Open Reduction & Internal Fixation (ORIF)
TYPICAL PROCEDURES
Open reduction of pediatric fractures requiring plate/screw, intramedullary, or open pin fixation — displaced condyle and supracondylar humerus, both-bone forearm, displaced distal radius, Monteggia, femoral shaft (flexible nail, rigid lateral-entry nail, or submuscular bridge plate), tibial shaft, ankle/physeal fractures, and SCFE requiring open reduction.
| CPT / PROCEDURES | |
| Supracondylar humerus — open, without intercondylar extension | 24545 |
| Supracondylar humerus — open, with intercondylar extension | 24546 |
| Humeral condyle (lateral or medial) — open | 24579 |
| Humeral epicondyle (medial or lateral) — open | 24575 |
| Monteggia fracture-dislocation — open | 24635 |
| Radial AND ulnar shaft (both-bone) — open, one bone / both bones | 25574 / 25575 |
| Distal radius — open: extra-artic / intra-artic 2 frag / 3+ frag | 25607 / 25608 / 25609 |
| Femoral shaft — open: intramedullary nail / plate-screws | 27506 / 27507 |
| Distal femur — supracondylar / w-intercondylar / condyle / physeal | 27511 / 27513 / 27514 / 27519 |
| Femoral neck — open | 27236 |
| Tibial shaft — intramedullary (flexible nail) / plate-screws | 27759 / 27758 |
| Ankle — med mall / post mall / lat mall (fibula) / bimalleolar | 27766 / 27769 / 27792 / 27814 |
| SCFE — open, single/multiple pinning or bone graft | 27177 |
| Note Femoral shaft: flexible (elastic) nailing and rigid lateral-entry nailing are both reported with 27506; submuscular bridge plating with 27507. Tibial flexible nailing = 27759. | |
CORE PHILOSOPHY
- Open the Pedipod War Chest (Card 5) for exposure, reduction, and bone work on every open reduction.
- Bovie and suction up and running; standard fracture trays plus the appropriate implant system.
- Confirm implant system and rep presence before incision — see femur priority note below.
POSITIONING & DRAPING
- Radiolucent table appropriate to the limb; bone-foam positioners for lateral decubitus (humerus / distal humerus / elbow).
- Standard extremity prep and drape; tourniquet per case (see roll-on tourniquets, Supply Catalog).
- Esmarch exsanguination — open a 3 in Esmarch for upper-extremity ORIF; open a 4 in Esmarch for lower-extremity ORIF (sterile, latex-free).
- C-arm draped in; plexiglass cover over the intensifier face.
IMPLANT SYSTEMS (CONFIRM VENDOR / REP AT SITE)
| Need | System / spec | Vendor options |
|---|---|---|
| Mini-fragment plating | 2.0 / 2.4 / 2.7 mm; good 2.7 selection | Globus ANTHEM Mini Fragment (1st) · any trauma vendor |
| Small-fragment plating | 3.5 mm; longer plates for tibia / long bones | Globus ANTHEM Small Fragment (1st) |
| Large-fragment plating | 4.5 mm; femoral submuscular bridge workhorse | Globus ANTHEM (1st) · DePuy 4.5 LCP |
| Flexible / elastic nails (ESIN) | Full size range, upper & lower extremity | OrthoPediatrics PediFlex · DePuy TEN (Globus: none) |
| Femur — rigid lateral-entry nail | GT-sparing lateral entry; adolescent / small-stature | OrthoPediatrics PNP · DePuy Synthes ALFN (peds lateral entry) |
| Femur — submuscular bridge plate | Anatomic, age-specific; long narrow 4.5 also serves | Globus ANTHEM · OrthoPediatrics physeal-sparing |
| SCFE — cannulated screw (stainless, fully threaded) | 6.5 & 7.5 mm (±8.0); 4.5 / 5.5 mm small for little kids | Globus CAPTIVATE 6.5/7.5 (1st) · OP 6.5/7.3 · Stryker Asnis (8.0) |
SCFE SCREW NOTE
Stainless-steel, fully-threaded cannulated screws — 6.5 mm and 7.5 mm are the workhorses, with 8.0 mm available for large adolescents and 4.5 / 5.5 mm for smaller children. The hospital trauma line is Globus, so use the Globus CAPTIVATE Headed Cannulated Screw System first (stainless steel, fully-threaded options; paired 6.5 / 7.5 mm, and 4.5 / 5.5 mm for little kids). OrthoPediatrics 6.5 / 7.3 mm cannulated is an excellent alternative — use their cannulated screws, NOT the Free-Gliding implant; the cannulated screws carry an internal thread that aids guided removal. For an 8.0 mm screw, Stryker Asnis III spans 4.0 / 5.0 / 6.5 / 8.0 mm. Catalog numbers in the Supply Catalog.
INSTRUMENTS
- Pedipod War Chest (Card 5) — retractors, reduction clamps, elevators, bone instruments, hand instruments.
- Wire driver / power capable of driving the full smooth K-wire range.
- Reduction clamps: 3–4 per set (not 2–3); lobster-claw serrated and Weber pointed; prefer ratcheting; medium, forearm/ankle-sized; some angled variants.
FEMUR PRIORITY NOTE
Goal is to have all femur options — rigid nail, flexible nail, and submuscular bridge plate — physically in-house with a nearby rep, so an emergent / same-night femur (e.g., an 11-year-old shaft fracture) is fixed the evening of presentation rather than held overnight waiting on instrumentation. OrthoPediatrics historically keeps few femur sets on the shelf with limited regional reps; establish the par level and rep relationship early. SCFE screw is rarely truly emergent — next-day rep delivery is acceptable for stable / chronic slips; in-house ideal for unstable slips.
CLOSURE / DRESSING
- Layered closure per case; absorbable subcuticular where appropriate.
- Skin closure: SYLKE silk-fibroin closure preferred over Steri-Strips when possible.
- Reston self-adhering foam over bony prominences (swear by it) · waffle padding to accommodate swelling · cast or splint per fracture.