ACS TQIP BEST PRACTICES IN THE MANAGEMENT OF ORTHOPAEDIC TRAUMA

Released November 2015 Table of Contents Introduction ...... 3

Triage and Transfer of Orthopaedic Injuries ...... 4

Open Fractures ...... 6

Damage Control Orthopaedic Surgery ...... 9

The Mangled Extremity ...... 12

Compartment Syndrome ...... 15

Management of Pelvic Fractures with Associated Hemorrhage ...... 18

Geriatric Hip Fractures ...... 21

Management of Pediatric Supracondylar Humerus Fractures ...... 25

Rehabilitation of the Multisystem Trauma Patient ...... 26

Appendix A: Performance Improvement Indicators ...... 28

Appendix B: Transfer Worksheet ...... 32

References ...... 33

2 INTRODUCTION

More than 60 percent of injuries involve the musculoskeletal system, and more than half of hospitalized trauma patients have at least one musculoskeletal injury that could be life threatening, limb threatening, or result in significant functional impairment. These orthopaedic injuries are often associated with significant health care costs, decreased productivity in the workplace, and, in some cases, long-term disability. The optimal management of trauma patients with orthopaedic injuries requires significant physician and institutional commitment. The American College of Surgeons (ACS) Resources for the Optimal Care of the Injured Patient, 2014 includes several key hospital and provider- level orthopaedic trauma criteria that must be met in order to attain American College of Surgeons trauma center verification. Although these criteria are important, they do not cover the entire breadth of orthopaedic trauma care. Furthermore, trauma centers may identify areas in need of improvement that are unique to their hospital. These best practice guidelines represent a compilation of the best evidence available for each respective topic. In areas where the literature is inconclusive, incomplete, or controversial, expert opinion is provided. As such, there are several points worth mentioning:

zz All facilities should have in place appropriate pain management guidelines for those suffering from traumatic orthopaedic injury.

zz All patients with orthopaedic injuries should be preferentially placed in hospital units staffed by nurses who receive ongoing orthopaedic-specific in-service training.

zz For high-risk injuries, facilities should have guidelines ensuring ongoing neurovascular assessments prior to fixation. zz When appropriate, prosthetics counseling, evaluation, and implementation should be made available in a timely manner.

In addition to an outline of best practices, we have also included appropriate performance improvement (PI) indicators (Appendix A) that you might use as a guide to continually evaluate the delivery of orthopaedic trauma care in your center.

3 zz Direct communication between TRIAGE AND TRANSFER transferring and receiving institutions is important prior to patient OF ORTHOPAEDIC transfer and when breakdowns INJURIES in the transfer process occur.

Key Messages The optimal care of patients with musculoskeletal injuries relies upon the zz Optimal care of orthopaedic injuries orthopaedic provider and the institution occurs when both the health care at which he or she practices. Although an providers and hospitals are capable individual orthopedist may be capable of of providing high-quality care. providing high-quality care, the facility Patients with a combination of TBI at which he or she works may not have (GCS score ≤ 15) and moderate to the ancillary resources necessary. To severe extra-cranial anatomic injuries ensure optimal care is provided, patients and Abbreviated Injury Score (AIS) ≥3 with musculoskeletal injuries should be should be rapidly transferred to the treated where both the provider and highest level of care within a defined hospital are able to adequately care for trauma system to allow for expedient a patient’s injuries. In the event that a neurosurgical and multidisciplinary provider feels comfortable managing assessment and intervention a given injury but the facility does not zz Hospitals should develop protocols have the adequate resources to provide and procedures for identifying ideal care (in other words, equipment, patients with orthopaedic injuries supplies, staffing, physical therapy, and who are likely to benefit from transfer so on), the patient should be transferred to a designated trauma center. to a facility that does have the capability of providing an optimal level of care. zz Certain orthopaedic injuries always warrant strong The variability in provider and consideration for transfer to a institutional capabilities make it difficult designated trauma center. to establish uniformly applicable criteria for whom to transfer and whom to zz In the setting of concurrent injuries, manage locally. However, the best co-morbidities, or extremes of interest of the patient should be the age, strong consideration should underlying principle guiding all transfer be given to transferring patients decisions. Appendix B is an example of with minor orthopaedic injuries. a tool that a trauma center might use to identify who can be cared for locally zz Transfer agreements between and who should be transferred to a hospitals can facilitate the timely higher level of trauma care. Using this transfer of injured patients. tool as a template, hospitals can develop institutional protocols and procedures that standardize the decision-making

4 process for transferring patients with zz Complex pelvic or orthopaedic injuries. Implementing acetabular fractures such protocols and procedures zz Fracture or dislocation with can help decrease the likelihood of a loss of distal pulses surgeons caring for injured patients at hospitals inadequately equipped to zz Vertebral fractures or findings manage certain orthopaedic injuries. concerning for spinal cord injury

Although hemodynamically stable zz More than two unilateral rib patients with orthopaedic injuries fractures or bilateral rib fractures may benefit from an orthopaedic with pulmonary contusion(s) in the evaluation prior to transfer, the transfer absence of critical care availability process should not be significantly delayed to obtain this evaluation. In some situations, patients with Hemodynamically stable patients with minor orthopaedic injuries warrant isolated orthopaedic injuries should be strong consideration for transfer to evaluated by a qualified orthopaedic a Level I or Level II trauma center. provider prior to making the decision Examples include patients with: to transfer to a trauma center. Again, zz Carotid artery, vertebral artery, or the decision to transfer should be other significant vascular injury based upon surgeon and hospital resource availability and guided by the zz Bilateral pulmonary contusions best interests of the patient. Although with a PaO2:FiO2 ratio < 200 provider and institutional resources zz Grade IV or V liver injuries requiring vary across hospitals, examples of transfusion of more than six units orthopaedic trauma patients who of red blood cells in six hours could be considered for management at a nontrauma center include: zz Penetrating injuries or open fracture of the skull zz Simple fractures without significant soft tissue injury or zz Glasgow Coma Score (GCS) neurovascular compromise <14 or lateralizing physical examination findings zz Patients without major medical comorbidities zz Significant torso injury in the setting of advance comorbid disease, such Strong consideration for transfer to as coronary artery disease or chronic a Level I or Level II trauma center obstructive pulmonary disease should be given to patients with the following orthopaedic injuries: zz Extremes of age, particularly with respect to the pediatric population zz Unstable pelvic fracture requiring transfusion of more than six units of red blood cells in six hours

5 To facilitate appropriate and timely management of patients with OPEN FRACTURES musculoskeletal injuries, formal transfer arrangements between Key Messages facilities should be agreed upon. The zz Open fractures occur when a “Orthopaedic Trauma Worksheet” fractured bone is exposed to provided in Appendix B may be helpful contamination from the external in establishing the types of injuries each environment through a disruption facility has the optimal resources to of the skin and subcutaneous tissues manage. Written transfer agreements and are susceptible to infection. should clearly specify the expectations of both the transferring and receiving zz Patients with open fractures should providers, should be mutually agreed receive intravenous antimicrobials upon, and should be frequently within one hour of presentation reviewed. When deviations from the to reduce the risk of infection. transfer agreement occur (for example, when an orthopaedic provider is out of  Patients with Gustilo open type town operating room [OR] or computed 1 or 2 fractures should receive a tomography [CT] scanner at the first-generation cephalosporin receiving facility is out of commission), (for example, cefazolin) they should be discussed both within  Gram negative coverage should and between the involved centers. be considered in patients with Gustilo type 3 fractures Direct, timely communication between (for example, gentamicin) orthopaedic providers at each facility prior to patient transfer is ideal and  The addition of a penicillin for should occur when possible. However, anaerobic coverage should such communication should not delay be considered in the presence patient transfer. In all cases where direct of severe contamination communication does not occur, the or impaired vascularity reasons should be clearly documented  In the presence of documented by providers on both ends of the -lactam allergies, consider transfer. Additionally, imaging studies regimens with a similar should never delay transfer of an spectrum of coverage

injured patient; however, if imaging zz Antibiotics should be administered studies are performed, the images for no longer than 24 hours after and reports should be sent to the a surgical procedure. In cases of receiving hospital with the patient. severe contamination, antibiotics may be continued for as long as 72 hours after a surgical procedure.

