What is the treatment and management plan for a patient requiring Open Reduction Internal Fixation (ORIF)?

Management of Patients Undergoing Open Reduction Internal Fixation (ORIF)

Preoperative Assessment and Planning

For patients requiring ORIF, obtain CT imaging as the gold standard for fracture characterization and surgical planning, particularly for complex fractures like tibial plateau injuries where CT demonstrates 100% sensitivity compared to 83% for plain radiographs. 1, 2

Initial Imaging Protocol

• Standard 3-view radiographs should be obtained initially for all fracture types 2, 3
• CT imaging with reconstructions is essential for:
  • Tibial plateau fractures to assess articular depression and predict meniscal/ligamentous injuries 1, 2
  • Distal radius fractures when radiographs are equivocal or to characterize DRUJ involvement 3
  • Scapular fractures to identify primary fragments requiring fixation 4
• MRI is preferred for evaluating radiographically occult fractures and soft tissue injuries in tibial plateau fractures 2

Urological Considerations in Pelvic Fractures

• Perform retrograde urethrography when blood is present at the urethral meatus after pelvic trauma before attempting catheterization 5
• Suprapubic tubes may be placed during ORIF of pelvic fractures without evidence of increased orthopedic hardware infection risk 5
• Establish prompt urinary drainage in patients with pelvic fracture-associated urethral injury, avoiding repeated blind catheter attempts 5

Antibiotic Prophylaxis

Administer prophylactic antibiotics prior to incision for all ORIF procedures, using short-course single-agent cephalosporin regimens (such as cefazolin) for closed and open fractures. 5, 1, 3

Specific Antibiotic Protocols

• For closed extremity fractures and ankle ORIF: Single-dose cephalosporin prophylaxis is recommended 5
• For open fractures:
  • Short-course cephalosporin regimen (≤24 hours) is sufficient 5, 1
  • No benefit to extending prophylaxis beyond 24 hours in type III open fractures without active infection 5, 1
  • Hand fractures do not require routine prophylaxis 5
• Avoid prolonged antibiotic courses (>24 hours) in the absence of risk factors like obesity, immunosuppression, or high ASA score 5

Intraoperative Considerations

Surgical Technique Selection

• For tibial plateau fractures: Standard ORIF is preferred over arthroscopic-assisted techniques, as evidence does not support routine arthroscopic use with no difference in 48-month outcomes 1
• For Bennett fractures: Closed reduction and percutaneous fixation (CRIF) is preferable to ORIF, showing lower rates of post-traumatic arthrosis (26.1% vs 57.5%), less fixation failure, and shorter operative times (30.2 vs 71.9 minutes) 6
• For complex acetabular fractures: Greater fracture complexity via anterior approach increases bleeding risk; intraoperative cell salvage (ICS) may be cost-effective 5

Blood Conservation Strategies

Intraoperative cell salvage may be utilized during ORIF procedures for pelvic trauma, particularly with anterior approaches or preperitoneal pelvic packing, without evidence of worsening clinical outcomes. 5

• ICS can reduce allogeneic transfusion requirements by 40-45% in trauma laparotomies 5
• No increased infection rates with ICS use in penetrating abdominal injuries 5
• Particularly indicated when estimated blood loss exceeds 2000 mL 5

Temperature Management

Apply early measures to reduce heat loss and actively warm hypothermic patients to achieve normothermia, as hypothermia increases mortality and impairs coagulation factor function by 10% per 1°C drop. 5

Postoperative Management

Wound Closure and Drainage

• Use urethral catheter drainage alone without suprapubic cystostomy following bladder injury repair, as this results in shorter hospital stays and lower morbidity 5
• Irrigate wounds thoroughly, close in layers, and apply sterile dressing with splinting 3
• Consider bone grafting for fractures with bone loss or comminution 3

Bladder Injury Management (When Concurrent with Pelvic ORIF)

• Perform surgical repair of complicated extraperitoneal bladder injuries during ORIF given minimal added morbidity 5
• Complicated injuries include: exposed bone spicules in bladder lumen, concurrent rectal/vaginal lacerations, or bladder neck injuries 5
• Catheter drainage for 2-3 weeks is standard for uncomplicated extraperitoneal injuries 5

Critical Pitfalls to Avoid

Technical Errors

• Failure to achieve anatomic reduction leads to post-traumatic arthritis, foot deformities, and significant disability 1
• Avoid prolonged attempts at endoscopic realignment in pelvic fracture urethral injuries, as this increases injury severity without improving long-term outcomes 5
• Do not place vertical limb of scapular incisions too medially, as this limits lateral exposure 4

Patient Selection Considerations

• Geriatric patients (≥65 years) without high-risk comorbidities should be offered ORIF for distal radius fractures, as age alone is not an independent predictor of complications when controlling for comorbidities 7
• Independent predictors of 30-day complications include: admission status, ASA classification, operative time, renal failure, and bleeding disorders 7
• Bilateral calcaneal fractures have significantly higher complication rates and less satisfactory outcomes compared to unilateral fractures due to high-energy mechanisms 8

Timing Considerations

• Open fractures and severe soft tissue injuries require urgent treatment; other fractures should be performed at appropriate timing when soft tissue conditions permit 8
• Primary realignment of pelvic fracture urethral injuries should only be attempted in hemodynamically stable patients within the first few days after injury 5