General Ortho Trauma Rotation Tips
Know Pertinent history- make sure you know the patient’s medical problems (just write them down on your sheet so you don’t have to think in conference)
especially heart history (attendings will ask if you think they need cardiology clearance),
blood thinners (which one and why they are on it, when they last took it, INR if applicable),
history of dementia, diabetes status, ambulatory status and smoking history
With any hardware or ortho surgical history know who performed their orthopaedic procedure if they have had one previously (even ones unrelated to the injury, for example spine fusion in patient with hip fracture)
Get dedicated xrays of implants on operative leg (knee xrays for total knee arthroplasty when working on an ipsilateral hip fracture for example)
Know what gen surg had to do with trauma surgery patients overnight (did they have to take out bowel or the spleen? It will affect if ortho attendings are okay with taking the patient to surgery the same day)
Don’t send patients out of the ED without a diagnosis, escalate imaging as needed
Read on the injuries you get overnight that are not super common (calc fractures, terrible triad injuries, lis franc, real spine trauma etc.) even if it’s just the first few minutes before conference, try to use that time to scroll orthobullets because they will pimp you hard especially your 1st block through. Have students and interns look up what came in overnight too.
Be nice to the nurses/PAs, techs and attendings no matter what, they can really help you out.
Always have each other’s backs, undoubtedly something will get missed or imaging will be forgotten, do not blame other residents, do not coax an attending on who is ripping another resident to you, just tell them you will get it corrected
Get BOTH operative and blood consent on EVERY operative patient when in the ED, hold on to the consents and place in their charts when they go up to the floor, if they are going straight to the OR from the ED the consent goes into a red folder in the preop area
Staffing technique (brief as possible, have a complete work up when possible, never staff prior to seeing a patient)
Send pictures and then call soon after (don’t wait a long time between sending pictures and calling)
Age, sex
Mechanism
List Ortho injuries/diagnosis
Your plan (always have your own plan)
In your notes be specific about your diagnosis in your assessment/plan (ideally don’t say “ankle fracture” or “hip fracture”, be more specific about anatomic description so when the attendings go through and have to co-sign a hundred notes they know which consult this one was)
Imaging
All MRIs should be without contrast, except with infection, cancer, or post op up to 1 year where it should be with and without contrast
CT scans for:
All distal 1/3 tibia fractures that have a spiral component to them (look for posterior malleolus fractures)
Proximal 1/3rd tibial metadiaphysis frxs (commonly extend into plateau, always get knee/ tibia CT scan)
Distal femur fractures with and without prosthesis (looking for Hoffa fragment)
Distal ⅓rd spiral femoral shaft fractures (look for extension into knee joint)
All bad elbow injuries need one as well (blasted distal humerus fx, terrible triad elbow injuries) with 3D recons
CT thin cut (<1mm) and 3D recons for all NATIVE hip dislocation reductions (look for acetabular wall fx, vs femoral head frx)
For SAD ankle injuries to rule-out anteromedial tibial plafond impaction but that is attending specific
For all trimal ankle fractures
For all high energy foot fractures or significant foot swelling without an obvious fracture
For 3 part proximal humerus fractures
Glenoid fractures
Scapular fractures if severe, include glenoid, or concurrent with clavicle fractures (floating shoulder)
Consider for Penetrating injuries (GSWs, Nails, etc… get CTA if concerned about vascular injury)
pilon fractures typically get CT AFTER ex-fix
Concern for traumatic arthrotomy (you can also consider joint loading)
All tibial plateau fractures (sometimes attendings want this after the ex fix if required)
Important x-rays
Get gravity ankle joint stress and full length tib/fibs on all isolated lateral mal fractures
Manual external rotation stress views for proximal third fibula fractures even with nondisplaced posterior mal fractures looking for Maisonneuve/ syndesmotic injuries
Canale view for talus fractures out of splint
Harris view for calc fractures, get before you place the splint (you can’t see through the plaster)
Greenspan view for radial head fractures
full length femur films on all hip dislocations PRIOR to reduction (don’t want to pull on a femoral shaft/distal femur fracture without knowing about it)
Axial view on medial humeral condyle fractures
Internal oblique view for lateral condyle fractures
Internal rotation traction view for proximal femur fractures you can’t tell is a femoral neck fracture or intertroch fracture
Traction pins (when to use)
Unstable native hip dislocations (such as in the setting of posterior acetabular wall fractures)
Very unstable acetabular fractures (protrusio acetabuli, or severely comminuted acetabular fractures)
Not required in elderly patients with protrusio and secondary congruence
Loose bodies in the hip joint. (Goal is to keep the cartilage surface from being damaged by loose bodies such as bone or bullets)
High energy and highly displaced intertrochanteric femur fractures
Ipsilateral to vertical shear pelvis fracture
Ipsilateral to high energy displaced and complete sacral ala fractures
Midshaft femur fractures
There can be >1L of blood loss in the thigh, placing tension on the musculature with traction closes down the potential volume and can theoretically decrease bleeding
Femoral shaft fractures in people with brain injuries (may not be fit for surgery for a long time and patients with brain injuries lay down alot of callus)
Prep for OR
Use checklist
Track lactic acid in high E injuries
Track INR in patients on blood thinners, ask medicine for reversal
Track what will cause OR delay (Echos, electrolytes, INR etc.)
Call SICU to make sure they are getting xrays on polytraumas overnight (they will avoid getting xrays on bad traumas)
Check clearances
Write down clearance status and COVID status on surgical case list print out for a fast reference prior to 5:30 am when attending calls (you need to know if everyone is clear and ready for the OR)
Splints
Only need bulky cotton splints on calcaneus fractures, all other splints can be thin webril
Don’t use bulky cotton when trying to hold a reduction
Attendings want to see stirrups on short leg splints end near tibial tubercle (ideally rolling out stirrups on really tall people is required)
Long leg splint with stirrups all the way up to the knee for tibial shaft fractures, some attendings prefer stirrups up to the lateralis ridge and groin
Plantar flexed short leg splints for achilles tendon injuries, tongue-type calc frxs
You don’t need dorsiflexion for distal tibial metadiaphysis frxs and pilon fractures
Long arm splints are okay for adult both bones so you can check compartments
Splint nondisplaced talar neck fractures in neutral, but don’t force dorsiflex as they can displace
Always get post splint xrays (peds and adult)
Record Timing of High Acuity Consults for Hospital Accreditation
In your notes record the time you were notified and time you saw consult in high acuity cases (pelvic trauma, open fractures, cauda equina, trauma bay consults, nec fasc…etc).
