OPEN REDUCTION AND INTERNAL FIXATION SURGERY (ORIF)

Definition (Mau)
An open reduction and internal fixation (ORIF) puts pieces of a broken bone into place using
surgery. An incision will be made in the skin above the break. The pieces of bone will be moved
into the right place. A plate with screws, a pin, or a rod that goes through the bone will be
attached to the bone to hold the broken parts together. The incision will be closed with staples or
stitches and covered with bandages. The area will be protected with a splint or cast.
Open reduction indicates that surgery is required to fix the fractured bone, and internal fixation
implies the usage of hardware (screws, plates etc.) to hold the bone in place. That is where the
term Open Reduction and Internal Fixation comes from.
The surgery is a two part process:
First, the broken bone is properly positioned back in its original location.
Then, an internal fixation device is surgically fixed to hold the broken bone together.

Purpose
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.
Indication (Gutierrez)
 Open fractures.
 Fractures associated with neurovascular compromise.
 All displaced fractures.
 Ipsilateral lower-extremity fractures.
 Irreducible fractures.
 Pathologic fractures.
Contraindications
 Severe, high-grade open fractures with soft tissue loss and gross contamination.
Possible Complications
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

Nursing Diagnosis
Characters:
 Scrub Nurse (SN): Maryjan Gutierrez
 Circulating Nurse (CN): Maureen Sanchez
 Narrator: Krizzia Raymundo
 Surgery Nurse: Glaira Valencia
 Surgeon: Hanna Sarmiento
 Anesthesiologist: Danica Tarusan
 Medical Technologist: Denise Lagata
 Patient: Alyssa Quibar

