I.

INTRODUCTION Surgery is the branch of medicine that deals with the physical manipulation of a bodily structure to diagnose, prevent, or cure an ailment. Ambroise Par, a 16th century French surgeon, stated that there were to perform surgery: "To eliminate that which is superfluous, restore that which has been dislocated, separate that which has been united, join that which has been divided and repair the defects of nature." The first surgical techniques were developed to treat injuries and traumas. A combination of archaeological and anthropological studies offer insight into man's early techniques for suturing lacerations, amputating insalvageable limbs, and draining and cauterizing open wounds. The oldest operation for which evidence exists is trepanation. Among some treatments used by the Aztecs (ethnic groups of central Mexico), according to Spanish texts during the conquest of Mexico, was the reduction of fractured bones. Jean-Andre Venel established the first orthopedic institute in 1780, which was the first hospital dedicated to the treatment of children's skeletal deformities. He is considered by some to be the father of orthopedics or the first true orthopedist in consideraton of the establishment of his hospital and for his published methods. Antonius Mathysen, a Dutch military surgeon, invented the plaster of Paris cast in 1851. An open reduction and internal fixation (ORIF) is a type of surgery used to fix broken bones. This is a two-part surgery. First, the broken bone is reduced or put back into place. Next, an internal fixation device is placed on the bone; this can be screws, plates, rods, or pins used to hold the broken bone together. IA. Procedure IA.1 positioning The patient is given (GETA) general endotracheal anesthesia which is indicated to this type of surgery. Desflurane, isoflurane and sevoflurane are the most widely used volatile anaesthetics today. This procedure attempts to sedate the patient and gives complete muscle relaxation. Oxygen supply via endotracheal tube is necessary because there is a risk for aspiration precaution due to muscles that helps lungs to function relaxes. The patient is supine with affected arm in a comfortable position; the other arm may be also extended on an arm board. A rolled sheet may be placed under the shoulder on the affected side. In distant fractures a tourniquet may be used. Apply electrosurgical pad.

IA.2 skin preparation Begin with the arm and hand; extend from the fingertips to the shoulder. Cleanse the axilla well; extend to the table posteriorly, beyond the midline of the chest anteriorly, and down to the level of the lower ribs. IA.3 proper procedure: Induction An appropriate incision is made over the fracture site avoiding neurovascular structures. If malfunction has occurred, osteotomy is performed to restore alignment. Generally the fractures is fixed with screws and a compression plate; for condylar fractures threaded kirschner wires or screws may be employed. The wound is closed.

IA4.Final check of osteosynthesis

Using image intensification, carefully check for correct reduction and fixation (including proper implant position and length) at various arm positions. Ensure that screw tips are not intraarticular. In the beach chair position, the C-arm must be directed appropriately for orthogonal views. Position arm as necessary to confirm that reduction is satisfactory, fixation is stable, and no screw is in the joint.

III.Instruments

Intestinal Forceps

Vascular mixter

Bobcock

Thumb Forceps

Tissue Forceps

DeBakey Forceps

Scalpel #3

Cautery

Suction Machine

Drill bits

Mosquito Clamps

Mayo

Cutting bone: Parkes Rasp

Bone file

Cutting bone: mini-liston bone cutting forcepts

Richardson Retractor

Malleable

Steinmanns pin Deaver retractor

Army navy

Bone curette

III. Nursing Responsibilities Count the instruments, sharps and sponges before the procedure and confirm with scrub nurse. During the Procedure: a. Remain in room and dispense materials as necessary Observe procedure as closely as possible. Begin establishing method of anticipating needs of surgical team. Care of specimen as indicated. Care of operative records as indicated Before the closing of the organ or peritoneum, count all instruments, sharps and sponges and confirm with scrub nurse Inform the surgeon and assistant surgeon of a report of the instruments Neither weight bearing nor heavy lifting is recommended for the injured limb until healing is secure. Mechanical support should be provided until the patient is sufficiently comfortable to begin shoulder use, and/or the fracture is sufficiently consolidated that displacement is unlikely. Once these goals have been achieved, rehabilitative exercises can begin to restore range of motion, strength, and function. The three phases of non-operative treatment are Immobilization: Passive; assisted range of motion then Progressive resistance exercises. immobilization is recommended for 2-3 weeks, followed by gentle range of motion exercises. Resistance exercises can generally be started at 6 weeks. Isometric exercises may begin earlier, depending upon the injury and its repair. If greater or lesser tuberosity fractures have been repaired, it is important not to stress the rotator cuff muscles until the tendon insertions are securely healed. Phase 1 (approximately first 3 weeks);Immobilization and/or support for 2-3 weeks; Pendulum exercises; Gently assisted motion; Avoid external rotation for first 6 weeks Phase 2 (approximately weeks 3-9); If there is clinical evidence of healing and fragments move as a unit, and no displacement is visible on the x-ray, then: Active-assisted forward flexion and abduction; Gentle functional use week 3-6 (no abduction against resistance) and then Gradually reduce assistance during motion from week 6 on Phase 3 (approximately after week 9); Add isotonic, concentric, and eccentric strengthening exercises; If there is bone healing but joint stiffness, then add passive stretching by physiotherapist.

Resources: pocket guide to the operating room 2nd edition, Goldman http://www.doctorsofusc.com/condition/document/539804

https://www2.aofoundation.org/wps/portal/!ut/p/c1/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARyd DRwML1yBXAyMvYz8zEwNPQwN3A6B8JLK8oYWBgWeop7OfsZOfgYGBCQHdfh75uan6BbkR5QAxe5oq/d l2/d1/L2dJQSEvUUt3QS9ZQnB3LzZfQzBWUUFCMUEwOEVSRTAySjNONjQwSTEwRzA!/?showPage=redfix &bone=Humerus&segment=Proximal&classification=11A1.3&treatment=&method=Open%20reduction;%20internal%20fixation&implantstype=&approach=&re dfix_url=1301988767386#stepUnit-4 https://www2.aofoundation.org/wps/portal/!ut/p/c1/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARyd DRwML1yBXAyMvYz8zEwNPQwN3A6B8JLK8oYWBgWeop7OfsZOfgYGBCQHdfh75uan6BbkR5QAxe5oq/d l2/d1/L2dJQSEvUUt3QS9ZQnB3LzZfQzBWUUFCMUEwOEVSRTAySjNONjQwSTEwRzA!/?redfix_url=13019 88767386&implantstype=&segment=Proximal&bone=Humerus&classification=11A1.3&approach=&showPage=approach&treatment=&method=Open%20reduction%3b%20internal%20fi xation http://en.wikipedia.org/wiki/General_anaesthetic#Inhalation http://www.thirdage.com/hc/p/539804/what-is-open-reduction-and-internal-fixation-surgery