The James F. Wenz, M.D.
Orthopaedic Surgery Resident Survival Guide
Editor: Frank J. Frassica M.D. Asst. Editors: Kevin W. Farmer, M.D. & Brett M. Cascio, M.D.
Table of Contents:
Compartment Syndrome Cauda Equina Pulmonary Embolism Deep Venous Thrombosis Labs Narcotics Chest Pain / Myocardial Infarction SICU Consult Hypotension Stroke Fat Embolism Epidural Hematoma Physical Exam/Motor Grading Splinting Casting Traction: Skeletal Traction: Skin Aspirations & Injections Preop Checklist OR Safety (Bovie,Tourniquet) Radiology Post Operative Care Medical Issues Consult Issues Follow-Up Clinics Ortho E-Learning IMPORTANT NUMBERS OPERATIVE NOTE FORMAT 5 7 8 9 10 11 12 12 13 13 14 15 16 17 19 21 22 23 24 25 28 31 32 33 34 36 37 42
“Patient Safety is Rule Number 1.” “Ask if you do not know.” “Do not do anything by yourself for the first time.”
Henry Boateng, M.D. Mark Clough, M.D.
Orthopaedic S u r g e r y Resident Sur vival G u i d e
James F Wenz, 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.
“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 us should strive to be.” Kevin Farmer, M.D. Class of 2008
Deep Venous Thrombosis Chest Pain / Myocardial Infarction Hypotension Stroke Fat Embolism Epidural Hematoma
ORTHOPAEDIC EMERGENCIES Compartment Syndrome Cauda Equina Pulmonary Embolism
“The price of safety is never-ending.” Frank J. unremitting vigilance.” “Never be afraid to ask.D. Frassica.” “Check & Double Check.
5 Level 1 case. Compartment measures? Measure pressures if you can not decide if a compartment syndrome is present. it is a Level 1 OR case for fasciotomies. Patients in severe pain will often try to sleep to forget about pain. Don’t forget about well leg.
If patient has compartment syndrome. etc Weakness: 0-5 grading. Compare exam to other side and to previous exams in chart!!!!
. Do not delay!
Pain: out of proportion to injury Pain on passive stretch: severe pain with passive movement of toes. 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 in case you check pressures. Pressure then impedes blood flow into compartment leading to potentially irreversible changes (nerve damage. Never hesitate to call the attending on call. Due to increased pressure within a fascial compartment. fingers. DO NOT MISS A COMPARTMENT SYNDROME UNDER ANY CIRCUMSTANCES!!!!
YOU MUST see the patient and evaluate. Do not Delay!!!! Have an extremely low threshold for concern. ankle. can occur in the non-injured extremity due to positioning in OR. Time is of the essence. etc). wrist. Compare to previous exams. muscle necrosis. and in any extremity. Compare to previous exam Numbness: Compare to other side. Can occur following any injury. Pain out of proportion to the injury and the physical examination is the most sensitive indicator! Call chief resident with concerns.
Use of the Stryker monitor 1.Chief’s Office. 9.
. Inform chief of compartment pressures. bleeding. GSS . zero the monitor at the level of the compartment to be tested. Preload a disposable syringe with fluid and connect to the measuring instrument. discomfort and remote chance of infection. 4. JHOC .Maria’s Office Whitemarsh . They will bring it to you. Use the Stryker monitor in situations where there is a question of diagnosis of compartment syndrome in a susceptible patient. The numbers on the monitor screen fall reasonably rapidly. add a disposable needle-catheter that comes as part of the set. To the other end. Prep the area to be tested with Betadine. 5. Ask and receive verbal consent for the procedure (potential benefit: early diagnosis and prompt treatment of compartment syndrome vs. insert the needle through the fascia keeping the unit parallel to the floor. 2.Measurement of Compartment Pressures
Location of Stryker Monitors JHH – Main OR desk. Using sterile gloves. 8. Check 9v battery if the unit does not turn “On”. Laura’s Office JHBMC – OR desk GSH – Page Nursing Supervisor. damage to nerves). Juniors must inform their chiefs prior to any compartment measurement. Remove the needle and apply a dressing.Clinic Office Indications for Compartment Measurement 1. 7. After the system is purged with some fluid. Do not attempt to anesthetize any deeper as this may alter your compartment measurements. Please return. 2. This is a procedure and must be taught to juniors by seniors prior to a junior performing the procedure alone. Remember to compare the compartment pressure to the diastolic blood pressure. and as the descent levels off a reading of the compartment pressure can be made. 3. Write a procedure note. Prior experience at another institution does not count. The device needs to be adequately “charged” for accurate use. 6. and infiltrate the skin with 1% lidocaine. Always use the compartment syndrome stickers. There is no need to stick a patient who clearly has or does not have compartment syndrome.
6 3. Depress syringe until saline fills the chamber & needle. Have an assistant record these by each compartment. 10. Perfusion pressure is the diastolic blood pressure minus the compartment pressure.
Causes include: disc herniation. fracture or narrowing of the spinal canal. decreased rectal tone) should prompt immediate concern.. Any changes (weakness. Call spine fellow immediately. Will need stat CT Myelogram vs. Compare exam to previous exams. gunshot. impaired bladder and/or bowel control. Do not hesitate to call the spine attending on call. urinary retention. parasthesias. Even if the problem gets treatment right away. Lower extremity motor/sensory changes.e. fall from significant height or penetrating (i. Always perform thorough motor. It may also happen because of a violent impact such as a car crash. Nerve roots that control the function of the bladder and bowel are especially vulnerable to damage. MRI with Gadolinium vs. Make NPO. tumor. sensory (pin prick.Cauda Equina
7 A True Surgical Emergency! Cauda equina syndrome occurs when the lumbosacral nerve roots are compressed and thereby injured. cutting off sensation and motor function. Have a Low Threshold Examine any post-op spine patients with new complaints (incontinence. stab) injury. Any delays could be catastrophic! THIS IS A PRIORITY EVENT! You can open up the checkbook if it is missed!!!