PREOPERATIVE PHASE
SCENE 1:ENDORSEMENT OF SURGERY NURSE TO CIRCULATING NURSE
Narrator: Preoperative phase starts the moment that the surgeon decides surgery until
transferred to OR Holding Area. Surgery Nurse endorsing the patient to the circulating nurse.
Surgery Nurse: Good morning, Endorsing patient Alyssa Quibar, 21 years old, female with left
proximal humeral fracture due to cycling accident. Birthdate Aug 3, 1999. For Open Reduction
Internal Fixation ngayong 8 a.m. Weight 55 kg. Height 5’4”. Blood type: O+. No medical
history, no allergies, do not consume alcohol and not smoking. No medication taken. With PNSS
IV fluid at 950 mL level inserted at the right metacarpal vein regulated at 25 gtts/min. NPO po
post-midnight.
Circulating Nurse: Completed na po kaya ang laboratory at diagnostic test ni patient?
Surgery Nurse: Yes po. Based sa radiographs with Grashey, Neer and Axillary View there is a
damage in the patient’s humeral area. Sa CT Scan ang result ay may 3-part proximal humeral
fracture ang patient and confirmed by the MRI scan.
Circulating Nurse: Vital signs po?
Surgery Nurse: Latest vital signs taken T: 38.8 Blood Pressure: 110/90mmHg RR: 23bpm HR:
105bpm O2Sat: 98%. Nurse Mau, prepared na po ang patient nakagown napo at nakatanggal ang
jewelries. Nail polish are removed po.
Circulating Nurse: Paano po kaya ang pre-op meds ni patient?
Surgery Nurse: antibiotic prophylaxis vancomycin administered earlier 7 A.M.
Circulating Nurse: Thankyou, Nurse Glai.
SCENE 2: OR HOLDING AREA
Narrator: Patient is being transferred to the OR holding area while the circulating nurse is
preparing the pre-operative checklist.
Circulating Nurse: Goodmorning po, ako po si Nurse Maureen, isa po sa mga nurse na
maghahandle sa inyo sa surgery. Ano nga po ulit ang pangalan nila?
Patient: Ako po si Alyssa Quibar
Circulating Nurse: Birthday po?
Patient: August 3, 1999.
Circulating Nurse: Confirmed ko lang, Ma’am kung nakapirma na kayo sa informed consent?
Patient: Opo tapos na po.
Circulating Nurse: Kumusta po ang pakiramdam ninyo ma’am?
Patient: Kinakabahan ako nurse. Takot kasi ako sa ganito. Masakit po ba?
Circulating Nurse: Ma’am, tuturukan po kayo nang anesthesia pampatulog. Ito po ay ituturok
sa inyong IV mamaya. Wala po kayong mararamdamang sakit habang nasa surgery po. Ma’am
may maintenance drugs ka po ba?
Patient: Wala po nurse. Nurse Maureen, ano na po mangyayari saakin pagkatapos nang surgery?
Circulating Nurse: Ma’am ineencourage po na igalaw ang apektadong braso. Tuturuan po kayo
nang exercise para doon. Asahan din po na nakataas ang braso para maiwasan ang pamamaga.
Patient: Makakarecover pa kaya ako, Nurse?
Circulating Nurse: Susundin po natin ang irerekomenda nang doctor, ma’am. Tulad po nang
pag-inom nang gamut para sa kirot, panatilihin pong malinis ang tahi, nakataas ang apektadong
braso, huwag pong bigyan nang pressure o gamitin ang braso sa mabibigat na Gawain hangga’t
wala pang abiso nang doctor at ipagpapatuloy ang exercise na tinuro sa inyo.
Patient: Ah ganun po ba nurse salamat po.
Circulating Nurse: May kasama po ba kayong guardian?
Patient: Nanay ko po.
Circulating Nurse: Sige po. Huwag kayong mag-alala, inform ko din si mother sa mga dapat
gawin mo.
Patient: Maraming salamat po ulit.
SCENE 3: OR PREPARATION
NARRATOR: During the operating room preparation the circulating nurse ensures that the
theater is clean. The Circulating Nurse will do the following:
Circulating Nurse:
1. Checks all equipment for proper functioning such as cautery machine, suction machine,
OR light and OR table. (CN will perform first*)
2. Make sure theater is clean. (CN will perform first*)
3. Arrange furniture according to use. (CN will perform first*)
4. Place a clean sheet, arm board (arm strap) and a pillow on the OR table. (CN will
perform first*)
5. Provide a clean kick bucket and pail. (CN will perform first*)
6. Collect necessary stock and equipment. (Narrator continue*)
7. Turn on aircon unit. (CN will perform first*)
NARRATOR: On the other hand, the scrub nurse is busy preparing the following:
Scrub Nurse:
1. Ensures that the circulating nurse checked the equipment. (Narrator continue*)
2. Ensures that the theater has been cleaned before the trolley is set. (Narrator continue*)
3. Prepares the instruments and equipment needed in the operation. (Narrator continue*)
SN: Nurse, Mau. Checked na po ba ang equipment?
CN: Yes, Nurse Mj. Naka-set na din ang theater.
SN: Okay, prepare ko na din instruments.

INTRAOPERATIVE PHASE
SCENE 4: ADMISSION TO OR
NARRATOR: The intraoperative phase starts when the patient is admitted to the operating room
until transfer to the recovery area. The scrub nurse:

Scrub nurse:
1. Uses sterile technique for scrubbing, gowning and gloving. (SN will perform first*)
2. Receives sterile equipment via circulating nurse using sterile technique. (may iaabot si
tyamau via screen tas iimik si Mj nang *received*)

NARRATOR: When the surgical team arrives the circulating nurse:

Circulating Nurse:
 1. Transfer and place the patient in a beach-chair position in the OR table. (CN will
perform first*)