6 zz Tetanus toxoid should be a result, the fractured bone is highly administered if the patient had an susceptible to contamination from the incomplete primary immunization, outside environment. These injuries are if it has been >10 years since his particularly susceptible to both bone or her last booster dose, or if the and soft tissue infections, and early immunization history is unknown or management strategies should aim to unclear. Tetanus immunoglobulin minimize the risk of such infections. should be administered if it has The recommendations provided in this been >10 years since the patient’s section are for open fractures occurring last booster dose or if he or as a result of blunt force injuries. she has a history of incomplete When a patient with an open fracture primary immunization. presents to the emergency department, zz Patients with open fractures should a sterile dressing should be placed be taken to the operating room for over the wound to minimize ongoing irrigation and debridement within wound contamination. It is strongly 24 hours of initial presentation recommended that patients with open whenever possible. Patients with fractures receive broad-spectrum severe fractures associated with intravenous antibiotics within one hour gross wound contamination should of presentation. For open fractures with be brought to the operating room a clean or moderately contaminated more quickly, and as soon as clinically wound less than 10 cm in length feasible, based on the patient’s without extensive soft-tissue damage, condition and resources available. flaps, or avulsions (Gustilo type I and II), a first generation cephalosporin zz Whenever possible, skin defects (cefazolin) is recommended. For open overlying open fractures fractures associated with wounds should be closed at the time greater than 10 cm in length, significant of initial debridement. contamination, extensive soft tissue zz Soft tissue coverage should be damage, or significantly comminuted completed within seven days of fractures (Gustilo type III), a first injury for open fractures associated generation cephalosporin and another with wounds requiring skin antimicrobial with gram-negative grafting or soft tissue transfers. coverage (for example, gentamicin) is recommended. For open fractures Open fractures occur when a fractured with severe contamination or impaired bone is exposed through a disruption vascularity, anaerobic coverage should of the skin and subcutaneous tissues. be added (for example, penicillin). In This type of fracture may occur when the presence of documented -lactam the fractured bone itself creates the allergies, consider regimens with disruption or when an overlying wound a similar spectrum of coverage. penetrates down to a broken bone. As

7 Scheduled dosing of antibiotics should debridement up to 24 hours does be continued until surgical management not increase infectious complications is performed. After the surgical for open fractures. Based on the best procedure, the duration of antibiotics is available evidence, the panel does dependent on the level of contamination. not endorse the “six hour rule.” A minimum of 24 hours of antibiotics Current evidence does, however, should be administered from the start demonstrate that the risk of infection of the surgical procedure. Generally, increases with increasing fracture severity antimicrobials are discontinued and time to surgical irrigation and 24 hours after the procedure, but debridement. Widely accepted timing continuation for up to 72 hours may be requirements have yet to be established, appropriate for highly contaminated as the ideal timing of operative wounds. Antibiotics should not be intervention likely varies based on a administered beyond 72 hours unless myriad of factors such as mechanism of a second operative intervention injury, degree of contamination, amount occurs within that time period. of vascular disruption, and the immune In addition to intravenous antibiotics, status of the patient, among others. all patients with open fractures Taking these issues into consideration, should be evaluated for the potential the panel recommends that patients need for tetanus vaccination. The with open fractures should be taken immunization history of the patient to the operating room for surgical should be obtained, and tetanus irrigation and debridement within 24 toxoid should be administered if the hours of presentation to the emergency last booster dose was given more department whenever possible. Patients than 10 years prior to evaluation or if with fractures with gross contamination, the vaccination history is unknown should be brought to the operating or unclear. Tetanus immunoglobulin room more quickly, and as soon as should also be given when it has been clinically feasible, based on the patient’s longer than 10 years since the last condition and resources available. booster dose or when the patient had Skin and/or soft tissue loss frequently an incomplete primary immunization. complicate the management of open Historically, dogma has led orthopaedists fractures. Open wounds represent to treat open fractures with surgical a persistent source of potential irrigation and debridement within six contamination and therefore infection. It hours of the injury or risk increased rates has been demonstrated that increasing of infection. This practice has come times from initial presentation to to be known as the “six hour rule” in definitive wound coverage is associated orthopaedic surgery. However, it has with increased risks of infection. It is been disproven in recent years by several recommended that, when possible, high quality studies demonstrating skin defects overlying open fractures that delaying surgical irrigation and should be closed at the time of initial

8 debridement. For open fractures  Open or closed compromised associated with wounds requiring or suspected compromise of coverage with skin grafting or soft soft tissues (soft tissue loss, tissue transfers (in other words, Gustilo significant contamination, type IIIB), it is recommended that severe closed soft tissue injury) coverage be completed within seven zz Damage control surgery should days from the time of the injury also be considered for patients *This document is specifically addressing who receive initial care in an open fractures associated with blunt trauma. Management of fractures associated with gunshot environment with limited wounds is outside the scope of this document. experience and/or resources.

zz The use of damage control orthopaedic surgery should Damage Control be monitored by the trauma performance improvement Orthopaedic Surgery program (PIPS). Key Messages zz If a patient is in extremis, it is zz Damage control surgery is an integral reasonable to place a skeletal traction tool in the armamentarium of the pin to aid in bony stabilization and orthopaedic trauma surgeon and alignment. Similarly, patients with should be considered as the first femur or pelvis fractures who are not stage of intervention when early stable enough to be anesthetized definitive surgical management is not for placement of spanning possible—typically in patients who external fixation or are unable to are critically injured or those with tolerate the additional blood loss significant soft tissue injuries pending or physiologic insult may benefit resuscitation and/or soft tissue injury from a period of skeletal traction. resolution. More specifically, damage zz Once patients are in the operating control surgery should be considered room for management of in patients who demonstrate: concurrent injuries or able to  Severe traumatic brain injury physiologically tolerate operative intervention, formal stabilization  Inability to be adequately with external or definitive resuscitated as demonstrated by: fixation should be performed. Ongoing fluid and blood requirements Damage control surgery is utilized for critically ill or injured patients High base deficit or lactate, as an early initial step to definitive which are not improving surgical management. The underlying Pulmonary dysfunction principle of damage control strategy requiring significant is to perform only those interventions ventilatory support