Bilateral buttock & lower extremity pain. loss of sexual function and other problems. Saddle anesthesia. it may cause permanent paralysis. light touch) rectal exam.
. weakness). Children may be born with abnormalities that cause CES. they may not recover complete function. infection. If you don’t get fast treatment to relieve the pressure. Bowel/bladder dysfunction (especially urinary retention). straight to OR as Level 1. post-op hematoma/swelling. sensory changes.
Make sure arrangements are made to follow INR once discharged (primary care. It is much more acceptable to over order spiral CT then to not order one in a patient who has a PE !!!
Have a low threshold to order a spiral CT on any of these patients. Do a cardiac and lung exam Patient will need long term therapeutic anti-coagulation. etc). patient should be SICU consult in a monitored setting (IMC at least) until therapeutic.e. coumadin clinic. Will need a large bore peripheral IV for spiral CT (i.
. 18 gauge). Let chief / attending know ASAP . Make sure patient does not have kidney problems prior to ordering spiral CT. Consider mucormyst 600 my po BID before spiral CT and for 2 days afterwards. Resuscitate them with normal saline IV before and after scan.Pulmonary Embolism
8 A potentially fatal event! Check vital signs. Consider V/Q scan if patient a high risk for renal failure.
Especially common following total joints and intramedullary rodding of a femur fracture.
Tachycardia Hypoxia Tachypnea. or Pleuritic type chest pain. Medicine consult for management.
Doppler if concerned. Let your chief / attending know if positive for DVT!!
Calf pain/cramping Leg swelling Palpable cords
Do not do a Homan’s sign (low yield.Deep Venous Thrombosis
9 Make sure all patients have anticoagulation plan!!! Use the DVT protocol. Continue current pathway and recheck dopplers in 48 hours to look for propagation. Will need arrangements to have coumadin and INR followed once discharged. Above the knee DVT: Must be treated! Medicine consult. Have a low threshold to order bilateral lower extremity dopplers for any patient with concerning symptoms. preferably by primary care physician. Also possible to have DVT in upper extremity. Vascular lab better than radiology if possible. potential to break off clot).
. Below the knee DVT: Must be treated! Treatment: Attending dependent. please fill out the pink form and put form in the front of the chart.
Blood Cx Less useful in orthopaedics. Orthopaedic Tumor Consult? Order CBC. Midnight Labs can be ordered. Frassica will ask for the calcium. UA Every hip fracture should have a UA on admission.M. BMP. knee and shoulder procedures should get one in the recovery room. These have a tendency to creep up. especially on weekends. Don’t let it jump up!!
A. ask the attending before ordering any labs. CRP. and review their pathology reports. CRP/ESR Every patient suspected of having an infection needs these labs. A lab that is ordered on your patient is your responsibility to check. Not part of our routine post op fever workup unless the fever is high or patient has documented infection. Dr. Pathology Reports Keep track of the patients you have operated on. BMP Watch the creatinine values on joint patients and patients on gentamicin or vancomycin carefully. SPEP/UPEP. ESR.
Femur fractures and large spinal. UA. PT/PTT Watch patients on coumadin like a hawk.Labs
10 Pertinent Labs: Hematocrit Most post op patients get one the first day after surgery. no matter whom else ordered it or is following the value. Place it in bold letters on sign-out so that other people know the patient is on coumadin. On the pediatrics service. Others as appropriate. labs are usually back by 10 am. Get in the habit of looking through EPR every day for rogue labs that someone else ordered. Keep potassium repleted. (1st draw AML) Don’t make a habit of signing out labs! There are fewer labs to worry about in Orthopaedics. If the patient is actively losing blood (recognized by precipitous pressure drop or heavy drain output). Often the kids don’t need them and the attendings will be miffed that they were ordered. order a post-transfusion hematocrit. hip.
g. G: Inform team and transport to monitored setting if clinically indicated.
Signs of Narcotic Overdose
Respiratory depression CNS depression Miosis Hypotension
B: Maintain Breathing Oxygen supplementation C: Circulatory Support Place patient on monitor D: Call code if necessary E: Stop all narcotic medications F: Naloxone (e.2 mg Dilaudid = 100 mcg of Fentanyl They have differing half-lives Dilaudid > Morphine > Fentanyl
Be wary of the narcotic naïve.
Constipation Colace 100 mg po bid Senna 2 tabs qDay (increases GI motility)
Appropriate Post-Operative Pain Management 1mg Morphine = 0.
. Patient should remain on monitor.Narcotics
11 Treatment of Narcotic Overdose A: Maintain Airway Call anesthesia if needed Do not prescribe narcotics on the weekends or evenings if you feel the patients are seeking drugs. Be wary of the narcotic seeking. Has short half-life / will likely need to be re-dosed. Narcan) 0.4mg-2mg q 2-3 min PRN. Call the chief resident or attending and let them handle the problem (FJF).
4. with you to the fellow. etc. Consider STAT CHEST X-ray. pneumothorax.SICU. nitroglycerin tablets. 3.
12 Top priority!! YOU MUST see all patients with complaints of chest pain.morphine. Same situation for the PICU fellow. talk to your chief or attending about the situation. your job is to transfer them from our service and into a monitored setting ASAP. labs. Cards. 5. Check EKG Compare to old EKG. If at night. 2. Send off Cardiac enzymes x 3. call cardiology for consult for acute MI if EKG changes or enzymes positive. Do not forget about: PE.
