shoulder, anterior or multidirectional instability

Physical Examination

A general systems examination is performed to identify abnormalities of the cardiorespiratory system which would require further assessment. In particular, cardiac murmurs, additional heart sounds, and abnormal chest signs in patients with no previously documented pathology require investigation and/or referral to an appropriate specialist. Review of the gastrointestinal (GI) system identifies any abdominal masses and previous surgical scars. Skeletal malformations such as kyphoscoliosis can be detected on examining the musculoskeletal system. Local skin abnormalities should be documented and any issues should be highlighted to the surgical team.

Observations including heart rate and blood pressure are recorded. Brief examination of the airway provides valuable information regarding the feasibility of intubation. Several factors must be considered when assessing the airway. These include whether the patient is obese, has a short neck and small mouth, or whether or not there is any soft tissue swelling at the back of the mouth or if there are any constraints to neck flexion or extension. Cervical spine stiffness should be followed up with a plain radiograph to aid the anaesthetic team in decision-making regarding intubation.

Specific examination of the shoulder involves inspection, palpation, movement and special tests which may be able to narrow down the diagnosis. Previous scars, skin abnormalities, erythema, bruising and shoulder symmetry are to be noted on inspection [5]. Palpation of the shoulder should reveal any specific tenderness around the joint, in addition to crepitus, especially with movement. Passive and active range of movement should then be assessed, comparing both sides.

Special tests of shoulder joint function involve Hawkins test for subacromial impingement, with the humerus abducted to 90 degrees and 30 degrees anteriorly in the line of the scapula. The elbow is then flexed to 90 degrees and the glenohumeral joint internally rotated. Pain constitutes a positive test. This test has a sensitivity of 91–92% and specificity of 25–43% [7]. The empty can test can also be used for detecting a torn rotator cuff, specifically for a supraspinatus tear. Pain and/or weakness signify a positive test when the patient resists a downward pressure with the arm in 90 degrees of abduction in the plane of the scapula. Sensitivity for this test is 18.7% with specificity being 100% [7]. The apprehension test can be used to test for anterior shoulder instability, following anterior shoulder dislocation and subluxation, with a sensitivity of 91.9% and specificity of 88.9%. The active compression test (O’Brien’s test) for acromioclavicular joint (ACJ) arthritis and labral pathology can also be utilised. With the arm flexed to 90 degrees and the elbow fully extended, the arm is then adducted about 15 degrees medially. The arm is internally rotated so that the thumb points to the floor, the patient then resists the downward force applied by the clinician. The arm is then supinated so the palm is facing upward and resisting another downward force. The test is positive and diagnostic of ACJ pathology if pain is elicited over the ACJ or on top of the shoulder in the thumb down position and reduced or eliminated in the palm up position. Sensitivity for this test is 100% with specificity of 96.6%

3 .

After ORIF, doctors and nurses will monitor your blood pressure, breathing, and pulse. They’ll also check the nerves near the broken bone.

Depending on your surgery, you may go home that day or you might stay in the hospital for one to several days.

If you have an arm fracture, you may go home later that day. If you have a leg fracture, you might have to stay longer.

ORIF surgery recovery time

Generally, recovery takes 3 to 12 months.

Every surgery is different. Complete recovery depends on the type, severity, and location of your fracture. Recovery can take longer if you develop complications after surgery.

Once your bones begin to heal, your doctor may have you do physical or occupational therapy.

A physical or occupational therapist can show you specific rehabilitation exercises. These moves will help you regain strength and movement in the area.

For a smooth recovery, here’s what you can do at home:

• Take pain medication. You might need to take over-the-counter or prescription pain medication, or both. Follow your doctor’s instructions.
• Make sure your incision stays clean. Keep it covered and wash your hands often. Ask your doctor how to properly change the bandage.
• Lift the limb. After ORIF, your doctor might tell you to elevate the limb and apply ice to decrease swelling.
• Don’t apply pressure. Your limb may need to stay immobile for a while. If you were given a sling, wheelchair, or crutches, use them as directed.
• Continue physical therapy. If your physical therapist taught you home exercises and stretches, do them regularly.

It’s important to attend all your checkups after surgery. This will let your doctor monitor your healing process.

Walking after ORIF ankle surgery

After ORIF ankle surgery, you won’t be able to walk for some time.

You can use a knee scooter, seated scooter, or crutches. Staying off your ankle will prevent complications and help the bone and incision heal.

Your doctor will tell you when you can apply weight on the ankle. The time will vary from fracture to fracture.

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Repairing Major Bone Breaks with Open Reduction Internal Fixation Surgery

• Procedure
• After surgery
• Recovery
• Risks and side effects
• Candidates
• Summary

Overview

Open reduction internal fixation (ORIF) is a surgery to fix severely broken bones.

