23345260 Orthopedic Emergencies

7/29/2019 23345260 Orthopedic Emergencies

1/37

The James F.Wenz, M.D.Orthopaedic SurgeryResident Survival Guide

Editor: Frank J. Frassica M.D.Asst. Editors: Kevin W. Farmer, M.D. & Brett M. Cascio, M.D.

2007


2/37

Table of Contents:

Patient Safety

is

Rule Number 1.

Ask

if you do not know.

Do not do anything

by yourself

for the first time.

Compartment Syndrome 5

Cauda Equina 7

Pulmonary Embolism 8

Deep Venous Thrombosis 9

Labs 10

Narcotics 11Chest Pain / Myocardial Infarction 12

SICU Consult 12

Hypotension 13

Stroke 13

Fat Embolism 14

Epidural Hematoma 15

Physical Exam/Motor Grading 16

Splinting 17

Casting 19

Traction: Skeletal 21

Traction: Skin 22

Aspirations & Injections 23

Preop Checklist 24

OR Safety (Bovie, Tourniquet) 25

Radiology 28

Post Operative Care 31

Medical Issues 32Consult Issues 33

Follow-Up Clinics 34

Ortho E-Learning 36

IMPORTANT NUMBERS 37

OPERATIVE NOTE FORMAT 42


3/37

This survival guide is dedicated to James F. Wenz, M.D., a true gentleman, scholar,and innovator. He was the type of patient and resident advocate that all of usshould strive to be.

Kevin Farmer, M.D.Class of 2008

Contributors:

Henry Boateng, M.D.

Mark Clough, M.D.

Phil Neubauer, M.D.

Kevin Farmer, M.D.

Kris Alden, M.D.

Michael Bahk, M.D.

Adam Farber, M.D.

Andrew Manista, M.D.

Ted Manson, M.D.

Brett Cascio, M.D.

Dennis Kramer, M.D.

June, 2007

OrthopaedicS u r g e r yR e s i d e n t

S u r v i v a lG u i d e

James F.Wenz, M.D.


4/37

4

Compartment Syndrome

Cauda Equina

PulmonaryEmbolism

Deep VenousThrombosis

Chest Pain / Myocardial Infarction

Hypotension

Stroke

Fat Embolism

Epidural Hematoma

IORTHOPAEDICEMERGENCIES

The price of safety is

never-ending, unremitting

vigilance.

Check & Double Check.

Never be afraid to ask.

Frank J. Frassica, M.D.


5/37

5

Level 1 case. Do not Delay!!!!

Have an extremely low thresholdfor concern.

Can occur following any injury, andin any extremity.

Dont forget about well leg, canoccur in the non-injured extremitydue to positioning in OR.

Due to increased pressure within afascial compartment.

Pressure then impedes blood flowinto compartment leading topotentially irreversible changes

(nerve damage, muscle necrosis, etc).

Pain out of proportion to theinjury and the physicalexamination is the mostsensitive indicator!

YOU MUST see the patient andevaluate.

Patients in severe pain will often tryto sleep to forget about pain.

Compare exam to other side and toprevious exams in chart!!!!

Call chief resident with concerns.

Never hesitate to call theattending on call.

Compartment measures? Measurepressures if you can not decide ifa compartment syndrome is present.Time is of the essence. Do notdelay!

CompartmentSyndrome

Pain: out of proportion to injury

Pain on passive stretch: severepain with passive movement of toes,ankle, fingers, wrist, etc

Weakness: 0-5 grading. Compareto previous exam

Numbness: Compare to other side.Compare to previous exams.

Tenseness:Feel compartments:

Do they feel tight?Shiny skin?

Tender to mild palpation?Pulses: Compare to opposite side

Pallor: Any color changes?

Diastolic Pressures: Document incase you check pressures.

Top priority!!

If patient has compartmentsyndrome, it is a Level 1 OR case

for fasciotomies.

DO NOT MISS ACOMPARTMENT SYNDROME

UNDER ANYCIRCUMSTANCES!!!!

LEVEL 1


6/37

6

Measurement ofCompartmentPressures

Indications forCompartment Measurement

1. Use the Stryker monitor insituations where there is a questionof diagnosis of compartment syndromein a susceptible patient.

There is no need to stick a patient whoclearly has or does not have compartmentsyndrome.

2. Juniors must inform their chiefsprior to any compartmentmeasurement.

3. This is a procedure and must betaught to juniors by seniors prior toa junior performing the procedurealone. Prior experience at anotherinstitution does not count.

Use of the Stryker monitor

1. Preload a disposable syringe withfluid and connect to the measuringinstrument. To the other end, add adisposable needle-catheter thatcomes as part of the set. Check 9vbattery if the unit does not turnOn.

2. The device needs to be adequatelycharged for accurate use. Depresssyringe until saline fills the chamber &needle.

3. Ask and receive verbal consentfor the procedure (potential benefit:early diagnosis and prompttreatment of compartmentsyndrome vs. discomfort and remotechance of infection, bleeding, damageto nerves).

4. Prep the area to be tested withBetadine, and infiltrate the skin with1% lidocaine. Do not attempt to

anesthetize any deeper as this mayalter your compartmentmeasurements.

5. After the system is purged withsome fluid, zero the monitor at thelevel of the compartment to be

tested.6. Using sterile gloves, insert theneedle through the fascia keepingthe unit parallel to the floor.

7. The numbers on the monitorscreen fall reasonably rapidly, and asthe descent levels off a reading of thecompartment pressure can be made.

Have an assistant record these byeach compartment.

8. Remove the needle and apply adressing.

9. Inform chief of compartmentpressures.

10. Write a procedure note. Always

use the compartment syndromestickers. Remember to compare thecompartment pressure to thediastolic blood pressure. Perfusionpressure is the diastolic bloodpressure minus the compartmentpressure.

Location of Stryker Monitors

JHH must be signed out andreturned from the Main OR desk.

