Procedures

Basic Format

ORIF Femur (Femoral Shaft)

Level II

Objectives• Assess the anatomy, physiology, and

pathophysiology of the ORIF Femur.• Analyze the diagnostic and surgical interventions

for a patient undergoing an ORIF Femur.• Plan the intraoperative course for a patient

undergoing ORIF Femur.

• Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives

• Choose the appropriate patient position• Identify the incision used for the procedure• Analyze the procedural steps for ORIF Femur.• Describe the care of the specimen• Discuss the postoperative considerations for a

patient undergoing ORIF Femur .

Terms and Definitions

• Open Reduction Internal Fixation

• Fixation Devices– Intermedullary Rodding– DHS System (Dynamic Hip Screw System)

Definition/Purpose of Procedure

• Realignment and fixation of a fracture of the femur through an operative incision

• Goal: solid union of bone in perfect alignment, to return joints and muscles to normal position, to prevent or repair vascular trauma, and to rehabilitate the pt as early as possible

Relevant A & P

Pathophysiology

• Classifications of fractures– Traumatic

• Closed (Simple)

• Open (Compound)

– Pathologic

Pathophysiology: Type of Fractures• Oblique (45 degree angle to bone)

• Spiral (curves around bone)

• Avulsed (fracture pulls bone & other tissues away from the point of attachment.

– Comminuted (bone breaks in many pieces)

– Compressed (bone is crushed)

– Impacted (broken bone ends are forced into each other)

– Depressed (broken bone is forced inward)

• Complete vs Incomplete• Stable vs Unstable

Fractures of Femoral Shaft

Fractures Overview

Methods of Treatment:

Closed reduction w/immobilization

Skeletal traction

External fixation

Internal fixation

Electrostimulation

Internal Fixation

• Overview• Screws, Plates, Nails• Intermedullary nailing

– Advantages: increase and evenly spread load sharing of the bone, reduced scarring, minimal blood loss, low infection rate, fracture hematoma preserved at fracture site.

– Type of nail

Fixation of a short oblique fracture using a plate and screws above and

below the fracture

Fixation of a long oblique fracture using screws through the fracture site

Fixation of a segmental fracture using a medullary

nail

Diagnostics

• Exams– X-ray

• Preoperative Testing

Surgical Intervention:Special Considerations

• Patient Factors• Room Set-up

– Position sterile tables on the affected side

• Etc– Have x-rays in room– Some surgeons prefer to double-glove and remove the

first pair following completion of draping– Observe x-ray precautions; notify radiology dept when

pt is being positioned for preliminary films; intraop x-ray will be used (either via portable machine or C-Arm flouroscopic image intensification)

– Wear protective goggles

Surgical Intervention: Anesthesia

• Method: General or epidural

• Equipment– Upper body Bair hugger available

Surgical Intervention: Positioning

• Position during procedure– Lateral position on Fracture Table or without; might be supine

• Supplies and equipment – If no FX Table, may use a leg holder and pillow placed between

legs and clear adhesive drape used to drape perineum out of field before skin prep

– Wide adhesive to stabilize patient at shoulders in addition to safety strap over the unaffected thigh

• Special considerations: high risk areas– Arm on unaffected side on armboard, other arm either flexed

across chest or postioned on pillow on Mayo stand– Padding around feet, ankles, bony prominences

Surgical Intervention: Skin Prep

• Method of hair removal: wet prep

• Anatomic perimeters– Begin over fracture site extending from

umbilicus to below the knee, well beyond midline anteriorly, and down table posteriorly. If no FX Table, leg and foot are completely prepared.

• Solution options: Betadine, Duraprep, Hibiclens

Surgical Intervention: Draping/Incision

• Types of drapes– Folded towels and sterile, plastic adhesive drape.

fenestrated sheet covers the field

• Order of draping – Four sheets may be draped around perimeter of site;

• Special considerations• State/Describe incision: at fracture site

Surgical Intervention: Supplies

• General– Basin set, Suction tubing, ESU pencil/holder, needle

magnet or counter, asepto or bulb syringe, graduated cylinder, 6 “ tube or impervious stockinette (if FX Table is not used)

• Specific– Sterile plastic adhesive U-drapes (2) (perineum and

operative site)

– Suture & Blades: Blades (2) # 10

– Medications on field (name & purpose)

– Catheters & Drains

Surgical Intervention: Supplies cont’d

Surgical Intervention: Instruments

• General– Basic orthopedic procedures tray

• Specific– AO femoral nail instrumentation set– Hip retractor tray– Bone holding instruments tray– Drill bits, including ¼ “ gauge– Power reamer and drill and cords, long guide wires, Extra

guide pins, screw set– Fixation device: Rods or nails (eg. Hanson-Street,

Kuntscher, Rush) or compression set and instrumentation particular to that device

Surgical Intervention: Instruments

• Specific– 13-mm calibrated drill bit, Large reverse awl, tissue

protector, radiographic ruler, a guide rod for cannulated nails, calibrated wire guide

Kuntschner Nail

Examples of Intramedullary nail and rod devices.

