OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF MIDSHAFT FRACTURES

Indications

1. (a) Open fractures.

2. (b) Painful non-union.

3. (c) Associated injury to the brachial plexus and/or subclavian artery.

4. (d) Floating shoulder.

5. (e) Bilateral fractures.

6. (f) Multiple-injured patient.

7. (g) Soft tissue interposition between the fragments.

8. (h) Impending skin necrosis or penetration from a prominent fragment.

Pre-operative planning

Clinical assessment

• Mechanism of injury: motor vehicle accident, sports injury, fall on outstretched hand, direct trauma.

• Deformity, ecchymosis, swelling, tenderness, crepitation.

• Look for pneumothorax or haemothorax, especially in presence of associated injuries.

• Assess and document vascular status of the upper arm and any difference in peripheral pulses between the injured and contralateral extremity.

• Assess neurological status (usually brachial plexus injury presents as an upper roots traction injury).

Radiological assessment

• Anteroposterior view of the clavicle, including sternoclavicular and acromioclavicular joints (Fig. 1.1).

• Oblique views.

• Lordotic view (usually after surgery for ORIF evaluation).

Operative treatment

Anaesthesia

• General anaesthesia at induction.

• Administration of prophylactic antibiotics as per local hospital protocol (usually second generation of cephalosporin is administered).

Table and equipment

• AO small fragment (3.5 mm) set.

• Ensure availability of the pre-planned plate length. A 3.5 DCP plate or a reconstruction plate can be used (Fig. 1.2a,b).

• Standard osteosynthesis set as per local hospital protocol.

Table set up

• The instrumentation is set up on the side of the operation.

• Image intensifier is from the ipsilateral side.

• Position the table diagonally across the operating room so that the operating area lies in the clean air field.