JHBMC must be signed out andreturned from OR desk

GSH call operator and pageNursing Supervisor. They will bringit to you. Kindly return it to them.


7/37

7

Cauda EquinaHave a Low Threshold

Examine any post-op spine patientswith new complaints (incontinence,urinary retention, parasthesias,weakness).

Always perform thorough motor,sensory (pin prick, light touch) rectalexam.

Compare exam to previous exams.

Any changes (weakness, sensorychanges, decreased rectal tone)should prompt immediate concern.

Call spine fellow immediately. Do nothesitate to call the spine attending oncall.

Make NPO.

Will need stat CT Myelogram vs. MRIwith Gadolinium vs. straight to ORas Level 1.

Bilateral buttock & lower extremitypain.

Bowel/bladder dysfunction(especially urinary retention).

Saddle anesthesia.Lower extremity motor/sensorychanges.

A True Surgical Emergency!

Cauda equina syndrome occurswhen the lumbosacral nerveroots are compressed andthereby injured, cutting offsensation and motor function.

Nerve roots that control thefunction of the bladder and bowelare especially vulnerable to damage.

If you dont get fast treatment torelieve the pressure, it may causepermanent paralysis, impairedbladder and/or bowel control,loss of sexual function and other

problems. Even if the problem getstreatment right away, they may notrecover complete function.

Causes include: disc herniation,post-op hematoma/swelling,tumor, infection, fracture ornarrowing of the spinal canal. It

may also happen because of aviolent impact such as a car crash,fall from significant height orpenetrating (i.e., gunshot, stab)injury. Children may be born withabnormalities that cause CES.

Any delays could becatastrophic!

THIS IS A PRIORITY EVENT!

You can open up the checkbookif it is missed!!!

LEVEL 2


8/37

8PulmonaryEmbolism A potentially fatal event!

Check vital signs.

Do a cardiac and lung exam

EKG medicine consult?

Especially common followingtotal joints and intramedullaryrodding of a femur fracture.

Make sure patient does not havekidney problems prior toordering spiral CT.

Consider mucormyst 600 my poBID before spiral CT and for 2 daysafterwards. Resuscitate them withnormal saline IV before and after scan.

Consider V/Q scan if patient a highrisk for renal failure.

Will need a large bore peripheral IVfor spiral CT (i.e. 18 gauge).

Tachycardia

Hypoxia

Tachypnea, or

Pleuritic type chest pain.

Patient will need long termtherapeutic anti-coagulation.

SICU consultpatient should bein a monitored setting (IMC at least)until therapeutic.

Medicine consult for management.

Make sure arrangements are madeto follow INR once discharged(primar y care, coumadin clinic , etc).

Let chief / attending know ASAP.

It is much more acceptable toover order spiral CT then to notorder one in a patient who has aPE !!!

Have a low threshold toorder a spiral CT on anyof these patients.


9/37

9Deep VenousThrombosis Below the knee DVT:

Must be treated!

Treatment:Attending dependent.

Continue current pathway and

recheck dopplers in 48 hoursto look for propagation.

Also possible to have DVT in upperextremity. Doppler if concerned.

Let your chief / attending knowif positive for DVT!!

Make sure all patients haveanticoagulation plan!!!

Use the DVT protocol, please fill outthe pink form and put form in thefront of the chart.

Do not do a Homans sign (low yield,potential to break off clot).

Have a low threshold to orderbilateral lower extremity dopplersfor any patient with concerningsymptoms.

Vascular lab better than radiologyif possible.

Above the knee DVT:

Must be treated!Medicine consult.

Will need arrangements to havecoumadin and INR followed oncedischarged, preferably by primarycare physician.

Calf pain/cramping

Leg swelling

Palpable cords

Presentation


10/37

10

There are fewer labs to worry aboutin Orthopaedics.

A lab that is ordered on yourpatient is your responsibility tocheck, no matter whom elseordered it or is following the value.

Get in the habit of looking throughEPR every day for rogue labs thatsomeone else ordered.

On the pediatrics service, askthe attending before orderingany labs.

Often the kids dont need them andthe attendings will be miffed thatthey were ordered.

LabsPertinent Labs:

HematocritMost post op patients get onethe first day after surgery.

Femur fractures and largespinal, hip, knee and shoulderprocedures should get one in therecovery room.

If the patient is actively losing blood(recognized by precipitous pressuredrop or heavy drain output), ordera post-transfusion hematocrit.

BMP

Watch the creatinine valueson joint patients and patientson gentamicin or vancomycincarefully. These have a tendencyto creep up. Keep potassium repleted.

PT/PTTWatch patients on coumadinlike a hawk. Place it in boldletters on sign-out so that

other people know the patient ison coumadin.

Dont let it jump up!!

A.M. labs are usually back by 10 am.

Midnight Labs can be ordered,especially on weekends. (1st draw AML)

Dont make a habit of signing out labs!

UAEvery hip fracture should have aUA on admission. Others asappropriate.

CRP/ESREvery patient suspected of

having an infection needsthese labs.

Blood CxLess useful in orthopaedics. Notpart of our routine post op feverworkup unless the fever is high orpatient has documented infection.

Orthopaedic Tumor Consult?Order CBC, CRP, ESR, BMP,SPEP/UPEP, UA.

Dr. Frassica will ask for the calcium.

Pathology ReportsKeep track of the patients youhave operated on, and reviewtheir pathology reports.


11/37

11Narcotics

Appropriate Post-OperativePain Management

1mg Morphine

=

0.2 mg Dilaudid

=

100 mcg of Fentanyl

They have differing half-livesDilaudid > Morphine > Fentanyl

Be wary of the narcotic nave.

Be wary of the narcotic seeking.

Do not prescribe narcotics onthe weekends or evenings if youfeel the patients are seekingdrugs.

Call the chief resident orattending and let them handle

the problem (FJF).