9 needed to preserve life or limb until the presence of hypothermia, coagulopathy, patient is resuscitated. This approach and/or acidosis, or who have severe implies that early procedures are closed or open soft tissue injuries. often truncated, with a view toward Modern orthopaedic approaches staged definitive interventions over to fractures may in many cases be the ensuing days. Damage control thought of as a soft-tissue injury that surgery thus prioritizes resuscitation and contains within it a fractured bone. correction of metabolic derangements, Severe compromise of this soft-tissue coagulopathy, hypothermia, and/ envelope presents another indication or resolution of soft tissue injuries for damage control surgery. Examples of over early definitive surgical repair. this issue include heavily contaminated In orthopaedic surgery, the focus open fractures or closed injuries that of damage control surgery is often historically have been shown to do to control hemorrhage, decrease poorly with acute open reduction contamination through debridement, and internal fixation (ORIF), such as and provide bone and soft tissue pilon fractures and bicondylar tibial stabilization to patients unable to plateau fractures (unicondylar plateau undergo definitive repair. External fractures are typically amenable to fixation is often used in damage control immediate ORIF). Soft tissue injuries orthopaedic surgery, particularly in evolve over the hours or days following femur fractures, to minimize ongoing injury. In this context, temporary soft tissue damage, decrease risks of approaches to skeletal fixation allow fat embolism, control hemorrhage the full extent of the soft tissue injury and contamination, alleviate pain to declare itself before committing due to fracture motion, and facilitate to a definitive internal fixation. patient mobilization. Additionally, external fixation is used to regain and/ Timing of Definitive Repair or maintain gross length, rotation, and following Damage Control Surgery alignment of extremities with unstable There is considerable variability in the fractures and soft tissue injuries that duration and severity of physiologic preclude early internal fixation. derangements that occur after trauma. After a period of resuscitation, patients In many cases, these derangements are taken back to the operating room may be short lived and early definitive for definitive management of their fracture management may be pursued. injuries. In general, patients who could In others, definitive management may benefit from damage control surgery be significantly delayed. The optimal are those undergoing emergent timing and physiologic targets that control of life-threatening injuries by indicate it is safe to proceed to definitive other disciplines (for example, trauma management are controversial. surgery, neurosurgery, and so on) or Normalization of heart rate and blood who are reaching the limits of their pressure are important, but measures physiologic reserve as determined by the of adequate resuscitation, including an

10 improving base deficit or lactate, might with early stabilization. In another study, be more accurate to inform decision- it was demonstrated that polytrauma making. A retrospective review of patients with long bone fractures traditionally resuscitated patients with treated with early mechanical ventilation an injury severity score (ISS) of >18 and and early fracture stabilization had a femur fracture stabilized within 24 a decrease in the incidence of acute hours of admission found that patients respiratory distress syndrome (ARDS) with a lactate of >2.5 had a higher and decreased mortality rate for the pulmonary and infectious complication most severely injured patients with rate when compared with those with an ISS >50. A randomized controlled a normal lactate. Additionally, patients trial comparing femoral shaft fractures with severe traumatic brain injury stabilized less than 24 hours after injury proceeding to definitive fixation are with those stabilized after 48 hours less likely to have dips in their cerebral found that early fixation in patients with perfusion pressure in the operating an ISS >18 decreased the incidence of room if they have been adequately pulmonary complications (ARDS, FES, resuscitated. Although there is no clearly pneumonia), intensive care unit (ICU) identified end point for resuscitation, length of stay, and hospital length of stay. trauma centers should understand the Based on current evidence, long bone different markers of resuscitation and fractures should be stabilized early in choose one or more for evaluating multiply injured patients. The method patients within their institution. for doing so depends on whether a status can be used to set CPP goals as damage control approach is required. described above. In a similar fashion, If the patient presents with isolated TCD ultrasonography and hemodynamic injuries and there is no indication for challenge can also be used to assess damage control surgery (resuscitated autoregulation in TBI patients. patient, no severe traumatic brain injury (TBI), adequate soft tissue envelope), Long Bone Fractures then early definitive stabilization Historically, long bone fractures were is appropriate. For these patients, acutely managed with traction due earlier stabilization simply leads to a to a perceived increased risk of fat decreased length of hospital stay and embolization syndrome (FES) in the a lower risk of complications related to time immediately following injury. immobilization. However, for patients in However, several decades of research extremis or those in whom resuscitation have demonstrated the benefits of early is incomplete, alternatives to definitive stabilization of long bone fractures with fixation need to be considered, no increased risk of FES or their sequelae. most commonly external fixation. For example, in one retrospective study, 22 percent of patients treated with delayed stabilization developed FES compared with only 5 percent treated

11 Patients with Thoracic Injuries to experience transient episodes of and a Femoral Shaft Fracture hypotension in the operating room. This injury pattern was the initial focus The under-resuscitated patient or of damage control orthopaedics, those patients whose ICP and cerebral with the concern being significant perfusion pressure (CPP) have not yet worsening of pulmonary dysfunction stabilized are best served with damage due to FES. If the patient has been control procedures or traction. adequately resuscitated and meets no other indication to hold off on definitive Damage Control and fixation, there appears to be little risk Performance Improvement to proceeding. The exception might Although damage control interventions be patients who at or shortly following in orthopaedic surgery are necessary presentation have evidence of significant at times, delay of definitive fixation pulmonary dysfunction on high levels leads to higher rates of skin breakdown, of ventilatory support who could not prolonged hospital length of stay, tolerate any nonessential operative increased pain, decreased patient procedure. Temporary external fixation satisfaction, and delays to rehabilitation. might be reasonable in this scenario. The utilization of damage control orthopaedic surgery and subsequent Patients with Concurrent complications should be monitored Severe Traumatic Brain Injury through the performance improvement Special consideration should be given to process. Similarly, failure to employ a patients with concomitant orthopaedic damage control approach to orthopaedic and TBI. The management of fractures in injuries where it is indicated could patients with TBI represent a particular result in severe physiologic insult and challenge in that early surgical fixation even amputation (in an otherwise may complicate the acute management salvageable extremity) or death. of TBI. The goals of acute TBI management are to maintain adequate cerebral perfusion, prevent hypotension, THE MANGLED provide adequate oxygenation, avoid hypo- and hypercarbia, and maintain EXTREMITY normothermia. Efforts should be Key messages: made to adhere to each of these goals. Intraoperative monitoring of intracranial zz A mangled extremity has an injury to pressure (ICP) should be considered to three of the four major components support cerebral perfusion pressure. In of a limb: soft tissues, nerves, vascular the context of a stable ICP and mean supply, and skeletal structures. arterial pressure (MAP), definitive fixation zz If the patient has inadequate can be considered in the resuscitated physiologic reserve due to patient, as these patients are less apt associated other injuries, or the

12 mangled extremity is contributing The mangled extremity presents a to significant physiologic unique set of challenges to orthopaedic derangement, attempts at limb surgeons. The goals of this section salvage should not be considered: are to summarize the important life takes precedence over limb. considerations in the decision-making process when weighing the risks zz Limb salvage should be and benefits of limb salvage versus attempted only when there is amputation, and to outline what patients a reasonable expectation that might expect with either approach. the limb is salvageable. A mangled extremity is a limb with an zz Surgical decision making should injury to three of the four systems within take patient- and injury-specific the extremity. These systems include: factors into consideration (1) soft tissues (muscle, fascia, and skin),  Age, comorbidity, functional (2) nerves, (3) vascular supply, and (4) status, occupation, patient skeletal structures. The involvement preference, and self-efficacy/ of multiple functional systems within social support systems are a limb makes the mangled extremity important patient factors. a particularly severe orthopaedic injury. Most importantly, these injuries  The extent of soft tissue injury, are not simply “open fractures.” fracture pattern, level of the vascular injury, warm ischemia time, the anatomic status Assessment of the of nerves (in other words, Mangled Extremity transection versus continuity Patient- and injury-specific factors injury), and the status of the need to be considered when assessing ipsilateral foot (for lower the mangled extremity. Patient’s age, extremity injuries) are important comorbidities (for example, diabetes), injury specific factors. occupation, and preferences all factor zz Limb salvage and amputation into decision making. Associated injuries are both associated with and the presence of shock are also significant morbidity, but important considerations. There needs overall functional outcomes to be a full evaluation of the extremity, and quality of life are similar. including the fracture pattern, level of the vascular injury, warm ischemia time, the zz Decision to undergo multiple anatomic status of nerves to ensure that operations for limb salvage is often deficits are not related to a neuropraxia, a multidisciplinary process and and the status of the ipsilateral foot should be considered in conjunction (for lower-extremity injuries). If time with other providers (orthopaedics, allows, early assessment should be vascular, plastics, and trauma) along multidisciplinary so that priorities are with strong patient engagement. managed in a manner that preserves

