1. Basic Format ORIF Femur (Femoral Shaft) Level II
Procedures
Basic Format
ORIF Femur (Femoral Shaft)
Level II
Goldman p. 330: Surgical intervention may be indicated in certain fractures of the femur in the adult patient. Fractures of the femur in children and young adults are treated with traction followed by immobilization. Intramedullary nails include Hansen-Street, Kuntscher, Lottes, Rush, Schneider, Enders, and Zickel. If a compression plate is used, it must have at least 3 holes above and below the fracture.
Fuller p. 442 Fractures of the femoral shaft are treated with rods, pins, or plates. Compression plates that reduce the fracture mechanically are commonly employed.
B & K p. 751: Mechanical means are used to reduce a fracture and immobilize the parts, maintaining the fragments in proper alignment. Fractures must be handled gently, with support above and below the site to prevent further trauma. A physician should assume responsibility for supporting the fracture site during transfer of the patient to or from a stretcher, bed, or table. The surgeon directs removal of temporary splints, traction, or pneumatic counterpressure. Upon transfer, be sure there are adequate # of personnel to lift gently, and lifters should be on the affected side to support the fracture during transfer.

2. 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.

3. 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 .

4. Terms and Definitions Open Reduction Internal Fixation
Fixation Devices
Intermedullary Rodding
DHS System (Dynamic Hip Screw System)
ORIF: Internal fixation can be accomplished thru a surgical procedure called Open Reduction and Internal fixation. In this procedure, the fracture is reduced (placed in correct anatomic alignment) and nails, screws, or pins are inserted to hold the bones in place (pictures following after pathophys slide).
Open fractures of the arms and legs are most often repaired this way. Hip fractures in older clients are almost always repaired with ORIF to prevent complications and to allow for early rehab.
Fixation Devices: external and internal fixation devices are used to stabilize or immobilize bone, usually after skeletal injury. External devices provide temporary support during healing. Many types of screws, plates, and nails are used for temporary or permanent internal fixation of fractures or bone segments after a reconstructive procedure.
Intermedullary rodding is an internal fixation method used for fractures of the femoral shaft
DHS (Compression plates and screws) are used for fractures of the femoral neck.

5. 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

6. Relevant A & P
STST p. 815
The femur is the largest bone in the body, extending from hip to knee. The proximal end of the femur consists of the femoral head and neck, and the greater and lesser trochanters. A & P views above. The greater trochanter is located on the upper, lateral part of the upper shaft of the femur. It serves as the point of insertion for the gluteus medius and gluteus minimus. The iliopsoas muscle inserts into the lesser trochanter. Located at the distal end of the femur are the lateral and medial condyles that articulate with the condyles of the tibia and form the knee joint. The femoral condyles are separated bya depression called the patellar surface (groove) forming the articulating surface for the patella.

7. Pathophysiology Classifications of fractures Traumatic Pathologic
Closed (Simple)
Open (Compound)
Pathologic
L & B p. 1193: A fracture occurs when the bone is subjected to more kinetic energy than it can absorb. They may result from a direct blow, a crushing force (compression), a sudden twisting motion (torsion), as severe muscle contraction, or a disease that has weakened the bone (pathologic).
B & K p. 751
Fractures vary by cause, location, type of fracture line, and extent of injury. They are either traumatic or pathologic.
Traumatic: the impact, forced twisting, or bending of an accidental injury can break one or more bones in the body. They can occur when the bone has become fatigued from overwork or has inadequate muscle to support during exertion (a stress fx may result). Traumatic fx are either closed or open. Closed are when broken fragments do not protrude thru adjacent tissue to puncture the skin. Open are referred to as compound and are either at the proximal or distal end of bone, or both, protrude thru fracture site and adjacent tissues and skin. Because of the risk of infection developing in the exposed bone, an open fracture is a surgical emergency.
Pathologic: can occur as a result of the demineralization process of bone (eg osteporosis or the aging process) and primary or metastatic malignant bone disease can spontaneously fracture a bone without undue stress. Although they are technically simple fractures, pathologic fractures may require more than simple fixation of bone fragments. Bone allografts or alloplastic grafts may be needed. Methyl methacrylate bone cement may be used to increase the strength of a fixation implant or as an adjunct to fill a bone defect. (eg after removal of a tumor around a pathologic fracture). A compound made from collagen protein mixed with ceramic material may serve to stimulate creation of cartilage and osteoblasts (bone-forming cells).

