Ridha Ramdani Rahmah 130110110108 OPEN REDUCTION AND INTERNAL FIXATION (ORIF) Definition An open reduction internal fixation

(ORIF) refers to a surgical procedure to fix a severe bone fracture, or break. 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. Procedures 1. Principles Correct anatomical reduction is required to reproduce the original structure of the zygomaticomaxillary complex and the proper alignment of the orbital walls. In order to achieve proper reduction of the lateral orbital wall the greater wing of the sphenoid and the zygoma must be properly aligned. Plate fixation At least two screws should be placed on both sides of the fracture. Ideally, the first screw should be placed on the side of the mobile fragment, and the plate used as a handle to close the gap and reduce the bone. The first two screws should be placed in the plate holes closest to the fracture, one on each side of the fracture. Make sure that the fracture is adequately spanned so that each screw is placed in solid bone. Order of reduction and fixation In a fracture of this nature, the reduction and fixation of the zygoma should be performed first. Reconstruction of the orbital floor should be performed after the zygoma has been reduced and stabilized. 2. Zygoma reduction methods The first step is to obtain proper 3-D reduction of the zygoma using an elevator, hook, screw, or Carroll-Girard type device to mobilize the zygoma into its proper position. a. Elevator b. Hook c. Screw and traction

d. threaded reduction tool

3. Placement and fixation of first plate Placement of first plate The first plate is placed across the frontozygomatic fracture area. It is recommend to use a minimum of a 5-hole plate with one hole spanning the fracture line. The plate should be properly adapted. Fixation of first plate Only one screw should be placed on each side of the fracture in the holes nearest to the fracture, until the surgeon has verified the proper 3-D reduction of the zygoma at the other two points. The final two screws in the zygomaticofrontal plate should be placed at the end of the intervention.

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4. Placement of additional plates Placement of second plate When looking through the lower eyelid incision, the orbital rim plate should be properly adapted. Use a minimum of a 5-hole plate with the extra hole spanning the fracture line. Reconfirm that the lateral orbital wall (greater wing of the sphenoid and zygoma) has been properly reduced prior to placing this plate. A minimum of two screws should be placed on each side of the fracture. Placement of third plate Looking through the maxillary vestibular approach, the fracture of the zygomaticomaxillary buttress is aligned. A larger L-shaped plate is ideal for the fixation of this fracture. This is the most difficult plate to properly adapt in a zygoma fracture. It is important that the leg of the L-plate be placed on the most lateral portion of the lateral maxillary buttress, where the bone is fairly thick. 5. Reconstruction of the orbital floor defect The orbital floor defect is exposed by using orbital retractors and retractors on the lower eyelid. Many different devices have been used to facilitate retraction of the orbital contents, including malleable retractors, spoons, and special orbital retractors designed for the globe 6. Postoperative examination Parasymphyseal Mandible Fracture 1. Reduction Mandibulomaxillary fixation (MMF) In symphyseal fractures with basal triangular fragments, an arch bar is preferred for MMF. Reduction of the main fragments Reduction of the fragments is done manually with the use of elevators, bone hooks, or bone screws inserted as handles. Gross reduction is done prior to the MMF application.

2.

Fixation of superior border plate

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Plate countering The plate is contoured to the outer surface of the superior aspect of the mandible in a position avoiding tooth roots. Drill first screw hole Hold the plate with an appropriate instrument in place (eg, periosteal elevator or forceps). Insert screw Insert a 2.0 mm screw, 6 mm in length. Do not fully tighten it until the final reduction and plate position are confirmed. Insert second screw Insert a second screw in the hole next to the fracture line on the opposite side of the fracture. The periosteal elevator is used now to keep the far end of the plate at the correct vertical level. Tighten both screws. The clamp can be removed afterwards. Additional screw placement Fill the remaining plate holes with screws in an orderly fashion continuing from the plate holes next to the fracture to the outer plate holes. 3. Fixation of lower border plate Pearl: plate insertion in parasymphyseal fractures An obstacle to plate placement are the exiting branches of the mental nerve. This area represents a danger zone for nerve damage. The bone region below the branches must be dissected carefully. The plate is positioned in the space below the mental foramen, if necessary. Drill first screw hole Hold the plate with an appropriate instrument (eg, periosteal elevator, forceps). Insert first screw Insert second screw

Additional screw placement

4. Final check Release the MMF and check the occlusion for accuracy and the bony surfaces for precise anatomic reduction. Final osteosynthesis