Constipation

Colace 100 mg po bid

Senna 2 tabs qDay (increases GImotility)

Treatment of NarcoticOverdose

A: Maintain AirwayCall anesthesia if needed

B: Maintain BreathingOxygen supplementation

C: Circulatory SupportPlace patient on monitor

D: Call code if necessary

E: Stop all narcotic medications

F: Naloxone (e.g. Narcan)0.4mg-2mg q 2-3 min PRN.

Has short half-life / will likely needto be re-dosed. Patient shouldremain on monitor.

G: Inform team and transportto monitored setting if clinicallyindicated.

Respiratory depression

CNS depression

Miosis

Hypotension

Signs of NarcoticOverdose


12/37

12

SICU Consult

Chest Pain /MyocardialInfarction

Top priority!!

YOU MUST see all patients withcomplaints of chest pain.

Pertinent questions

Radiation? Nausea? Diaphoresis?

Type of pain? Shortness of Breath?

Physical Exam

Check vitals.

Cardiac/Lung Exam.

Check EKG

Compare to old EKG.If story not concerning, and EKGunchanged:May stop there and monitor.

Do not forget about:PE, pneumonia, pneumothorax, etc.

Consider STAT CHEST X-ray.

Let chief / attending knowif situation is bad.

If any concerns with story or ifany EKG changes:

1. Send off Cardiac enzymes x 3, first onestat.

2. If at night, take EKG and showSICU fellow. Have a convincing storyas to why youre concerned.

3. If able to, call cardiology forconsult for acute MI if EKG changesor enzymes positive.

4. MONA - morphine, oxygen,nitroglycerin tablets, aspirin.

5. If patient is having an acute MI,

your job is to transfer them fromour service and into a monitoredsetting ASAP- SICU, Cards.

We should not bemanaging a MI !

Talk to SICU fellow for any patientswith concerns. Dont try to be ahero!! Bump it up if you have a worry.Have a good story. Take EKG, labs, etc.with you to the fellow. They areusually willing to help you out if youpresent it to them in way that shows

you have done all the necessary work-up and you have legitimate concerns.If they are not receptive, talk to yourchief or attending about the situation.

Same situation for the PICU fellow.


13/37

13Hypotension

Make sure patient is stable.

Check pulse, Urine output.

Is patient alert?

If urine output is low, bolus with1 Liter Normal Saline

Check HctBlood > Normal Saline > NSfor intravascular resuscitation.

PulseHighhypovolemia? Sepsis? PE? A-fib?Lowheart failure?

Meds: Beta blocker, calcium channel blocker?Check EKGmedicine consult?Cards consult for arrythmia.

Let chief / attending knowif situation is bad.

If patient in unstable(unresponsive, etc):

Stat IV bolus NS.Stat SICU consult (they will want toknow EKG, Hct, WBC, ABG etc).Have blood available.

ABCs.

Call code if concerned enough - ACLS?

Stroke Document your Neuro Examas thoroughly as possible.

Neurology Consult:Call the Stroke pager ASAP.

JHH:410.283.7777

Bayview:410.283.8810

Good Samaritan:410.532.4040


14/37

14Fat Embolism

What is it ?

Fat embolism is a release of fatdroplets into systemic circulationafter a traumatic event.

Fat embolism syndrome is a rareclinical consequence of the above.

Pathophysiology unclear.

Risk factors

Increased risk with increasednumber of long bone fractures.

Femur fractures especially.Non-op treatment has highest risk.

IM nailing? Controversial!

Diagnosis

CLINICAL DIAGNOSIS!!

Lab and XR findings are non-specific.

Workup:

Stat portable CXRMay see diffuse bilat infiltrates

ABGIncreased Aa gradient

CBC, platelets, fibrinogen.Anemia, thrombocytopenia,low fibrinogen

Continuous O2 monitor.

Spiral CT to rule out PE whenstable.

Non contrast head CT if mental

status changes.

Treatment:

Early supportive pulmonary therapy.100% O2 on non-rebreather if on floorContinuous O2 monitoring

May need to be intubated

ICU or IMC transfer.SICU fellow consult stat

Notes: Mortality 10-20%

Pulmonary distress ARDS-like

Mental status changes

Petechial rashOccur transiently in 50%Reddish-brown spots in upper bodyand axilla or subconjunctival

Fever >38.5

Tachycardia >110

24-72 hrs after long bonefracture or pelvic fracture

Presentation


15/37

15Epidural Hematoma

What is it?

In Brain: hematoma between skulland dural membrane.

In Spine: hematoma compressing onspinal dura.

Brain:

Mental status changes after a fall

May have a lucid interval

Severe headache, vomiting, seizure

Spine

Usually post-op, especially iflaminectomy

Unrelenting back pain

Progressive neurologic deficit

Presentation

Declining neuro exam mandates statimaging or immediate operativeexploration!

Imaging options if concern forpostop hematoma:

CT myelogramNeed to speak with radiologist on call.A radiology team will have to be called.MRINot as good, especially if hardware in place.

Treatment:Brain Epidural Hematoma

Stat neurosurg consult.

May need immediate evacuationin OR by neurosurg.

ICU / NCCU transfer

Spinal Epidural Hematoma

ORTHOPAEDIC EMERGENCY !

Needs stat decompressionin OR as level 1.

YOU MUST escort patient tomonitored setting.

Workup

Stat non-contrast head CT forall possible head traumas.

This includes all patients who fall andhit their head while in the hospital.

Any unwitnessed falls should get

head CT.Do not need radiologist approval forthese tests.

Dont forget to check the results.Test should only take minutes!

Postop Spine Patients

Full neuro exam meticulous

documentation.

Any post-op patient complaining ofsevere back pain must be re-evaluated!

Does deficit correspond with level ofsurgical site?

Any neuro deficits, speak withchief & spine fellow.

If cant get in touch with spinefellow then call spine attending.

