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Open Reduction and Internal Fixation (ORIF)

Bones are strong and are somewhat flexible when an outside force is placed on them, but if this force is excessive, the bones can break. There are many kinds of broken bones (fractures). Some fractures are not visible outside the body and some result in the bone piercing through the skin. The latter is referred to as an open or compound fracture. This type of fracture is considered fairly serious due to the risk of wound infection. In this case the bone will also require a surgical procedure called a fixation, where materials like pins and wires will be used to hold the two (or more) parts of the fracture together so the bone can heal.

There are two types of fixation:
  1. External fixation is the stabilization of the fracture by placing pins, screws, and/or wires into the bone on both sides of the fracture and the pins are then secured together outside of the skin using a series of clamps and rods known as the external frame. This technique is used for a serious break that causes injury to soft tissue, muscles, and nerves, making it prone to infection, such as a severe open fracture. This technique can be used as both a temporary or definite treatment. The purpose of external fixation is to:
  • Stabilize the fracture.
  • Support the fusion of bone and repair of the injured muscles.
  • Make it easy to clean the open wound.
  • Correct deformities caused by injury of the arms, legs, and hips.
  • Reduce the chance of disability due to injury and tumor growth.
  1. Internal fixation is part of a procedure referred to as “open reduction and internal fixation” or ORIF. Surgery is done to visualize the fracture and reposition or reduce the bones so they are aligned. Then plates and screws, intramedullary rods or nails, and/or pins and wires are attached directly to the bone to hold it in place. The purpose of internal fixation is to:
  • Stabilize the bone if closed reduction fails.
  • Treat the fracture that involves joint dislocation.
  • Treat the pathological fracture.
  • Treat the fracture that involves injury to blood vessels and nerves.
  • Help the patient move around more quickly when they have other injuries to prevent further complications.
  1. Please let the doctor know about all medication that you are taking as some may need to be stopped before the procedure. Blood-thinning medications such as aspirin, Persantin, Plavix, warfarin, Heparin, and Fraxiparine have to be stopped at least one week before the procedure or as recommended by the doctor.
  2. You will undergo a thorough health examination that will include blood tests, x-rays, and electrocardiogram (EKG), as recommended by the doctor.
  3. Get adequate rest before the procedure. Do not smoke or drink alcohol before the procedure as these can increase the risk of complications during surgery.
  4. Please let the hospital or doctor know if you are not feeling well before the surgery, such as if you have a fever or a cold.
  5. You will likely need to avoid food and water for six to eight hours before the procedure or as recommended by the doctor.
  6. The area that will be operated on will be thoroughly sterilized before surgery.
The procedure may be done with general or regional anesthesia. The doctor will make an incision over the fracture and reduce the bones back into alignment. The doctor will then use the necessary hardware, be it plates, screws, pins, and/or wires, to hold the bones in place. Screws and pins are drilled directly into the bones, down into the marrow. The exact procedure will depend on the type, location, and severity of the fracture.
 
  1. After the surgery, you will be moved to the recovery room where you will be monitored closely until the anesthesia wears off. Side effects from general anesthesia may include headache, nausea, and vomiting, which can be managed with medication.
  2. Post-operative pain may be managed with regional anesthesia patient-controlled anesthesia (PCA), which allows you to press a button that administers a specific amount of pain-relieving medication intravenously. Both may have side effects that include nausea and vomiting as well as drowsiness.
  3. While you are on intravenous fluids, you will not be able to eat, but will be allowed to take sips of water. Once the intravenous is removed you will work your way up from a soft diet to normal food.
  4. The surgical site will be closed with stitches or staples, which will likely stay in place for 10 to 14 days. Drainage tubes may be inserted during this time to drain blood and fluids into a small vacuum bottle. The tubes are usually removed after 48 to 72 hours. It is important that the wound is kept dry and clean until it heals.
  5. An elastic bandage will be wrapped around the area and it is important to ensure that it isn’t too loose or too tight. Once wrapped you should be able to place one finger underneath the bandage and feel snug against that finger. If you cannot insert a finger, it is too tight. If it feels loose after one finger is inserted, it is too loose and should be rewrapped.
  6. While at the hospital, nurses will encourage you to cough and take deep breaths to prevent pneumonia. The affected limb will be elevated to prevent swelling. If able, you should get out of bed and take short walks a few times a day to prevent complications. Physical therapy may be prescribed to help you learn exercises to preserve muscle and range of motion. These may include:
  • Exercising the quadriceps by contracting the muscles of your thighs so it can accommodate your weight when you can stand and walk again. Contract the muscles for five seconds and release. Continue until the muscle is fatigued.
  • Exercising the joints to preserve range of motion.
  • Exercising the hips by lying flat and raising one leg at a time and holding it for five seconds. Contract the muscles of the raised leg at the same time.
  • Flexing and rotating your ankles to help with circulation.
  • Gluteal setting exercise.
  • Encouraging you to get out of bed (ambulation).
    • If the surgery was done on your leg, you will not be able to get out of bed until you receive permission from your doctor.
    • Initially you will need to use crutches to avoid placing any weight on the affected leg. Once you are able to walk well, the doctor and physical therapist may allow you to place partial weight on the affected leg.
    • Pain can be controlled by elevating the limb when you are in bed. This will help increase blood circulation and prevent blood clots.
  • If you had metal hardware placed in your leg and are not able to get up for a period, it is important to do exercises in bed to strengthen the muscles of the thighs, hips, and ankles of the affected leg as well as the unaffected one. This is to maintain muscle strength and tone as keep all the joints moving so they do not become stiff.
  1. Monitor the affected area for decreased sensation, increased swelling and severe pain that is not managed with medication. Also, watch for a high fever and coldness of the extremities. If you experience any of these symptoms, contact your doctor immediately.
  2. Follow the instructions of the physical therapist and do your exercises regularly to speed up recovery so you can resume normal activities. Do not overdo it and stop if you experience excessive pain or notice swelling.
  3. Once you are home, you may need to change your dressing once a day. Always observe the wound for signs of infection, such as swelling, redness, and seeping of fluid. Keep the wound clean and the dressing dry. Always come to all scheduled appointments, especially the one to remove the stitches as they can become infected if left in for too long.
  4. Keep your follow-up appointment, so your doctor can observe the wound and the healing of your bone, as well as for you to meet with a physical therapist.
  5. Maintain good health by eating nutritious food. There are usually no dietary restrictions.
  1. The fracture does not heal and additional surgery and/or bone transplantation is required.
  2. Metal hardware becomes loose or dislodges, requiring surgery to repair.
  3. Some hardware has to be removed during the healing process.
  4. Bone deformity due to the fracture or misalignment of the bones. The organ then cannot be used and will require additional treatment.
  5. Injury to blood vessels, requiring additional treatment with surgery.
  6. Infection of the bone or the wound, requiring additional surgery and/or antibiotics.
  7. The risk of blood clots forming in the leg, which can then break off and travel to the lungs. This condition must be treated immediately or can result in life-threatening complications.
  8. Injury to the nerves, requiring additional treatment with surgery.
  9. Abnormal pain due to surgery. This pain can become more severe and limit movement.
  10. Surgery can impact sensation and color of the skin where the procedure was done. Sometimes the wound may look different or abnormal in certain patients. The scar may become raised or look thick or red. Some scars may be painful.
The risk of complications is higher in patients who are obese or who smoke. They are more likely to experience infection at the wound as well as the chest, heart, and lungs. They are also more likely to develop blood clots.
 