Talk to SICU fellow for any patients with concerns. Take EKG. If story not concerning. pneumonia. Cardiac/Lung Exam. oxygen.Chest Pain / Myocardial Infarction
Let chief / attending know if situation is bad. MONA . Have a good story. If any concerns with story or if any EKG changes: 1. aspirin. Have a convincing story as to why you’re concerned. and EKG unchanged: May stop there and monitor. take EKG and show SICU fellow. first one stat. etc. If patient is having an acute MI. Pertinent questions Radiation? Nausea? Diaphoresis? Type of pain? Shortness of Breath? Physical Exam Check vitals. If able to. If they are not receptive. We should not be managing a MI ! you have done all the necessary workup and you have legitimate concerns. They are usually willing to help you out if you present it to them in way that shows
. Don’t try to be a hero!! Bump it up if you have a worry.
Neurology Consult: Call the Stroke pager ASAP. etc): Stat IV bolus NS.ACLS?
Let chief / attending know if situation is bad. WBC.4040
. ABC’s. Is patient alert? If urine output is low.8810 Good Samaritan: 410. Pulse High hypovolemia? Sepsis? PE? A-fib? Low heart failure? Meds:Beta blocker. Check pulse.7777 Bayview: 410. Hct.532. Call code if concerned enough .Hypotension
13 Make sure patient is stable. Urine output.
JHH: 410. bolus with 1 Liter Normal Saline Check Hct Blood > Normal Saline > ½ NS for intravascular resuscitation.283.283. Have blood available. Stat SICU consult (they will want to know EKG. ABG etc).
Document your Neuro Exam as thoroughly as possible. If patient in unstable (unresponsive. calcium channel blocker? Check EKG medicine consult? Cards consult for arrythmia.
IM nailing? Controversial! Diagnosis CLINICAL DIAGNOSIS!! Lab and XR findings are non-specific. Treatment: Early supportive pulmonary therapy. 100% O2 on non-rebreather if on floor Continuous O2 monitoring May need to be intubated ICU or IMC transfer. Anemia.
. Non contrast head CT if mental status changes. Workup: Stat portable CXR May see diffuse bilat infiltrates ABG Increased Aa gradient CBC. Spiral CT to rule out PE when stable. low fibrinogen Continuous O2 monitor. fibrinogen.Fat Embolism
14 What is it ? Fat embolism is a release of fat droplets into systemic circulation after a traumatic event. Femur fractures especially. SICU fellow consult stat Notes: Mortality 10-20%
Pulmonary distress – ARDS-like Mental status changes Petechial rash Occur transiently in 50% Reddish-brown spots in upper body and axilla or subconjunctival Fever >38. thrombocytopenia. Non-op treatment has highest risk. platelets. Pathophysiology unclear.5 Tachycardia >110 24-72 hrs after long bone fracture or pelvic fracture
Fat embolism syndrome is a rare clinical consequence of the above.
Risk factors Increased risk with increased number of long bone fractures.
Don’t forget to check the results. Declining neuro exam mandates stat imaging or immediate operative exploration! Imaging options if concern for postop hematoma: CT myelogram Need to speak with radiologist on call. Do not need radiologist approval for these tests. especially if laminectomy Unrelenting back pain Progressive neurologic deficit What is it? In Brain: hematoma between skull and dural membrane.
15 Workup Stat non-contrast head CT for all possible head traumas. Any unwitnessed falls should get head CT. This includes all patients who fall and hit their head while in the hospital. A radiology team will have to be called. must do Q2-4h neuro exams and document results. If can’t get in touch with spine fellow then call spine attending.especially if hardware in place. MRI Not as good.Epidural Hematoma
Brain: Mental status changes after a fall May have a lucid interval Severe headache. seizure Spine Usually post-op. vomiting. Treatment: Brain Epidural Hematoma Stat neurosurg consult. YOU MUST escort patient to monitored setting.
. In Spine: hematoma compressing on spinal dura. speak with chief & spine fellow. May need immediate evacuation in OR by neurosurg. If decide to observe. ICU / NCCU transfer Spinal Epidural Hematoma ORTHOPAEDIC EMERGENCY ! Needs stat decompression in OR as level 1. Any post-op patient complaining of severe back pain must be re-evaluated! Does deficit correspond with level of surgical site? Any neuro deficits. Test should only take minutes! Postop Spine Patients Full neuro exam – meticulous documentation.
Motor Grades (Not a perfect system!) Designed for Spinal Cord Injury and joints with full range of motion. Adult spine surgery NOS notes should also include rectal tone. lung. Sensory exam-Document abnormal sensation as to area. Document what you see. You should be able to explain every deficit you find. -) Grade 5-normal
A patient with a tibial fracture is not going to have 5/5 strength in his foot. Document your findings accurately.
16 Children with supracondylar humerus fractures are often hard to assess. Compare to other side!!! Preop History and Physical Must include Cardiac. & abdomen to be considered complete!!
Spine Surgery Notes
UPPER EXT Right Left LOWER EXT Right Left HipFlex L2 KneeExt L3 Biceps C5 WristExt C6
. Check that anterior interosseous & ulnar nerves are in when you see them in the ER. Index finger DIP flexion tests the Anterior Interosseous Nerve (Branch of median) Small finger DIP flexion tests Ulnar Nerve Patients with an active nerve block from anesthesia should be reassessed when their block wears off. Grade 0:Nothing. or you should notify someone senior. Every patient’s NOS note or H+P should have a motor exam written out so that we can track progress or decline. Do the rectal with a nurse present and warn the patient. adult and peds should also be tested for clonus. Pediatric spine patients do NOT need a rectal.II
P H Y S I C A L E X A M
Motor Exam Motor exams are critical in orthopaedics. ACDF’s do NOT typically need a rectal. Spine surgery patients. Grade 1:Flicker Grade 2:Full range of motion-gravity removed Grade 3:Full range of motion-against gravity Grade 4-weak (only grade with +. even though the nerves may be fine. EPL tests the radial nerve. wink & perianal sensation for all thoracolumbar cases & extensive cervical cases. light touch & pinprick (paperclip). not for orthopaedic trauma.