If decide to observe, must do Q2-4hneuro exams and document results.


16/37

16

Motor Exam

Motor exams are critical inorthopaedics. Document yourfindings accurately.

Every patients NOS note or H+Pshould have a motor exam writtenout so that we can track progress ordecline. You should be able to

explain every deficit you find, or youshould notify someone senior.

Motor Grades(Not a perfect system!)Designed for Spinal Cord Injury and jointswith full range of motion, not for orthopaedictrauma.

Grade 0:Nothing,

Grade 1:FlickerGrade 2:Full range of motion-gravityremovedGrade 3:Full range of motion-againstgravityGrade 4-weak (only grade with +, -)Grade 5-normal

A patient with a tibial fracture is notgoing to have 5/5 strength in hisfoot, even though the nerves may befine. Document what you see.

Adult spine surgery NOS notes shouldalso include rectal tone, wink &perianal sensation for all

thoracolumbar cases & extensivecervical cases.

Do the rectal with a nurse presentand warn the patient. ACDFs doNOT typically need a rectal.

Pediatric spine patients do NOTneed a rectal.

Spine surgery patients, adult andpeds should also be tested forclonus.

Spine Surgery Notes

IIP H Y S I C A LE X A M

Children with supracondylar humerusfractures are often hard to assess.

Check that anterior interosseous &ulnar nerves are in when you seethem in the ER.

EPL tests the radial nerve.

Index finger DIP flexion tests the Anterior

Interosseous Nerve (Branch of median)Small finger DIP flexion tests Ulnar Nerve

Patients with an active nerve blockfrom anesthesia should be reassessedwhen their block wears off.

Sensory exam-Document abnormalsensation as to area, light touch &pinprick (paperclip). Compare to

other side!!!

Preop History and PhysicalMust include Cardiac, lung, &abdomen to be considered complete!!

UPPER Biceps WristExt Triceps Grip FingerAbd

EXT C5 C6 C7 C8 T1

Right

Left

LOWER HipFlex KneeExt FootDorsi ToeExt FootPlantEXT L2 L3 L4 L5 S1

Right

Left


17/37

17

Adult

Adults do not get casts acutely,the one exception may be cylindercasts for patella fractures (veryrarely, Dr. Frassica prefers paddedsplint). Only splint acute fractureswith plaster to accommodateswelling. No fiberglass. A splintshould generally try to immobilizethe joint above and the joint belowa fracture.

A good splint stabilizes the fracturewithout causing a pressure ulcer. Ingeneral, use at least 3 layers of softroll to protect the skin from the

For fractures that can balloon withswelling, use Robert Jones cotton forextra padding. Overwrap with aKerlix to help apply gentlecompression to control the swelling.Fractures that require this are oftenhigh energy or have significant

comminution dusted elbows,pilons, tibial plateau fractures. Wealso tend to splint tibial shaftfractures with Robert Jones cottonand Kerlix here as well.

However, too much padding maynot provide enough support tomaintain a reduction. A distal radiusneeds just enough soft roll toprotect the skin without losingreduction.

When holding a reduction as asplint hardens, use broad surfaces toapply forces, use the palm of thehand. Do not use fingers or theplaster will pick up the grooves andcause an ulcer.

Splinting

IIIP R O C E D U R E S

plaster and 1 layer of soft roll onthe superficial side of the plaster sothat it doesnt stick to the ACEwrap. Do not pull the softroll orACE wrap. This is too tight &patients will be calling you in a fewhours for blue or tingling fingers.

Just roll i t on.

Pad bony prominences well! Thismeans putting on extra padding atthe elbow joint for sugar tongs oron the heel for AO splints. Dr.Campbell often uses ABD pads forthe heel.

Make sure no plaster or thinly

padded plaster touches the skin.This is especially true at the endsof splints.

Make sure your posterior slab for anankle fracture does not dig into thepopliteal fossa. You will be amazedhow fast an ulcer can develop.

Upper extremity often requires 10-

12 layers of plaster. Lower extremityoften requires 12-14 layers.However, modify as necessary. A bigperson may require more layers.Measure off the good limb.


18/37

Humeral shaft Coaptation splint Pad the axilla extension wellwith ABDs, carry the shoulderextension high, pad the elbow

Elbow Posterior slab with Buttress The buttress gives support

consider Jones cotton if dusted

Distal radius Sugar tong Pad the elbow well, keep splintproximal to MCPs

Boxers Fracture Ulnar gutter Mild wrist extension with asmuch MCP flexion

Thumb / scaphoid Thumb spica

Tibial plateau Long posterior slab Use Robert Jones cottonwith 2 side slabs

Tibial Shaft Long posterior slab including Use Robert Jones cottonfoot with long stirrup

Ankle Posterior slab with stirrup Start applying plaster at calf and then double over on footplate if excess. Apply 1 layer ofsoft roll in between slab & stirrup

Foot Posterior slab

Fracture Splint Tips


19/37

19Casting

Pediatrics

In general, fiberglass casts are appliedwith the following layers in sequentialorder:

- Stockinette (cut out creases);- Soft roll (at least 2 layers thick);- Fiberglass (at least 2 layers thick).- Over-wrap with ACE wrap afterbivalving the cast.

Take care to avoid pressure pointswhich may cause cast sores.

Bivalve all casts unless there is

minimal swelling and a low-energymechanism with little potential forswelling (i.e. buckle fracture), or asignificant time has elapsed since theinjuring event (i.e.> 2 days).

Short Arm Cast

Volarly do not extend the cast distalto the distal transverse palmar creaseso that MCP flexion may occur;dorsally the cast should extend to themetacarpal heads. Leave ample roomaround the thumb. Obtain a goodinterosseous (A to P) and ulnar mold.

Long Arm Cast

As above for the short arm cast. Inaddition, cast with the elbow flexed at90. Apply a supracondylar mold.Extend the cast as proximal as

possible, but avoid impinging on theaxilla. Make sure you wrap the soft rollwith the elbow flexed at 90, so thatwrinkles do not develop.

