Setup for an Open Reduction and Internal Fixation (ORIF) of the Tibia (South College, Knoxville, TN)

CHAPTER 1

Hi, guys, my name is Madison Campbell. I work at South College in Knoxville, Tennessee. I am full-time faculty, and I also work at a local facility here in Knoxville. And today, I'm going to talk to you about a setup for an open reduction internal fixation, which is an ORIF, of a tibia.

CHAPTER 2

So I already have my table double-draped, and I actually used a reinforced 3/4 sheet, which is really nice to have, since in orthopaedics, we like to double-drape everything so that we don't puncture holes in our table drapes and we keep our patients safe. So I'm going to go ahead and start organizing my stuff and putting things where it needs to go. So I like to put my indicator glove inside of my outer glove. For my surgeon, I go ahead and put their gown on top of that. I put their gown on top of the 3/4 sheet that I'm going to use before I put the patient's drape on. And I'm gonna put that on my non-working end, which is gonna be over here on my right side. I also like to go ahead and put my stockinette over here with that stuff, since it's gonna be something I use during draping. It would be surgeon's preference on if they use a cotton stockinette or an impervious stockinette. So an impervious stockinette is blue and white most of the time, and it doesn't allow stuff to get through or out of it. Cotton stockinettes are a little different. They actually allow things to get through and outside of. So it's just kinda surgeon's preference on what they like to use. I'm also going to move my towels over here on my non-working end. And then, I also have some Ioban. We don't always use it for ORIFs, but I like to have it just in case. My trash bag and my Mayo stand cover. I don't utilize a Mayo stand during my ORIFs, just because I like to work off of my back table. So I won't use that and I'll put it over here. It's just extra space. I also don't use my suture trash bag. It's just something that I personally don't like to use.

CHAPTER 3

The rest of this stuff, I'm gonna go ahead and get out, organize it as I need to. I like to grab my whole bucket a lotta times and just start organizing how I like. My softs, I like to put on my working end. This is a sticky pad that we like to use locally. I'm gonna put my sutures here, my sharps box with all of my sharps. I'm gonna leave my Bovie tip in there. This will be for irrigation. So in orthopaedics, a lotta times, you'll see smoke because some people's bone is a lot more tough than an elderly person's. So we like to go ahead and have irrigation readily available so that we don't cause a fire. I also have my pulse lavage, which will be hooked to a bag of irrigation, which is saline. And the rest of this is actually just gonna go right over here so that when I'm ready for it, I can have it. In this bucket, I also have my Esmarch which is used to exsanguinate when we have a tourniquet on our patient, so we can keep minimal blood flow to the extremity while we're working and don't have to navigate around all the blood flow. My kidney basin, I will keep my medicine cup in, my labels, my marker, my ruler, and my syringe in.

CHAPTER 4

At this point, I am ready to grab my trays. My circulator will be checking the trays as I'm picking them up, giving me the go-ahead to put them on my table. So to make sure I don't turn my back to my table, I'll come over here, grab my pan with my hands, lift up, make sure my indicators in here are good, and make sure that my circulator has given me the go-ahead. My next tray will be this rep tray. So you always have to check the wrapper on the outside first. Check your lid, make sure there's an indicator here. I like to take my lid off and give it to an unsterile person. And then I like to pick up my tray, make sure that everything in here is good. I see everything, there's no debris or anything viral burden. And then my circulator will lift up that blue wrap to the light and check it for holes. My last tray is going to be my drill. So again, my circulator will check that tray before I put it on my table. I actually like to move stuff around a little bit.

CHAPTER 5

So at this point, I'm ready to go ahead and make my roll towel. A lotta facilities around here do things differently. Some facilities will keep their stringer in their casket, and some will keep it on their back table. So I have my stringer out ready to go. At this point, I'm just going to organize my pickups in a organized fashion. I'm also gonna organize my retractors to make them look nice and pretty. It'll be surgeon's preference on what they like to use, whether it be a big rake or a Senn. It also depends on your patient's size. I like to go ahead and grab out a bipolar forcep just to have it. It'll be surgeon's preference. A lotta times, they either use a Gelpi or a Weitlaner. It'll be surgeon's preference on that. I like to grab out a couple of Bennett retractors or elevators, and sometimes I grab out a couple of Hohmanns. It just depends on surgeon's preference. I like to have out a couple of osteotomes, so if we have to debulk some bone, we can do that. I also like to have out a couple of rongeurs, either single-action or double-action. This is a double-action. My knife handles so that I can load my blades. I also use a Freer elevator on almost every single ortho case. I also like to have out a couple of bone curettes, so if we have to debulk the bone, if it fractured a little funny, if we've got some spurs or anything that we need to take care of, we can use these.