NARRATOR: The anesthesiologist will induct the anesthesia through IV while the circulating
nurse will assist the anesthesiologist and will perform the following:
Circulating Nurse: Open po ang OR light. Naka positioned na din po si patient.
Narrator: While the anesthesiologist are inducting the anesthesia, the circulating nurse
anticipate the anesthesiologist’s needs.
Anesthesiologist: General anesthesia, propafol inducted through IV. Nurse Mau beach-chair
position pa rin. Paasikaso nalang ng fractured area sa arm boards.
CN: Okay po doktora.
Anesthesiologist: Assess ko lang ang patient kung natalab na ang anesthesia. Ma’am kinig niyo
po ba ako?
Patient: Opo (mahina)
Anesthesiologist: Alam niyo po ba kung nasan kayo?
Patient: Nasa hospi---------
Anesthesiologist: Propafol is working. The patient is now asleep.
Narrator: After placing the patient’s arms in the arm boards, the circulating nurse is ready for
skin preparation and then for draping the patient.
*CN will change clean gloves to sterile gloves*
CN: For skin preparation po, I prepared 3 sponges for each 7.5% povidone iodine and 10%
povidone iodine. Sa paglilinis po una kong ilalagay ang 7.5% povidone iodine from inner to
outer area. Three times po gagawin for each sponges. Next naman po ay ang 10% povidone
iodine, 3 times din po from inner to outer area. Afterwards po ay, kunin ko lang po ang kanyang
vital signs. Temperature: 36.7 C. RR: 19 bpm. PR: 95 bpm. BP: 110/70 bpm, O2Sat: 98 %

NARRATOR: The scrub nurse:

1. Perform assisted gowning and gloving to the surgeon and assistant surgeon as soon as
they enter the operation suite. (Narrator continue*)
2. Assemble the drapes according to use. Start with towel, towel clips, draw sheet and
then lap sheet. (SN will perform first*)
3. Place blade on the knife handle using needle holder, assemble suction tip and suction
tube. (SN will perform first*)
 4. Bring Mayo stand and back table near the draped patient after draping is completed.
(SN will perform first*)
5. Secure suction tube and cautery cord with towel clips or allis. (SN will perform
first*)
6. Prepares sutures and needles according to use. (SN will perform first*)
7. Maintain sterility throughout the procedure. (Narrator continue*)
8. Awareness of the patient’s safety. (Narrator continue*)
9. Adhere to the policy regarding sponge count/ instruments count/ surgical needles.
(Narrator continue*)
10. Arrange the instrument on the mayo table and on the back table. (SN will perform
first*)

Narrator: After skin preparation of the circulating nurse and draping of the scrub nurse. The two
are now ready for the surgical counting.

Counting:
1. Allis forceps (6) 16. Awl (1)
2. Curved Mayo Scissors (3) 17. Sutures (4)
3. Reduction Clamp (2)  No. 2 Ethibond Suture (1)
4. Thumb Forceps (2)  Chromic 1 (1)
5. Senn Retractor (2)  Chromic 0 (1)
6. Army Navy Retractor (1)  Chromic 2.0 (1)
7. Weitlaner Retractor (1) 18. Needle Holder (1)
8. Suction tip (1) 19. Needle Handle (2)
9. Suction tube (1)  No. 3 (1)
10. Curette (1)  No. 4 (1)
11. Periosteal Elevators (1) 20. Blades (2)
12. Proximal Humeral Locking Plate (1)
 No. 10 (1)
13. K-wire (6)
 No. 20 (1)
14. Screws (9)
21. Suture needles (2)
 3.5 Non Locking Screws (3)
 Taper-point (1)
 4.0 Locking Screws (6)
 Cutting needle (1)
15. Drill (1)
22. Sponges (8)

CN: Counting of instruments, done total number of 58

NARRATOR: Before the operation begins, the circulating nurse will perform time out.
Circulating Nurse: Patient X, 21 years old, male with proximal humeral fracture due to cycling
accident. Birthdate Aug 3, 1999. Surgery to perform Open Reduction Internal Fixation in a
Dectopectoral Approach in the proximal humeral site. No specimen needed, no medication taken
prior to surgery and no known allergies. The patient is in beach-chair position. Now, for the
surgical team introduction.
Circulating: Maureen Sanchez, circulating nurse
Scrub: Maryjan Gutierrez, scrub nurse
Surgeon: Dra. Hanna Sarmiento, surgeon. I have already marked the incision site of the patient
above the proximal humeral fracture.
Anesthesiologist: Danica Tarusan, anesthesiologist. Pre-op vancomycin given 1 hour prior to the
surgery. Propafol through IV was given as anesthetic drug.
Medical Technologist: Denise Lagata, technologist. Assigned for the fluoroscopic images.