Indicated for unstable forearmfractures, forearm fractures whichrequired reduction, and pediatricelbow fractures using neutral rotation.

Short Leg Cast

Cast with the ankle dorsiflexed to 90.Make sure the tips of the toes arevisible. Apply ample soft roll to theheel to avoid a heel ulcer at all costs.Mold the cast in the shape of the tibia(i.e. triangular shape with crest anteriorly).

Long Leg Cast

Same as for short leg cast. Inaddition, cast with the knee flexed at30. This prevents kids from being ableto weight-bear. Apply a supracondylarmold (M to L). Extend the cast as

proximal as possible (it is never ashigh as you think). It often helps toabduct the hip off of the bed toobtain space under the proximalthigh. Make sure you wrap the softroll with the knee flexed so thatwrinkles do not develop. Indicated fortibial shaft fractures and anklefractures which required reduction.

Ask a child his or her color preference!


20/37

20

SPICA Cast for Femur Fractures

Requires conscious sedation,the spica table, and usually 2additional people.

Usually the unaffected extremity iscasted to include the thigh only and

the affected extremity is casted distally:Dr. Sponseller includes the foot andankle; Dr. Leet likes to stop the castabove the ankle (make sure you padthis area well to avoid heel ulcer).

The goal position includes 90of kneeflexion on the affected extremity,30-45 of hip abduction, and 45-60

of hip flexion. Use of the mini-C-armto check reduction before and duringcast application will prevent the needfor recasting and save significant time.

Insert towel into abdomen to allowappropriate space for breathing andabdominal distension. Leave ampleperineal space for hygiene; use of safetypins on the stockinette is key.

Wrap soft roll and fiberglass in spicapattern at hips and around perineum.

Apply a strut of fiberglass over theinguinal crease from the thigh to theabdomen on the affected side toreinforce this weak area. Petal cast atcompletion (Nurses will usually dothis).

Cast Saws

Can still cut and burn skin.

Use two hands: one to hold the saw, andone to prevent diving in.

Use up and down motion only.

DO NOT MOVE THE SAWDISTALLY WHEN ON THE SKIN!

That is how cuts are made. Use up anddown, and only move distally/proximally when on cast surface.

Bivalve entire cast, not just part of it.No clamshelling here.


21/37

21

Traction is the use of a pullingforce to treat long bonefractures prior to operativefixation. Traction serves severalpurposes: it aligns the ends of afracture by pulling the limb into astraight position; it ends musclespasm and relieves pain.

Skeletal Traction

Skeletal traction is performed whenmore pulling force is needed thancan be withstood by skin traction.Skeletal traction uses weights of 25-40 pounds.

This is an invasive procedure that isdone either in an operating roomor in the E.R. with local anesthesia.Steinman pin trays are kept in boththe Bayview (pyxis) and JHH ER inthe supply room.

Traction can be set up once thepatient gets a bed on the floor. Callcentral supply to have them deliverthe traction cart to the floor whereyou will need it.

Proximal Tibia

Proximal tibial pins are morecommonly used, and are helpful in a

femoral shaft fracture in order tokeep the patient out to length, andto relieve pain prior to going to theOR.

Contraindications include ligamentinjury to ipsilateral knee and shouldnever be used in children. These pinsare inserted from lateral side toavoid damaging peroneal nerve.

The pin insertion site is 2.5 cmposterior to and 2.5 cm distal totibial tubercle. Make a skin incisionabout 1 cm in length, placed about3 cm below the lesser tuberosity.

Traction: SkeletalDistal Femoral

Distal femoral traction pins areinserted on medial side to avoidinjury to the femoral artery.

It is best to flex the knee and thighon several folded sheets to facilitate

pin insertion from the opposite sideof the bed and go from medial tolateral. This also facilitates obtaining alateral radiographic view.

The entry site is just proximal to theadductor tubercle (proximal tomedial epicondyle and/or growthplate ~ 1 finger breadth above

superior pole of patella when leg inextension.

Distal pin placement risks enteringjoint at intercondylar notch, andmore proximal pin insertion risksinjury to femoral artery at Hunterscanal.

As the short longitudinal incision is

made, turn the knife 90 deg (once itis buried under the skin) in order tomake a small transverse nick in theIT band. Place pin perpendicular toknee joint rather than perpendicularto femoral shaft.


22/37

22

Apply adhesive straps to the cottonpadding both medially and laterallyand secure with an overwrap of anace wrap. The straps are attached toa footplate, which is connected tothe desired weights through a pulleysystem.

The pulley system is adjusted toobtain the necessary angle oftraction. Hip flexion is secured witha folded blanket posterior to thethigh or a sling about the thighattached to a weight through apulley system.

The contra-lateral extremity is

likewise padded, wrapped, and placedin traction.

Elevate the foot of the bed toprevent a child from sliding downthe bed because of the traction.

Skin traction uses five-to sevenpound weights depending on the sizeand weight of the child.

The amount of weight that can beapplied through skin traction islimited because excessive weight willirritate the skin and cause it toslough off.

Preparation

Prep the area well with betadine andhave all of your equipment ready inorder to keep things sterile.

Inject 1% lidocaine into the skin anddown to bone around the areas

where your insertion and exit siteswill be.

Make your incision as above andplace pin medial to lateral.

Finally, check an x-ray after you arefinished to make certain you are inbone and not in the joint.

Keep the pin sites covered withsterile guaze or xeroform until goingto the OR, where the pin will likelybe removed.

Skin Traction

The skin should be cleansed andthen prepared with a non-allergenic

adherent dressing to prevent skinirritation. Make sure that the leg andbony prominences of the malleoli andheel are well protected with castpadding, and that the leg is wrapped.

Traction: Skin


23/37

23

General:1. Sterile technique: alcohol prep,then betadine or chlorhexidine.

