All your shifts will be in Team Center B. You’re in charge of the ortho rooms +/- other orthopedic pts in TCB. You should only go to the stab room if it’s an ortho case.PGY-1 ED Orthopedics
General info:
All your shifts will be in Team Center B. You’re in charge of the ortho rooms +/- other orthopedic pts in TCB. You should only go to the stab room if it’s an ortho case.
There is usually a G2 ortho resident floating around the department that you can consult, but also let them know about anything cool you’re doing so they can learn from it, too.
Don’t forget about the numerous research studies going on in the ED! Many are applicable to ortho cases, e.g. morphine vs oxycodone, procedural sedation studies, US for Colles Reduction.
Procedure notes should be done for all procedures, even just putting on a gel cast or Velcro wrist brace! These also are billable procedures!
To order crutches, cane or walker, enter the order ‘gait training’, specify device and weight-bearing status. The nurse or aide will then fit the device for the pt and instruct them how to use it.
Splinting:
Orthoglass: less messy, faster, lighter, stronger but less moldable and hard. Ortho doesn’t like it. You can use it if there’s no fracture or chance of edema. With our pt population it’s too risky b/c it’s so hard and unmoldable it can cause skin break down and injury unless closely monitored.
Plaster of Paris: use 8-10 layers for upper extremity, 12-15 layers for lower extremity. It’s exothermic when wet as it recrystalizes so it can burn the pt! Increased risk of burn if you wet the plaster with warm water. Also, the warmer the water, the faster it sets and the less time you have to work with it. Tell your pts it can take up to a day to full cure, so don’t rest their cast in 1 spot for too long that first day, e.g. in RJ splint, don’t rest heel on floor.
How to apply splints. Technique and preference varies widely. Just remember you want to immobilize at least one joint proximal and distal to the injury. Use some combination of stockinette, Webril and/or cotton batting under the plaster. Make sure to use extra padding over bony prominences like elbow, ankles, heels. Always pad between digits when splinting hands/feet or when buddy taping. Avoid wrinkles! Than apply plaster. (To be nice to the person that removes the splint, also put one layer of Webril over the plaster so it doesn’t stick to the Ace wrap.) Apply Ace wrap.
Upper extremity splints:
elbow/forearm:
Long arm posterior
- distal humerus fx, both-bone forearm fx.
- doesn’t completely eliminate supination/pronation
Double sugar-tong
- elbow and forearm fx, radius and ulnar fx
- better for most distal forearm and elbow fx b/c it limits
flex/ex and pronation and supination
Forearm/wrist:
volar forearm
- soft tissue hand/wrist injuries (sprain, carpal tunnel)
- most wrist fx
- 2nd-5th metacarpal fx
Sandwhich splint
- volar forearm splint + dorsal splint
Sugar-tong
- distal radius and ulnar fx
- prevents pronation/supination and immobilizes elbow
Hand/fingers: The correct position for most hand splints is the position of function (the neutral position), with the hand placed like it’s holding a hamburger. Wrist is slightly extended (10-25 degrees) with fingers flexed. If immobilizing metacarpal neck fx, the MCP joint should be flexed all the way to 90 degrees. If necessary, have the pt hold an Ace wrap while splinting to keep them in position.
Ulnar gutter
Radial gutter
Thumb spica
- scaphoid fx
Finger splints: buddy taping or dorsal/volar finger splints. Gutter splints are better for proximal phalangeal fx
Lower extremity
Knee:
Knee immobilizer (kept in the ortho closet) or Bledsoe
Posterior Knee splint
Ankle:
Posterior ankle
- distal tib/fib fx, reduced dislocations, severe sprains, tarsal/metatarsal fx
Robert Jones splint (RJ)
- adding a stirrup to the post ankle splint (although some people call
just a stirrup splint an RJ)
- eliminated inversion/eversion
- unstable fx and sprains
Stirrup
Clinical pearls from my experience/reading. Management varies widely but this is hopefully a guideline.
Ankle & foot:
Review the Ottowa Rules, found in the reading packet for this rotation.
Ankle sprains:
Generally treated with RICE, Ace wrap, gel cast and crutches with weight bearing as tolerated. Give them contact info for Sports Medicine clinic to call if they are not improving in a week.
Ankle fractures:
Classified as malleolar, bimalleolar, trimalleolar and pylon or via the Weber system.
The Danis-Weber classification system uses the position of the level of the fibular fracture in its relationship to its height at the ankle joint.
