The James F. Wenz, M.D. Orthopaedic Surgery Resident ... · The James F. Wenz, M.D. Orthopaedic Surgery Resident Survival Guide The James F. Wenz, M.D. Orthopaedic Surgery Resident

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




Table of Contents:

“Patient Safetyis

Rule Number 1.”

“Askif you do not know.”

“Do not do anythingby yourself

for the first time.”

Compartment Syndrome 5Cauda Equina 7Epidural Hematoma 8Pulmonary Embolism 9Deep Venous Thrombosis 10Narcotics 11Chest Pain / Myocardial Infarction 12SICU Consult 12Hypotension / Stroke 13Fat Embolism 14Physical Exam/Motor Grading 15Labs 16Joint Reductions 17Splinting 21Casting 23Traction: Skeletal 25Traction: Skin 26Aspirations 27Injections 28Preop Checklist 29OR Safety (Bovie, Tourniquet) 30Radiology 33Post Operative Care 36Medical Issues 37Consult Issues 38Ortho E-Learning 39Ultravisual 40Sharepoint 41Posting 42

Table of Contents:

“Patient Safetyis

Rule Number 1.”





Table of Contents:

“Patient Safetyis

Rule Number 1.”





Table of Contents:

“Patient Safetyis

Rule Number 1.”





Brett Cascio, M.D.

Dennis Kramer, M.D.

Derek Papp, M.D.

Addisu Mesfin, M.D.

Payam Farjoodi, M.D.

Jamie Johnson, M.D.

Joseph Gjolaj, M.D.

Karthikeyan Ponnusamy, 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 usshould strive to be.”

Kevin Farmer, M.D.Class of 2008

Contributors:

June, 2007

OrthopaedicS u r g e r yR e s i d e n tS u r v i v a lG u i d e

James F. Wenz, M.D.

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.

Derek Papp, M.D.

Addisu Mesfin, M.D.


Jamie Johnson, M.D.

Joseph Gjolaj, M.D.


Concept & Design: Gail Richter-Nelson



Contributors:

June, 2007


James F. Wenz, M.D.

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.


Ted Manson, M.D.

Brett Cascio, M.D.

Dennis Kramer, M.D.

Derek Papp, M.D.

Addisu Mesfin, M.D.


Jamie Johnson, M.D.

Joseph Gjolaj, M.D.





Contributors:

June, 2007


James F. Wenz, M.D.

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.


Ted Manson, M.D.




Contributors:

June, 2007


James F. Wenz, M.D.

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.


Ted Manson, M.D.

Brett Cascio, M.D.

Dennis Kramer, M.D.

Derek Papp, M.D.

Addisu Mesfin, M.D.


Jamie Johnson, M.D.

Joseph Gjolaj, M.D.



4 4

4 4

Compartment Syndrome

Cauda Equina

Epidural Hematoma

PulmonaryEmbolism

Deep VenousThrombosis

Chest Pain / Myocardial Infarction

Hypotension

Stroke

Fat Embolism

I

EMERGENCIES

“The price of safety isnever-ending, unremitting

vigilance.”

“Check & Double Check.”

“Never be afraid to ask.”

Frank J. Frassica, M.D.

“No patient should ever die on the orthopaedic service.”Payam Farjoodi, M.D.


Cauda Equina

Epidural Hematoma

PulmonaryEmbolism



Hypotension

Stroke

Fat Embolism

I

EMERGENCIES


vigilance.”






Cauda Equina

Epidural Hematoma

PulmonaryEmbolism



Hypotension

Stroke

Fat Embolism

I

EMERGENCIES


vigilance.”






Cauda Equina

Epidural Hematoma

PulmonaryEmbolism



Hypotension

Stroke

Fat Embolism

I

EMERGENCIES


vigilance.”





5 5

5 5

CompartmentSyndrome Level 1A. Do not Delay!!!!

Have an extremely low threshold forconcern.

Can occur following any injury, andin any extremity.

Don’t forget about well leg,can occur in the non-injuredextremity due 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.

Compare exam to other side andto previous exams in chart!!!!

Call chief resident with concerns ie:change in exam.

Never hesitate to call theattending on call.

Measure pressures if you cannot decide if a compartmentsyndrome is present. Notify Chiefbefore measuring. Time is of theessence. Do not delay!

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 otherside. Compare to previous exams.

Tenseness:Feel compartments:

Do they feel tight?Shiny skin? Wrinkles?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!!!!

HIGHEST RISK FRACTURES

Tibial shaftCalcaneus

Both bone forearmAnything casted

High energy mechanismSupracondylar Humerus FX

LEVEL 1A






















Top priority!!


for fasciotomies.







LEVEL 1A






















Top priority!!


for fasciotomies.







LEVEL 1A






















Top priority!!


for fasciotomies.







LEVEL 1A

6 6

6 6

Measurement ofCompartmentPressures

Indications forCompartment Measurement

1. Use the Stryker monitor in situationswhere there is a question ofdiagnosis of compartment syndrome ina 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 turn“On”.

2. The device needs to be adequately“charged” 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 betested.

6. Using sterile gloves, insert theneedle through the fascia keeping theunit 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 by eachcompartment. MEASURE TWICE!

8. Remove the needle and apply a dressing.

9. Inform chief of compartment pressures.

10. Write a procedure note. Alwaysuse the compartment syndromestickers. Compare compartmentpressure to the diastolic bloodpressure. Diastolic blood pressureminus the compartment pressure isperfusion pressure. If perfusionpressure is less than 30, there is acompartment syndrome.

