Ateneo de Zamboanga University
College of Nursing
NURSING SKILLS OUTPUT (NSO)
Open Reduction
I.
DESCRIPTION:
Open Reduction Internal Fixation (ORIF) involves the implementation of implants to guide
the healing process of a bone, as well as the open reduction, or setting, of the bone
itself. Open reduction refers to open surgery to set bones, as is necessary for
some fractures.Internal fixation refers to fixation of screws and/or plates, intramedullary bone
nails (femur, tibia, humerus) to enable or facilitate healing. Rigid fixation prevents micromotion across lines of fracture to enable healing and prevent infection, which happens when
implants such as plates (e.g. dynamic compression plate) are used. Open Reduction Internal
Fixation techniques are often used in cases involving serious fractures such
as comminuted or displaced fractures or in cases where the bone would otherwise not heal
correctly with casting or splinting alone.
Risks and complications can include bacterial colonization of the bone, infection, stiffness and
loss of range of motion, non-union, mal-union, damage to the muscles, nerve damage and
palsy, arthritis, tendonitis, chronic pain associated with plates, screws, and pins,compartment
syndrome, deformity, audible popping and snapping, and possible future surgeries to remove
the hardware.
II.
MATERIALS AND EQUIPMENT NEEDED:
Basic orthopedic tray
Soft tissue tray
Drill bits
Retractors
III.
Basin set
Suction
Power source for drill
Tourniquet
Insufflator
Sheet wadding
PROCEDURE with Illustration
eduction
of
the
glenohumeral
joint
should
be
performed
as
an
emergency
procedure.
There are various techniques to reduce the glenohumeral joint.
Combined traction technique
Modified Stimson technique
Unless reduction is carried out very soon after dislocation, analgesia or anesthesia are typically
necessary. An initial attempt with conscious sedation may succeed. If not, general anesthesia with
complete muscle relaxation may be required. If closed reduction is unsuccessful, open reduction may
be necessary.
Combined traction technique
The patient is placed supine on a table. The injured arm is pulled longitudinally and, with the help of a
second
person,
laterally
as
well.
A sheet around the chest may be used for counter-traction.
Modified Stimson technique
In the modified Stimson technique the patient is placed prone with the shoulder beyond the lateral
edge of the table. A weight is attached to the wrist. Over time the musculature becomes fatigue
and/or relaxed so that the humeral head reduces spontaneously, or with gentle manipulation.
Confirmation of reduction
The reduction is confirmed by x-ray. One should pay special attention to obtain a true AP view in order
to confirm the glenohumeral reduction. Look carefully at the greater tuberosity, and determine its
degree of displacement accurately.
Stay sutures
Insert stay sutures through the supraspinatus, and if necessary, the infraspinatus tendon.
Cleaning the fracture bed
Clean the fracture bed and remove any hematoma. Prepare the margin of the fracture by removing or
reflecting the periosteum, 2 or 3 mm back from the fracture line.
Reduction
Reduce the greater tuberosity properly by pulling on the stay suture(s). Be careful not to fragment the
tuberosity
with
bone
holding
clamps.
Once the fragment is at the correct level, rotate the arm so that the fragment can fit anatomically into
the bony defect.
Preliminary fixation
Temporarily secure the reduction with 1 or 2 K-wires.
General considerations
There are several techniques to fix the greater tuberosity. The choice depends on
Size of the fragment
Bone quality (osteoporosis)
Degree of fragmentation
Techniques
A)
This
Screw
is
include:
fixation
mainly
(cannulated
indicated
B)
for
or
standard
single
large
screws;
fragment
Tension
with
or
with
without
good
bone
band
washers)
quality.
sutures
Tension band sutures are more secure for patients with osteoporosis or comminution because they can
be placed through tendon insertion sites, which may be stronger than the bone itself. The sutures can
be
placed
in
patterns
that
are
optimal
for
stabilizing
comminuted
fractures.
Distal anchorage of tension band sutures can be through an anterior to posterior drill hole in the
humerus (B1), to screws (B2), through suture anchors, or through the lateral cortex of the humerus
just distal to the fracture site. Combinations of these techniques are possible.
Lag screw
Insert a 3.5 mm lag screw. The lag screw should engage the medial cortex, distal to the articular
surface. Cannulated screws may also be used.