CHAPTER 6

So one of the fun things about orthopaedics is that we don't typically count our instruments. So we only count our softs and our sharps. We don't count our instruments because we're not actually entering a cavity. So if we were doing a big belly case, absolutely, we would count our instruments. But because we're not entering a cavity, you don't have to do that. So I'm actually gonna go ahead and unstring my instruments. And I like to put my stringer underneath my casket just so I know where it is at the end of the case. At this point, I will go ahead and start counting and do my initial count with my circulator. So I like to start with my laps. Don't take your band off of your softs before you're ready to count. We don't like to have questions about how much is actually there, so you always want two eyes on your counts. I like to go ahead and fan them, make sure that all my one side is together. So laps, I have one, two, three, four, five. Ray-Tecs, same thing here, I like to use the one side, kinda fan 'em a little bit. I have one, two, three, four, five, six, seven, eight, nine, and 10. I'm gonna use my knife handle so that I can count my sharps. So blades, I have one, two. Hypos, I have one, two. Suture needles, I have one, two. And then this pack actually has two in it, so I like to go ahead and expose both of them so there's no question about how much there is. There's one, two. So for a total of four needles. I also have a Bovie tip and a plastic Yankauer suction tip.

CHAPTER 7

Once I have everything kinda organized and ready to go, my stringer, it'll be surgeon's preference. There are a lotta surgeons in the area who use a lotta different things for their ORIFs. So one thing you're always gonna need is your bandage scissors. You always need those are the very end of the case. So I like to go ahead and have them kinda set out, ready to go. You'll also know you'll need a needle driver so that you can close the skin and all the other tissues. Some surgeons like to have an Allis or a Kocher at hand so that you can grab onto tissue or bone as you need. You'll also need suture scissors so that you can cut your sutures. And then for fine dissection, you'll use Metzenbaums, of if you have a lot of thick tissue, you'll use curved Mayos. Pickups-wise, you always want something traumatic as you're going in and as you get deeper. Your dressing forceps will be used to place dressings and adjust your dressings as you need to go.

CHAPTER 8

My drill, I like to go ahead and make sure that it works, my battery's actually been charged. So I'll go ahead and load it and test it and make sure it actually works and have it here loaded and ready to go. There are several different attachments that go with your drills. So you have your quick connect. That's used quite frequently, so I always grab that out. I always also grab out a pin driver or a wire driver, depending on what my surgeon's using. And then, occasionally, I'll grab out a Jacobs chuck. And for the Jacobs chuck, you have to have a key.

CHAPTER 9

My rep trays. So every rep tray is a little different. If you have something in this tray that you don't have or that you need, you can always ask your rep in the room for assistance. I always make sure that my screws are in the correct spot and make sure that I have the correct amount. And if I don't, I tell my rep. I also like to make sure that I have all the drill bits and things that I need. My wires, I like to go ahead and make sure that I have any range from small to big. My screwdriver, I like to go ahead and have it ready to go. I also like to go ahead and have a power screwdriver ready to go. So this is a screw grabber, and we'll put it on our screwdriver so that we can grab our screws easier. I like to use bone wax occasionally or just pick it up with my fingers. Sometimes they get stuck in there, though, so you have to use your screw grabber. Also, any time you're doing an orthopaedic case and you're drilling, you always need to drill, measure, screw. So I always grab out my measuring stick and put it over here. And then, depending on your surgeon's preference, you might use a soft tissue sleeve or a wire guide or something in your tray to help you with this procedure. At the bottom of this tray are plates. I like to make sure that my numbers match up on the plates to make sure that, when my nurse is charting and doing order sheets and everything, everything's matching up. Something that I do as well is I make sure that I write down my screws that are used. So I write down the size, cannulated, not cannulated, and I write down how many of each screw that I use so that if my rep isn't paying attention or there's a question about what screws have been used, I have it here ready to go and reference. So this is a setup for an ORIF of a tibia. Thank you for watching.