2. Lidocaine local.

3. Aspirate with at least 1 inch 20

ga, preferably 19 ga, consider spinalneedles.

4. Tap until dry.

Aspirations5. Send Red and Green tops, sterile

collecting cup/tube for culture.Be careful with transferring fluid to tubes.

6. Send for: (Make sure it is markedStat on pink pathology form)

Gram Stain

Cultures-aerobic/anaerobic(add fungal if immunocomp)

Cell Count and DifferentialCrystals

Sometimes glucose

7.Walk it down to lab yourself!!!

Hips and shoulders should bedone with fluoro guidance toensure that it is intraarticular.Talk to radiology.

BursaOlecranon, prepatellar: Needle only;may leave an angio cath 16 ga fordaily lavage if pt is being admitted.

Do not I & D: they drain forever!!

Injections

Joint

Prep the area with betadine andalcohol.

Knee-supralateral or supramedial.Can also go anterolateral/medial, but

need to flex knee close to 90.

Shoulder

Subacromial bursa: Posterolateralaspect of acromion. Slide underbone.

Joint: Tough to know if you are reallyin. Can go from posterolateralshoulder or anterior betweencoracoid and AC joint.

Abcess

IVDA: Need x-rays and CT scan w

contrast minimum prior to cuttingskin.

Gas Gangrene? Needs ORdebridement.

Be wary of mycotic aneurysms inIVDA patients.

Consider dopplers if concerned.

Sterilely prep area. Incise skin alongLangers lines.

Send cultures.

Pack and dress wound.

IV antibiotics vs. po (see if patientcan go to EACU).


24/37

24

History

Physical

NEED heart and lung exam

Consent

Attending is not listed as staff. Listsome of the most likely attendings(Adult, Peds, Shock Trauma, Fellows).

Standard Risks & Specific Risks

Bleeding, infection, non-union,malunion, injury to nerves or vessels,weakness, numbness, pain, hardware

failure, breakage, loosening,compartment syndrome, loss offunction, arthritis, need foradditional procedures, limp, cosmeticdeformity, leg length discrepancy (totalhip, femoral nail etc.), reflexsympathetic dystrophy, stiffness.

Peds Risks

Growth plate injury causing leglength discrepancy

Blood consent

Films

Preop ChecklistChest Xray

EKG

LabsCBC T2S or T2CChemistry

Coags

Mark Site

D/C Blood ThinnersLovenox, Coumadin, ASA, Plavix...

NPO

Consults

MedicineAnesthesia

Posted

Patients discharged to follow upin Chiefs clinic.

Preop fully - including contactnumbers

Level 1 posting: must stay withpatient and personally bring toO.R.

IVPREOPERATIVEC A R E


25/37

25

The Bovie should not be used in thepresence of any flammable liquid(alcohol or tincture based agents).

Make sure the patient is not in

contact with any metal parts of thetable.

Once bovie pad has been placed onbody do not remove it and replaceit on the skin, once it is removed anew pad should be opened.

When not in use the activeelectrode (the bovie pencil) should

be placed in a clean, dry ,nonconductive plastic containerwithin the surgical field.

The electrode gel pad should beplaced on the positioned patient, onclean dry skin over a large musclemass as close to the operative field aspossible, limbs with metal implants

should be avoided.The skin should be inspected beforeand after removal of the pad. Keeparea dry avoid allowing liquidsespecially prep solutions fromcoming in contact with pad site.

VO P E R A T I N GROOM SAFETY

Electrocautery(Bovie)


26/37

26

When placing a tourniquet on anextremity the tourniquet shouldoverlap at least 3 inches, but no morethan 6 inches.

The cuff should be placed at thepoint of maximum limb circumference

( i.e. the proximal thigh).

Padding in the form of stockinetsupplied with cuff of web role shouldbe applied prior to cuff positioningthis should be wrinkle free.

Once applied a cuff should not berotated to a new position.

Liquids and skin preparations shouldnot be allowed to collect or poolunder the cuff.

A U drape should be applied oneinch below the distal edge of the cuffprior to the use of skin prepsolutions.

Tourniquet pressures depend on thepatients age, blood pressure andlimb size, but should never exceed400mm Hg.

Normal settings are 100mm Hg overthe patients SBP.

Do not leave the tourniquet cuffinflated on an arm for greaterthan one hour or on a thighgreater than 1.5 hrs.

Prior to inflating the tourniquet thelimb should be exsanguinated usingan ace wrap of es-marc.

Tourniquet


27/37

27

The surgeon(At Bayview: this is theattending, Downtown: it is the residentwho consented the patient or who isdoing the surgery)should identifythe patient and confirm theoperative side and level.

Once this is done he/she MUSTmark that side and or level with hisor her initials in the center ofthe surgical field, as close to themiddle of where the patient will beprepped and draped, and so that,once draped, the initials can bevisible prior to making the incision.

The Informed Consent must becomplete and must include thepatients name, the description of theprocedure and must include theside/site and level of the surgery.

A time out MUST be performedprior to incision. This is carriedout by the attending physician, thenurse and the anesthesiologist

together in a controlled andorganized manner.

The circulating nurse will use theconsent form and verbally verifywith the attending surgeon, and theanesthesia care provider, as well asany scrub personnel caring for thepatient, that the patients name,

surgical side, site, and level arecorrect.

Post-Op Orders

Need PT/OT consult.

Need WB status & ROM.

Order DVT prophylaxis.

Post-Op Labs

Post-Op Antibiotics

Dont Forget 3 As:

ActivityAntibiotics

Anticoagulation

Surgical Site Marking


28/37

28

Fluoroscopy

Must have lead prior to operatingFluoro.

Make sure every one in room iscovered prior to fluoroscopy announce that fluoro is being used.

6 feet minimum safe distance toavoid radiation if not wearingprotection.

Make sure that you have informedanesthesia prior to fluoro use sothat they are protected.