13 life over limb and then maximizes outcome and quality of life should functional potential of the extremity. be the goal rather than preservation of a dysfunctional extremity. Limb Salvage Limb salvage should be attempted Amputation only when there is an expectation that There is limited evidence in the literature the extremity is salvageable, though regarding absolute indications for often times an absolute indication for amputation in the context of the limb salvage versus amputation is not mangled extremity. As a result, there present. The decision to proceed with are few well-defined, objective criteria attempted limb salvage requires that for amputation. Higher energy injuries the patient has adequate physiologic and presentation with shock increase reserve to tolerate the necessary the probability of amputation but surgical procedures. Patients who are are contributing factors to decision- persistently hemodynamically unstable, making rather than absolute indications. acidotic, coagulopathic, or in extremis Common indications for amputation are not appropriate candidates for include total or “near total” amputations, attempts at limb salvage. This fact is warm ischemia time > six hours, particularly true when the mangled complete anatomic sciatic or tibial nerve extremity is a contributing component transection, and/or loss of plantar skin to the patient’s clinical condition. and soft tissues. Inability to re-vascularize an extremity (and unsuccessful attempts Delayed amputation following at re-vascularization) is also predictive of attempted limb salvage is not without failed limb salvage and the ultimate need consequence. One potential issue is for amputation. Evidence suggests there that during the limb salvage process is a hierarchy of injuries that influence patients become particularly invested decision-making where soft tissue > in the management of their injured nerve > bone >artery, emphasizing limb, making it more difficult for them the importance of soft tissues in the to consider delayed amputation when preservation of the mangled extremity. salvage attempts are unsuccessful. It is important to note that most Failed limb salvage is often associated patients will not have an absolute with numerous hospitalizations, surgical indication for an amputation but will procedures, infectious complications, fall into an indeterminate grey zone. nonunion, and might ultimately still end in amputation. Additionally, there Which Has Better Civilian might be significant social, economic, Patient Outcomes, Limb and psychological consequences, Salvage or Amputation? making it important to consider the longer impact on the patient when all Patients often want to know which efforts are being expended to preserve treatment strategy will provide them the limb. Maximizing functional with better outcomes, limb salvage or

14 amputation. This is a difficult question to answer due to injury heterogeneity, COMPARTMENT variability in patient goals/preferences, and conflicting results in the literature. SYNDROME Therefore, this decision becomes a Key Messages very individualized one that must take into account many patient, social, zz A high index of suspicion for surgical, and injury-specific factors. compartment syndrome should Longitudinal analyses suggest both be maintained for all patients choices have significant morbidity with extremity injuries. and that overall functional outcomes zz Compartment syndrome can result for both approaches are equivalent. in irreversible tissue damage within However, salvage attempts require six hours of impaired perfusion. more surgical procedures (with associated complications) and lengthier  Caution regarding the rehabilitation than early amputation. estimation of elapsed time is Chronic pain, particularly with prolonged important, as the time of precise standing, can be a significant issue onset is often uncertain. for patients following limb salvage. zz Compartment syndrome is a However, approximately 50 percent dynamic process and, in patients of patients undergoing amputation with high-risk injuries, an evaluation experience phantom limb pain. should occur every one to two Amputees, however, are more frequently hours for a 24 to 48 hour period. required to change occupations, while many salvage patients can eventually  Sequential physical examinations return to their previous line of work. should be performed for individuals at risk for The decision making regarding pursuing compartment syndrome, as limb salvage or early amputation is often a single exam at one point a team decision. Although plastic surgery, in time is unreliable. vascular surgery, trauma surgery, or other specialty services may contribute to the zz The most reliable early clinical care of a mangled extremity, treating findings of compartment orthopaedic surgeons should discuss the syndrome are: treatment options with the patient and  Pain out of proportion to the the patient’s family, as patient preference injury (in other words, pain may ultimately have the greatest role that is initially well controlled in the decision-making process and then becomes refractory to and/or requires escalating doses of analgesics

15  Pain with passive stretch of tissue and skeletal muscle can be seen in the musculature within the as little as six hours. Delays in treatment, involved compartment even if only for several hours, can result

 Paraesthesias of the in severe and irreversible morbidity that nerve(s) running through may ultimately necessitate amputation. the compartment(s) Early fasciotomy has been shown to be associated with improved outcomes and zz Clinical findings are very should be performed emergently when reliable in ruling out acute a compartment syndrome is suspected. compartment syndrome. Compartment syndrome results in tissue zz Patients with an unreliable or ischemia that worsens with passing time unobtainable clinical exam may and/or increasing intracompartmental benefit from measurement of pressure. It is also important to consider intracompartmental pressures. A that damaged tissue is more vulnerable gradient of <30 mmHg between to increases in intracompartmental the diastolic blood pressure and pressure. Higher pressures result in intracompartmental pressure is rapid progressive ischemia, whereas predictive of patients who would lower pressures result in slower, but benefit from a fasciotomy. still progressive, ischemia. For this zz When a compartment syndrome reason, a single “normal” compartment is suspected, early fasciotomies assessment is unreliable, and multiple should be performed using long, repeat evaluations should be performed generous skin and fascial incisions every one to two hours for a minimum of to release all the compartments 24 to 48 hours or as clinically warranted. of the involved limb, and those In the setting of orthopaedic trauma, incisions should be left open at it is essential to maintain a high index the conclusion of the procedure. of suspicion for the development of Compartment syndrome is a true a compartment syndrome. All high- orthopaedic surgical emergency. energy injuries warrant consideration Although compartment syndrome of compartment syndrome. A detailed is most common in the leg and the history regarding the mechanism of forearm, it can occur in any fascial the injury, a thorough physical exam compartment of the extremities, specifically evaluating for compartment including the hand, forearm, upper syndrome, and radiographic studies arm, deltoid, buttocks, thigh, calf, and assessing the extent of bony injuries foot. Following the onset of impaired (which may be indicative of the perfusion, microscopic findings of tissue magnitude of energy absorbed by compromise can be seen in as little as the limb) are key. Most compartment two hours. Changes resulting in clinical syndromes occur in the calf or forearm. symptoms can occur within two to four In patients with associated vascular hours, and irreversible changes in nerve injuries, the development of a