It’s only used for serious fractures that can’t be treated with a cast or splint. These injuries are usually fractures that are displaced, unstable, or those that involve the joint.

“Open reduction” means a surgeon makes an incision to re-align the bone. “Internal fixation” means the bones are held together with hardware like metal pins, plates, rods, or screws. After the bone heals, this hardware isn’t removed.

Generally, ORIF is an urgent surgery. Your doctor might recommend ORIF if your bone:

• breaks in multiple places
• moves out of position
• sticks out through the skin

ORIF may also help if the bone was previously re-aligned without an incision — known as closed reduction — but didn’t heal properly.

The surgery should help reduce pain and restore mobility by helping the bone heal in the right position.

Despite the increasing success rate of ORIF, recovery depends on your:

• age
• health condition
• post-surgery rehabilitation
• severity and location of the fracture

ORIF surgery

ORIF is performed by an orthopedic surgeon.

The surgery is used to fix fractures in the arms and legs, including bones in the shoulder, elbow, wrist, hip, knee, and ankle.

Depending on your fracture and risk for complications, your procedure might be done immediately or scheduled in advance. If you have a scheduled surgery, you may have to fast and stop taking certain medications first.

Before surgery, you might receive a:

• physical exam
• blood test
• X-ray
• CT scan
• MRI scan

These tests will allow the doctor to examine your broken bone.

ORIF is a two-part procedure. The surgery can take several hours, depending on the fracture.

An anesthesiologist will give you general anesthesia. This will put you in a deep sleep during the surgery so you won’t feel any pain. You might be put on a breathing tube to help you breathe properly.

The first part is open reduction. The surgeon will cut the skin and move the bone back into the normal position.

The second part is internal fixation. The surgeon will attach metal rods, screws, plates, or pins to the bone to hold it together. The type of hardware used depends on the location and type of fracture.

Finally, the surgeon will close the incision with stitches or staples, apply a bandage, and may put the limb in a cast or splint depending on the location and type of fracture.

What to expect following the procedure

After ORIF, doctors and nurses will monitor your blood pressure, breathing, and pulse. They’ll also check the nerves near the broken bone.

Depending on your surgery, you may go home that day or you might stay in the hospital for one to several days.

If you have an arm fracture, you may go home later that day. If you have a leg fracture, you might have to stay longer.

ORIF surgery recovery time

Generally, recovery takes 3 to 12 months.

Every surgery is different. Complete recovery depends on the type, severity, and location of your fracture. Recovery can take longer if you develop complications after surgery.

Once your bones begin to heal, your doctor may have you do physical or occupational therapy.

A physical or occupational therapist can show you specific rehabilitation exercises. These moves will help you regain strength and movement in the area.

For a smooth recovery, here’s what you can do at home:

• Take pain medication. You might need to take over-the-counter or prescription pain medication, or both. Follow your doctor’s instructions.
• Make sure your incision stays clean. Keep it covered and wash your hands often. Ask your doctor how to properly change the bandage.
• Lift the limb. After ORIF, your doctor might tell you to elevate the limb and apply ice to decrease swelling.
• Don’t apply pressure. Your limb may need to stay immobile for a while. If you were given a sling, wheelchair, or crutches, use them as directed.
• Continue physical therapy. If your physical therapist taught you home exercises and stretches, do them regularly.

It’s important to attend all your checkups after surgery. This will let your doctor monitor your healing process.

Walking after ORIF ankle surgery

After ORIF ankle surgery, you won’t be able to walk for some time.

You can use a knee scooter, seated scooter, or crutches. Staying off your ankle will prevent complications and help the bone and incision heal.

Your doctor will tell you when you can apply weight on the ankle. The time will vary from fracture to fracture.

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Risks and side effects from ORIF surgery

As with any surgery, there are potential risks and side effects associated with ORIF.

These include:

• bacterial infection, either from the hardware or incision
• bleeding
• blood clot
• allergic reaction to anesthesia
• nerve or blood vessel damage
• tendon or ligament damage
• incomplete or abnormal bone healing
• metal hardware moving out of place
• reduced or lost mobility
• muscle spasms or damage
• arthritis
• tendonitis
• audible popping and snapping
• chronic pain due to hardware
• compartment syndrome, which occurs when there’s increased pressure in the arm or leg

If the hardware gets infected, it might need to be removed.

You may also need to repeat the surgery if the fracture doesn’t heal properly.

These problems are rare. However, you’re more likely to develop complications if you smoke or have medical conditions such as:

• obesity
• diabetes
• liver disease
• rheumatoid arthritis
• history of blood clots

To limit your chances of complications, follow your doctor’s instructions before and after surgery.