Type A: fracture below the ankle joint
Type B: fracture at the level of the joint, with the tibiofibular ligaments usually intact
Type C: fracture above the joint level which tears the syndesmotic ligaments.
Reduce the fracture if necessary, splint and keep non-weight bearing with orthopedic f/u usually in 1 week. Remember to check proximal fibula for Maisonneuve fx.
Toe fractures: Generally buddy-taped together +/- ortho f/u
1st and 5th metatarsal fractures: treated as non-weight bearing with cast and early ortho f/u.
2nd, 3rd and 4th metatarsal fractures: generally treated with weight-bearing cast or orthopedic hard-soled shoe.
Lisfranc fracture: disruption of 2nd metatarsal from medial cuneiform. Consult ortho! All require ORIF.
Knee:
Do the knee exam we all learned in med school. If concern for proximal tib/fib fracture, then xray. If concern for patella fracture/dislocation, order additional views (eg sunrise view). Unless there’s true pathology, treat with knee immobilizer and f/u with PCP, sports medicine or ortho.
Hip fractures: have low threshold to xray the hip of an old person c/o hip pain. Occult fractures are not uncommon. All hip fractures require ortho consult.
Pelvic fractures:
usually will not be walking into TCB.
You may want to image the pelvis for c/o hip/pelvis pain. Be advised that when you order ‘pelvic xray’ in Epic, it doesn’t specify the views so radiology will be calling you. In my limited experience, always get an AP. An inlet view is the best for evaluating the ring structure, for AP displacement of pelvic ring fx fragments or opening of pubic symphysis, for looking at the SI joint. An outlet view evaluates for vertical shift of pelvis (migration of hemipelvis), for displacement of anterior and posterior arch fractures, the sacrum and neural foramina. The Judet view is an oblique view good for seeing the area of the sciatic notch and also the acetabula. If unsure, just tell the radiology tech what you want to evaluate and they will suggest which views to use.
Hand fractures:
Phalangeal fractures: distal tuft fx past the DIP you don’t do anything for but wrap/splint for comfort. Nondisplaced mid and proximal phalynx fx are usually splinted with close orthopedic follow up. Consult ortho for intraarticular fx.
Metacarpal fractures: Splint with ortho f/u, usually in 1 week. Any fx involving the 2nd or 3rd metacarpals requires early ortho management.
Scaphoid/navicular fracture: High index of suspicion needed! If negative Xray but positive exam, treat with long arm thumb spica splint and ortho f/u for repeat exam.
Arm fractures:
Radial head/neck fx: usually due to fall on outstretched arm. Check Xray for posterior fat pad. Usually consult ortho in ED.
Colles’ fracture: Usually managed in the ED with close ortho f/u. Hematoma block with lidocaine. Grab your pit boss or attending for reduction, done by reproducing and exaggerating the injury and applying volar angulation. Check reduction with ultrasound and reduce again if necessary. Apply sugar tongue splint with hand slightly flexed and ulnar deviation. Check post-reduction Xray.
Supracondylar distal humerus fracture: true ortho emergency! Consult ortho or splint in place with urgent ortho f/u
Shoulder:
AC joint separation: Grade 1- clinical diagnosis. Grades 1 and 2 usually treated non-operatively with sling, ice, analgesia and ortho f/u. Grade 3+ may require operative repair depending on pt’s age and how functional it needs to be. To image: AP and lateral Xray. Stress views with pt holding weights can be obtained to cinch the diagnosis, but not done in the ED.
Possible rotator cuff injury- analgesia, f/u sports med clinic.
Tendon lacs: all flexor tendon injuries, consult ortho for repair. Extensor tendon injury- consult ortho but we can usually fix it if we can see both ends of the tendon and don’t have to extend the laceration and no big nerve damage.
Suggested reading:
Accident and Emergency Radiology by Nigel, Berman and Lacy, 2nd edition, 2005.
Adkins, SB, Figler, RA. Hip Pain in Athletes. Am Fam Phys 2000; 61
Mary will put the manual for this portion of the rotation into your box. Basically it consists of 3 things you need to do:
1. An orientation to the 911 Call center. This is located in the county courthouse at 350 south 5th St.
2. An 8 hour ambulance ride-along. The number to arrange this is in the manual.
3. A 4 hour MD ride along – to be arranged with Jeff Ho. His number is in the manual.
Jeff Ho is responsible for this rotation and you can contact him with any questions.