Trauma Conference
Every morning around 5am print out OR case list, ensure everyone is on the board, write out covid status and if clear or not, double check that all preop is done and will not cause delays, use checklist for everyone/ every time
Be sure to pull up images for the morning conference in an order that makes sense : Typically Injury Film –> Reduction –> CT Scan –> MRI, always make sure to have plain x-rays up on the far left first then advanced imaging to the right etc.
If you pull up the xrays early like at 4-4:30am you may have time to order anything you may have missed
Xrays must be high quality. Order repeats and go take them yourself if necessary (this will also save you alot of time because bad xrays can make it look like you need to redo splints)
Presentations: be brief and move quickly, if you want to eat breakfast, keep it succinct and don’t go off on in-depth stories of the injury or the patient’s back story, know that stuff so if they ask so it looks like you know the patient but only present what is important (it’s an art)
Name, age, sex, pertinent PMH
Mechanism
Ortho Injuries while going through imaging (good to mention spine/gen surg injuries when pertinent)
Physical Exam
Assessment and Plan
Trauma Bay Management: High energy trauma
Systematic Process in Order:
Pelvis binder? (Place if able to close down volume of pelvis)
Fracture finding and exam (call out xrays and imaging you need if someone is standing by)
Irrigation, note what is injured, CT if concerned for traumatic arthrotomy
Prioritize and execute plan while setting up supplies
Reduction, Splinting, and Traction
Any dislocated joint from carpals to tarsals should be reduced (except spine)
Notes:
Ideally if stable you get all imaging done prior to all procedures (avoid multiple sedations)
Important: Take pictures of all open injuries, any rule out nec fasc, bad cellulitis, and video patients that have bad injuries with concern for nerve damage, moving their extremities around so the attendings believe you and you have ammo to support your physical exam
If a high energy trauma patient comes in and isn’t oriented or is intubated get xrays on all long bones as a screening tool (gen surg gets “1000s of images for what they are responsible for in the form of CTs head to pelvis), add on feet and hand xrays if there is trauma there, and then specific joint xrays if high suspicion or newly found xrays on long bone films
Get xrays on any bruise, pain, or laceration on trauma patients, distracting injuries will hide fractures
Always review all the films systematically, often you can find fractures before radiology and this will save your team members from having to do new consults on missed fractures
Review radiologist comments to check your work, they can really help you pick up on small details that you may have missed, but do not rely on them
Make sure when you are consulted on a trauma to do a full extremity exam
Range all joints, push/squeeze every inch of each patient’s extremity, check joint stability (varus/valgus/anterior/posterior drawer with knees, varus/valgus elbows…etc)
This will prevent you from missing things and it will also make you efficient at your physical exams
Adult trauma
When to check ABIs?
Use same cuff on leg and arm if possible (dont use arterial pressure on machines, this will differ from the cuff)
Serial ABIs on schatzker type 4 tib plateaus, occult knee dislocations or, full knee dislocations
Get ABI when concerned for vascular injury such as GSW to the thigh
1 ABI for all tib plateaus (more important on schatzkers 4,5,6)
if ABI less than .9 order:
formal ABI through radiology to verify your measurement (vascular will want this)
get CTA
vascular consult (attendings will ask what vascular said)
Get CTA if concerned for distal arterial injury (if open tibial shaft with poor pulses for example or nail gun to volar wrist near artery)
You can’t do ABIs for more distal tibial shaft injuries
If getting CTA ask for Bone windows in comments of order
When to do compartment checks?
Needs checks every 2-4 hours with progress notes depending on how concerned for progression
Compartment checks for knee dislocations, crush injuries, tibial shaft fractures, femoral shaft, both bone forearms, high energy tib plateaus, displaced proximal tibial physeal frxs in peds, any real concern for developing compartment syndrome
Any concern for necrotizing fasciitis
Okay to ask for admit to ED obs for compartment checks, only admit if plan is for surgery
Compartment syndrome consults
xrays
if patient does not have compartment syndrome but they have a concerning mechanism, keep overnight, personally elevate their leg or arm to the heart level
Document the compartment checks in the EMR every 2-3 hours if there is a real concern
Set up for OR if real (pain with passive stretch, firm compartments, pain out of proportion)
Staff ahead of time if real concern of developing overnight
Proximal humeral shaft frx that is very displaced,
Especially if patient requires walker to ambulate, attendings will consider ORIF even if no skin compromise (def OR w skin dimpling or compromise), ensure shoulder reduced on axillary, uprights in cuff and collar,
staff w attending for possible OR
Proximal humerus fracture in elderly
Upright shoulder xrays, always check axillary view
NWB, Cuff and collar
Follow up with APP clinic in 10-14 days
Elderly comminuted acetabular fractures
Judets vs. inlet outlets with AP pelvis xrays
CT pelvis (thin cuts <1mm and 3D recons)
If secondary congruence in acetab fractures plan is usually non operative treatment
FFWB on side with acetabular fractures or unstable appearing pelvic ring fractures
Post ambulation xrays
Staff
Midshaft humerus and distal third humerus fractures
Xrays humerus, low threshold for shoulder (axillary view) and elbow xrays
Exam (radial n. Injury common)
Coaptation splint by you or sarmiento brace placed by Hangar in ED (usually only available during business hours)
Post splint transthoracic lateral and AP humerus xrays
Criteria for alignment
<20 anterior angulation, <30 varus/valgus, <3cm short
Cuff and collar to hold wrist in flexion
Okay for non op in brace (if within parameters of 20 AP and 30 varus valgus) even w radial n. Palsy, NWB f/u in APP clinic in a week
Prep for OR if surgery indicated (brachial plexus injury, vascular injury requiring repair, severe soft tissue injury or bone loss, open frx, floating elbow (ipsilateral forearm frx) relative indication commonly cited (pendulous breasts)
Staff if surgery required
Elbow dislocations
Elbow xrays (low threshold for above and below)
Sedation and reduction