Location of Stryker Monitors

JHH – Zayed 3 OR desk, 11Eequipment room

JHOC - Chief ’s Office, Clinic Office

JHBMC – OR desk

GSS - Clinic Office

Whitemarsh - Clinic Office





















JHBMC – OR desk

GSS - Clinic Office






















JHBMC – OR desk

GSS - Clinic Office






















JHBMC – OR desk

GSS - Clinic Office


7 7

7 7

Cauda EquinaHave a Low Threshold

Examine any post-op spinepatients with new complaints ie:incontinence, urinary retention,parasthesias, weakness.

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

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, cuttingoff sensation and motorfunction. Nerve roots that controlthe function of the bladder andbowel are especially vulnerable todamage.

If you don’t get fast treatment torelieve the pressure, it may causepermanent paralysis, impairedbladder and/or bowel control,loss of sexual function and otherproblems. 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. Itmay 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!!!

NOTIFY SPINE FELLOW& ATTENDING







Make NPO.




Saddle anesthesia.
















Make NPO.




Saddle anesthesia.
















Make NPO.




Saddle anesthesia.










8 8

8 8

Epidural 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 gethead CT.

Do not need radiologist approval forthese tests.

Don’t forget to check the results.Test should only take minutes!

Postop Spine Patients

Full neuro exam – meticulousdocumentation.

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

Does deficit correspond with level ofsurgical site?

Any neuro deficits, speak withthe spine fellow.

If can’t get in touch with spinefellow then call spine attending.

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

Epidural Hematoma

What is it?



Brain:




Spine




Presentation







ICU / NCCU transfer





Workup













Epidural Hematoma

What is it?



Brain:




Spine




Presentation







ICU / NCCU transfer





Workup













Epidural Hematoma

What is it?



Brain:




Spine




Presentation







ICU / NCCU transfer





Workup













9 9

9 9

PulmonaryEmbolism 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 Febrile

Hypoxia

Tachypnea, or

Pleuritic type chest pain.

Patient will need long termtherapeutic anti-coagulation.

SICU consult à patient should be in amonitored setting (IMC at least) untiltherapeutic, if unstable.

Medicine consult for management.

Make sure arrangements are madeto follow INR once discharged(primary 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.


Check vital signs.



Especially common followingtotal joints, intramedullaryrodding of a femur fracture,pelvic fracture.


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



Tachycardia Febrile

Hypoxia

Tachypnea, or










Check vital signs.



Especially common followingtotal joints and intramedullaryrodding of a femur fracture.


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



Tachycardia Febrile

Hypoxia

Tachypnea, or










Check vital signs.



Especially common followingtotal joints, intramedullaryrodding of a femur fracture,pelvic fracture.


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



Tachycardia Febrile

Hypoxia

Tachypnea, or









10 10

10 10

Deep VenousThrombosis Below the knee DVT:

Treatment:Attending dependent.

Continue current pathway andrecheck 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!!!

Do not do a Homan’s 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


Must be treated!






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




Above the knee DVT:



Calf pain/cramping

Leg swelling

Palpable cords

Presentation










Above the knee DVT:



Calf pain/cramping

Leg swelling

Palpable cords

Presentation


Must be treated!






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




Above the knee DVT:



Calf pain/cramping

Leg swelling

Palpable cords

Presentation

11 11

11 11

Narcotics

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 naïve.

Be wary of the narcotic seeking.

Do not prescribe narcotics onthe weekends or evenings.

Call the chief resident orattending and let them handlethe problem (FJF).

Constipation

Colace 100 mg po bid

Senna 2 tabs qDay(increases GI motility)

Pediatric patients should havetheir narcotics managed by thepediatric pain service.

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

Narcotics


1mg Morphine

=

0.2 mg Dilaudid

=

100 mcg of Fentanyl






Constipation













CNS depression

Miosis

Hypotension


Narcotics


1mg Morphine

=

0.2 mg Dilaudid

=

100 mcg of Fentanyl






Constipation













CNS depression

Miosis

Hypotension


Narcotics


1mg Morphine

=

0.2 mg Dilaudid

=

100 mcg of Fentanyl






Constipation













CNS depression

Miosis

Hypotension


12 12

12 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 EKGCompare to old EKG.If story not concerning, andEKG unchanged:

May stop there and monitor.

Order:STAT CHEST X-Ray

Evaluate: PE, pneumonia,pneumothorax, etc.

Let chief / attending knowimmediately.

If any concerns with story or ifany EKG changes:

1. Send off Cardiac enzymes x 3, timed 6hrs apart. For first one, you may need todraw the lab yourself.

2. If at night, take EKG and showSICU fellow. Have a convincing storyas to why you’re 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 monitored

setting ASAP- SICU, Cards.

We should not bemanaging a MI !

Talk to SICU fellow for any patientswith concerns. Don’t try to be ahero!! Bump it up if you have a worry.Take EKG, labs, etc. with you to thefellow. They are usually willing to helpyou out if you present it to them inway that shows you have done all the

necessary work-up and you havelegitimate concerns. If they are notreceptive, talk to your chief orattending about the situation.

Same situation for the PICU fellow.

SICU Consult


Top priority!!


Pertinent questions


Physical Exam


















SICU Consult


Top priority!!


Pertinent questions


Physical Exam


















SICU Consult


Top priority!!


Pertinent questions


Physical Exam


















13 13

13 13

HypotensionMake 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 > ½ NSfor intravascular resuscitation.Be careful with CHF. Considerbolusing 500 cc.