4 .

Seek care immediately if:

• Your arm or leg feels warm, tender, and painful. It may look swollen and red.
• You have severe pain, even after you take medicine.
• Your stitches come apart.
• Your cast or splint breaks.
• You cannot move your fingers or toes.
• You have tingling or numbness in your fingers or toes.

Call your doctor or surgeon if:

• You have a fever.
• Your cast or splint gets wet or begins to smell.
• Your bandage or cast feels too tight or too loose.
• You have a lot of itching under your cast or splint.
• Your incision is red, swollen, or draining pus.
• You have questions or concerns about your condition or care.

Medicines:

You may need any of the following:

• Prescription pain medicine may be given. Ask your healthcare provider how to take this medicine safely. Some prescription pain medicines contain acetaminophen. Do not take other medicines that contain acetaminophen without talking to your healthcare provider. Too much acetaminophen may cause liver damage. Prescription pain medicine may cause constipation. Ask your healthcare provider how to prevent or treat constipation.
• Blood thinners help prevent blood clots. Clots can cause strokes, heart attacks, and death. The following are general safety guidelines to follow while you are taking a blood thinner:
  • Watch for bleeding and bruising while you take blood thinners. Watch for bleeding from your gums or nose. Watch for blood in your urine and bowel movements. Use a soft washcloth on your skin, and a soft toothbrush to brush your teeth. This can keep your skin and gums from bleeding. If you shave, use an electric shaver. Do not play contact sports.
  • Tell your dentist and other healthcare providers that you take a blood thinner. Wear a bracelet or necklace that says you take this medicine.
  • Do not start or stop any other medicines unless your healthcare provider tells you to. Many medicines cannot be used with blood thinners.
  • Take your blood thinner exactly as prescribed by your healthcare provider. Do not skip does or take less than prescribed. Tell your provider right away if you forget to take your blood thinner, or if you take too much.
  • Warfarin is a blood thinner that you may need to take. The following are things you should be aware of if you take warfarin:
    • Foods and medicines can affect the amount of warfarin in your blood. Do not make major changes to your diet while you take warfarin. Warfarin works best when you eat about the same amount of vitamin K every day. Vitamin K is found in green leafy vegetables and certain other foods. Ask for more information about what to eat when you are taking warfarin.
    • You will need to see your healthcare provider for follow-up visits when you are on warfarin. You will need regular blood tests. These tests are used to decide how much medicine you need.
• Take your medicine as directed. Contact your healthcare provider if you think your medicine is not helping or if you have side effects. Tell him or her if you are allergic to any medicine. Keep a list of the medicines, vitamins, and herbs you take. Include the amounts, and when and why you take them. Bring the list or the pill bottles to follow-up visits. Carry your medicine list with you in case of an emergency.

Self-care:

• Ask about activity. Do not lift heavy objects. Ask when you can drive and return to work, school, or your daily activities.
• Use support devices as directed. You may need to use crutches, a cane, or a walker if you had ORIF surgery on your leg or foot. It is important to use crutches or a walker correctly. Ask your healthcare provider for more information about how to use these walking devices.
• Ask when you can bathe. When you are allowed to bathe, cover your cast or splint with 2 plastic bags. Tape the bags to your skin or use rubber bands to keep the water out. Keep the cast or splint out of the water so it does not get wet. If you do not have a cast or splint, carefully wash the wound with soap and water. Pat the area dry and put on new, clean bandages as directed. Change your bandages when they get wet or dirty. Check the surgery area for signs of infection, such as redness, swelling, or pus.
• Elevate your limb as directed. Raise your leg or arm above the level of your heart as often as you can. This will help decrease swelling and pain. Prop your leg or arm on pillows or blankets to keep it elevated comfortably.

Ice the fractured area as directed. Ice helps decrease swelling and pain. Ice may also help prevent tissue damage. Use an ice pack or put crushed ice in a plastic bag. Cover it with a towel and place it on the area for 15 to 20 minutes every hour as directed.

Go to physical therapy if directed. A physical therapist teaches you exercises to help improve movement and strength, and to decrease pain.

Cast or splint care:

If you have a cast or splint, do the following:

• Check the skin around the cast or splint every day. Apply lotion on any red or sore areas.
• Do not push down or lean on any part of the cast or splint. It may break or move the injured area.
• Do not scratch the skin under the cast with any sharp or pointed object inside the cast.
• If your splint is too tight, gently loosen it so that your fingers or toes are comfortable.

Follow up with your doctor or surgeon as directed:

You may need to return to have your wound checked and stitches or staples removed. Write down your questions so you remember to ask them during your visits.

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