This is too tight & patients will be calling you in a few hours for blue or tingling fingers. In general.17
plaster and 1 layer of soft roll on the superficial side of the plaster so that it doesn’t stick to the ACE wrap. You will be amazed how fast an ulcer can develop. Campbell often uses ABD pads for the heel. A distal radius needs just enough soft roll to protect the skin without losing reduction. Fractures that require this are often high energy or have significant comminution – dusted elbows. tibial plateau fractures. Do not pull the softroll or ACE wrap. However. pilons. Do not use fingers or the plaster will pick up the grooves and cause an ulcer. use broad surfaces to apply forces. Lower extremity often requires 12-14 layers. A splint should generally try to immobilize the joint above and the joint below a fracture. When holding a reduction as a splint hardens. We also tend to splint tibial shaft fractures with Robert Jones cotton and Kerlix here as well.
For fractures that can balloon with swelling. Dr. Make sure no plaster or thinly padded plaster touches the skin. However. use the palm of the hand. No fiberglass. modify as necessary.
Adult Adults do not get casts acutely. A big person may require more layers. Overwrap with a Kerlix to help apply gentle compression to control the swelling. This is especially true at the ends of splints. A good splint stabilizes the fracture without causing a pressure ulcer. Measure off the good limb. use at least 3 layers of soft roll to protect the skin from the
. Just roll it on. Dr. too much padding may not provide enough support to maintain a reduction. Upper extremity often requires 1012 layers of plaster. Pad bony prominences well! This means putting on extra padding at the elbow joint for sugar tongs or on the heel for AO splints. Make sure your posterior slab for an ankle fracture does not dig into the popliteal fossa. use Robert Jones cotton for extra padding. Frassica prefers padded splint). the one exception may be cylinder casts for patella fractures (very rarely. Only splint acute fractures with plaster to accommodate swelling.
pad the elbow The buttress gives support consider Jones cotton if dusted Pad the elbow well. Apply 1 layer of soft roll in between slab & stirrup
Pad the axilla extension well with ABD’s. keep splint proximal to MCP’s Mild wrist extension with as much MCP flexion
Posterior slab with Buttress
Boxer’s Fracture Thumb / scaphoid Tibial plateau
Ulnar gutter Thumb spica Long posterior slab with 2 side slabs Long posterior slab including foot with long stirrup Posterior slab with stirrup
Use Robert Jones cotton
Use Robert Jones cotton
Start applying plaster at calf and then double over on foot plate if excess. carry the shoulder extension high.
.e. so that wrinkles do not develop. cast with the elbow flexed at 90°. dorsally the cast should extend to the metacarpal heads. It often helps to abduct the hip off of the bed to obtain space under the proximal thigh. Extend the cast as proximal as possible (it is never as high as you think). Short Leg Cast
Cast with the ankle dorsiflexed to 90°. and pediatric elbow fractures using neutral rotation. . Extend the cast as proximal as possible.Over-wrap with ACE wrap after bivalving the cast. buckle fracture).Fiberglass (at least 2 layers thick). cast with the knee flexed at 30°. or a significant time has elapsed since the injuring event (i. Mold the cast in the shape of the tibia (i. Indicated for tibial shaft fractures and ankle fractures which required reduction. Make sure you wrap the soft roll with the knee flexed so that wrinkles do not develop. Long Arm Cast As above for the short arm cast. Ask a child his or her color preference! Volarly do not extend the cast distal to the distal transverse palmar crease so that MCP flexion may occur. In addition. triangular shape with crest anteriorly). Leave ample room around the thumb. Make sure the tips of the toes are visible. Bivalve all casts unless there is minimal swelling and a low-energy mechanism with little potential for swelling (i. but avoid impinging on the axilla. This prevents kids from being able to weight-bear. In addition. forearm fractures which required reduction. Make sure you wrap the soft roll with the elbow flexed at 90°.e.Soft roll (at least 2 layers thick). Take care to avoid pressure points which may cause cast sores. Apply ample soft roll to the heel to avoid a heel ulcer at all costs. . Apply a supracondylar mold. Obtain a good interosseous (A to P) and ulnar mold. fiberglass casts are applied with the following layers in sequential order: .Stockinette (cut out creases). Indicated for unstable forearm fractures. Long Leg Cast Same as for short leg cast.> 2 days).Casting
Short Arm Cast Pediatrics In general.e. Apply a supracondylar mold (M to L).
and 45-60° of hip flexion.
. DO NOT MOVE THE SAW DISTALLY WHEN ON THE SKIN! That is how cuts are made. The goal position includes 90°of knee flexion on the affected extremity. Petal cast at completion (Nurses will usually do this). No clamshelling here. Dr. Wrap soft roll and fiberglass in spica pattern at hips and around perineum. Leet likes to stop the cast above the ankle (make sure you pad this area well to avoid heel ulcer). and one to prevent diving in. Leave ample perineal space for hygiene. Use of the mini-C-arm to check reduction before and during cast application will prevent the need for recasting and save significant time. Apply a strut of fiberglass over the inguinal crease from the thigh to the abdomen on the affected side to reinforce this weak area. and only move distally/proximally when on cast surface. the spica table. Usually the unaffected extremity is casted to include the thigh only and the affected extremity is casted distally: Dr. and usually 2 additional people. Use two hands: one to hold the saw. Cast Saws Can still cut and burn skin. Use up and down. not just part of it.20 SPICA Cast for Femur Fractures Requires conscious sedation. Use up and down motion only. Bivalve entire cast. 30-45° of hip abduction. use of safety pins on the stockinette is key. Insert towel into abdomen to allow appropriate space for breathing and abdominal distension. Sponseller includes the foot and ankle.