Reduce with arm in extension to take tension off triceps
Exam under sedation, check for varus valgus stress and check full flexion and extension in pronation and supination
Note where joint subluxes and document stability (ex. Stable in supination from 30-130 degrees)
Splint with stirrups in adults
Add extra slab from posterior arm over forearm to hold in supination vs. if required to keep elbow reduced (example: hold in supination in case of UCL injury with subluxation of ulnohumeral joint on post reduction fluoro lateral)
Post reduction xrays
CT if fractures involved
Knee dislocations
Xrays of knee pre and post reduction
ABIs, if less than .9, order formal ABI through radiology to verify your measurement (vascular will want this), get CTA, vascular consult
Reduction
Knee exam under sedation (varus/valgus/ant/posterior drawer)
Knee immobilizer place in ED, order hinged knee brace from hangar
If very stable unlocked in hinged knee brace, non weight bearing
If a little more unstable, hinged knee brace locked in extension, non weight bearing
If very unstable or open, plan for knee spanning ex fix
High Energy Pelvic fractures
Exam, if open book apply sheet binder w 4 kocher clamps (padded with ABDs against skin)
Check holes (urethra/anus/vagina/foley for blood)
Examine all extremities, be liberal with xrays to find other injuries. If unable to communicate xray long bones
Ap pelvis out of binder if no images and stable to do so
If vertical sheer or displaced column fractures place ipsilateral femoral traction
CT pelvis (add comments thin cuts <1mm with 3D recon)
Order foley or straight cath to drain bladder of contrast prior to pelvis xrays
Judets for acetabular fractures
Inlet outlets for pelvic ring injuries
Prep for OR: ex fix vs operative fixation pelvis fractures; (exam under anesthesia if posterior wall with no dislocation, or unstable appearing rami fractures)
If plan is non operative treatment plan is post ambulation xrays (inlet outlets vs judets depending on fracture type)
Staff
Penetrating injuries
Xrays
Exam, see how deep it goes, need to know what tendons, ligaments, nerves or vessels are injured
If concerned for vascular injury do thorough exam
Get ABIs if <0.9 get CTA, if abnormal consult vascular
If no vascular injury, can consider CT to eval how deep wound is
If concern for traumatic arthrotomy get a CT
Staff if concerning
Gunshot wounds
Plan on staffing
Xrays and CT (CTA if ABI <.9)
Splint if indicated based on fractures
If high velocity, set up for External fixation vs. operative fixation vs. I&D vs. revision amputation vs. wound vac and all indicated procedures, treat with IV antibiotics, staff
Low velocity
Most low velocity if no exam abnormality, IV ancef dose, normal fracture protocol, if no bone involvement or tendon injury then can treat these non-operatively
Intra-articular bullet fragments set up for OR
If in hip joint, plan distal femoral traction
Nondisplaced incomplete long bone fractures can consider non operative treatment
Concern for Periprosthetic joint infection
Xrays
ESR/CRP
Don’t tap unless you get permission from joints attending who performed surgery (specific for butterworth)
If not acutely ill, this can get worked up on outpatient basis
If draining from joint then it is consider infected (Link)
If acutely ill, may consider tap with trauma attending permission for possible I&D and poly exchange
Don’t start abx unless systemically ill with SIRS/Sepsis/bacteremia
Extremity abscess
Xrays
CT with and without contrast to eval depth of abscess
If above fascia general surgery, if deep to fascia, ortho consult is sensible
If deep to fascia commonly recommend IR drain trial
If failed IR drain, plan on OR for I&D
Staff if needs surgery
Plan to round to eval for improvement overtime with drain, if none may need OR
Tibial plateau fractures
Xrays knee (low threshold for femur and tib/fib to see joint above and below when high energy)
Neurovasc exam
Check skin (positive wrinkle, swollen no wrinkle or taught?)
ABI check on every one (more helpful in high energy)
Serial ABIs every 3-4 hours only required for Schatzker type 4s due to this causing a knee dislocation and stretching the neurovascular bundle (this can cause intimal tearing of artery that propagates over time)
Compartment checks
Knee immobilizer (easiest option for tib plateaus to check compartments)
If severely valgus, plan on correcting deformity and placing in side stirrups splint from thigh to ankle (no need to immobilize ankle if no ankle fractures)
Prep for OR for Schatzker severe type 2s, 4, 5, 6, or any plateau fracture that also has subluxation of the joint or associated dislocation of medial or lateral plateau (ex fix vs operative fixation)
You only need ex fix for length unstable fractures or with associated dislocations
Know operative indications
Varus valgus instability
>5mm condylar widening
>3mm joint depression
Schatzker type 4, 5, or 6
If operative indication met for a type 1-3, but not severe and fracture is length stable, no concern for developing compartment syndrome, generally okay to send out in knee immobilizer and NWB for exam in clinic and possible surgical discussion
Staff
Periprosthetic hip dislocation
If chronic dislocation >3 weeks, it may not reduce
If constrained total hip, still attempt reduction if no fractures, if you can’t get the hip reduced, leave it perched in the center of the cup (the patient’s muscle spasms may reduce the hip over a long period of time if it stays perched)
Xrays of pelvis and femur (femur series includes hip xrays, make sure it includes cross table lateral)
Order post reduction xrays ahead of time
ESR/CRP
Serum cobalt/chromium
Call xray right before sedation starts (so you don’t have to wait for xray)
If anterior dislocation, straight traction
If posterior dislocation, hip flexion, internal rotation, and traction
Knee immobilizer every time
Check post reduction xrays for fractures
WBAT if no fractures, follow up with joint surgeon who did the total hip, if patient isn’t connected okay to follow up with SHMG joints
For non-eventful reductions, staffing not required
Native hip dislocation
Ask for sedation
Prep for distal femoral traction (supply list, ask for traction bed and cart)
Find all injuries with xrays prior to sedation
Have high suspicion for posterior wall and inability to hold reduction without traction, if unsure place traction after reduction
If chronic or associated with fracture may want to discuss prior to reduction attempt to avoid fractures
If associated fracture of acetab or displaced pipkin 2 or above femoral head fracture preop for OR
Reduce hip
Post reduction/ traction xrays including repeat judets