Differential DiagnosisHigh hypovolemia? Sepsis? PE? A-fib?Low heart failure?Meds: Beta blocker, calcium channel blocker?Check EKG medicine consult?Cards consult for arrythmia.

Let chief / attending know.

Treatment

Start with IV fluid bolusD/C any hypertensive meds if patient

is unstable (unresponsive).Stat SICU consult (they will want to

know EKG, Hct, WBC, ABG etc).Have blood available.ABC’s.Call code if concerned.

Stroke Document your Neuro Examas thoroughly as possible.

Check for asymmetry.Head CT without contrast.

Call a Brain Attack Team (BAT)for code.

JHH:410.283.7777

Bayview:410.283.8810



Is patient alert?





Treatment







JHH:410.283.7777

Bayview:410.283.8810



Is patient alert?





Treatment







JHH:410.283.7777

Bayview:410.283.8810



Is patient alert?





Treatment







JHH:410.283.7777

Bayview:410.283.8810

14 14

14 14

Fat EmbolismWhat 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 mentalstatus changes.

Treatment:

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





Risk factors





Diagnosis



Workup:







Treatment:







Fever >38.5

Tachycardia >110


Presentation





Risk factors





Diagnosis



Workup:







Treatment:







Fever >38.5

Tachycardia >110


Presentation





Risk factors





Diagnosis



Workup:







Treatment:







Fever >38.5

Tachycardia >110


Presentation

15 15

15 15

Motor Exam

Motor exams are critical in orthopaedics.Document your findings accurately.Compare to previous exams.

Every patient’s NOS note or H+Pshould have a motor exam writtenout so that we can track progress ordecline. You should be able toexplain 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 his foot,even though the nerves may be fine.Document what you see.

Adult spine surgery NOS notes shouldalso include rectal tone, wink &perianal sensation for allthoracolumbar cases & extensivecervical cases.

Do the rectal with a nurse present andwarn the patient. ACDF’s do NOTtypically need a rectal.

Pediatric spine patients do NOT needa 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 see themin the ER.

EPL tests the radial nerve.

Index finger DIP flexion tests the AnteriorInterosseous 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 toother 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 FootPlant

EXT L2 L3 L4 L5 S1

Right

Left

Motor Exam










Spine Surgery Notes











EXT C5 C6 C7 C8 T1

Right

Left


EXT L2 L3 L4 L5 S1

Right

Left

Motor Exam










Spine Surgery Notes











EXT C5 C6 C7 C8 T1

Right

Left


EXT L2 L3 L4 L5 S1

Right

Left

Motor Exam










Spine Surgery Notes











EXT C5 C6 C7 C8 T1

Right

Left


EXT L2 L3 L4 L5 S1

Right

Left

16 16

16 16

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 throughPOE and EPR (until EPR isdiscontinued) every day for roguelabs that someone else ordered.

On the pediatrics service, askthe attending before orderingany labs.

Often the kids don’t need them andthe attendings will be upset 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.

BMPWatch the creatinine valueson joint patients and patientson gentamicin or vancomycincarefully. These have a tendencyto creep up. Keep potassium repletedabove 3.5.

PT/PTTWatch patients on coumadinlike a hawk. Place it in boldletters on sign-out so thatother people know the patient ison coumadin.

Don’t let it jump up!!

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

Don’t make a habit of signing out labs!

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

CRP/ESREvery patient suspected ofhaving 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.

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





LabsPertinent Labs:


















LabsPertinent Labs:


















LabsPertinent Labs:














17 17

17 17

GOAL:To reduce ASAP withoutcausing additional damage

Place sheet around flexed forearm andtie same sheet around your waistsnugly. Gently pull on forearm wileleaning your weight back on sheet androtate arm.

Stimson/Gravity Technique

Patient is prone. Hang arm down atside of bed.

Tie weight (10lb) to distal forearm.You may place weight in stockinetteand wrap around distal forearm.

May take several hours to reduce.

Post-Reduction

Document NV exam. Obtain axillaryview or CT if unstable to ensurereduction.

Joint Reductions

IIIP R O C E D U R E S Glenohumeral Joint Reduction

(Anterior Dislocation 95%)

Traction-Countertraction Method

Requires an assistant. Supine patient.

Assistant: Stands on opposite side ofpt. Place sheet under pt’s affectedaxilla/upper trunk and pull/providecountertraction.

Resident: Pulls arm gently oppositeaxis of countertraction whilerotating OR flexes elbow of affectedarm to 90°.







Post-Reduction


Joint Reductions













Post-Reduction


Joint Reductions













Post-Reduction


Joint Reductions







18 18

18 18Elbow Reduction(Posterior/Posterolateral 80%)

Beware of terrible triad: fx of coranoid,fx of radial head, elbow dislocation.

Document NV exam. Consentpatient. Provide pt with conscioussedation/analgesia.

Pt is supine, elbow extended, useassistant if available.

Assistant: Pulls countertraction onhumerus.

Resident: Pulls gentle longitudinaltraction. Corrects medial/lateraldisplacement. Use gentle flexion.Should hear clunk if reduced.

Post-Reduction

Document NV exam. X-Ray AP/Lateral of elbow to confirmreduction.

Perform range of motion of elbow toensure stability.

With elbow at 90° place in wellpadded posterior splint. Sling.