Note: washers may make the screw heads more prominent and may result in shoulder impingement.
Washers may be less problematic with more distally placed screws.
Check the fixation under image intensifier control.
If possible, insert a second lag screw in order to achieve rotational stability.
Note: make sure to avoid the axillary nerve by placing the second screw rather proximal.
Once the lag screw(s) are inserted, the K-wire(s) used for temporary fixation, and any stay sutures,
should be removed.
Tension band suture
The most secure anchorage for a tension band suture is in the rotator cuff tendon, just before it
inserts into the bone. Pass the needle parallel to the bone, picking up a good bite of tendon. In
osteoporotic patients, these sutures are stronger than when placed through the bone.
Distal
Distal
anchorage
anchorage
can
be
done
through
drill
a
drill
hole,
hole
typically
horizontal.
Use a 2.0 mm drill bit to prepare the drill hole and a suture passer as needed.
The suture is passed, shown here in a figure-of-eight fashion through the bore hole and tied securely.
The suture should be passed to stabilized comminution as needed.
Distal
anchorage
screw
Pass the suture through a washer and the washer over a cortex screw. The screw is then placed into
the
neck
region.
Note: be aware of the axillary nerve when inserting the screw.
The suture is then tightened and tied.
Using a screw rather than a drill hole for anchoring has the advantage of less space and a smaller
approach required.
Alternative:
intraosseous
sutures
Sutures can be placed through the rotator cuff tendon, and around a small tuberosity fragment, so the
suture lies deep to the fragment and over it. Distal suture anchorage is here shown with monocortical
drill holes, through the humeral cortex distal to the tuberosity fragment. Several such sutures should
be placed to increase stability.
Once the sutures are placed, the tuberosity fragment is reduced and stabilized with K-wires.
Then,
the
sutures
are
tied
individually
to
secure
the
fragment.
Option: the sutures could be placed as mattress sutures through the tendon proximal to the tuberosity
fragment.
Note the monocortical drill holes through which the sutures are anchored distally.
Tension band suture with proximal suture anchors
Especially in osteoporotic bone and/or multifragmentary tuberosities, additional suture anchors are
helpful. If suture anchors are used, they have to be inserted prior to reduction
The suture anchor is placed directly into the margin of the fracture as close as possible to the articular
cartilage.
The sutures are then passed through the supraspinatus tendon, close to the medial insertion line of
the supraspinatus.
Reduce the greater tuberosity anatomically and secure it temporarily with one or two K-wires. Tighten
and tie the sutures of the suture anchors.
Distal fixation is illustrated here to a screw below the tuberosity fragment as shown previously.
Pass the sutures through the washer of a screw inserted in the metaphyseal region distal to the
fragment greater tuberosity to anchor the tension ban. Tighten the suture to hold the tuberosity and
fragment in place and to counteract the pull of the rotator cuff. Remove the inserted K-wires.
Combination of lag screw fixation and tension band suturing
The beneficial effect of tension band suturing can be combined with screw osteosynthesis.
Repair of rotator cuff interval
Place several additional sutures or a running suture to close the lateral portion of the rotator cuff
interval between the supraspinatus and subscapularis tendons. Any rotator cuff tear identified should
also be repaired.
IV.
NURSING RESPONSIBLITIES
Ask consent from the patent.
Explain the procedure to the patient.
Place the patient into a comfortable position.
Assemble all necessary equipments needed for the procedure.
Use a local anesthesia to anesthetize the site for reduction
Have X-ray capabilities in the room
Be prepared to assist the surgeon in applying a cast or splint.
Check tank levels for power equipment before beginning the procedure.
Have adequate help to hold up and stabilize arm during prepping and draping
procedure.
If distal fracture (near wrist), a hand table (side extension table) may be used.
Reference:
http://emedicine.medscape.com/article/2000429-overview#showall
http://www.winchesterhospital.org/health-library/article?id=539804
http://www.netdoctor.co.uk/surgical-procedures/broken-ankle-open-reductionand-fixation.htm
January 22, 2014
Date
Mr. Kimmel Ismael, RN MN
Clinical Instructors
initial
Lintag, Patrick Amos D.A.
BSN- IIIC