Post reduction Thin cut <1mm CT pelvis with 3D recon
Staff
Traction pins
Ask for sedation prep
If no sedation possible, prep lidocaine 50ml per leg
Prep materials
Get xrays of whole femur prior to placement (prioritize distal femur, even in very large patients, dont pull through ligamentous knee)
Post traction xrays of hip and pelvis
Start with 12-20lbs
Can go up to 20% body weight, until hip remains reduced on repeat xrays (ap pelvis, vs repeat judets if acetab frx)
If CT in traction required okay to take off weights but make moves carefully (can consider wearing lead and standing in CT)
Repeat pelvis xrays post CT if dislocated, reduce with traction, increase weights as needed until reduced with very steep pulling angle (high as pulley can be placed)
High energy and highly displaced intertrochs or subtrochs
Pelvis and full femur xrays
Plan for skeletal traction (most attendings)
Full length femurs and pelvis xrays pre and post traction
Preop
Staff
Mangled extremity
Prep supplies (gauze boats, ABDs, kerlix/ webril, dilute betadine, ace wraps, splints)
Ancef + more abx as indicated and tetanus
Apply direct pressure to wounds as needed to stop acute bleeding
Examine pelvis, and identify all injuries and imaging needed
Examine extremity
Take down tourniquet if in place, with suture ties ready if needed,
tie off pulsatile bleeding if possible, if unable raise tourniquet
If no pulsatile bleeding okay to take tourniquet off
Rinse off debris as able
Sterile saline soaked gauze and ABDs with kerlix wrap, splint as necessary
Must get Xrays/imaging prior to OR, if unable to get xrays due to acuity get CT scans if ortho trauma to follow gen surg in OR
Prep for OR: I and D, possible operative fixation, ex fix, possible amputation, wound vac and all indicated procedures
Staff
Open fracture
Ancef/tetanus (add penicillin if dirt, cipro if wet, ceftriaxone if high energy in gustilo type 3 which includes all open femurs no matter opening size)
Prep splints
Examine pelvis then find other fractures
Examine extremity with open fracture
Wash out as much debris as possible note debris (add betadine to bottle of saline, rinse with as much saline as needed) adjust abx as necessary (penicillin if dirt), attendings will ask how dirty wound is
Reduce fracture if needed (bone out of skin, or joint dislocation)
Add saline soaked gauze, ABD wrapped with webril/kerlix/acewrap
Splint
Prep for OR
Staff
Calcaneus fractures
Foot xrays
Calc xray series (specify harris view in comments must be out of splint) order this prior to splint
Exam: Check skin for blisters or blanching on back of heel with tongue types
Splint with bulky cotton in plantar flexion for tongue types, window w cast saw to see heel skin if concerned
CT scan
Staff
Prep for OR w tongue types, some joint depression types
Pelvic ring injuries
Binder on unstable pelvis that you can close down volume APC 2-3,
If came in with binder from EMS, get xray out of binder if not unstable and replace w flat sheet binder
Inlet outlet, AP pevis for all ring injuries, get judets if frxs involve acetab
CT pelvis (thin cuts <1mm and 3D recon)
Know Denis classification
If incomplete sacrum and rami frxs stable plan non op.
If incomplete sacrum but rami frxs are oblique or horizontal allowing shortening and collapse of the ring, plan OR for stress view or post ambulation xrays if nondisplaced.
Complete nondisplaced sacrum ambulate with post ambulation inlet outlets if too painful to ambulate consider SI screw, prep for OR if unsure.
If bilateral sacral frxs, check sagittal CT for U-type
If APC 2-3 plan OR for exfix vs ORIF
Vertical sheer or complete and very displaced sacral fractures, plan traction on ipsilateral side and prep for OR
Staff if surgery required
Traumatic Knee effusion
Xrays 3 view knee, 4 view gets you sunrise view of patella
Exam anterior/posterior drawer, varus valgus stress, straight leg raise
If low energy and likely ACL injury okay for WBAT in knee immobilizer f/u SHMG sports if no fractures
In high energy mechanisms have a high suspicion for multilig knee injuries, patellar and quad ruptures
ABIs for multiligament knee injuries (possible occult dislocation)
If laxity get MRI knee without contrast
If fracture, get CT scan
If just quad or patellar tendon injury conclusive on exam okay for outpatient vs inpatient surgery, if inconclusive get ultrasound, escalate to MRI if needed
Knee immobilizer okay, if multilig knee order hinged knee brace
Most WBAT in knee immobilizer (unless tib plateau fractures and very unstable multilig knees)
Follow up SHMG sports for multilig knees with no fractures (if fractures APP clinic)
For tendon injuries requiring surgery follow up in attending clinic
Staff if will require surgery (tendon ruptures, multilig knees…etc. immediate staffing not required for basic ACLs)
Distal radius fracture
Ask ED to help with setup (versed on standby to help patient relax, c-arm, lead, tech, hematoma block materials)
Plan 10ml 1% lidocaine with or without epi for hematoma block
Only sedate if needed (multiple fractures, super stiff w parkinsons, etc)
Exam to check for acute carpal tunnel (median nerve paresthesias)
Hematoma block first to get it working as soon as possible, then set up splint/ room
Can Hang in finger traps while setting up or if you have more consults you can go hematoma block the next distal radius
Reduce
Sugartong
Post reduction xrays (don’t settle for poor quality xrays, they can falsely make your reduction look bad)
Staff real volar bartons for possible OR next day (posterior cortex is completely intact in true volar bartons. If posterior cortex not intact outpatient followup is okay even with comminuted coronal splint)
Keep extremely displaced comminuted/ intraarticular for dorsal distraction plate/ Staff
If ipsilateral scaphoid fracture also present, hand surgery team should see the consult with hand surgery follow up
Staff for acute carpal tunnel, volar bartons, those that might need dorsal distraction plate
Most can follow up in APP clinic in a week, NWB in surgartong
Midshaft Femur fracture
Xrays femur, pelvis, knee, tibi/fib
Prep traction
Need CT pelvis <1mm to check for ipsilateral femoral neck
If no femoral neck fracture okay for traction
Have a high suspicion for ipsilateral ligamentous knee
Prep for OR
Staff
Occult hip fracture
Occult hip MRI order (this is a fast pelvis T2 sequence, different from pelvis MRI)
If unable to bear weight, pain w log roll, not coming from infectious etiology, get MRI
Isolated greater troch fracture, get MRI to see if it extends medially, if so prep for OR for a nail for occult IT