Distal Radius Fx-Reduction/Splinting Technique

Elbow Reduction(Posterior/Posterolateral 80%)






Post-Reduction











Post-Reduction











Post-Reduction





19 19

19 19

Hip Dislocation(Native Posterior more common thanAnterior)Leg will be flexed/IR/Adducted

Must be reduced within 6 hrs ofinjury.

Document NV exam. (To see ifsciatic nerve injury is present.Peroneal section of sciatic nerve ismost commonly injured).

Perform knee ligamentous exam.

Consent patient. Consciously sedate(ask for Etomidate or Propofol). Ask for an assistant.

Allis Technique (Can also be usedfor dislocated THA)

Requires an assistant.

Supine patient (on bed or on groundwith a backboard).

East Baltimore Lift (Invented atHopkins) (not commonly used)

Patient is supine on bed.

Resident: stands at side of dislocationat level of pat’s pelvis.

Assistant: stands across bed.

Resident: Places arm under pt’s calfand places arm on assistant’sshoulder. Uses free hand to stabilizept’s ankle.

Assistant: Places arm under pt’s calfand places arm on resident’sshoulder. Uses free hand on pelvisfor countertraction.

Both resident and assistant stand upon toes and use arms as fulcrum forreduction.

Post-Reduction

Document NV exam. Range hip toensure stability. CT to ensure nointra-articular fragments/congruence.If acetabulum fx (usually posteriorwall) pt will need femoral tractionpin (make sure you have all equipmentready & available to place traction pinafter reduction if necessary).

Assistant: Pushes down on pelvis at ASIS.

Resident: Pulls inline traction gently.Flex hip to 60-90° while pulling up onpt’s calf with right arm.

Rotational movement of hip along withadduction. Should hear clunk whenreduced.

If not successful with 2 closedreductions then take to OR forreduction under general anesthesia.









East Baltimore Lift (Invented atHopkins) (not commonly used(







Post-Reduction





















Post-Reduction





















Post-Reduction






20 20

20 20

Knee Dislocation(Anterior most common)

(Beware of popliteal artery &peroneal nerve injury)

Kennedy Classification: position oftibia in relation to femur: anterior/posterior/med/lateral.

Schatzker IV is considered a kneedislocation variant.

Dimple Sign: posterolateraldislocation: medial femoral condylebuttonholes through anteromedialcapsule. Medial structures becomeentrapped. Requires open reduction.

Document pulses/peroneal nervefunction/compartment of affectedextremity.

Perform ABI: Hand-held Doppler andBP cuff. Check UE systolic, anklesystolic of DP & PT (use the one thatis higher. LE systolic/UE systolic=ABI.Nmle “I”.

If ABI <0.9 or No Pulses cool foot.Consult Vascular surgery. CT angio.

Anterior Dislocation Reduction


Consent patient. Conscious sedation.

Assistant: Provides counter tractionon femur.

Resident: Pulls gently longitudinaltraction on tibia and pulls up.

Posterior Dislocation Reduction




Resident: Pulls gently longitudinaltraction on tibia and lifts up on tibia.

Post-Reduction

Document NV exam.

X-Ray: post-reduction AP/lateralknee.

Knee immobilizer: Long bulky splint.

Serial compartment checks.

MRI

Displaced Ankle Fracture

Reduction/Splinting Set-Up













Resident: Pulls gently longitudinaltraction on tibia and pulls up on.






Post-Reduction

Document NV exam.




MRI





















Post-Reduction

Document NV exam.




MRI





















Post-Reduction

Document NV exam.




MRI



21 21

21 21

Adult

Adults do not get casts acutely.Only splint acute fractures withplaster to accommodate swelling. Asplint should generally try toimmobilize the joint above and thejoint below a fracture.

A good splint stabilizes the fracturewithout causing a pressure ulcer. Ingeneral, use at least 3 layers of softroll to protect the skin from theplaster and 1 layer of soft roll on thesuperficial side of the plaster so thatit doesn’t stick to the ACE wrap. Donot pull the softroll or ACE wrap.

Fractures that require this are oftenhigh energy or have significantcomminution – dusted elbows,pilons, tibial plateau fractures. Wealso tend to splint tibial shaftfractures with Robert Jones cottonand softroll here as well.

However, too much padding maynot provide enough support tomaintain a reduction. A distal radiusneeds just enough softroll to protectthe skin without losing reduction.

When holding a reduction as asplint hardens, use broad surfaces toapply forces, use the palm of the hand.

Do not use fingers or the plaster willpick up the grooves and cause anulcer.

Splinting

This is too tight & patients will becalling you in a few hours for blue ortingling fingers. Just roll it on.

Pad bony prominences well! Thismeans putting on extra padding atthe elbow joint for sugar tongs or onthe heel for AO splints. Can useABD pads for the heel.

Make sure no plaster or thinlypadded 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 big personmay require more layers. Measure offthe good limb.

For fractures that can balloon withswelling, use Robert Jones cotton forextra padding. Overwrap with asoftroll to help apply gentlecompression to control the swelling.