Before the Procedure
  • The patient will be evaluated and diagnosed by the doctor before surgery is planned and the surgery will take place as soon as possible, depending on the patient’s readiness. This can be one to two days or within 24 hours.
  • It is recommended that you stay at a hotel close to the hospital for convenience in traveling to the hospital before and after the procedure, as recommended by the doctor, for physical therapy and follow-up appointments.
After the Procedure
  • You should plan to remain in Thailand for at least two weeks through the duration of your treatment. This may vary from person to person, depending on your individual health and medical condition before the procedure as well as your age. Certain factors may require a longer stay in Thailand. This does not include the time for physical therapy after the surgery.
  • When you return for your follow-up appointment you will undergo a physical examination and your wound will be checked, You will receive documentation of your treatment history, a medical certificate, follow-up appointment slips, your “fit to fly” certificate, and a Medical Information Card (Bone Card).
  • You may travel by car if it is a four-seater and it is recommended you sit in the passenger seat with the seat reclined. If you are traveling in a van, it is recommended you sit behind the driver and recline your seat.
  • Normally patients can travel home by air. Please discuss this with your doctor to confirm that you are healthy enough to fly before making flight arrangements. If you need a walking aid, such as a walker, crutches, or cane, be sure to let the airline know in advance if you will need a wheelchair at the airport and when you get off the airplane at your destination.
 
  • If you are traveling in First or Business class:
    • You can recline your seat normally, but support the affected limb to keep it from dangling and to maintain it in normal alignment. Exercise your leg muscles regularly while you are in the air by flexing and pointing your toes. Take 10 consecutive long deep breaths every hour to improve blood circulation.
    • Drink at least 2,000 to 2,500 milliliters of water each day. Avoid caffeine, sedatives, and alcohol. If you have been prescribed venous thromboembolism (VTE) prophylaxis, follow your doctor’s instructions strictly.
    • If your doctor has recommended that you wear a brace or an arm sling, please keep it on for the duration of the flight, except when you recline your seat. You may take it off at that time. If you have an elastic bandage around the affected limb, you may loosen it slightly while in the air.
  • If you are traveling in Economy Class, be sure to select a seat in the exit row or a bulkhead seat.
    • You can recline your seat normally, but support the affected limb to keep it from dangling and to maintain it in normal alignment. Exercise your leg muscles regularly while you are in the air by flexing and pointing your toes. Take 10 consecutive long deep breaths every hour to improve blood circulation. Please get up and move around at least every 30 minutes.
    • Drink at least 2,000 to 2,500 milliliters of water each day. Avoid caffeine, sedatives, and alcohol. If you have been prescribed venous thromboembolism (VTE) prophylaxis, follow your doctor’s instructions strictly.
    • If your doctor has recommended that you wear a brace or an arm sling, please keep it on for the duration of the flight. If you have an elastic bandage around the affected limb, you may loosen it slightly while in the air.
The success of the procedure depends on many factors, such as any complications from the surgery. If the bone becomes deformed and the limb cannot be used, more treatment will be necessary.
 
What is this procedure is not performed?
Some types of broken bones heal on their own, but often they don’t heal correctly, which is why it is important to seek medical treatment to ensure the bone is put back into the right position and heals properly. Complications that can occur without appropriate treatment includes pain caused by a bone that does not heal at all or does not heal well, deformity, bone fragments affecting nearby organs, risk of broken bone piercing through the skin, inability to walk, and post-traumatic osteoarthritis.
 
How a broken bone is treated depends on the extent of the injury and your doctor will determine the best treatment to ensure that your bone heals well and you are able to return to normal activities. Other treatment options for broken bones may include cast immobilization, where the broken bone is put back into place and then kept in position with a cast, a functional cast or brace that allows for limited movement of nearby joints, traction, where the bone is aligned using a gentle, steady pulling action, and external fixation, where metal pins or screws are placed in the bone that are then connected to a metal bar outside the skin.
 

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