If occult femoral neck, prep for hip pinning
Hematoma causing skin compromise
Xrays
Normally hematomas can just be WBAT, rec stopping anticoags, compressive acewrap, repeat exam once or twice if concern for changes overtime
If hematoma is causing skin blanching this is something that will require surgical I&D to decompress hematoma (if near joint sometimes plastics or gen surg won’t take care of it)
Can rec plastics or general surgery eval, if they don’t take care of it ortho should be involved
Staff if surgery required
Scapula fractures
scapula xrays (low threshold for shoulder xrays)
CT scan
Most are extraarticular scapular body fractures
Plan is WBAT, no sling required, sling if needed for comfort for 1-2 then discontinue. Follow up APP clinic in 10-14 days
Staff if surgical criteria is met (Link)
AC joint separation
Bilateral AC view
Clavicle xrays (Zanca view shows AC joint)
Shoulder xrays to rule out dislocation (axillary view required)
Check for skin compromise or blanching
Up to grade 3 are commonly treated nonoperatively
Sling, okay for pendulums, NWB
If non-op follow up in a week SHMG sports
Staff if surgery required
Clavicle fractures
Clavicle xrays (specify upright in comments)
Ensure no floating shoulder in high energy trauma (ipsilateral glenoid neck, and clavicle frx or AC joint separation)
Know smoking status, R/L handed, activity level, job, social history
Check for skin compromise (skin tenting or blanching), neuro/vasc injury
If medial frx and high energy check CT to look for SC dislocation
If midshaft or lateral most can be treated non op, sling NWB f/u, ask smoking, activity, job, hand dominance, fixing will be elective decision based on loss of overhead endurance with non-op, most heal without surgery
If distracted (fragments are pulled apart), or polytrauma and if >100% displaced and 2cm short will consider fixing while inpatient
Prep for OR if op indications met (open, subclavian vein/artery injury, skin tenting, floating shoulder)
Most can follow up in APP clinic in a week, NWB, sling for comfort
Staff if surgery required
Deep and large lacerations
Dose of ancef and tetanus
Xrays
Detailed exam (what anatomy is injured)
Bedside irrigation to better eval wound
Ortho consult only required if tendon, bone, or joint involvement
If laceration is large and none of the above are affected then closure per ED versus plastic surgery
If plastic surgery does not close then sometimes ortho attendings want to take to the OR for I&D and closure rather than have the ED close
Staff if surgery required
Dislocated shoulder
Always have pre-reduction xrays, AP, Grashey, and Axillary
Sedation
if posterior dislocation, have high suspicion for contralateral side (seizure scenario)
If unstable, hold the shoulder reduced, attempt to find a stable position. Take axillary xray while holding it reduced to prove it was in and take one without holding reduced (this proves that it is reducible but unstable)
If chronically dislocated may need to leave dislocated if no stable position
Shoulder immobilizer placement
Post reduction xrays
CT scan shoulder if fractures present
Most can follow up in APP clinic in 10-14 days, NWB in immobilizer
Prep for OR if unable to reduce
Staff if unable to reduce
Displaced talus fracture dislocation/ subtalar dislocations
Xrays of foot and ankle
Always check skin for blanching as any bone surrounding the ankle if dislocated can cause skin breakdown
Note swelling amount
If toes are fixed in a flexed position, talus fragment is causing pressure on (Tom, Dick, and Harry, Tibialis posterior, flexor digitorum and FHL)
Sometimes tendons can be incarcerated, don’t injure tendons, if they are caught it will likely require OR for reduction
Plan reduction for any dislocation or displaced/translated talar neck/dome fracture (if reduction looks great the surgery can be delayed which is helpful for the attending)
Reduction technique:
For Hawkins 2: Fully flex knee and plantarflex ankle, pull as hard as you can in plantarflexion until subtalar joint is reduced
Short leg splint
Post splint xrays
Post reduction CT scans
Know Hawkins classification
Prep for OR if unable to reduce, may be able to send out if well reduced and stable in splint
Staff
Lisfranc
If midfoot very swollen have a high suspicion for lis franc
Foot xrays
CT scan
Reduction required if any dislocation present
Short leg splint (avoid CAM boots in anything that could be a lis franc, if in doubt, short leg splint)
Plan OR if metatarsal heads are not staying reduced
If no dislocation can usually follow up in splint for outpatient procedure vs non op
If possible ligamentous lis franc, follow up clinic will consist of weight bearing foot xrays
If patient has been walking on it you can ordered weight bearing foot xrays (this stresses the lic franc, look for widening between 1st/2nd metatarsal bases, dorsal displacement of 2nd metatarsal base on lateral)
Staff if surgery is required (dislocation or staying in the hospital for other reasons and will need procedure)
Base of metatarsal fractures (2-4)
Foot Xrays
CT scan
If dislocation, plan reduction
Always plan short leg splint (no CAM boots as this could be a ligamentous lis franc)
They will follow up for weight bearing xrays in clinic
Ankle fractures
Ankle xrays (AP, Mortise, and Lateral)
Sedation and reduction for dislocation
Hematoma block for Weber B fractures that require reduction
If fragment is caught on dermis but not open, ensure that skin isn’t dimpled/caught on bone fragment after reduction (if caught discuss surgery)
Weber A: don’t need stress view, WBAT in CAM boot
Weber B: gravity stress view, if no widening WBAT in CAM boot, if wide at syndesmosis or medial clear space plan is reduction in short leg splint and NWB
Weber C: sedation and reduction/ short leg splint NWB
CT for trimal fracture dislocations with large posterior mal fractures and SAD ankles looking for plafond impaction
Don’t overpad splints shoot for total of ~5 layers of webril over prominences
Hold splint until cooling down (no chance of displacing)
If you had great technique you can be more confident knowing that the splint may not hold the ankle reduced (sometimes really bad parkinsons, BMI >60 with really large legs)
Do not send out with any medial clear space widening (this can cause skin necrosis and cartilage damage)
Most are sent out for clinic follow up, if needed prep for OR if required (ex fix vs operative fixation)
Staff if requiring surgery
Open talus dislocation
Foot and ankle xrays prior to reduction
Sedation
Irrigation, identify what tendons could be injured (note any dirt)
Reduction requires knee fully flexed and ankle fully plantarflexed (take tension off gastrocs)