Adult







Splinting







Adult







Splinting







Adult







Splinting







22 22

22 22

Proximal Humerus Sling

Humeral shaft Coaptation splint Pad the axilla extension wellwith ABD’s, carry the shoulderextension high, pad the elbow

Elbow Posterior slab with Buttress The buttress gives supportconsider Jones cotton if dusted

Distal radius Sugar tong Pad the elbow well, keep splintproximal to MCP’s

Boxer’s Fracture Ulnar gutter Mild wrist extension with asmuch MCP flexion

Thumb / scaphoid Thumb spica

Tibial plateau Schatzker 1-111 Bulky Jones with knee Use Robert Jones cottonimmobilizerSchatzker 1V-VI Long leg bulky Jones

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

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

Foot Posterior slab

Fracture Splint Tips










Foot Posterior slab











Foot Posterior slab











Foot Posterior slab


23 23

23 23

Casting

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 (Dr. Tis prefersunivalve & use of spacer) unlessthere is minimal swelling and a low-energy mechanism with littlepotential for swelling (i.e. bucklefracture), or a significant time haselapsed since the injuring 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(smooth flat ulnar surface).

Long Arm Cast

As above, but cast with the elbowflexed at 90°. Do not bend elbow>90°. Do not bend elbow after rollingfiberglass. Apply a supracondylar mold.Extend the cast as proximal aspossible, but avoid impinging on theaxilla. Make sure you wrap the soft rollwith the elbow flexed at 90°, so thatwrinkles do not develop.

For unstable forearm fxs, forearm fxswhich required reduction, & pediatricelbow frxs using neutral rotation.

Short Leg Cast

Cast with the ankle dorsiflexed to90°. 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 asproximal as possible (it is never as highas you think). It often helps to abductthe hip off of the bed to obtain spaceunder the proximal thigh. Make sureyou wrap the soft roll with the kneeflexed so that wrinkles do not develop.Indicated for tibial shaft fractures andankle fractures which requiredreduction.

Ask a child his or her color preference!

Casting

Pediatrics





Short Arm Cast


Long Arm Cast



Short Leg Cast


Long Leg Cast



Casting

Pediatrics





Short Arm Cast


Long Arm Cast



Short Leg Cast


Long Leg Cast



Casting

Pediatrics





Short Arm Cast


Long Arm Cast



Short Leg Cast


Long Leg Cast



24 24

24 24

SPICA Cast for Femur Fractures

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

Usually the unaffected extremity is notcasted (single leg spica). Dr. Sponsellerincludes the foot and ankle; Dr. Tisstops above the ankle (make sure youpad this area well to avoid heel ulcers).

The goal positions are 30-45° of hipabduction, with either 60° of hipflexion and 30° of knee flexion or 45°of hip flexion and knee flexion.

Use of the mini-C-arm to checkreduction before and during castapplication will prevent the need forrecasting and save significant time.

Insert towel(s) 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).

Alignment of Femur:No more than 2 cm shortening,15 degrees var/valg20 degrees sagittal plane

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.

Can wet cast saw with alcohol pad toprevent overheating.

DO NOT MOVE THE SAWDISTALLY WHEN ON THE SKIN!

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

Bivalve entire cast, not just part of it.










Cast Saws

















Cast Saws

















Cast Saws








25 25

25 25

Traction serves several purposes:it aligns the ends of a fractureby pulling the limb into astraight position; it ends musclespasm and relieves pain.

Skeletal Traction

Skeletal traction is performed whenmore force is needed than can bewithstood by skin traction. Skeletaltraction uses weights of 25-40pounds.

This is an invasive procedure that isdone either in an operating room orin the E.R. with local anesthesia.

Steinman pin trays and tractionbows are kept at the Bayview ORand JHH (Zayed 3 OR, 9E SICU, andER supply room).

Proximal Tibia

Proximal tibial pins are morecommonly used, and are helpful in afemoral 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 about 3cm below the tibial tubercle.

Use smooth pins. Protect the cutends of the pins with test tubes orballs supplied.

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 facilitatepin 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 abovesuperior pole of patella when leg inextension.

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

Mark the knee joint line with amarker and use that as a guide forpin placement. The pin should beparallel to the joint line.


Skeletal Traction




Proximal Tibia



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 tibial tubercle.









Skeletal Traction




Proximal Tibia












Skeletal Traction




Proximal Tibia











26 26

26 26

Traction: SkinThe skin should be cleansed andthen sprayed with benzoin spray.

Wrap a single layer of non-overlapping softroll around theextremity. Make sure the skin iscompletley covered with softroll andthat the softroll is not overlapping.

Apply adhesive straps to the cottonpadding both medially and laterallyand connected to a footplate that isconnected to the pulley sytstem.Overwrap the adhesive straps withan ACE.

Traction: Skeletalcont.

Preparation

Prep the area well with betadine orchloraprep and have all of yourequipment ready in order to keepthings sterile.

Inject 1% lidocaine into the skin anddown to bone around the areaswhere 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.

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 islikewise 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















Preparation















Preparation











27 27

27 27

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

2. Lidocaine local.

3. Aspirate with at least 1 ½ inch 20ga, preferably 19 ga, consider spinalneedles.

4. Tap until dry.

5. Send Red and Green tops, sterilecollecting cup/tube for culture.Be careful with transferring fluid to tubes.

6. Place order in POE.

7. Print labels & place in biohazardbag with specimen.

Gram Stain

Cultures-aerobic/anaerobic(add fungal if immunocomp)

Cell Count and DifferentialCrystals

Sometimes glucose

7. Walk it down to lab yourself!!!

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

Do not I & D: they drain forever!!

ElbowDocument neurovascular exam priorto aspiration.

Mark out relevant anatomy (lateralepicondyle, radial head, olecranon).

Midlateral/Direct lateral Approach:Draw triangle connecting lateralepicondyle, radial head & olecranonand identify soft spot at center oftriangle.

Prep area (see General).

Aspirate with 18/19 gauge needleuntil dry.

Post aspiration, documentneurovascular exam.

