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Orthopedic Trauma Lightning Guide

Orthopedic Trauma 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, INR if applicable),

    •  history of dementia, diabetes status, ambulatory status and smoking history – that is what they care about when you present

    • also know who performed their orthopaedic procedure if they have had one previously  

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 

  • Make sure when you are consulted on a trauma to do a full extremity exam and push/squeeze every inch of each patient’s extremity even if they are only complaining of their open ankle fracture, this will prevent you from missing things and it will also make you efficient at your physical exams, x-ray what you are concerned about.

  • Be sure to get full films on all patients (joint above and joint below)

  • 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

  • MUST have an axillary view on all patients with proximal humerus fractures especially if they involve the head. The humeral head can also be dislocated which will likely need surgery

    • Ask the attending before reduction attempt with humeral head dislocation with proximal humerus fracture, as there is a high incidence of neuro/vascular injury

    • If someone has attempted a shoulder reduction unsuccessfully, get repeat xrays before attempting, if there was a fracture during the previous attempt you need to know about it

    • get an axillary view on your shoulder reductions as well if the patient feels stable after reduction and you aren’t concerned about a big bony bankart, otherwise order a velpeau view

      • Consider having someone on the team call xray just prior to successful reduction so you don’t have to wait to ensure the shoulder is reduced

    • If a bony bankart, get a CT

Axillary View

Velpeau View

  • Other important x-rays

    • Get gravity ankle joint stress and full length tib/fibs on all isolated lateral mal fractures

    • 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

  • CT scans for

    • All distal 1/3 tibia fractures that have a spiral component to them (look for posterior malleolus fractures)

    • All bad elbow injuries need one as well (blasted distal humerus fx, terrible triad elbow injuries) with 3D recons 

    • After all NATIVE hip dislocation reductions (look for acetabular wall fx)

    • Distal femur fractures (looking for Hoffa fragment)

    • 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

    • For 3 part proximal humerus fractures

    • Glenoid fractures

    • Scapular fractures if severe, include glenoid, or concurrent with clavicle fractures (floating shoulder)

    • Abnormal distal radius fractures

    • pilon fractures typically get CT AFTER ex-fix

  • Take pride in your Splints – don’t do a sloppy job, make sure they look nice and that they are the appropriate length. Also for your bulky jones, make sure to pull the padding off that lies directly over the dorsal flexor crease to prevent sores (this goes for kids too)

  • Extensor mechanism injuries (patella/quad tendon ruptures) – do NOT trust the ED exam for any reason, if they call you on this, go see the patient and see if they truly can extend their knee and feel for palpable defect

  • Ligamentous injuries (ACL/PCL etc.) If the cause is a basketball game, put them in a knee immobilizer and send out, if the cause is a car accident, have a low threshold to see this to rule out multi-ligament knee injury/knee dislocation


  • Peds ankle fractures (tri-planes)/distal tibia fractures require long leg casts (there is newer literature that some attends are adopting that show you can get away with a short leg cast), you will need a sedation for almost all of these

    • Toddler’s fractures if non-displaced, do okay in a boot, if displaced consider long leg splint with stirrups (this is residency and attending specific)

  • Cerebral palsy kids with femur fractures- attending specific, some will ask you put a splint on, others will be okay with leaving the kids alone as long as they are comfortable in the position they are in, if miserable, consider traction pin but call before doing one if the kid is not near skeletal maturity (my cutoff is usually if they are <10-11 yo)

  • Look at old scans/x-rays, if available. Sometimes there are chronic problems that you can’t fix in the ER (chronically dislocated shoulders)

  • Young <~5-6 years old femoral shaft fractures can be placed in a lateral long leg splint securing up to waist, if you end at the gluteal cleft the splint usually ends very close to the fracture site and isn’t helpful


  • 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

  • Rule out cauda equina- do a rectal exam every time because you don’t want to miss this, MRI should be done on every patient with concern for this, no imaging = no idea if there is anything to operate on and attendings wont accept that

  • 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)

General Rules:

  • 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

  • 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.

  • 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)

  • Important things to know for AM rounds: Hgb, INR, drain output (and what it looks like), Culture results, KNOW WHETHER OR NOT A PATIENT HAS CLEARED FOR SURGERY

  • Get BOTH operative and blood consent on EVERY operative patient when in the ED, I would suggest taping their consents to their bed sheets so they don’t get lost by the secretaries, if you hand them in to an ED secretary there is a 25% chance the consent will be lost, do so at your own risk 

  • Compartment syndrome consults: if patient does not have compartment syndrome but they have a concerning mechanism, keep overnight, personally elevate their leg by raising foot of bed as high up as possible(for lower extremity) and placing at least 4 pillows under the leg/arm etc and check on them every 2-3 hours, DOCUMENT the checks in the EMR so the attendings can see you were paying attention, another trick for upper extremity is to get an IV pole and waist band and raise the arm above the level of the heart 

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