8. 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
L & B p. 1194: Complete involve entire width of bone, whereas incomplete do not involve the entire width of the bone.
Stable fracture: (nondisplaced): bones maintain their anatomic alignment
Unstable fracture: (displaced): bones move out of correct anatomic alignment. If displaced, immediate interventions are required to prevent further damage to soft tissue, muscle, & bone.

9. Fractures of Femoral Shaft
Alexanders p. 880
Transverse
Oblique
Spiral
Comminuted
Longitudinal split
Complete bone loss

10. Fractures Overview Methods of Treatment:
Closed reduction w/immobilization
Skeletal traction
External fixation
Internal fixation
Electrostimulation
B & K p. 752

11. 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
B & K p Internal fixation is necessary for fractures that are not amenable to closed reduction and stabilization with cast or brace immobilization, skeletal traction, or external fixation methods. The fracture must be reduced to align fragments. Open reduction exposes the fracture sit for realignment under direct visualization; closed reduction sometimes precedes the insertion of an internal fixation device.
STST p. 851: Fx of the femoral shaft require attention and repair asap—a delay of 12 hrs or more can lead to difficulties in reducing the fracture. If delayed, traction is recommended. The choices for treatment include closed reduction, skeletal traction, and surgical repair. In general, repair of femoral fracture by way of external fixation and plates and screws are not as common today as use of intramedullary fixation nails (called femoral nails). Complications associated with plates and screws have been infections and broken or bent screws and plates, which have contributed to femoral refracture. Advantages of the femoral nail (above)

12. Fixation of a short oblique fracture using a plate and screws above and below the fracture

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

14. Fixation of a segmental fracture using a medullary nail

15. Diagnostics
Exams
X-ray
Preoperative Testing

16. 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

17. Surgical Intervention: Anesthesia
Method: General or epidural
Equipment
Upper body Bair hugger available

18. 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

19. 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

20. 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

21. 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

22. Surgical Intervention: Supplies cont’d

23. 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

24. 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

25. Kuntschner Nail Examples of Intramedullary nail and rod devices.
Pics from Fuller and B & K Ortho chapters
Examples of Intramedullary nail and rod devices.

26. Surgical Intervention: Equipment
General
Suction, ESU, Power Source for drill
Specific
Fracture Table or leg holder (optional)

27. Surgical Intervention: Procedure Steps
Phases of fracture treatment
Reduction
Immobilization
Rehabilitation

28. 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
This comes straight from STST pp Too confusing to mix and match sources on this one….

29. 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

30. 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

31. 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.

32. 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.

33. 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.

34. Counts Initial: Sponges and sharps First closing Final closing Sponges

35. 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

36. Specimen & Care
Identified as (N/A)
Handled: routine, etc.

37. Postoperative Care Destination
PACU
Expected prognosis (Good, Depends on Dx)

38. Postoperative Care Potential complications
Hemorrhage
Infection
Other: Damage to….
Surgical wound classification: Class I, unless traumatic injury with visible debris--

39. Resources Alexander’s pp. 880-882 Berry & Kohn p. 751- 755
Goldman pp
Lemone & Burke pp
MAVCC Info Sheets Unit 10
STST pp

40. Supplies and equipment Types Technique
Cast Application
Supplies and equipment
Types
Technique
Explain various casting supplies and equipment.
Discuss types of casts.
Demonstrate application of a short arm or short leg cast.
L & B p. 1200: Casts are rigid devices applied to immobilize the injured bones and to promote healing. It is applied to immobilize the joint above and below the fractured bone so that it will not move while healing. A fracture is first reduced manually and then the cast applied. They are applicable for patients with relatively stable fractures.

41. 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
STST p
B & K p
What should be on a well-stocked cast cart?

42. 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