Reduction attempt 2-3 times, if unsuccessful don’t push it as tendons may be interposed (further reduction attempts could cause tendon rupture)
Know what tendons may be interposed depending on laterality (Link)
Short leg splint
Sterile saline soaked gauze with short leg splint
Post splint xrays
Prep for OR (I&D, ex fix vs operative fixation)
Staff
Pilon fractures
tib/fib xrays, ankle xrays (low threshold for full extremity xrays in high energy mechanisms)
If very displaced and short, plan sedation and reduction, otherwise okay to place splint without sedation (versed if needed to help relax patient)
Short leg splint
Post splint xrays
Prep for OR (ex fix vs operative fixation)
CT after exfix unless attending wants CT prior
Staff
Both Bone Forearm fractures
forearm xrays, low threshold for wrist/elbow joints
If no impending skin breakdown and not extremely displaced, no formal reduction required
Posterior long arm splint or sugartong is fine (posterior long arm is nice because it makes it easier to check compartments)
Compartment checks
Prep for OR
Staff
Necrotizing Fasciitis
See as soon as possible
Xrays of any area of concern
Exam (check for bullae and crepitance), mark out border to observe progression overtime
Pain out of proportion
Pain outside of area of obvious skin changes
Dishwater drainage
CT scan entire extremity if concern for nec fasc (if time for CT)
Prep for OR (possible amputation, I&D)
Staff
Diabetic foot wounds and amputation consults
Xrays
If no concern for nec fasc, podiatry consult
Ortho consult should only be for below knee amputation
Amputations are performed when patient unstable
Amputation considered if podiatry says, “no more I&Ds”, patient is ready for amputation, all of this is commonly done on outpatient basis (unless acutely ill like previously stated)
Spine
Don’t curbside spine consults
Make sure you ask the patient what they do for a living, if they smoke, if they are a diabetic, how active they are, how they ambulate, these are all questions the spine guys like to know about
Look through all the CT scans/MRIs regardless of what you get consulted for, more often than not you will find something that the radiologist missed or the trauma team didn’t read the radiology read and didn’t tell you about it,
also make sure to look at old scans (especially if you notice the patient has had multiple MRIs/CTs done over the last several months (it is very helpful to know if something is new vs. chronic)
Radiculopathy due to herniated disk, facet cysts, facet spurs
Needs MRI
Know exactly which nerve roots are being compressed based on where disk is
Look at imaging, don’t just rely on rad reads
No selective nerve root blocks (SNRBs) for the cervical spine
If young <40 and severely painful sometimes attendings will elect for surgery (more rare)
Can try IV 8mg of IV decadron and medrol dose pack and see if they can go home (usually the ED has tried this)
Multimodal pain control
Gabapentin, IV 10mg decadron IV q8 for 3 doses, IR consult for SNRB (place level that you want blocked in comments of consult order)
Can recommend an epidural if multilevel radiculopathy
Upright xrays and CT scan (if bone contribution to impingement) if surgery required
Low energy L Spine Compression fracture
Check for Dish vs ankylosing spine, if present in area of fracture then get MRI of that area, treat like unstable spine with spine precautions
If no Dish/ ankylosing then spine exam
Upright xrays, if no kyphotic collapse then non op, if significant kyphotic collapse in younger active patient, some will consider surgery
No brace, unless really painful
Calcitonin
Bone health
Okay to staff if questions, but generally not necessary for standard
F/u in 10-14 days
C collar clearance in negative CTs
If in ED, no widening or injuries on CT, no real concern for an injury, no paresthesias can have them follow up with PCP for clearance (okay to curbside in benign scenarios)
If being admitted and spine is consulted you should see the consult for clearance
If there are distracting injuries and midline tenderness of C-spine you can’t clear. Have them follow up with Spine attending in clinic for clearance
If awake with distracting injuries and unable to clear clinically get uprights in C collar, have them f/u in spine clinic in a week remaining in collar
If intubated, MRI c spine, keep in collar if increased signal on STIR images which communicates ligamentous injury
Pathologic fracture
Important to identify (ask details about mechanism, recent weight loss, antecedent pain, cancer history)
Non contrast CT scan if suspicious (save contrast if tumor work up required for Chest/abdomen/pelvis CT with contrast)
Staff with MSK onc surgeon as soon as possible (may delay surgery if more work up needed prior to OR)
High energy spine fractures with spinal cord injury
Full spine Exam, bulbocavernosus, rectal, if complete can use blunt tipped needle to find level of injury
CT full spine wo contrast
Ensure good C collar fit
Order spinal precautions
Order post void/ foley
Order stat MRI of injured area (it can be done after surgery based on attending preference) call MRI
SICU for MAPS >85 (contact sicu attending and then charge for transfer)
Staff
Prep for OR
Lumbar spinal stenosis
Can look really bad on MRI, ED will be concerned about cauda equina
Rule out cauda equina clinical symptoms (high post void >400-500, diminished rectal tone, saddle anesthesia, unilateral or bilateral leg weakness, can be progressive over a couple of weeks)
Ask about typical symptoms
hx of neurogenic claudication and how long problems have been going on
Relief with forward flexion resting on shopping cart
Ask about cervical myelopathy symptoms (dropping cups, difficulty w fine motor tasks of hands, L spine and C spine stenosis often occur together) if convincing exam and history for cervical myelopathy get C spine MRI wo contrast
Plan often PT/OT pain control, outpatient f/u for non op vs surgery discussion
For incidental C spine stenosis on CT imaging
Plan is usually follow up in clinic for discussion unless severely symptomatic w cervical myelopathy, can consider inpatient procedure (often these consults are in patients that are very sick with other problems and neurology orders MRI of brain and C spine and the stenosis is discovered incidentally)
Get MRI while inpatient for diagnosis and f/u in clinic for possible surgery
Cauda equina
Clinical diagnosis, but need MRI L spine every time
Rectal exam every time (“Squeeze your buttcheeks” does not work as a diagnostic test, I tested this on a real cauda equina patient and they could still do this.)