AnkleMark out relevant anatomy (anteriortibial tendon, extensor hallucislongus, dorsalis pedis, medialmalleolus).

Anteromedial Approach: Identify softspot medial to anterior tibial tendon.

Prep area (see General)



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


2. Lidocaine local.


4. Tap until dry.




Gram Stain



Sometimes glucose

















2. Lidocaine local.


4. Tap until dry.




Gram Stain



Sometimes glucose

















2. Lidocaine local.


4. Tap until dry.




Gram Stain



Sometimes glucose
















28 28

28 28

InjectionsJoint:Prep the area with betadine andalcohol or chloraprep.

Knee-supralateral or supramedial.Can also go anterolateral/medial, butneed to flex knee close to 90°.

ShoulderSubacromial bursa: Posterolateralaspect of acromion. Slide underbone.

JointTough to know if you are really in.Can go from posterolateral shoulderor anterior between coracoid andAC joint. Discuss with Chief/Attending.

Abcess

IVDA: Need x-rays and CT scan wcontrast minimum prior to cuttingskin.

Gas Gangrene? Needs ORdebridement. Call General Surgery.

Be wary of mycotic aneurysms inIVDA patients.

Consider dopplers if concerned.

Sterilely prep area. Incise skin alongLanger’s lines.

Send cultures.

Pack and dress wound.

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





Abcess






Send cultures.







Abcess






Send cultures.







Abcess






Send cultures.



29 29

29 29

History

Physical

NEED heart and lung exam

Consent

List all attendings on service: (Adult:Osgood, Shafiq, Hasenboehler, Peds:Sponseller, Tis, Ain, Varghese, Lee, &Fellow).

Standard Risks & Specific Risks

Bleeding, infection, non-union,malunion, injury to nerves or vessels,weakness, numbness, pain, hardwarefailure, breakage, loosening,compartment syndrome, loss offunction, arthritis, need for additionalprocedures, limp, cosmetic deformity,leg length discrepancy (total hip,femoral nail etc.), reflex sympatheticdystrophy, stiffness.

Peds Risks

Growth plate injury causing leglength discrepancy

Blood consent

Preop ChecklistFilms

All necessary outside films should beuploaded into Ultravisual.

Chest Xray, EKG

LabsCBC Type & CrossChemistry - 2 UnitsCoags BHC-GUA Type & Screen

Mark Site

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

NPO

ConsultsMedicine Anesthesia

Posted

Patients discharged to follow up.

Preop fully - including contactnumbers

Level 1A: must stay with patientand personally bring to O.R.

IVPREOPERATIVEC A R E

History

Physical


Consent




Peds Risks


Blood consent



Chest Xray, EKG


Mark Site


NPO


Posted





History

Physical


Consent




Peds Risks


Blood consent



Chest Xray, EKG


Mark Site


NPO


Posted





History

Physical


Consent




Peds Risks


Blood consent



Chest Xray, EKG


Mark Site


NPO


Posted





30 30

30 30

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

Make sure the patient is not incontact with any metal parts of thetable.

Once bovie pad has been placed onbody do not remove it and replace iton the skin, once it is removed a newpad should be opened.

When not in use the active electrode(the bovie pencil) should be placed ina clean, dry , nonconductive plasticcontainer within 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 fieldas possible, limbs with metal implantsshould 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)

























31 31

31 31

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 thepatient’s 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 2 hours or on a thigh greaterthan 2 hours.

Prior to inflating the tourniquet thelimb should be exsanguinated usingan ace wrap or esmarch.

Tourniquet











Tourniquet











Tourniquet











Tourniquet

32 32

32 32

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 MUST markthat side and or level with his or herinitials in the center of thesurgical 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 thepatient’s name, the description of theprocedure and must include the side/site and level of the surgery.

A time out MUST be performedprior to incision. This is carried outby the attending physician, the nurseand the anesthesiologist together ina controlled and organized manner.

The circulating nurse will use theconsent form and verbally verify withthe attending surgeon, and theanesthesia care provider, as well asany scrub personnel caring for thepatient, that the patient’s name,surgical side, site, and level arecorrect.

Post-Op OrdersNeed PT/OT consult.

Need WB status & ROM.

Order DVT prophylaxis.

Post-Op Labs, Antibiotics, X-Rays,Out of bed & Ambulation Orders,Pain Medicines.

Don’t Forget 3 A’s:

ActivityAntibiotics

Anticoagulation

Surgical Site MarkingThe 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.










ActivityAntibiotics

Anticoagulation

Surgical Site Marking

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.










ActivityAntibiotics

Anticoagulation

Surgical Site MarkingThe 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.










ActivityAntibiotics

Anticoagulation

Surgical Site Marking

33 33

33 33

Fluoroscopy

Must have lead on 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 so thatthey are protected.

Mini C arm

1 foot min safe distance.

Should use xray gown if available.

Mini C arm is located in Peds ER.Make sure you return it after use.

VIR A D I O L O G Y

Plain Xray

Always x-ray the joint above andbelow the injury!!!

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.

On Hip xrays obtain cross tablelateral of affected side.

Special Views

Axillary views on all shoulderfilms, except, if CT scan showsglenohumeral joint reduced, no needfor axillary.

If tech unwilling, you will have toposition the arm for the film.

Pelvis: Judet views. Evaluate for allpossible acetabular fx.

Inlet Outlet View if there ispossible disruption of pelvic ring.