SCENE 5:BEFORE THE INCISION

NARRATOR: Before the incision begins, the scrub nurse:

1. Provide 2 sponges on the operative site prior to incision. (SN will perform first*)
2. Passes the 1st knife for the skin to the surgeon with blade facing downward. (SN will perform
first*)
3. Hand the retractor to the surgeon. (SN will perform first*)
4. Watch the field/s procedure and anticipate the surgeon’s needs.. (Narrator continue*)
5. Pass the instrument in a decisive and positive manner. (Narrator continue*)
6. Watch out for hand signals to ask for instruments a keep instrument as clean as possible by
wiping instruments with moist sponge. (Narrator continue*)
7. Always remove charred tissue from the cautery tip. (SN will perform first*)
8. Notify circulating nurse if you need additional instruments as clear as possible (Narrator
continue*)
9. Keep 2 sponges on the field. (SN will perform first*)
10. Remove excess instrument from the sterile field. (SN will perform first*)
11. Adhere and maintain sterile technique and watch for any breaks. (Narrator continue*)
NARRATOR: The operation begins. Configuration of the axillary nerve:
Surgeon: Cutting time?
CN: 8.00 a.m.
Surgeon: Scalpel
SN: *hands the scalpel*

NARRATOR: The surgeon incised the patient with 6-8 cm incision.

Surgeon: Sean Retractor

SN: *hands over the retractor*
Surgeon: Thumb Forceps
SN: *hands over the forceps*
Surgeon: Mayo scissors
SN: *hands over the mayo scissors*

NARRATOR: The surgeon will identify the axillary and cephalic vein by dissection. Once
identified, reduction will start.

Surgeon: Ethibond suture

SN: *hands over the sutures*
Surgeon: Senn Retractor
SN: *hands over the retractor*

NARRATOR: Sutures are placed in the greater and lesser tuberosity. This is to allow
mobilization of the fracture fragments which in turn assist in reduction. The bicep tendon was
identified.

Surgeon: Periosteal Elevator

SN: *hands over the elevator*
Surgeon: Curette
SN: *hands over the currete*

NARRATOR: To scrape clot and callous formation out of the bone before fixation. This is to
disinfect the part of the fracture. Elevators allow cleaning of tissue before the placement of
hardware. During the operation, the circulating nurse must:
1. Remain in theater throughout the operation. (Narrator Continue*)
2. Focus the OR light every now and then. (Narrator Continue*)
3. Ensure the theater door remain closed and patient’s dignity is upheld. (Narrator
Continue*)

Circulating Nurse: *focus OR light* *notes*

Circulating Nurse: Dra.Tarusan. Update po of the patient’s status.
Anesthesiologist: Stable ang patient. Temperature: 37 C. RR: 20 bpm PR: 98 bpm. BP: 110/90
bpm. O2Sat: 97%
Circulating Nurse: Noted po, Document ko po

Surgeon: Locking plate

SN: *hands over the plate*

NARRATOR: This plates are used for weight bearing bones such as the humerus. This is placed
5mm lateral to the bicipital groove.

Surgeon: K-wire
SN: *hands over the K-wire*
Surgeon: Drill
SN: *hands over the drill*

NARRATOR: This is used for temporary fixation of the reduced humeral fracture. Drill is used
for the insertion of the screw.
Surgeon: 3.5 nonlocking Screws
SN: *hands over the screws*
Surgeon: Reduction clamp
SN: *hands over the clamp*
Surgeon: K-wire
SN: *hands over*
Surgeon: Weitlaner
SN: *hands over the retractor*

NARRATOR: Reduction clamp will secure the top part of the locking plate to the bone while
placing the screws. Additional K-wire was added at the head of the plate. Weitlaner retractor will
allow to hold tissue while placing the K-wires.

Surgeon: Prepare fluoroscopy images

SN: Assist the surgeon by moving the patient’s hands
Medtech: The plate is in right position.
Surgeon: Okay, continue.