16 compartment syndrome should be physical exam finding. It is important presumed until proven otherwise. to remember that paralysis, pallor, and pulselessness are typically very late It is important to note that not all findings of compartment syndrome and compartment syndromes are the result might never be present. Although the of high-energy or associated vascular degree of “tightness” or “fullness” of the injuries. Compartment syndrome can compartment on physical examination occur after relatively minor injuries to is often used to assess patients with an an extremity, even in the absence of equivocal exam, this symptom has been fracture. This reality emphasizes the need shown to have low diagnostic sensitivity to maintain a high index of suspicion for and specificity, even in the hands of all patients presenting with extremity experienced clinicians. Overall, clinical injuries. Additionally, compartment findings have been shown to have a low syndrome can develop in the setting sensitivity and positive predictive value. of hemorrhage into an extremity However, when more than two clinical compartment. Patients who take findings are present, the sensitivity anticoagulants, who have long periods of and positive predictive value improve. leg elevation, and those who have been While making the diagnosis based “found down” after a prolonged period on clinical exam might be insensitive, of time are also at an increased risk for a negative physical exam without a developing compartment syndrome. tense compartment is very helpful to In a patient that is awake with a rule out compartment syndrome. normal sensorium, the diagnosis of In the appropriate clinical context (for compartment syndrome is best made example, extremity injury with soft by physical examination. Classically, the tissue swelling and/or concerning development of compartment syndrome signs or symptoms), the diagnosis of is marked by a constellation of clinical compartment syndrome should be findings, which are often referred to as made by physical exam. In patients with the “P’s” of compartment syndrome. suspected compartment syndrome but Paraesthesias, pain out of proportion to an unreliable or unobtainable clinical injury, and pain with passive stretch are exam (for example, unconsciousness, reliable early physical exam findings of altered sensorium, distracting compartment syndrome. Typically, pain injuries, pediatric patients), measuring is the earliest and most pronounced intracompartmental pressures can clinical finding. Specifically, worsening be helpful. Historically, absolute pain or pain that becomes refractory to pressures from 30 to 45 mm Hg were medication is particularly concerning considered diagnostic of compartment for the development of compartment syndrome. However, tissue perfusion syndrome and warrants further is determined by the arteriovenous examination. In some patients, pain may pressure gradient, which is dependent be difficult to assess. In these patients, upon a patient’s arterial blood paraesthesias may be the first detectable pressure. Due to the variability in blood

17 pressure between patients, the use zz Hemodynamically unstable of an absolute intracompartmental patients with pelvic fractures pressure is not recommended. Instead, should have a pelvic binder or compartment syndrome should be circumferential sheet used to diagnosed when the difference between temporarily stabilize their pelvis. a patient’s diastolic blood pressure zz Early activation of a massive and compartment pressure (ΔP) is transfusion protocol should less than 30 mm Hg. When ΔP is less be strongly considered. than 30 mm Hg, fasciotomy should be performed. This diagnostic approach zz When angiography is unavailable, has demonstrated very low rates of preperitoneal packing and/ a missed compartment syndrome or external fixation of the and is recommended when taking pelvis should be performed. If adjunctive measurements to supplement this step is not possible, early an equivocal clinical exam. Where transfer to a designated trauma continuous compartmental pressure center is recommended. monitoring is possible, a ΔP less than 30 mmHg for two hours is very sensitive zz Selective embolization is preferred for acute compartment syndrome. over nonselective embolization, when possible, due to a lower risk of complications. MANAGEMENT OF zz Patients with pelvic fractures are at high risk for deep vein thrombosis PELVIC FRACTURES (DVT) and pulmonary embolism (PE). WITH ASSOCIATED Early initiation of pharmacologic HEMORRHAGE DVT prophylaxis is recommended. Key Messages Initial Evaluation and Diagnosis

zz Hemodynamically stable patients Hemodynamically Stable Patients with pelvic fractures should undergo Following the primary and secondary cross-sectional imaging to evaluate surveys, hemodynamically stable the extent of the injury and for the patients with evidence of a pelvic presence of pelvic hemorrhage. fracture on X ray should undergo zz Patients with evidence of contrast cross-sectional imaging with a CT scan extravasation on imaging and for further evaluation. Prior to being either significant hemorrhage or taken to CT, these patients should be hemodynamic instability should placed in a temporary pelvic binder undergo formal angiography and for injury patterns at high risk for potential angioembolization. bleeding, such as open book and vertical shear patterns. CT with correct timing of intravenous contrast (CT- angiography) provides important

18 information relevant to the type of pelvic fracture related bleeding is responsible. ring injury and source and extent of This can be accomplished through hemorrhage. The presence of contrast portable X rays of the chest and pelvis. blush on CTA is predictive of a potential To rule out intraabdominal hemorrhage, need for angioembolization. Early a Focused Assessment with Sonography consultation of a team with angiographic in Trauma (FAST) scan or diagnostic capabilities is recommended. peritoneal aspiration (DPA) should be performed. If intraabdominal In the absence of CT evidence of active hemorrhage is diagnosed, extravasation, signs of ongoing pelvic hemodynamically unstable patients hemorrhage such as hypotension, should be taken to the operating room tachycardia, increasing base deficit, or for exploration and should be considered decreasing hemoglobin may also be for pelvic fracture external fixation. indications for formal angiographic evaluation. In this scenario, bleeding If intraabdominal hemorrhage is not may not have been evident at initial diagnosed by FAST scan or DPA, patients evaluation due to hypovolemia or should undergo pelvic stabilization vasospasm. With resuscitation, bleeding with either a temporary pelvic binder or may become apparent. Additional sheet followed by surgical stabilization factors such as anti-coagulant or and preperitoneal packing. Stability anti-platelet therapy may lower the provided by an external fixator provides threshold for pursuing angiography. greater support for pre-peritoneal packs and thus if time allows, there Angiographic evaluation should include is better control of hemorrhage if selective bilateral hypogastric artery fixation is achieved prior to packing. angiograms, with treatment of active Patients who remain hemodynamically extravasation, pseudoaneurysms, unstable following pelvic stabilization tapering of vessels, or vessel and those with preperitoneal packing irregularity in the area of injury in place should undergo angiography Hemodynamically Unstable Patients and potential embolization.

When patients are hemodynamically For patients in extremis solely from pelvic unstable as a result of hemorrhage, bleeding, several options are available a massive transfusion protocol depending on hospital resources. should be activated. While initiating Although the treatment algorithm is resuscitative efforts in hemodynamically similar to the algorithm mentioned unstable patients with pelvic previously, for patients truly in extremis, fractures, a temporary pelvic binder a potential alternative initial intervention or circumferential sheet should is Resuscitative Endovascular Balloon be positioned around the greater Occlusion of the Aorta (REBOA). Early trochanters. Additionally, a rapid and experience with REBOA in lieu of or thorough assessment to exclude other in addition to preperitoneal packing sources of potential hemorrhage is has shown promising results. required before assuming that pelvic-

19 In centers that do not have angiography Complications availability 24/7 and where procedure Complications of pelvic embolization such as preperitoneal packing are rare, but include gluteal or rectal and REBOA are rarely performed, necrosis, wound infections, nonhealing, hemodynamically unstable patients and re-bleeding. To minimize these with pelvic fractures should be complications, selective embolization promptly transferred to a higher level of hypogastric artery branches is of care following placement of pelvic preferred over nonselective proximal binder and initiation of resuscitation. embolization. However, in situations Role of External Fixation of severe hypotension with active extravasation of one or more hypogastric Reducing pelvic volume and minimizing branches, rapid proximal embolization movement of fractured segments of the is warranted and may be life-saving. pelvis are critical for patients with active pelvic bleeding. Therefore, early pelvic DVT Prophylaxis in Pelvic stabilization with a temporary pelvic Fracture Patients binder, a sheet, or an external fixator is Among patients with pelvic fractures, recommended. Temporary stabilization up to 34 percent develop proximal DVTs is especially important for open book/ and up to 12 percent go on to have anterior compression, vertical shear, or pulmonary embolism. Pharmacologic combined fracture types, as significant DVT prophylaxis with either low- bleeding occurs with sacroiliac joint molecular weight heparin or low-dose and pubic symphyseal disruption. heparin should be initiated as quickly Additionally, temporary stabilization as possible, as it has been shown via external fixation is important to to prevent the formation of DVT. If achieving successful preperitoneal immediate pharmacologic prophylaxis is packing, as it maintains a stable pelvis contraindicated, bilateral lower extremity against which to place hemorrhage- pneumatic compression devices controlling packing. The main goals of should be considered as the injury the external fixator are to reduce pelvic pattern allows. There is no high quality motion to allow stabilization of the evidence regarding preferred timing or pelvic hematoma, to reduce the risk of agent for DVT prophylaxis in patients further bleeding from osseous motion/ with pelvic fractures. It is reasonable damage, and to reduce the pelvic to start pharmacologic prophylaxis volume. Several methods of external once bleeding has ceased as defined fixation are available and should be by lack of ongoing transfusion and performed by the orthopaedic surgeon. stabilization of hemoglobin. This theory Due to the reported complications, is supported by a study of 100 patients use of a pelvic “C” type clamp is who received low-molecular-weight discouraged. A pelvic binder should heparin within 24 hours of admission be used. Definitive stabilization should (hemodynamically stable patients) be performed as early as other injuries or upon establishing hemodynamic and the patient’s physiology allow. stability (patients not hemodynamically

20 stable within the first 24 hours of osteoporosis screening, and early admission) who demonstrated a physiotherapy and rehabilitation lower incidence of DVT compared are important components of with patients with delayed initiation postoperative care following hip of pharmacologic DVT prophylaxis. fracture surgery in the elderly.