Fluoroscopy





Mini C arm




VIR A D I O L O G Y

Plain Xray




Special Views





Fluoroscopy





Mini C arm




VIR A D I O L O G Y

Plain Xray




Special Views





Fluoroscopy





Mini C arm




VIR A D I O L O G Y

Plain Xray




Special Views





34 34

34 34

Radiographic Views for Orthopaedic Trauma

SPINE: Fracture in one area necessitates x-rays or CT of the whole spine!!!

C-SPINE 2. Flex/Ext views onlyafter talking to senior first

1. AP/LAT/ODONTOID 3. CT scan for any frx ornon-visualized area (C7-T1)

T/L-SPINE 2. CT scan for fracture1. AP/LAT 3. Obliques if you suspecttraumatic spondylolisthesis.

SHOULDER 2. Can get Int/Extrotation views

1. AP/AXILLARY VIEWDo not present a shoulderconsult w/o an axillaryview!! If tech unwilling, youwill have to position thearm for the film.

3. Get CT scan foroperative proximalhumerus fractures ifintraarticular

4. 40 degree cephaladx-ray & CT scan forSC joint dislocation

HUMERALSHAFT

1. AP/LAT

FOREARM 1. AP/LAT

ELBOW 2. Obliques & possiblyCT for difficult injuries

1. AP/LAT Lateral mustbe dead on for pediatricSC humerus frx

3. Traction views forcomminuted frx

4. Get films of wristfor radial head frxs

WRIST 2. Traction views forALL distal radius frxs& ALL wrist injuries

1. AP/LAT/OBLIQUE 3. Scaphoid view(ulnar deviation AP)if indicated

HAND 1. 3 views with spotview of fingers if youneed it










HUMERALSHAFT

1. AP/LAT

FOREARM 1. AP/LAT

















HUMERALSHAFT

1. AP/LAT

FOREARM 1. AP/LAT

















HUMERALSHAFT

1. AP/LAT

FOREARM 1. AP/LAT








35 35

35 35

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 for Weber B lateral malleolus frx w/o medial malleolus frx.

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.

FEMORALSHAFT

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

KNEE 2. Obliques for tibialplateau fracture

1. AP/LAT 3. CT scan for all tibialplateau frxs that will notbe ex-fixed. If ex-fix, canget CT after surgery.

4. Traction views &CT scan for displaceddistal femur frx

TIBIALSHAFT

1. AP/LAT











FEMORALSHAFT





TIBIALSHAFT

1. AP/LAT











FEMORALSHAFT





TIBIALSHAFT

1. AP/LAT











FEMORALSHAFT





TIBIALSHAFT

1. AP/LAT

36 36

36 36

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 forfever work-up during first 48 hours(due to 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 concernfor sepsis.

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

Night of Surgery Notes (NOS)

Vital Signs. Pain.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 RetentionCheck post void residuals on allspine patients. Cauda Equina?

Straight cath if it’s been greater that8 hours, leave in if output > 300 cc.

Remove foley next am to letdetrusor muscle relax.

If you straight cath a spine patientdowntown, perform rectal and

VIIPOSTOPERATIVEC A R E

document your exam. Check rectaltone/sensation and rule out saddleanesthesia in spine patients.

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

Evaluate patient for distention. Inpediatric patients may be moreconservative about cathing. Considerchecking post void residuals.

VAC DressingsMust act if suction is notholding. Cover any openings withop-site etc.

Non-working VAC sponge is abroth for badness!! Don’t letsomeone get toxic shocksyndrome because you didn’tcheck the VAC!!!

Cultures/Infectious DiseaseConsultations

Pathology

Keep an eye on all cultures andspecimens sent from OR!!! Don’tmiss an infection or other badness!!





Examine incision.









PACU x-rays / Hgb














Pathology






Examine incision.









PACU x-rays / Hgb














Pathology






Examine incision.









PACU x-rays / Hgb














Pathology


37 37

37 37

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

Decubitus ulcers

Air mattress, heels off bed, heelsprotected, turn q2 hours, wound carenurse.

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 forwound 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 colchicine.

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 contaminatedwounds.

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 recommendationsshould 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/artersticks for labs, if needed. Discusswith senior resident first.

Make sure patient is not onanticoagulation!!!!


Decubitus ulcers


Check daily.



Nutrition




Colchicine



Antibiotics

Post Op:




Open Fractures:










Decubitus ulcers


Check daily.



Nutrition




Colchicine



Antibiotics

Post Op:




Open Fractures:










Decubitus ulcers


Check daily.



Nutrition




Colchicine



Antibiotics

Post Op:




Open Fractures:









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

SPINE Spine Fellow

Adult: Shared with neurosurgery.

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 you’re 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 clavicle 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 ORTHO TEAM (410.283.4505)

Pediatric InPatient 7am-5pm

HAND

Rotates weekly with Plastics.If we’re not on, we don’t want it!!!

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

Any microvascular repair goesto Plastics.

Day

After Hrs& Wkend

Day


SPINE Spine Fellow





PRIORITIZE!!!




Day

ON-CALL (410.283.1254)

All ER 7am-5pm

All ERAll InPatient





HAND




Day

After Hrs& Wkend

Day


SPINE Spine Fellow





PRIORITIZE!!!




Day

ON-CALL (410.283.1254)

All ER 7am-5pm

All ERAll InPatient





HAND




Day

After Hrs& Wkend

Day


SPINE Spine Fellow





PRIORITIZE!!!