Mini C arm

1 foot min safe distance.

Should use xray gown if available.

Mini C arm located in Urgent care:Make sure you return it after use.

Plain Xray

At least 2 views of all extremities:AP & Lateral.Insist on perfectlaterals, otherwise they will beoblique, and YOU, not the XR techwill be spanked at AM board rounds.

VIR A D I O L O G Y

On Hip xrays obtain cross tablelateral of affected side.

Always x-ray the joint aboveand below the injury!!!

Special Views

Axillary views on all shoulderfilms. If tech unwilling, you will haveto position the arm for the film.

Pelvis: Judet views. Evaluate for allpossible acetabular fx.

Inlet Outlet View if there ispossible disruption of pelvic ring.

CT Scans for

Tibial Plateau fracturesPelvic fracturesPilon fracturesSpine fracturesCalcaneal fractures


29/37


30/37

PELVIS 2. Inlet/Outlet views ifthere is possible disruptionof pelvic ring (includingpelvic rami)- Inlet shows hemipelvisrotation (ie. open book)- Outlet shows hemipelvisvertical translation

1. AP PELVIS 3. Judet views for anyacetabular fracture- Obturator obliqueshows anterior column& posterior wall- Iliac oblique showsposterior column &anterior wall

ANKLE 2. CT scan forPilon fractures

1. AP/LAT/MORTISE 3. Stress views forisolated lateral malleolusfractures (lidocaine block)

4. Tib/Fib forMaisonneuve frx iftender over prox fib

5. Foot filmsif tender in foot

FOOT 2. CT scan for allhindfoot & midfootfractures

1. AP/LAT/OBLIQUE 3. Harris (axialcalcaneus) forcalcaneus frx

4. Weight-bearingAP if you suspectLisfranc injury

HIP 1. DEDICATED AP & LATERAL OF HIP + AP PELVIS

- AP Pelvis is not an AP of the hip. Get a dedicated view.- Best AP of femoral neck is a 15 degree internal rotation AP. You often have to hold for these.- Get femur films for templating / looking for distal lesions.

FEMORAL

SHAFT

1. AP/LAT 2. A/P & lateral of hip torule out concomitantfemoral neck fractures

KNEE 2. Obliques for tibial

plateau fracture

1. AP/LAT 3. CT scan for all

tibial plateau frxs

4. Traction views &

CT scan for displaceddistal femur frx

TIBIAL

SHAFT

1. AP/LAT


31/37

29

Fever:Respond to all temps > 38.5.

Low grade fever within first 24-48hours of surgery is normal, but donot let that fool you.

UA is the most sensitive test for feverwork-up during first 48 hours (dueto foley, etc). Send C&S as well.

Check vitals make sure pt is stable.

Examine incision.

Check for calf tenderness. If positive orsuspicious for DVT, order Ultrasound.

Chest Xray to eval for Atelectasisand Pneumonia (if lungs sound junky).

Send blood cultures x 2 (if valid

concern for sepsis).

Remember:Wind ,Water, Wound, Walking,Wonder Drug

Night of Surgery Notes (NOS)

Vital Signs

See how pain is.Any concern for compartmentsyndrome?

Appropriate exams:Spine ExamNeurovascular exam for extremitiesLook at op note

Make sure dressing/splints/VACs areintact.

PACU x-rays / Hgb

Let chief know about anyconcerns.

Constipation / IleusAll patients on colace. Dulcolax, fleets,soap suds, Mag Citrate, etc as needed.

Urinary RetentionHave concern if a spine patient.Cauda Equina? Check post void

residuals on all spine patients.

Straight cath if its been greater that8 hours, leave in if output > 300 cc.

Remove foley next am to letdetrusor muscle relax.

VIIPOSTOPERATIVEC A R E

Review I&Os, check BUN/Cr forkidney status. Evaluate nephrotoxicdrugs such as aminoglycoside orvancomycin.

Evaluate patient for distention. Inpediatric patients may be moreconservative about cathing. Consider

checking post void residuals.

Potential for cauda equine syndromein post op spine patients. Checkrectal tone/sensation and rule outsaddle anesthesia in spine patients.

VAC DressingsMust act if suction is not

holding. Cover any openings withop-site etc.

Non-working VAC sponge is abroth for badness!! Dont letsomeone get toxic shocksyndrome because you didntcheck the VAC!!!

Cultures/Infectious Disease

Consultations

Pathology

Keep an eye on all cultures andspecimens sent from OR!!! Dontmiss an infection or other badness!!


32/37

30

VIIIM E D I C A LI S S U E S

Decubitus ulcers

Air mattress, heels off bed, heelsprotected, turn q2 hours, woundcare nurse.

Check daily.

Waffle boots/heel protectors.

For consults: consider osteomyelitis.

W/u should include xray, CT scan,inflammatory markers (ESR, CRP),local wound care-local debridement,wet to dry dressing changes/Silvadene.

Nutrition

Nutritional status: always an issue for

wound healing and preventinginfection. Very important in elderlyhip fractures.

W/u should include albumin,prealbumin, transferrin. Ensureshakes/pudding TID.

On discharge recommendosteoporosis/osteopenia work up &calcium supplementation. Nutritionconsult.

Colchicine

No ortho resident shouldprescribe colchicines.

Rheumatology consult to medicallymanage.

Antibiotics

Post Op:

Ancef one gram IV Q8hr x 24hr.

If PCN allergic Clinda 600mg IVQ8hr or Vanc one gram IV Q12hr.

Revision surgery and prior infectionwill dictate coverage and may beattending dependant.

Open Fractures:

Type I or II: 1st generationcephalosporin.

Type IIIA: 1st generationcephalosporin + aminoglycoside; addpenicillin for grossly contaminated

wounds.

Always check levels on nephrotoxicdrugs especially on patient withpreexisting renal insufficiency ordiabetes. (i.e. Gent or Vanc levels).