NARRATOR: Fluoroscopy is performed to ensure the placement of the plate and the screw. And
is evaluated by internal and external rotation.

Surgeon: Locking Screw

SN: *hands over the screw*
Surgeon: Drill
SN: *hands over*

NARRATOR: After the reduction process, remaining screws are placed at the head and shaft.
Locking screws are placed to compress the head fragment, thus will allow for fixation.
Surgeon: Fluoroscopic image please
SN: Internal and External Rotation
Medtech: Properly aligned and set, Dra.

NARRATOR: Once the locking plate is properly aligned with the head and the shaft of the
humeral bone, fixation will be performed.

Surgeon: Locking Screws

SN: *hands over*
Surgeon: Prepare for the final fluoroscopy
SN: *moves the arm of the patient*
Medtech: Locking plate properly aligned, screws are well connected.

NARRATOR: After the final images, the surgeon will now close the incision by sutures.

Surgeon: Round needles with chromic 1 suture

SN: *hands over*
Surgeon: Army Navy
SN: *hands over*
Surgeon: Chromic 0 suture
SN: *hands over*

CN: Preparation for counting before suturing the fascia

Counting:
23. Allis forceps (6) 30. Suction tip (1)
24. Curved Mayo Scissors (3) 31. Suction tube (1)
25. Reduction Clamp (2) 32. Curette (1)
26. Thumb Forceps (2) 33. Periosteal Elevators (1)
27. Senn Retractor (2) 34. Proximal Humeral Locking Plate (1)
28. Army Navy Retractor (1) 35. K-wire (6)
29. Weitlaner Retractor (1) 36. Screws (9)
  3.5 Non Locking Screws (3) 41. Needle Handle (2)
 4.0 Locking Screws (6)  No. 3 (1)
37. Drill (1)  No. 4 (1)
38. Awl (1) 42. Blades (2)
39. Sutures (4)  No. 10 (1)
 No. 2 Ethibond Suture (1)  No. 20 (1)
 Chromic 1 (1) 43. Suture needles (2)
 Chromic 0 (1)  Taper-point (1)
 Chromic 2.0 (1)  Cutting needle (1)
40. Needle Holder (1) 44. Sponges (8)

CN: Counting of instruments, done total number of 58

Surgeon: Chromic 2.0 on cutting needle

SN: *hands over*

NARRATOR: After the closure of the incision, the scrub nurse will now help in applying the
dressing.
1. Clears away instrument and equipment.
2. Removes and disposes of drapes
(Scrub nurse will perform*)

NARRATOR: On the other hand, the circulating nurse will assist the scrub nurse in removing
and disposing drapes.
1. Assist the scrub nurse taking the instrumentations to the service room.
2. Helps to prepare the patient for the recovery room.

(Circulating nurse will perform*)

NARRATOR: The scrub nurse must will now remove her Personal Protective Equipment,
completes documentation and later hand the patient over to recovery room.
SN: All PPE removed na po Nurse, Maureen.
CN: Okay Nurse Mj, mag sasign na po ako sa theater register.

POSTOPERATIVE PHASE
NARRATOR: Postoperative phase will start with the patient on the recovery room until follow-
up check-up.
CN: Goodmorning po. Endorsing patient Alyssa Quibar, 21 years old female. Undergone Open
Reduction and Internal Fixation Surgery via Dectopectoral Approach due to cycling accident. 8
A.M – 10 A.M under Dra. Sarmiento. With PNSS at 750 mL in the left metacarpal vein
regulated at 25 gtts/min. Latest vital signs are as follows. Temperature: 36.8 C. RR: 21 bpm. PR:
101 bpm. BP: 110/80 bpm, O2Sat. 99 Bpm.
NARRATOR: the circulating nurse will ensure that the theater is ready for the next case.
 RESOURCES
https://www.winchesterhospital.org/health-library/article?id=539804
https://www.healthline.com/health/orif-surgery
https://www.healthline.com/health/orif-surgery#risks-and-side-effects