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Pre-operative management

Discuss about the Pre and Post Operative Management of ORIF for Orthopaedics.

One of the most complicated surgeries belonging to the sector of the orthopaedics is considered to be the open reduction internal fixation. Internal fixation can be defined as an orthopaedic operation that involves a surgical implant procedure that serves the purpose of repairing bone fractures. Internal fixation is a surgical phenomenon that can be aged back to the late 19th centuries, it has advanced considerably.  There are different variations of internal fixation surgeries available nowadays. One of the most common and most abundantly used variations is the open reduction internal fixation surgery or ORIF (Assal, Ray & Stern, 2015). Open reduction internal fixation surgery is nothing but a open surgery to set not just place the implant but also set the bone in the right alignment with it; which is required in case of some fractures, such as displaced fracture or comminuted fractures.

However, the entire surgical procedure is meticulous and precise, involving intricate steps and hence, there are various risk factors associated with it as well like infection, loss of mobility range, mal-union, muscular damage, bacterial colonization of the bone, and many more. Hence a specialized and well articulated patient centred preoperative and post operative management is an absolute prerequisite for a successful ORIF surgery (Backes et al., 2014). This assignment will focus on stringing together an apt pre operative and post operative management plan for a patient undergoing ORIF surgery taking the example of a case study; the case study represents a condition where the patient is in need for a ORIF in the right tibia and fibula due to a motor bike crash.

The open reduction internal fixation surgery utilizes different equipments and interventions and is undoubtedly a very complex and there are several precautionary measures that are needed to be taken while preparing a patient for the surgery. The very first and foremost consideration in case of any treatment procedure is patient education and obtaining consent from the patient. Hence, the patient will be required to be informed about the entire procedure, the medication used, the implant used, the precaution, and the possible side effects of the ORIF surgery. Along with that, the legal framework for safe and patient centred care would also require taking informed consent from the patient or any member of the family before proceeding with the surgical procedures (Basques et al., 2015).

Post operative management

Followed by that, a few preoperative tests will need to be performed in order to check the suitability of the patient before going forward with the surgery, so that there is no probable risk for any perioperative complication or mortality. Firstly the risk for cardiac arrest during a complicated surgery is the highest; hence a few tests will need to be performed like BUN/Cr, CXR, and EKG. Along with that, the possibility of the patient haemophilia, renal or hepatitic diseases will also need to be tested that can increase the risk of patient succumbing to pulmonary complicatiosn or other perioperative mortalities (Chalmers et al., 2014). The radiographic imaging or CT scan of the fractured right tibia and fibula will also be required to check the exact position and severity of the broken bones.

In case of the medication needed as a part of preoperative management and preparation of the patient, a few perioperative antibiotics will need to be administered such as Cefazolin or Cefuroxim in order to avoid the chances of the patient acquiring surgical site infection or bacterial colonization of the bone during or after the surgery (Chen et al., 2014).

Before the commencement of the surgery, the patient will need to be administered anaesthesia, either a general anaesthesia that will help the patient sleep though the entire surgical procedure. Or the patient can be administered a local anaesthesia, the choice of anaesthesia will depend entirely upon the severity of the fracture and past medical history of the patient. The wound site will also need to be cleaned aseptically, and the vital signs of the patient will need to be monitored throughout, specifically the heart rate and the blood pressure of the patient.

It is very common for patients to feel anxious prior to a complicated surgery and that will be reflected as the high heart rate and blood pressure which can increase the risk for peri- operative complications like seizure, panic attack and myocardial infarction. Hence the patient needs to be made comfortable and relaxed, all the while being counselled throughout so that he is reassured and relaxed throughout the surgery. A mild relaxation medication can also be administered if the condition of the patient demands (Jiang et al., 2014).

Open reduction internal fixation surgeries are undoubtedly one of the best options for treating communited fractures, however there are a myriad of post operative complication that follows an open reduction internal fixation surgery. Some example of the post operative complications include risk for infection, bacterial colonization of the bone, incision site bleeding, nerve damage, bone misalignment, restricted mobility, bone damage or skin irritation due implant material, and many more. Therefore, the need for adequate post operative management is crucial for speedy recovery for the patient (Leroux et al., 2014).

In case of any surgery, pain management is one of the first course of action needed to be taken; it needs to be mentioned in this context that pain medication needs to be administered to the patient during the surgery and after the surgery as well. as the effects of these analgesics wear off within 8 to 12 hours, hence, in most cases the patients require the aid of narcotic pain medication, preferably for a short period of time. In case the patient feels more pain when the swelling peaks, administering narcotic pain medication like Percocet, Norco or Vicoden, administered for a small amount of time will help in better management of the pain. Although these pain medications have significant side effects like nausea, vomiting, drowsiness, and constipation, hence these issues also need to be addressed while administering narcotic pain medication to the patient. In case of extreme pin and swelling periodic icing can also prove to be extremely helpful (Lin et al., 2014).

Another very important element of post operative management can be considered the infection control, and there are a few steps of an optimal aseptic wound management, associated with it. Taking the wound care into consideration, after the surgery is completed, the wound needs to be covered with sterilized gauze and be placed inside a plaster splint. In case of excessive bleeding, the cast needs to be changed and the wound needs to be dressed again taking extreme caution to avoid contamination. In some cases the chances of blood clotting right after the surgery is seen, in such cases the patient will need to take a blood thinner for a short period of time right after the surgery (Smith, Stone & Furey,  2016).

