Fx - Tx: General Ortho Trauma And Call Tips

Front 1

Suspected Traumatic Arthrotomy

Back 1

[Vrahas/MGH attendings say : if you have to go looking for it, it doesn't need to go to the OR - a little bug in the joint won't hurt. Vrahas said CT to rule out air in the joint is unnecessary and to never inject with saline. If it is an obvious traumatic arthrotomy that you don't have to look hard to find , it should go to the OR. If the overlying wound is major or contaminated, it should also go to the OR. Otherwise just wash it out and close in the ED.]

175 ml must be injected in a saline test to the knee to get 99% sensitvity.

CT scan is 100% sensitive.

In my opinion, if asked, recommend they get a CT scan [prior to the consult to avoid crap from the attending]. Also be sure the lac is not severe enough itself to warrant the OR.

Front 2

Femoral Shaft Fracture Immobilization Options

Back 2

If a short time to OR Smith says it's OK to use the skin traction device.

My preference is a big knee immobilizer up to the groin. Get help and have one person pull traction. [Smith ok with this].

Another option is a long leg splint that goes up above the butt. I find this to be a hassle.

Last option is a skeletal traction pin. Useful if the OR is days away. Best for pain control but a hassle to set up and patient s don't always like the idea. Usually ok to ask the attending in the am if they want it done.

Front 3

Minimally displaced tibial fracture in adult

Back 3

Give the patient the option of IMN vs. LLC.

Advantage of LLC is no operation, but they will be NWB for 6 weeks.

Advantage of IMN is immediate weight bearing, but chance of knee pain and infection

Front 4

Posterior fat pad in adult elbow

Back 4

Likely radial head fracture. DON'T splint them (the immobilization/stiffness is worse than the fracture). Sling them.

If you want, you can acutely make them feel better by aspirating the hematoma.

Front 5

How to deal with a "dry tap"

Back 5

1. Always put some lidocaine in the injection site first so the patient tolerates things better. This will give you more time to be confident about moving the needle around.

2. Use a large bore needle to aspirate - ideally 18G. For TKA patients, use an 18G spinal needle - their scar tissue can be so thick you can barely penetrate it with any other needle.

3. Don't give up right away. Redirect the needle a bit and feel around and be sure you are in the joint. Rotate the needle as well (in case the intake is stuck in soft tissue)

4. Try keeping the needle in and switch out the syringe to a IV flush. If you can put fluid into the space very easily, you are very likely in the joint. Switch back and re-aspirate out the fluid you just put in. You can send that for gram stain and culture.

5. Consider imaging with fluoro if in the room to prove you are in the joint if possible (best for ankles)

6. If you only get a miniscule sample, swab it for gram stain and culture. Even a tiny sample is sufficient.

7. After all of the above, if you truly get nothing it may be that they just had no effusion and that is your result (i.e. negative for septic joint)

Front 6

What traction to use?

Back 6

femur fx - use a lat to medial to tibial traction pin (largest k wire or Steinman pin 2.5 cm distal and 2.5 cm post to tibial Tubercle, avoid peroneal nerve)

acetabulum fx with dislocation - use a medial to lateral femoral traction pin (30 degree flexed knee, 1-2 cm prox to top of patella).

Use your fingers as a marker, each one is a cm.