It is best to flex the knee and thigh on several folded sheets to facilitate pin insertion from the opposite side of the bed and go from medial to lateral. These pins are inserted from lateral side to avoid damaging peroneal nerve.Traction: Skeletal
21 This is an invasive procedure that is done either in an operating room or in the E. Call central supply to have them deliver the traction cart to the floor where you will need it. As the short longitudinal incision is made. Distal Femoral Distal femoral traction pins are inserted on medial side to avoid injury to the femoral artery.
Traction is the use of a pulling force to treat long bone fractures prior to operative fixation. The entry site is just proximal to the adductor tubercle (proximal to medial epicondyle and/or growth plate ~ 1 finger breadth above superior pole of patella when leg in extension.R. Distal pin placement risks entering joint at intercondylar notch. it ends muscle spasm and relieves pain. Make a skin incision about 1 cm in length. This also facilitates obtaining a lateral radiographic view. and more proximal pin insertion risks injury to femoral artery at Hunter’s canal. Steinman pin trays are kept in both the Bayview (pyxis) and JHH ER in the supply room. Proximal Tibia Proximal tibial pins are more commonly used. Contraindications include ligament injury to ipsilateral knee and should never be used in children.5 cm posterior to and 2. and are helpful in a femoral shaft fracture in order to keep the patient out to length.5 cm distal to tibial tubercle. Traction can be set up once the patient gets a bed on the floor. Skeletal Traction Skeletal traction is performed when more pulling force is needed than can be withstood by skin traction. and to relieve pain prior to going to the OR.
. placed about 3 cm below the lesser tuberosity. with local anesthesia. Skeletal traction uses weights of 2540 pounds. Place pin perpendicular to knee joint rather than perpendicular to femoral shaft. turn the knife 90 deg (once it is buried under the skin) in order to make a small transverse nick in the IT band. Traction serves several purposes: it aligns the ends of a fracture by pulling the limb into a straight position. The pin insertion site is 2.
Make your incision as above and place pin medial to lateral.Traction: Skin
22 Preparation Prep the area well with betadine and have all of your equipment ready in order to keep things sterile. Skin traction uses five-to seven pound weights depending on the size and weight of the child. Make sure that the leg and bony prominences of the malleoli and heel are well protected with cast padding. Apply adhesive straps to the cotton padding both medially and laterally and secure with an overwrap of an ace wrap. where the pin will likely be removed. The amount of weight that can be applied through skin traction is limited because excessive weight will irritate the skin and cause it to slough off. The straps are attached to a footplate. Skin Traction The skin should be cleansed and then prepared with a non-allergenic adherent dressing to prevent skin irritation. which is connected to the desired weights through a pulley system.
. and placed in traction. The contra-lateral extremity is likewise padded. Keep the pin sites covered with sterile guaze or xeroform until going to the OR. The pulley system is adjusted to obtain the necessary angle of traction. and that the leg is wrapped. wrapped. Hip flexion is secured with a folded blanket posterior to the thigh or a sling about the thigh attached to a weight through a pulley system. Inject 1% lidocaine into the skin and down to bone around the areas where your insertion and exit sites will be. Finally. Elevate the foot of the bed to prevent a child from sliding down the bed because of the traction. check an x-ray after you are finished to make certain you are in bone and not in the joint.
preferably 19 ga. Incise skin along Langer’s lines. Pack and dress wound. Consider dopplers if concerned. may leave an angio cath 16 ga for daily lavage if pt is being admitted.
Joint: Tough to know if you are really in.
23 5. Aspirate with at least 1 ½ inch 20 ga. Lidocaine local.Aspirations
General: 1. sterile collecting cup/tube for culture. Sterile technique: alcohol prep. Knee-supralateral or supramedial. Send cultures. prepatellar: Needle only. Do not I & D: they drain forever!!
Gram Stain Cultures-aerobic/anaerobic (add fungal if immunocomp) Cell Count and Differential Crystals Sometimes glucose 7. 4. Slide under bone. Walk it down to lab yourself!!!
Joint Prep the area with betadine and alcohol. 2. IV antibiotics vs. Be careful with transferring fluid to tubes. Shoulder Subacromial bursa: Posterolateral aspect of acromion. but need to flex knee close to 90°. Can go from posterolateral shoulder or anterior between coracoid and AC joint. Tap until dry. then betadine or chlorhexidine. Gas Gangrene? Needs OR debridement. 6. Abcess IVDA: Need x-rays and CT scan w contrast minimum prior to cutting skin. Send for: (Make sure it is marked
“Stat” on pink pathology form)
Hips and shoulders should be done with fluoro guidance to ensure that it is intraarticular. Send Red and Green tops. 3. Bursa Olecranon.
. po (see if patient can go to EACU). Can also go anterolateral/medial. consider spinal needles.
Be wary of mycotic aneurysms in IVDA patients. Sterilely prep area. Talk to radiology.
loosening. Fellows). need for additional procedures. numbness. femoral nail etc.