It is rare for long standing severe Lumbar spine stenosis to develop cauda equina
Rule out cauda equina clinical symptoms (high post void >400-500ml, diminished rectal tone, saddle anesthesia, unilateral or bilateral leg weakness, can be progressive over a couple of weeks, not always as acute as a compartment syndrome would present)
if no obvious compression/ mechanical cause on MRI Lumbar spine, and still concerned for cauda equina get T spine MRI
If no findings on T spine for compression, consider recommending Neuro vs psych eval, (conversion syndrome)
If imaging and clinical diagnosis fits for cauda equina prep for OR
Staff if real
Discitis vs epidural abscess vs septic arthritis of facet joint
Detailed spine exam
Full spine MRI w/ wo looking for skip lesions, they often occur together
If neurologic changes with canal narrowing prep for OR
Infectious disease consult
Blood cultures prior to antibiotics
If no positive blood cultures bacterial diagnosis then you can recommend IR biopsy of disc to guide antibiotics (ID can put consult in if they feel like they need it)
If no neuro changes can usually treat non-operative with long term IV antibiotics
Staff
DISH versus Ankylosing spine three column injuries
Have high suspicion in patients with severe pain and signs of AS or DISH (sometimes patients have both)
CT full spine
MRI of spine in area of fractures (often has fractures in multiple areas, sometimes full spine MRI required)
Look for epidural hematoma, if hematoma present perform serial exams over time to see if exam changes
Place unstable spinal precaution orders, add comments in order and in your note “patient does not need to lay flat, optimize patient comfort with head elevated”
Provisionally keep NPO at midnight
Prep for OR if MRI shows that all three columns involved in fracture
Prep for OR if CT shows significant displacement
Staff
Central Cord Syndrome
Looks for bilateral hand paresthesias
Weakness = more severe
C-collar, bed rest, okay for head of bed to 30 degrees
MRI C-spine
Some attendings like IV decadron 6mg-10mg Q8
If muscle weakness, some attendings prefer MAPs monitoring >85 in SICU (check w attending)
If just sensory okay for floor
Prep for OR
Staff
Peds
Casting Pearls
Shoot for 4 layers of webril everywhere and don’t go over 5 layers over bony prominences such as the knee/tibial tubercle, heel, and malleoli.
4 layers of webril allows for less chance of burning skin during removal and it is not too padded for holding reductions)
No more than 12 layers of fiberglass (too hot to remove)
Ask ED to use intranasal versed and seated on parent’s lap (injured leg between their legs, with bed elevated)
This way gravity is working to help reduce the leg
If really painful have nitrous on back up
If sedation is required, try have the patient slid down the bed so that he injured leg is draped off the side and you can have gravity help you reduce the leg
With midshaft and distal third tibial shaft fractures, it is okay to not dorsiflexion the ankle, this will displaced your fracture into recurvatum
Get post cast xrays to eval your work
For pure Toddlers fractures only age 1-3 nondisplaced distal third tibia fractures
Okay for WBAT in WEE walker boot (CAM boot for kids)
Sometimes attendings like a short leg cast
For tibia fractures that are displaced and more proximal conservative treatment is bivalved long leg cast or long leg splint and non weight bearing
Displaced and nondisplaced spiral tibial shaft fractures
Xrays tib/fib
Plan for bivalved long leg cast vs long leg splint (brownie posts for casting, splints if super busy)
Versed and seated on parent’s lap (injured leg between their legs)
Post splint xrays
NWB, follow up in a week
Picu newborn consults clubfoot polydactyly, hip dysplasia… etc.