Cultures from infections should bechecked for sensitivities andInfectious Disease recommendations

should be followed for properantibiotic coverage.

Lack of peripheral I.V. Access

Do not put in central lines or A.lines. 24 hour stop on I.V. team

Femoral, radial, brachial vein/arter

sticks for labs, if needed. Discusswith senior resident first.

Make sure patient is not onanticoagulation!!!!


33/37

31

IXC O N S U L TI S S U E S

SPINESpine Fellow

Adult: Shared with neurosurgery.

Only see spine consults withoutneuro changes. Any neuro changesneurosurgery!!!

Peds: Basically all spine.Discuss case with attending tosee if NUS should be involved also.

RESPONSE TIMECall back within 10 minutes!(Tell OR nurses that youre on calland ask them to return pages).

See patients as soon as possible!

PRIORITIZE!!!

See the emergencies first.

Compartment Syndrome, Cauda Equina,Open Fractures, Septic joint, etc.

The clavical fractures, etc can wait untilthe emergencies are handled.

Day

ON-CALL(410.283.1254)

All ER 7am-5pm

All ERAll InPatient

ADULT ORTHO TEAM(rotating pager)

Adult InPatient 7am-5pm

PEDIATRIC ORTHOTEAM(410.283.4505)

Pediatric InPatient 7am-5pm

HAND

Rotates weekly with Plastics.If were not on, we dont want it!!!

Hand includes:Soft tissue distal to elbow.Bone distal to distal radius.Distal radius is always Ortho.

Any microvascular repair goes

to Plastics.

Day

AfterHrs&Wkend

Day


34/37

32

XF O L L O W - U PC L I N I C S

1. Pediatric Chief Resident ClinicEvery Monday.All fractures in children


35/37

33

Medicaid (does not require referral)

Amerigroup MCO/Americaid (only Ortho does not require referral)

Patients should be instructed to obtain a referral from their primarycare doctors office for :

JAI MCO

Maryland Physicians Care

Priority Partners

The referral MUST be physically here in the office (fax accepted) before wecan proceed with scheduling a follow-up appointment.

Fax JHOC 410-955-0180 Fax line for referrals only!Fax BAYVIEW 410-550-0622 Fax line for referrals only!

We do not participate with the following insurances,however, a patient can be seen by our Chief Resident Follow-Up Clinic if seen first in ED,

but must have authorization # from insurerto be scheduled in the Chiefs Clinic.

Diamond Plan MCO

Helix MCO

United Heath Care MCO

Insurances Under the Medical AssistanceUmbrella


36/37

34

XIIO R T H OE - L E A R N I N G

NetOrthoDoc Website

NetOrthoDoc is a password-protected e-learning website ofthe Johns Hopkins Department ofOrthopaedic Surgery.

The site is for resident education,

and contains an ever-expandinglibrary of talks with sound andvisuals from Grand Rounds, facultylectures, the JHOrthopaedic ReviewCourse, and other specialty courses.

NetOrthoDoc also has video clipsfrom anatomy courses created byDr. David Hungerford: Anatomy ofthe Knee, and Anatomy of the Hip.

The syllabi for rotations can also befound at the site. Some have weeklyobjectives and reading assignments.The yearly lecture schedule is alsoposted at NetOrthoDoc.

From NetOrthoDoc you can link tosets of tutorials and questions onvarious topics. Pediatrics has over200 questions, and Dr. Frassica willbe including weekly current topicsfor review. Each resident will have apersonalized login for this feature.

http://www.netorthodoc.org

LOGIN: jhuorthoPW: resident

(the Hopkins firewall may ask for thesetwice, just enter them a second timeand disregard the request for adomain name)

Contact for Ortho E-Learning:

Gail Richter-Nelson(o) 410.502.5885, (c) 443.629.3848

JHOC #5240


37/37

OPERATIVE NOTE FORMAT

- Your name, Patient Name,7-digit History #, AttendingSurgeon, Assistants or othersurgeons present in OR incl.residents (spell names)

- Date of Procedure, Title ofOperation (include Codes)

- Indications for Surgery

- Pre-Operative/Post-OperativeDiagnoses (include Codes)

- Anesthesia (Specify type)

- Specimen (Bacteriological,Pathological, or other)

- Prosthetic Device / Implant

- Narrative:- Technical Procedures (incl skin

prep, incision, closure, drains etc .)- Description of Findings- Stage of Cancer

- Clinical size of tumor- Clinical nodal size- Evidence of Metastasis

- Estimated Blood Loss/Given- Fluids Given- Sponge count- Post-Operative Condition

- Indication of dual Attendings

DISCHARGE SUMMARY FORMAT

- Your name, Patient Name,7-digit History #, Admission &Discharge Dates, AttendingPhysician, other Physicians (spellnames)

- Condition on Discharge

- Diagnoses/Problems

- Procedures

- Brief History, Major Findings,Hospital Course (500 wds or less)

- Reportable Diseases

- Adverse Drug Reactions,

Allergies, Complications ofProcedures

- Discharge Medications

- Discharge Instructions (Diet,Activity, Other Follow-Up Car

CC List (include address of non-JHH doctors)

CLINIC NOTE FORMAT

- Your name, Patient Name,7-digit History #, Date of ClinicVisit, Clinic #, AttendingPhysician, other Physicians (spellnames)

- Reason for Visit (ChiefComplaint)

- History of Present Illness (mayinclude past medical/surgical, familyhistory, social history, immunization)

- Medications

- Allergies

- Major Findings (including PE,pertinent lab or imaging studyresults)

- Assessments

- Problems/Diagnoses

- Procedures & Immunizations

- Plans

- Medication Changes

- CC List (include address of non-JHH doctors)

Patient MUST be registered(clinic notes are linked to an outpatientepisode of care

23345260 Orthopedic Emergencies

Documents

Transcript of 23345260 Orthopedic Emergencies