Day

ON-CALL (410.283.1254)

All ER 7am-5pm

All ERAll InPatient





HAND




Day

After Hrs& Wkend

Day

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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 by Dr.David Hungerford: “Anatomy of theKnee,” and “Anatomy of the Hip.”

The syllabi for rotations can also befound at the site. Some have weeklyobjectives and reading assignments.

Reading materials and instructionsfor OITE study, Resident Researchand Motor Skills labs are onNetOrthoDoc.

You can also link to NetOrthoDocfrom the ortho homepage:www.hopkinsortho.org.

http://www.netorthodoc.org

LOGIN: jhuorthoPW: resident

(the Hopkins firewall may ask for thesetwice, just enter them a second time anddisregard the request for a “domain”name)

Contact for Ortho E-Learning:

Gail Richter-Nelson(o) 410.502.5885, (c) 443.629.3848JHOC #5264


NetOrthoDoc Website













NetOrthoDoc Website













NetOrthoDoc Website












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TO CREATE A FILM LIST INULTRAVISUAL

- Click EXAM LIST

- Click NEW EXAM LIST

- Click ADD TO PRIVATE FOLDERS

- Give a NAME to the LIST

- Change the DAY on STUDIESACQUIRED to 2 DAYS

- Click ADD

- Click COMPOSITE and/or NODEand Click OK

- Click on PATIENT ID

- In VALUE Box, type in PTS MR#without the check digit and nospaces. Press OK.

- To add another patient repeat fromClick ADD to end.

BAYVIEW SHAREPOINThttps://collaborate.johns hopkins.edu/sites/Orthosignoutsheet/

- Site is password protected with yourJHED ID and Password

- List of Patients is saved to the sharedfiles daily and can be opened from thesite.

- Every consult seen in ED, but notadmitted should be added to the “TASK”section.

- Patient’s Name, Phone, Bayview #,Diagnosis

- After showing films at board to anattending, task should be updated as towhether this is operative or non-op, andwhere they should follow up.

- The secretaries at Bayview have accessto this site and will use this informationto schedule appointments. MAKE SUREINFO IS CORRECT.


- Click EXAM LIST





- Click ADD













- Click EXAM LIST





- Click ADD













- Click EXAM LIST





- Click ADD












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JHH ORTHO SHAREPOINThttp://ortho.jhu.edu

- DOCUMENTS:Trauma PostingsDocuments & ResourcesDaily Lists

- LISTS:Trauma Schedule Calendar,Patient Phone Calls & Requests

- Discussions:Trauma Patients (PendingSurgery),Morbidity & Mortality List

- ON CALL RESIDENT RESPONSIBILITIES- Update ALL Adult Consults thatneed or may need surgery

- Click Trauma Patients icon underDiscussions List- Click NEW, CREATE NEW DISCUSSION- In subject, list patient’s name, mrn,and injury. Include treatment (nonop, ORIF)- Provide: who saw, treatment, dispo, contactSubject: Doe, John MR# 1-234-56-789.Left bimalleolar ankle fx requiring ORIFBody: seen by ortho doc on 1/28/2010 and treatedwith closed reduction & splinting.D/C home with plan for OR next wk.Contact (cell): 410-867-5309If consented for surgery FAX CONSENTto MMF (1-866-341-2834)

DAILY LISTS: ADULT INTERN or ON-CALL RESIDENT

A copy of list should be uploaded to sharepoint each AM after list isupdated with labs BEFORE ROUNDS.

- Click Daily Lists icon under Documents List- Click Upload- Select Upload a document from your computer to thislibrary- Upload list

RETURNING PHONE CALLS: CHIEF, TRAUMA 2, & ON CALL PA

Laronda Johnson (Dr. Osgood’s assistant) lists these phone calls onwebsite. Should be handled daily.

- Click Patient Phone Calls & Requests under Lists- Click on any pending phone call issues- If request is for narcotics, make sure there are no notes in EPRprohibiting. If not, write script. Leave note in EPR using the“Prescribing Meds” note type.- DELETE the discussion from sharepoint, so only one Rx is written.- Leave script on Laronda’s desk JHOC 5





































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POSTING CASES: CHIEF & TRAUMA PGY-2

- Scheduled surgery, but NOT next or same day( these must be called in)- Posting sheet must be created so Laronda can postthe case for us. Once she has posted it, it will showup on OR schedule.- Even if date is not known, posting MUST BECREATED at time patient is consented.

COMPLETING A POSTING SHEET:

- Open Ortho Posting Sheet Brief (if no templateexists for your surgery.- Save file to I drive with header of Patient’s Name,MR#, Procedure,and date- Subject: Doe, John MR# 1-234-56-789. Left bimalleolarankle fx, ORIF for 1/11/11- Fill out posting sheet general info: name, MR#, ICD-9, CPT codes.- True trauma cases are posted to our room: OR15- All other cases to ANY OR (e.g. ROH)- Outpatients should be seen in PEC center andbox: CALL PATIENT should be checked (notPatient To Call)- Under EQUIPMENT, add what’s needed: fluoro,ortho basic, table type, ortho minor, bump, lateralpositioning, etc. If you include all info in this sectionyou do not need to fill in boxes on form.

MORBIDITY & MORTALITY: CHIEF &TRAUMA PGY-2

- Add patients to M&M list after case discussed withDr. Osgood.- Cases should be removed or archived oncepresented at M&M

- Click on Morbidity & Mortality List icon underDiscussions List- Click NEW, CREATE NEW DISCUSSION- Subject: Patient’s Name, MR#, Treatment,Complication- Body: Any additional information




