Fractures of the proximal femur, or hip fractures, are common injuries GERIATRIC HIP in the elderly. Typically, this injury is the result of relatively “low energy” FRACTURES mechanisms of injury such as falls from Key Messages standing height. The elderly patient population is particularly susceptible zz Hip fractures are common among to hip fractures due to the increased the elderly, are associated with prevalence of osteoporosis and medical substantial morbidity and mortality, co-morbidities that predispose them and result in a significant cost to falls. Furthermore, when these to the health care system. injuries do occur, elderly patients are at an increased risk of experiencing zz Early consultation with medical or geriatric specialists is recommended complications from their injuries for geriatric hip fracture patients with and prolonged hospitalization or significant medical co-morbidities. readmission. The extent of advanced age, comorbidities, frailty, and zz Peri-operative regional anesthesia complications of hospitalization reduces pain and might reduce conspire such that almost 30 percent of delirium and cardiac events in patients die within one year of injury. the postoperative period. In response to the significant burden zz Timely surgical intervention of hip fractures in the elderly, the within 48 hours for hip fractures American Academy of Orthopaedic is recommended. If appropriate Surgeons (AAOS) published clinical resources are available at the practice guidelines in 2014 entitled admitting hospital, it is not necessary “Management of Hip Fractures in the to transfer isolated hip fractures Elderly,” which are solely dedicated to to a designated trauma center. the care of geriatric patients with hip fractures (aaos.org/research/guidelines/ zz Surgical reduction and fixation GuidelineHipFracture.asp). Through or reconstruction are the multidisciplinary collaboration, these primary treatment options guidelines provide a detailed overview of for geriatric hip fractures. the optimal practices regarding the pre-, zz Multimodal analgesia, venous intra-, and postoperative management thromboembolism (VTE) prophylaxis, of hip fractures in the elderly. Many of delirium prevention/management, the recommendations included in this nutritional supplementation, section are detailed in the full AAOS clinical practice guideline document.

21 Injury Assessment and management in patients with hip Medical Optimization fracture and may reduce postoperative When a geriatric patient presents with delirium and cardiac events. severe hip pain, particularly following a Geriatric fractures of the proximal fall, a hip fracture should be suspected. femur broadly fall into three categories: Under such circumstances, a thorough femoral neck fractures, intertrochanteric history and physical examination fractures, and subtrochanteric fractures. should be performed, with particular The different methods of surgical attention given to the evaluation for treatment are detailed in subsequent concurrent injuries. Additionally, in the portions of this document. presence of significant medical co- morbidities outside of the management Operative Care expertise of the orthopaedic surgeon, early consultation with an inpatient The volume of geriatric hip fractures medical or geriatric specialist may be in need of timely surgical intervention beneficial, as they can help manage is substantial. In general, operative and medically optimize injured geriatric management of geriatric hip fracture is patients. Additionally, geriatric specialists an urgent rather than emergent priority or hospitalists may help streamline at most centers. The volume of emergent preoperative testing and serve as surgical cases at designated trauma an effective liaison to the anesthesia centers has the potential to, at times, team. Given the unique challenges in compromise timely surgical repair of providing care to the injured elderly, a geriatric hip fractures. In fact, managing well-coordinated and multidisciplinary these patients locally may facilitate timely approach to the initial management of surgical intervention and ultimately geriatric hip fractures is encouraged. provide the patient with the high quality of care available in the local community. The diagnosis of a hip fracture is typically Surgical reduction and internal fixation or evident on standard radiographic reconstruction are the primary treatment assessment of the affected hip. When a options for geriatric hip fractures. hip fracture is suspected in the setting of While there is a general agreement that normal radiographs, it is recommended operative management of hip fractures that additional imaging (for example, is appropriate, there is variability in MRI) be obtained to evaluate for the opinions regarding specific treatment presence of a nondisplaced fracture. options in different clinical situations. A Once diagnosed with a hip fracture, summary of current recommendations these patients are typically admitted to for optimal surgical management based the hospital, medically optimized, and on specific injury patterns and patient should be surgically treated as soon factors is listed in Table 1. A detailed as able, preferably within 48 hours. discussion of these recommendations is There is strong evidence that regional provided in the AAOS “Management of anesthesia improves perioperative Hip Fractures in the Elderly” evidence- based clinical practice guidelines.

22 Table 1. Geriatric Hip Fracture Fixation Options.

Healthy/Community Multiple Medical Co-Morbidities/ Ambulator Limited Ambulator

Undisplaced Femoral Neck Fracture Fixation Fixation

Displaced Femoral Hemiarthroplasty or Neck Fracture Fixation Hemiarthroplasty or Fixation

Stable Intertrochanteric Sliding Hip Screw or Sliding Hip Screw or Fracture Cephalomedullary Nail Cephalomedullary Nail

Unstable Intertrochanteric Cephalomedullary Nail Cephalomedullary Nail Fracture

Reverse Obliquity/ Subtrochanteric Fracture Cephalomedullary Nail Cephalomedullary Nail

Anesthesia is an essential component these injuries. Unipolar and bipolar of the operative management of hemiarthroplasty for these fractures have geriatric hip fractures. The best similar outcomes. However, the use of a evidence currently available suggests bipolar component may be associated similar clinical outcomes for patients with higher implant cost, making the undergoing general or spinal anesthesia routine use of bipolar hemiarthroplasty for hip fracture surgery. As a result, as a reconstructive option for geriatric hip one modality is not recommended fractures potentially less cost effective. over the other and patient-specific For patients with unstable inter- factors and preferences should be trochanteric fractures, subtrochanteric considered. It may be beneficial for fractures, or reverse obliquity fractures, individual hospitals to standardize the use of a cephalomedullary device is approach to anesthesia for geriatric hip recommended. In rare cases, proximal fractures in order to streamline care. femoral replacement may be indicated. For patients with unstable femoral neck fractures, strong evidence supports the use of arthroplasty for managing