Another complication that is frequently encountered in case of ORIF or any other surgical treatment for fracture is the misaligned regrowth of bones; in order to avoid the occurrence of a misaligned growth of bones for the patient under consideration in the assignment, a few intervention techniques can be implemented. For instance, early weight bearing can be one intervention technique that will help the casting for any incidence of delayed or late union. Another highly beneficial intervention technique can be the bone stimulation technique, which functions by delivering electromagnetic waves to stimulate bone alignment. There is some medication available for treating the mal- alignment or delayed alignment of the bone such as teriparatide, especially for the patent that have osteoporosis (van Dreumel et al., 2015).

After a bone restructuring surgery, it is very common for the patient to experience mobility restriction, while the discomfort to some extent is physical; the fear to movement is the most contributing factor behind it. After 3-4 days of the surgery, the patient should be encouraged to elevate the operated leg to the chest whenever he is comfortable to decrease and retain mobility of the leg. As the patient continues to progress and the swelling is reduced the patent should be encouraged and assisted to walk as well, so that mobility restriction or anxiety does not develop.

Lastly, diet is also a significant part of a post operative management, right after the surgery the patient might feel nauseated due to the side effects of the anaesthetics, in such cases the patient should remain on light, liquid diet. Slowly the patient should be moved to protein and mineral rich diet, and in order to boost elevated bone growth, food rich in calcium and vitamin D is preferred (Xia et al., 2014).

Conclusion:

On a concluding note, it can be said that the patient undergoing a internal fixation open reduction surgery will require a highly specialized and customized care plan. Hence the care planning and management must take into consideration all the specific factors related to the health of the patient and past medical complications. ORIF is a very common surgical intervention technique, which is opted in all situations where the patient suffers a communited fracture. And with proper pre and post operative management, this surgical intervention has proved to yield the best results for treatment of severe fractures.  

References:

Assal, M., Ray, A., & Stern, R. (2015). Strategies for surgical approaches in open reduction internal fixation of pilon fractures. Journal of orthopaedic trauma, 29(2), 69-79.

Backes, M., Schepers, T., Beerekamp, M. S. H., Luitse, J. S., Goslings, J. C., & Schep, N. W. (2014). Wound infections following open reduction and internal fixation of calcaneal fractures with an extended lateral approach. International orthopaedics, 38(4), 767-773.

Basques, B. A., Miller, C. P., Golinvaux, N. S., Bohl, D. D., & Grauer, J. N. (2015). Morbidity and readmission after open reduction and internal fixation of ankle fractures are associated with preoperative patient characteristics. Clinical Orthopaedics and Related Research®, 473(3), 1133-1139.

Chalmers, P. N., Slikker, W., Mall, N. A., Gupta, A. K., Rahman, Z., Enriquez, D., & Nicholson, G. P. (2014). Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction–internal fixation and hemiarthroplasty. Journal of shoulder and elbow surgery, 23(2), 197-204.

Chen, H. W., Liu, G. D., Ou, S., Zhao, G. S., Pan, J., & Wu, L. J. (2014). Open Reduction and Internal Fixation of Posterolateral Tibial Plateau Fractures Through Fibula Osteotomy–Free Posterolateral Approach. Journal of orthopaedic trauma, 28(9), 513-517.

Jiang, J. J., Phillips, C. S., Levitz, S. P., & Benson, L. S. (2014). Risk factors for complications following open reduction internal fixation of distal radius fractures. The Journal of hand surgery, 39(12), 2365-2372.

Leroux, T., Wasserstein, D., Henry, P., Khoshbin, A., Dwyer, T., Ogilvie-Harris, D., ... & Veillette, C. (2014). Rate of and risk factors for reoperations after open reduction and internal fixation of midshaft clavicle fractures: a population-based study in Ontario, Canada. JBJS, 96(13), 1119-1125.

Lin, T., Xiao, B., Ma, X., Fu, D., & Yang, S. (2014). Minimally invasive plate osteosynthesis with a locking compression plate is superior to open reduction and internal fixation in the management of the proximal humerus fractures. BMC musculoskeletal disorders, 15(1), 206.

Smith, N., Stone, C., & Furey, A. (2016). Does open reduction and internal fixation versus primary arthrodesis improve patient outcomes for Lisfranc trauma? A systematic review and meta-analysis. Clinical Orthopaedics and Related Research®, 474(6), 1445-1452.

van Dreumel, R. L. M., van Wunnik, B. P. W., Janssen, L., Simons, P. C. G., & Janzing, H. M. J. (2015). Mid-to long-term functional outcome after open reduction and internal fixation of tibial plateau fractures. Injury, 46(8), 1608-1612.

Xia, S., Lu, Y., Wang, H., Wu, Z., & Wang, Z. (2014). Open reduction and internal fixation with conventional plate via L-shaped lateral approach versus internal fixation with percutaneous plate via a sinus tarsi approach for calcaneal fractures–A randomized controlled trial. International Journal of Surgery, 12(5), 475-480.

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