. pain. arthritis.. injury to nerves or vessels. Peds. weakness. non-union.IV
History Physical NEED heart and lung exam Consent Attending is not listed as “staff”. NPO Consults Medicine Anesthesia Posted Patients discharged to follow up in Chiefs clinic.. loss of function. stiffness.R. breakage. List some of the most likely attendings (Adult. Peds Risks Growth plate injury causing leg length discrepancy Blood consent Films Chest Xray EKG Labs CBC Chemistry Coags Mark Site T2S or T2C
PREOPERATIVE C A R E
D/C Blood Thinners Lovenox. limp. Standard Risks & Specific Risks Bleeding. Shock Trauma. ASA. cosmetic deformity. Plavix. infection. leg length discrepancy (total hip. hardware failure.). Coumadin. reflex sympathetic dystrophy. compartment syndrome. malunion.including contact numbers
Level 1 posting: must stay with patient and personally bring to O. Preop fully .
dry . limbs with metal implants should be avoided. Once bovie pad has been placed on body do not remove it and replace it on the skin. on clean dry skin over a large muscle mass as close to the operative field as possible. The electrode gel pad should be placed on the positioned patient. The skin should be inspected before and after removal of the pad.V
The Bovie should not be used in the presence of any flammable liquid (alcohol or tincture based agents). once it is removed a new pad should be opened. Keep area dry avoid allowing liquids especially prep solutions from coming in contact with pad site. Make sure the patient is not in contact with any metal parts of the table. nonconductive plastic container within the surgical field.
O P E R AT I N G ROOM SAFETY
. When not in use the active electrode (the bovie pencil) should be placed in a clean.
. Prior to inflating the tourniquet the limb should be exsanguinated using an ace wrap of es-marc. but should never exceed 400mm Hg. Liquids and skin preparations should not be allowed to collect or pool under the cuff. Do not leave the tourniquet cuff inflated on an arm for greater than one hour or on a thigh greater than 1. blood pressure and limb size. Padding in the form of stockinet supplied with cuff of web role should be applied prior to cuff positioning this should be wrinkle free. Tourniquet pressures depend on the patient’s age. Normal settings are 100mm Hg over the patients SBP.5 hrs. Once applied a cuff should not be rotated to a new position.Tourniquet
When placing a tourniquet on an extremity the tourniquet should overlap at least 3 inches.e. but no more than 6 inches. The cuff should be placed at the point of maximum limb circumference ( i. A U drape should be applied one inch below the distal edge of the cuff prior to the use of skin prep solutions. the proximal thigh).
and level are correct. once draped. surgical side. as well as any scrub personnel caring for the patient. the nurse and the anesthesiologist together in a controlled and organized manner. and the anesthesia care provider.
Need PT/OT consult. Downtown: it is the resident who consented the patient or who is doing the surgery) should identify the patient and confirm the operative side and level. that the patient’s name.Surgical Site Marking
The surgeon (At Bayview: this is the attending. The Informed Consent must be complete and must include the patient’s name. Once this is done he/she MUST mark that side and or level with his or her initials in the center of the surgical field. the description of the procedure and must include the side/ site and level of the surgery. A time out MUST be performed prior to incision. Post-Op Labs Post-Op Antibiotics Don’t Forget 3 A’s: Activity Antibiotics Anticoagulation
. the initials can be visible prior to making the incision. This is carried out by the attending physician. and so that. as close to the middle of where the patient will be prepped and draped.
27 The circulating nurse will use the consent form and verbally verify with the attending surgeon. Need WB status & ROM. site. Order DVT prophylaxis.
Make sure that you have informed anesthesia prior to fluoro use so that they are protected. Plain Xray At least 2 views of all extremities: AP & Lateral. Evaluate for all possible acetabular fx. otherwise they will be oblique. Make sure every one in room is covered prior to fluoroscopy – announce that fluoro is being used. Pelvis: Judet views.28
Fluoroscopy Must have lead prior to operating Fluoro. Mini C arm 1 foot min safe distance. Always x-ray the joint above and below the injury!!! Special Views Axillary views on all shoulder films. 6 feet minimum safe distance to avoid radiation if not wearing protection. and YOU. Insist on perfect laterals. you will have to position the arm for the film. CT Scans for Tibial Plateau fractures Pelvic fractures Pilon fractures Spine fractures Calcaneal fractures
. If tech unwilling.
On Hip xrays obtain cross table lateral of affected side. Inlet Outlet View if there is possible disruption of pelvic ring. Should use xray gown if available. not the XR tech will be spanked at AM board rounds. Mini C arm located in Urgent care: Make sure you return it after use.
Get CT scan for operative proximal humerus fractures if intraarticular 4. you will have to position the arm for the film. AP/AXILLARY VIEW 2. Get films of wrist for radial head frxs
1. AP/LAT SHAFT FOREARM 1. CT scan for any frx or non-visualized area (C7-T1) 3. 3. Can get Int/Ext Do not present a shoulder rotation views consult w/o an axillary view!! If tech unwilling. AP/LAT/ODONTOID 2. HUMERAL 1. Obliques if you suspect traumatic spondylolisthesis. 3 views with spot view of fingers if you need it
. AP/LAT/OBLIQUE 2. Obliques & possibly CT for difficult injuries 2. AP/LAT Lateral must be dead on for pediatric SC humerus frx 1. CT scan for fracture 3. Traction views for ALL distal radius frxs & ALL wrist injuries
SHOULDER 1. Traction views for comminuted frx 3.Radiographic Views for Orthopaedic Trauma
SPINE: Fracture in one area necessitates x-rays or CT of the whole spine!!! C-SPINE 1. Flex/Ext views only after talking to senior first 2. Scaphoid view (ulnar deviation AP) if indicated
4. 40 degree cephalad x-ray & CT scan for SC joint dislocation
T/L-SPINE 1. AP/LAT ELBOW 1.