23 hip fracture patients. To help prevent Postoperative Recovery delirium, it is recommended that and Rehabilitation optimal analgesia is achieved through Similar to the initial assessment and nonopioid medications whenever medical optimization of geriatric hip possible. Additionally, medications that fracture patients, the postoperative risk inducing delirium should be avoided. recovery and rehabilitation process When delirium does occur, it is strongly should involve a multidisciplinary recommended that benzodiazepines be team of health care providers, avoided as a first-line treatment strategy, including orthopaedists, medical or unless specifically indicated. Detailed geriatric specialists, and rehabilitation information regarding the recommended specialists. The goal of the recovery preventative and treatment strategies and rehabilitation process is to for postoperative delirium in the achieve a safe, timely, and maximal elderly are provided in the American restoration of functional status. Geriatrics Society (AGS) “Clinical Practice Guideline for Postoperative The early postoperative period should Delirium in Older Adults” and in the include any necessary resuscitation, ACS TQIP guidelines on management optimal analgesia, and venous of the elderly trauma patient. thromboembolism (VTE) prophylaxis. It is recommended that the blood Nutritional supplementation is also transfusion threshold for postoperative beneficial for geriatric hip fracture resuscitation of asymptomatic hip patients, as evidence supports fracture patients is no higher than 8 g/dl. that postoperative nutritional Additionally, the use of multimodal pain supplementation reduces mortality and management after hip fracture surgery is improves nutritional status. Similarly, recommended based on a strong body providing supplemental vitamin D of supporting evidence. Multimodal and calcium to patients following pain management may consist of a hip fracture is also recommended. combination of NSAIDS, acetaminophen, Patients should be evaluated for narcotic analgesics, neurostimulation, osteoporosis with a view toward local or regional anesthetics, epidural intervention where appropriate. There anesthetics, and/or relaxation techniques. is moderate evidence that a means of With respect to VTE prophylaxis, there evaluating and managing osteoporosis is moderate evidence supporting the in this population might reduce mortality use of pharmacologic prophylaxis in the and the rate of subsequent fractures. postoperative period, although there Perhaps one of the most important is no single regimen that is preferred. components of the postoperative care Postoperative delirium prevention is of the elderly is rehabilitation. The also important to providing optimal rehabilitation process should be initiated postoperative care. Postoperative upon hospital admission and continue delirium can significantly complicate through discharge. It is recommended the postoperative course for elderly that both occupational and physical

24 therapy be provided throughout Supracondylar fractures of the humerus the hospitalization and following are common pediatric injuries, discharge. Intensive postdischarge accounting for more than half of all physical therapy is also recommended, pediatric elbow fractures. These fractures as it has been shown to be associated most commonly occur in children with improved functional outcomes. ages five to seven years old, with a similar frequency in males and females. Supracondylar humerus fractures are typically a result of an extension injury, MANAGEMENT most often a fall on an outstretched OF PEDIATRIC hand. Neuropraxias, vascular injuries, and/or an ipsilateral distal radius SUPRACONDYLAR fracture are of particular concern in HUMERUS FRACTURES supracondylar humerus fractures, and all patients with these fractures should Key Messages be evaluated for these concomitant zz A supracondylar distal humerus injuries. Failing to appropriately manage fracture or a suspected supracondylar these injuries can result in significant fracture in a skeletally immature complications, including vascular patient warrants evaluation by compromise with subsequent loss of an orthopaedic surgeon. neurological function, muscular function, and/or improper bone growth. zz There should be a low index of suspicion for concomitant nerve When evaluating patients with potential injuries, vascular injuries, and supracondylar humerus fractures, a ipsilateral distal radius fractures thorough physical exam is required, in a child with a supracondylar including a thorough evaluation for fracture of the humerus. any neurological, vascular, and other osseous abnormalities. Any radiographic zz Nonoperative and operative evidence of a supracondylar fracture, management may be used for including the presence of a “posterior the appropriate fractures. fat pad sign,” should prompt evaluation

zz When there is vascular by an orthopaedic surgeon. compromise to the distal upper In 2011, the American Academy of extremity, immediate closed Orthopaedic Surgeons (AAOS) published reduction is indicated. clinical practice guidelines entitled

 Failure to reperfuse the hand “Guideline on the Treatment of Pediatric after a closed reduction in the Supracondylar Humerus Fractures.” Many operating room suggests a need of the recommendations included in for open exploration of the this section are detailed in the full AAOS vessel in the antecubital fossa. clinical practice guideline document.

25 for being able to monitor patients for Patients with displaced supracondylar the development of muscle ischemia humerus fractures (Gartland Type since they cannot be monitored for II or III and displaced flexion type the development of numbness and/or fractures) without neurologic or vascular increasing pain. While evidence is limited, compromise should be considered for strong consideration should be given closed or open reduction followed by pin to rapidly taking these patients to the fixation in the operating room. For these operating room given the challenges fractures, closed reduction is typically in following their clinical exam for attempted first. When closed reduction is evidence of progressive muscle ischemia. unsuccessful, open reduction should be Recommendations regarding the performed. Nonoperative management indications/timing for electro diagnostic of these types of displaced supracondylar studies and nerve exploration cannot humerus fractures is not recommended. be made given currently available Recommendations regarding the optimal evidence. As a result, the diagnostic and timing of surgery have not been clearly management of these nerve injuries defined. However, treatment within 12 should be handled on an individual basis. to 18 hours of the injury for Gartland Type III fractures is recommended.

All patients with supracondylar humerus fractures with evidence of decreased REHABILITATION OF perfusion to the hand should undergo an THE MULTISYSTEM immediate emergent closed reduction of TRAUMA PATIENT the fracture. When signs of compromised perfusion to the hand persist following Key Messages a closed reduction and pinning of the zz A multidisciplinary rehabilitation fracture in the operating room, urgent team can provide optimal care operative exploration of the vessel in to multiply-injured patients and the antecubital fossa is recommended. should be integrated into the When pulses in the wrist remain absent acute care hospitalization. following reduction but the hand is well perfused (for example, the hand is pink zz Initial evaluation by a rehabilitation and warm on examination), the decision team should occur as early as to explore the antecubital fossa should possible following admission, be made on a case-by-case basis. even for critically ill patients unable to actively participate. There is not strong enough evidence to support specific recommendations for  Early evaluation provides the optimal management approach for an opportunity for the patients with nerve injuries as a result of development of a proactive a supracondylar fracture. These patients rehabilitation program and are often challenging to manage, might reduce functional decline particularly in the acute setting when a during hospitalization. lack of normal sensation raises concern

26 zz Effective communication their in-hospital rehabilitation, and for is key for an efficient, well- anticipated posthospital disposition functioning rehabilitation team needs. Additionally, the early evaluation to optimize the functional of such patients can facilitate the outcomes of injured patients. development of a rehabilitation plan that can be implemented as soon as Rehabilitation is a vitally important the patient is able to participate and component of trauma care, particularly thus avoid delays in rehabilitation. in the setting of orthopaedic injuries that result in an acute decline in Following the initial evaluation by functional status. The rehabilitation the rehabilitation team, the role of process should begin as soon as the team varies based on the clinical possible following admission and condition of the patient. When patients should involve multidisciplinary are unable to participate in physical or collaboration. Although the specific occupational therapy, the rehabilitation rehabilitation needs of individual team can provide valuable guidance patients will ultimately determine the in making recommendations on bed members of their multidisciplinary positioning, splinting/bracing, and rehabilitation team, team members passive range of motion exercises. These may include the trauma team, other actions alone can help prevent skin surgical teams, medical consultants, breakdown, contractures, and other rehabilitation physicians (physiatrists), sequelae of prolonged immobility. physical therapists, occupational Members of the rehabilitation team can therapists, speech and language also provide assistance managing pain, pathologists, neuropsychologists, spasticity, nerve injuries, and agitation. medical social workers, nurses, and When patients are able to actively discharge planners. The expertise participate in therapy, the focus of of these individuals facilitates the the rehabilitation process typically optimal care of injured patients. focuses on improving mobility, gait, Assessment by the rehabilitation team and activities of daily living through should occur as early as possible, ideally physical and occupational therapy. within the first 48 hours of admission. While the therapists focus on the The presence of concomitant injuries active rehabilitation process, the other complicates rehabilitation efforts of members of the team typically make orthopaedic injuries, particularly when preparations for discharge. This step they might prevent patients from early often includes determining discharge participation in rehabilitation. However, disposition, arranging for postdischarge this fact does not preclude the initiation therapy, and obtaining any necessary of the rehabilitation process, as even supplies or equipment a patient may intubated, critically ill patients can be need after discharge. Effective planning evaluated for baseline functional status, includes evaluating the patient’s co-morbidities that may impact their social support network, addressing rehabilitation course, specific needs for challenges within the home, having an