Surgical Intervention: Equipment

• General– Suction, ESU, Power Source for drill

• Specific– Fracture Table or leg holder (optional)

Surgical Intervention: Procedure Steps

• Phases of fracture treatment– Reduction– Immobilization– Rehabilitation

Surgical Intervention: Procedure Steps

• Surgeon confirms nail length with flouroscopy

• Obtains AP view of proximal femur

• Ruler is held along the lateral side of the thigh and placed until the top is level with tip of greater trochanter, skin marked at this level

• AP view of distal femur is taken

• Proximal end of the ruler is placed at the skin mark and nail length is read from the ruler

Surgical Intervention: Procedure Steps

• Surgeon makes a longitudinal incision proximal to the greater trochanter thru the gluteus medius and maximus

• The 3.2 calibrated guidewire is placed using the power drill. It is placed in the medullary canal to a depth of 100 mm at the entry point where the nail will be placed.

• The 13-mm cannulated drill bit with tissue protector is placed over the guidewire and drilled to a depth of 100 mm. This opening will allow for insertion of 9 to 12 mm nails.

• For 13- to 15- mm nails, the broach is used instead to enlarge the opening. The drill bit is removed after the opening has been created.

• STSR assembles insertion instruments

Surgical Intervention: Procedure Steps

• Use of cannulated screws:

• The correct connecting screw is placed into the insertion handle and secured to the nail with the ball hexagonal screwdriver.

• The driving cap is screwed onto the insertion handle. This serves as the striking point when the hammer is used.

• STSR hands the assembly to the surgeon, who manually inserts the nail into the femoral opening as far as possible.

• For cannulated nails, the nail is inserted over the guidewire, which passes thru an opening in the side of the insertion handle

Surgical Intervention: Procedure

• Next: the surgeon is given the hammer to drive the nail into the distal metaphysis. The guidewire is removed.

• Next: the proximal locking bolts are placed:

• The standard aiming arm is attached to the insertion handle. The STSR assembles the triple trocar assembly, 11.0/8.0 mm protection

sleeve, 8.0/4.0 mm drill sleeve, and 4.00 mm trocar.• The STSR loads the 4.0-mm calibrated drill bit onto the power drill

and hands it to the surgeon, who drills thru both cortices until the drill

sleeve presses against the cortex. • The locking bolt length is read from the calibrated drill and

communicated by the surgeon to the STSR.

Surgical Intervention: Procedure

• The STSR hands the surgeon the locking bolt, protection sleeve, and screwdriver to insert the locking bolt. This step is repeated for the second proximal locking bolt.

• Next: distal locking bolt is placed with the use of flouroscopy: C-Arm is placed to show the most distal hole in the femoral nail

• A stab incision is made over the site of the distal hole with a # 10 knife blade

• STSR hands surgeon the power drill w/4.0 mm drill bit, which is placed in the distal hole and drilled thru both cortices.

• Using a depth gauge, the surgeon measures the length of the locking bolt.

• STSR should remind surgeon to add 2-4 mm to the reading to make sure the thread of the bolt engages far into the cortex.

• STSR hands the surgeon the correct size bolt, holding sleeve, and screwdriver for insertion of the bolt.

Surgical Intervention: Procedure

• Next: insertion instruments are removed.

• STSR hands the surgeon the hexagonal screwdriver and end cap to be threaded onto the proximal end of the nail.

• STSR should be prepared to hand the surgeon the ratchet wrench to tighten the end cap.

• Surgeon closes the stab incisions, places dressings, and pt taken to PACU.

Counts

• Initial: Sponges and sharps

• First closing

• Final closing– Sponges– Sharps

Dressing, Casting, Immobilizers, Etc.

• Types & sizes: N/A

• Type of tape or method of securing:

heavy gauze pad and tape of choice—foam or silk tape

Specimen & Care

• Identified as (N/A)

• Handled: routine, etc.

Postoperative Care

• Destination– PACU

• Expected prognosis (Good, Depends on Dx)

Postoperative Care

• Potential complications– Hemorrhage– Infection– Other: Damage to….

• Surgical wound classification: Class I, unless traumatic injury with visible debris--

Resources

• Alexander’s pp. 880-882

• Berry & Kohn p. 751- 755

• Goldman pp. 330-332

• Lemone & Burke pp. 1193-1203

• MAVCC Info Sheets Unit 10

• STST pp. 851-853.

Cast Application

Supplies and equipment

Types

Technique

Casting Supplies

• Plaster of Paris or fiberglass cast material

• Webril and soft roll as needed

• Bucket and water to requested temperature

• Clean gloves

• Cast cutter, spreaders, heavy bandage scissors on standby

Types of Casts: See STST Table 21-5

• Short arm• Long arm• Shoulder spica• Short leg• Long leg• Cylinder• One-and-one half hip spica cast• Body jacket