Traction views & CT scan for displaced distal femur frx
FEMORAL 1.Best AP of femoral neck is a 15 degree internal rotation AP. AP/LAT 5. You often have to hold for these.30 PELVIS 1. CT scan for all hindfoot & midfoot fractures 3. Obliques for tibial plateau fracture 3. Judet views for any acetabular fracture . Foot films 1.Outlet shows hemipelvis vertical translation 3.AP Pelvis is not an AP of the hip. AP/LAT/OBLIQUE 2. Harris (axial calcaneus) for calcaneus frx 4. AP/LAT
TIBIAL SHAFT ANKLE
1. Get a dedicated view.Obturator oblique shows anterior column & posterior wall . Inlet/Outlet views if there is possible disruption of pelvic ring (including pelvic rami) . AP/LAT SHAFT KNEE 1. 2. AP/LAT/MORTISE 2.Iliac oblique shows posterior column & anterior wall
1. . .Tib/Fib for Pilon fractures isolated lateral malleolus Maisonneuve frx if if tender in foot fractures (lidocaine block) tender over prox fib 1. CT scan for all tibial plateau frxs 4.Inlet shows hemipelvis rotation (ie. Weight-bearing AP if you suspect Lisfranc injury
. DEDICATED AP & LATERAL OF HIP + AP PELVIS . CT scan for 3. Stress views for 4. A/P & lateral of hip to rule out concomitant femoral neck fractures 2. AP PELVIS 2. open book) .Get femur films for templating / looking for distal lesions.
Remove foley next am to let detrusor muscle relax. leave in if output > 300 cc. Potential for cauda equine syndrome in post op spine patients. VAC Dressings Must act if suction is not holding. Cover any openings with op-site etc. order Ultrasound. PACU x-rays / Hgb Let chief know about any concerns. UA is the most sensitive test for fever work-up during first 48 hours (due to foley. In pediatric patients may be more conservative about cathing. Examine incision. Remember: Wind . Check rectal tone/sensation and rule out saddle anesthesia in spine patients. Dulcolax. Straight cath if it’s been greater that 8 hours. If positive or suspicious for DVT. Chest Xray to eval for Atelectasis and Pneumonia (if lungs sound junky). etc as needed. Check for calf tenderness. Wonder Drug
Review I&O’s. but do not let that fool you. Urinary Retention Have concern if a spine patient. Evaluate nephrotoxic drugs such as aminoglycoside or vancomycin.
POSTOPERATIVE C A R E
Fever: Respond to all temps > 38. Non-working VAC sponge is a broth for badness!! Don’t let someone get toxic shock syndrome because you didn’t check the VAC!!! Cultures/Infectious Disease Consultations Pathology Keep an eye on all cultures and specimens sent from OR!!! Don’t miss an infection or other badness!!
.5. Send C&S as well. Walking. Low grade fever within first 24-48 hours of surgery is normal. Any concern for compartment syndrome? Appropriate exams: Spine Exam Neurovascular exam for extremities Look at op note Make sure dressing/splints/VACs are intact. Mag Citrate. check BUN/Cr for kidney status. Constipation / Ileus All patients on colace. Send blood cultures x 2 (if valid concern for sepsis). Cauda Equina? Check post void residuals on all spine patients. soap suds.31
Night of Surgery Notes (NOS) Vital Signs See how pain is.Water. Evaluate patient for distention. Consider checking post void residuals. etc). Wound. Check vitals make sure pt is stable. fleets.
(i. heels off bed. Rheumatology consult to medically manage. team Femoral. Very important in elderly hip fractures. turn q2 hours. Cultures from infections should be checked for sensitivities and Infectious Disease recommendations should be followed for proper antibiotic coverage. Colchicine No ortho resident should prescribe colchicines. add penicillin for grossly contaminated wounds. Type IIIA: 1st generation cephalosporin + aminoglycoside.
W/u should include albumin. radial. wet to dry dressing changes/ Silvadene. Check daily. Gent or Vanc levels). lines. Antibiotics Post Op: Ancef one gram IV Q8hr x 24hr. wound care nurse. Make sure patient is not on anticoagulation!!!!
M E D I C A L I S S U E S
Decubitus ulcers Air mattress. 24 hour stop on I. W/u should include xray. prealbumin. Revision surgery and prior infection will dictate coverage and may be attending dependant.V. local wound care-local debridement. Nutrition consult. Nutrition Nutritional status: always an issue for wound healing and preventing infection. Ensure shakes/pudding TID. brachial vein/arter sticks for labs. CRP). inflammatory markers (ESR. CT scan.
Open Fractures: Type I or II: 1st generation cephalosporin. Always check levels on nephrotoxic drugs especially on patient with preexisting renal insufficiency or diabetes. Lack of peripheral I. Waffle boots/heel protectors. transferrin. heels protected. Discuss with senior resident first. Access Do not put in central lines or A. if needed. If PCN allergic Clinda 600mg IV Q8hr or Vanc one gram IV Q12hr. For consults: consider osteomyelitis. On discharge recommend osteoporosis/osteopenia work up & calcium supplementation.
etc can wait until the emergencies are handled. See patients as soon as possible!
Rotates weekly with Plastics. Open Fractures. If we’re not on.33
ON-CALL (410. Any microvascular repair goes to Plastics. Discuss case with attending to see if NUS should be involved also. Any neuro changes neurosurgery!!! Peds: Basically all spine. Distal radius is always Ortho. Compartment Syndrome. we don’t want it!!! Hand includes: Soft tissue distal to elbow. Only see spine consults without neuro changes.
PRIORITIZE!!! See the emergencies first.4505)
Day Pediatric InPatient
RESPONSE TIME Call back within 10 minutes! (Tell OR nurses that you’re on call and ask them to return pages). etc. The clavical fractures.1254)
C O N S U L T I S S U E S
All ER All InPatient
After Hrs & Wkend
Adult: Shared with neurosurgery.283. Cauda Equina.283.