Don’t need to see, F/u in 2 weeks to peds ortho clinic
Peds Supracondylar frx
Careful exams
All require posterior long arm splint
Type 1 okay to curbside, NWB f/u in a week, (beware of medial comminution that look like type 1, these will require surgery either inpatient or outpatient)
Very minimally displaced Type 2 possible for non op
More Displaced type 2s, staff for OR (some like to add on for next day) vs outpatient decision between non op and outpatient surgery
Type 3s posterior long arm okay to put into 10-15 deg flexion to take stretch off of bad hyperextended frxs, prep for OR, staff with attending
Only know it is type 4 intraop
OR prep for flexion types
Peds open fractures
Ancef and tetanus
If just a tiny poke hole and clean may consider irrigation reducing/ cast/splint and non op with IV dose ceftriaxone
Staff with attending
If larger than a poke hole, irrigation, provisional splint, staff and prep for OR
Minimally displaced peds buckle distal radius fractures
Okay for curbside for volar wrist splint if within angulation parameters
Velcro wrist splint or plaster/fiberglass by ED (I ask for the non-velcro if I want to make sure the splint stays on)
If volar cortex is fracture, should do a good sugartong to prevent displacement
Peds ankle fractures (Tri-planes)
Ankle xrays
If reduction required, plan sedation and short leg splint
-orthobullets says bivalved long leg cast for triplane fractures, but reduction and short leg splint is a reasonable option
CT scan ankle if displaced physis involved, get this post reduction (if reduction required)
NWB f/u in clinic in a week
Staff if surgery required
Concern for non accidental trauma
let ED vs. trauma team know, rec social work consult
Trauma team admit (not ortho admit)
Skeletal survey
Splint broken bones (okay to splint in babies)
Staff (doesn’t have to be in middle of night if no surgery required)
Radial neck fracture
Xrays elbow and forearm
Check DRUJ
if displaced >30deg plan sedation and reduction (radial neck is fairly close to the olecranon and can be identified under fluoro with a pen, rotate forearm until most displaced side of radial neck visualized on AP, while arm is placed in varus stress, push from just distal to proximal on radial head until reduced back into reasonably reduced position)
Posterior arm splint (can add stirrups for more stability)
If well reduced can treat non-op
Post reduction elbow xrays (specify true AP of proximal radius
NWB follow up in a week
Staff if surgery required
Monteggia fractures
Forearm and elbow xrays
A plastic deformity of the ulna is a fracture (may need correction for reduction of radial head to be successful)
Sedation and reduction
Splint in flexion ensuring radial head is reduced
Post reduction forearm and elbow xrays
Staff if surgery required
Plastic deformity
If just plastic deformity present, consider full sedation and reducing deformity (Dr. Cassidy has communicated that these do not heal because not enough bleeding, complete fracture if necessary to allow remodeling, orthobullets says plastic deformity up to 20deg can remodel)
Femoral shaft fractures
Long leg splint going up to mid lateral buttocks from 1 to 7 years
Consider Bucks traction from 7-15 years
>10-18 years of age (variable depending on attending) Skeletal traction for patients for highly displaced femoral shaft fractures, and patients that may not be able to receive a timely surgery (trauma with other injuries or brain injury)
if unsure you can start with Bucks, tell the attending your plan and verify with them
0-8months: Pavlik harness (combo with posterior long leg splint from 6-8 months)
Order small, medium, or large pavlik depending on size of child
Okay to ask nurses to place (ask them to look up youtube) and then you should double check their work
8 months to 5 years: Spica cast in OR
5-11 <49kg: Flex nails
5-11 >49kg and unstable or very proximal: Bridge plating
>11 years: >49kg antegrade nail,
>11 very proximal or distal or severe comminution: ORIF w bridge plating
Plan OR if required
Staff
Both bone forearm fractures
Forearm xrays
Plan sedation if necessary
Reduction criteria:
0-10 years: angle <15, malrotation <45, bayonet okay if <1cm short
>10 years: angle <10, malrotation <30, no bayonet
<2 years growth: angle 0, malrotation 0, no bayonet
Even when patient nearing skeletal maturity still plan on reduction
Univalve vs bivalved long arm cast (brownie points and board answer)
Sugartong with posterior arm splint
Both bones most commonly fail in apex ulnar (sugartong alone does not protect against this deformity)
Post reduction forearm xrays
NWB follow up in a week
Humeral shaft fractures
Humerus xrays
Non op for almost all pediatric humeral shaft fractures
Coaptation or sarmiento >5-6 years old
Sling and swathe or cuff and collar if <~4 years
Acceptable alignment <34-45 degrees in younger kids, older children approaching maturity near adult parameters (<20 varus/valgus procurvatum, <2cm short, <15 deg rotation)
NWB follow up in a week
Staff if surgery required
Open, polytrauma, floating elbow, segmental with shoulder injury, unacceptable alignment
Deep lacerations
If no tendon bone or joint involvement, closure per ED vs. plastic surgery
Plan ED vs. OR w ortho for arthrotomy, open fracture, tendon involvement
Staff if OR required
Preop Checklist
Elevator pillow
Covid Test
Ask last meal
DNR status
Case request and call OR desk
NPO
Full length bone films of operative site (every time)
Hold anticoagulants (Do this in orders)
Order blood products if needed
Correct imaging (full femur films in case of long nail for hip fractures)
Periop antibiotics, ancef if no anaphylaxis
TXA
Weight bearing status
EKG, chest xray
type and screen
PT/INR (am daily before surgery if concern)
CMP/CBC (make stat + early AM lab draws daily if concerns)
Pregnancy test (female 12 through menopause)
Diet order
Consent order (saints), sign by you (butterworth)
Consults, PerfectServe message them to let them know
Foley
Covid screen
Med reconciliation of home meds
Pain meds
Post-op:
Xrays in PACU (not always necessary for Nails or cases with saved fluoroscopy)
Pain (analgesics)
Puke (anti-emetic)
Pus (antibiotics)
Prophylaxis (DVT/PE)
Previous meds
Post op PT/OT
Med rec for discharge
Scripts for discharge, put in charge or e-prescribe
Discharge instructions
Transfer orders/documentation (if going to SAR)
Follow up provider
Traction Pin Guide
Materials:
Sterile Batteries
skeletal traction kit (has steinman pin set, avoid using pins with threads)
power cordless drill
stack sterile towels
11 blade, betadine
scrub brush iodine
60 lido (1ml per kG limit)
gauze padding for cut pin ends
acewrap to hold in place
traction bed, traction cart
sterile gloves multiple pairs
Make sure u have correct traction bow (tension bow for 2.0 pins)
15lbs traction weights to start, up to 20% body weight, (10lbs if bad femur in kids)
Set up bed first with bars and rope, set up traction with sterile technique, 2-2.5mm pin, start sedation reduce leg, train holders/help to keep patella pointed up, chloroprep, sterile towels
60cc syringe, 18-22guage
Use 25-30ml lido each side, use half at superficial skin/fascia and half right on the bone, medial and lateral to the distal femur with a large wheel over skin on lateral side
Start medial, at the level of the superior pole of the patella find anterior and posterior cortex shoot in middle use smooth steimen pin (threaded pins take too much bone)
Iodine scrub brush over pin against skin, then bow, then set up traction, trim
Make very secure knot that is easy to undo