ADULT ORTHO TEAM (rotating pager)
Day Adult InPatient
PEDIA TRIC ORTHOTEAM (410. Bone distal to distal radius.
. Septic joint.
or “Follow up in Chief Clinic. patients should be given the pink follow-up appointment card with the name of the clinic (can be Dr’s name or specialty). (Children are sent to clinic of the attending who was on call the day the patient was seen in ED. and follow-up date).) Each day residents who see ED patients also need to provide a list of ED patients given follow-up appts (pink cards) to the JHOC Residents’ Coordinator (57296) for next-day scheduling (list needs to include patient name. and has resulted in follow-ups at inappropriate times. UNDER the medical assistance umbrella (see chart). All other fractures NOT under the medical assistance umbrella (see chart). 3. Pediatric Chief Resident Clinic Every Monday. Pediatric Attending Clinic Mon: Sponseller Tues: Ain. Child is sent to clinic of attending on call the day patient was seen in ED. NOT under the medical assistance umbrella (see chart). JHH#. All fractures in children <4 yrs Complicated fractures <16 yrs UNDER the medical assistance umbrella (see chart). JHOC In the past. Chief Resident Clinic Every Wednesday AM. Private Fracture Clinic Every Thursday afternoon.U P C L I N I C S
1.” This has created substantial confusion. All fractures SELF-PAY and those UNDER the medical assistance umbrella (see chart). 4. Trauma Fracture Clinic Every Wednesday. All other fractures. Leet Thurs: Sponseller Fri: Ain All fractures in children <16 yrs. “Follow up in clinic”. with the date.
F O L L O W. Bayview Residents’ Coordinator April Lindenmuth (01504)
. patients in the JHHED have been told to.34
1. When residents see patients in the ED. 2.
but must have authorization # from insurer to be scheduled in the Chiefs’ Clinic. a patient can be seen by our Chief Resident Follow-Up Clinic if seen first in ED.
however. Fax JHOC Fax BAYVIEW 410-955-0180 410-550-0622 Fax line for referrals only! Fax line for referrals only!
We do not participate with the following insurances.35
Insurances Under the Medical Assistance Umbrella
Medicaid (does not require referral) Amerigroup MCO/Americaid (only Ortho does not require referral) Patients should be instructed to obtain a referral from their primary care doctor’s office for: JAI MCO Maryland Physicians Care
The referral MUST be physically here in the office (fax accepted) before we can proceed with scheduling a follow-up appointment.
Diamond Plan MCO Helix MCO United Heath Care MCO
502.” and “Anatomy of the Hip. Pediatrics has over 200 questions. the JHOrthopaedic Review Course. Some have weekly objectives and reading assignments. The yearly lecture schedule is also posted at NetOrthoDoc.5885. and contains an ever-expanding library of talks with sound and visuals from Grand Rounds. and other specialty courses.org LOGIN: jhuortho PW: resident (the Hopkins firewall may ask for these twice. NetOrthoDoc also has video clips from anatomy courses created by Dr. (c) 443. Frassica will be including weekly current topics for review.629. The site is for resident education.3848 JHOC #5240
. Each resident will have a personalized login for this feature. From NetOrthoDoc you can link to sets of tutorials and questions on various topics.
O R T H O E-LEARNING
http://www.” The syllabi for rotations can also be found at the site. just enter them a second time and disregard the request for a “domain” name)
Contact for Ortho E-Learning: Gail Richter-Nelson (o) 410. faculty lectures. and Dr. David Hungerford: “Anatomy of the Knee.netorthodoc.36
NetOrthoDoc Website NetOrthoDoc is a passwordprotected e-learning website of the Johns Hopkins Department of Orthopaedic Surgery.
Anesthesia (Specify type) .Narrative: .Clinical nodal size . Other Follow-Up Car CC List (include address of nonJHH doctors) CLINIC NOTE FORMAT .Diagnoses/Problems . closure. Assistants or other surgeons present in OR incl. or other) . Activity.Assessments . pertinent lab or imaging study results) . drains etc.Evidence of Metastasis .Sponge count . other Physicians (spell names) . Clinic #. Admission & Discharge Dates.Specimen (Bacteriological. family history. Major Findings.Medications .Technical Procedures (incl skin prep.Prosthetic Device / Implant .Medication Changes .CC List (include address of nonJHH doctors) Patient MUST be registered (clinic notes are linked to an outpatient episode of care
.Discharge Medications . Pathological. social history.Your name. Complications of Procedures . incision. 7-digit History #. Attending Physician.Reportable Diseases .Post-Operative Condition .Major Findings (including PE. Patient Name. Date of Clinic Visit. Attending Surgeon. Title of Operation (include Codes) . Attending Physician.42 OPERATIVE NOTE FORMAT .Indications for Surgery .) .Reason for Visit (Chief Complaint) .Fluids Given . 7-digit History #.Clinical size of tumor .Brief History. 7-digit History #.Plans . Patient Name.History of Present Illness (may include past medical/surgical.Stage of Cancer .Your name.Your name.Discharge Instructions (Diet.Description of Findings .Procedures & Immunizations .Estimated Blood Loss/Given .Problems/Diagnoses .Indication of dual Attendings DISCHARGE SUMMARY FORMAT . Hospital Course (500 wds or less) . residents (spell names) .Procedures .Adverse Drug Reactions.Allergies .Date of Procedure. Allergies.Condition on Discharge .Pre-Operative/Post-Operative Diagnoses (include Codes) . immunization) . other Physicians (spell names) . Patient Name.