27 these indicators is not a requirement understanding of activity restrictions, for verification, but they might serve as and acknowledging potential equipment useful tools for process improvement needs. Given the multidisciplinary and reflect a combination of evidence nature of the rehabilitation process and expert opinion. Longitudinally following trauma, communication is tracking each of these metrics within essential. Representatives from the a hospital can provide valuable insight trauma and rehabilitation teams should into institutional practice patterns and meet regularly to discuss the care plans potential opportunities for improvement. for every patient. This step can be achieved through formal integration Triage and Transfer of into ward rounds or through regularly Orthopaedic Injuries scheduled interdisciplinary care meetings. Additionally, identifying zz All patients with orthopaedic injuries a single representative or leader are transferred to a higher level of from each specialty represented care when the resources to optimally on the rehabilitation team can manage the orthopaedic injury or help optimize communication and concomitant injuries exceed those facilitate smooth transitions of care available at the evaluating hospital. regarding the rehabilitation process. zz The transfer of all patients An effectively functioning with orthopaedic injuries to a multidisciplinary rehabilitation team higher level of care is conducted can be an integral component of in a timely (as defined by providing optimal care to the injured institutional protocol) manner. patient. Early involvement of the zz All deviations from predetermined rehabilitation team and effective transfer agreements are reviewed communication are important and and discussed both within and can help to optimize the surgical, between the involved centers. medical, and functional outcomes of These reviews are processed the multisystem trauma patient. through a secondary level of review by the trauma PIPS or equivalent committee within the hospital.

APPENDIX A: zz Direct and timely communication PERFORMANCE between orthopaedic providers IMPROVEMENT at each facility occurs prior to all patient transfers. When it does INDICATORS not occur, the reasons are clearly documented by providers on A list of suggested performance both ends of the transfer. improvement (PI) indicators for hospitals with a particular interest in improving the quality of orthopaedic trauma care is provided here. Using

28 zz Images and reports are sent are identified and reviewed by to the receiving hospital with the trauma PIPS or equivalent the patient. Where possible, committee within the hospital. images should be made available prior to patient arrival. The Mangled Extremity ***Adherence to this indicator zz All patients who present to the should not delay transfer. emergency department with a mangled extremity undergo Open Fractures prompt (as defined by institutional protocol) orthopaedic evaluation. zz Patients with open fractures receive intravenous antibiotics within zz All patients with a mangled 60 minutes of presentation. extremity have timely (as defined by institutional protocol) ***Optimal antibiotic regimen operative management. may vary based on extent of tissue damage and contamination. zz All patients with a mangled extremity undergo re-debridement and/ zz All patients with open fractures or definitive soft tissue coverage are evaluated for the potential within seven days of injury. need for tetanus vaccination. zz All patients with a mangled extremity zz Patients with open fractures are who do not have timely (as defined taken to the operating room for by institutional protocol) evaluation surgical irrigation and debridement or operative management (as defined within 24 hours of presentation. above) are identified and reviewed zz Patients with open fractures by the trauma PIPS or equivalent requiring wound coverage committee within the hospital. with skin grafting or soft tissue transfers have coverage completed Compartment Syndrome

within seven days of injury. zz All patients with signs or symptoms of compartment syndrome undergo Damage Control prompt (as defined by institutional Orthopaedic Surgery protocol) surgical evaluation. zz All patients with femoral shaft zz All patients diagnosed with fractures undergo fracture compartment syndrome undergo stabilization within the first 24 emergent fasciotomies of the hours of presentation, including involved compartments. patients with multi-system trauma. zz All patients with muscle zz All patients appropriate for damage necrosis that is identified control management but who during surgical intervention received early definitive management for compartment syndrome

29 committee in the hospital, unless zz are identified and reviewed by a specific contraindication is the trauma PIPS or equivalent documented in the medical record. committee within the hospital.

zz All patients diagnosed with Geriatric Hip Fractures compartment syndrome who zz All geriatric (≥65 years of age) ultimately require an amputation patients with hip fractures and of the involved extremity are multiple co-morbidities are identified and reviewed by evaluated by a multidisciplinary the trauma PIPS or equivalent team, including, at minimum, committee within the hospital. personnel with expertise in the care of the geriatric patients. Management of Pelvic Fractures with Associated Hemorrhage zz All geriatric patients with hip fractures who do not undergo zz Patients with hemorrhage from surgical repair within 48 hours pelvic fractures are evaluated are identified and reviewed by promptly (as defined by institutional the trauma PIPS or equivalent protocols) by orthopaedics. committee within the hospital. zz A team with angiographic zz The rehabilitation process is initiated capabilities is consulted and within 24 hours of admission and promptly (as defined by institutional is continued through discharge for protocols) evaluates all patients with all geriatric hip fracture patients. pelvic fractures, evidence of contrast extravasation on cross-sectional Management of Pediatric imaging, and either hemorrhage Supracondylar Humerus Fractures or hemodynamic stability. zz All patients with radiographic zz For all hemodynamically unstable evidence of a supracondylar humerus patients with pelvic fractures, fracture are promptly (as defined the time from arrival to initial by institutional protocol) evaluated hemorrhage control via pelvic by an orthopaedic surgeon. REBOA, angioembolization, or preperitoneal packing is zz All patients with supracondylar monitored and reviewed by fractures who do not receive the trauma PIPS or equivalent timely management (for example, committee within the hospital. surgical repair within 18 hours for Gartland Type III fractures) zz Initiation of pharmacologic deep are identified and reviewed by vein thrombosis (DVT) >48 hours the trauma PIPS or equivalent after admission are reviewed by committee within the hospital. the trauma PIPS or equivalent

30 zz Any patient with evidence of global forearm dysfunction or ischemia following supracondylar humerus fracture is identified and reviewed in the trauma PIPS or equivalent committee within the hospital.

Rehabilitation of the multisystem trauma patient

zz All delays in discharge of multisystem trauma patients due to inadequate or unavailable rehabilitation services are identified and reviewed by the trauma PIPS or equivalent committee within the hospital.

Notes

31 APPENDIX B: TRANSFER WORKSHEET

Here is an example of a worksheet that can be used by hospitals to predetermine the specific orthopaedic injuries they are appropriately resourced to optimally manage.

Orthopaedic Trauma Worksheet Indicate which orthopaedic conditions may be managed at your hospital.

Chest Spine Pelvis Flail chest Cervical spine fracture/ Open pelvic fracture dislocation Multiple rib fractures Stable pelvic ring disruption T/L spinal fracture/dislocation Scapular fracture with neuro impairment Unstable pelvic ring disruption Clavicular fracture Vertebral body fracture Acetabular fracture

Sterno-clavicular dislocation Vertebral burst Pelvic fracture with shock Spinal process fracture Compression fracture

Extremeties Open long bone fracture Hand/wrist comminuted Ankle fracture fractured with nerve Two or more long involvement Talus fracture bone fractures Carpal dislocation Calcaneus fracture Fracture or dislocation with loss of distal pulses Metacarpal fracture Midfoot dislocation Extremity ischemia Hand amputation Subtalar dislocation Fracture with abnormal Finger amputation Metatarsal fracture neuro exam Finger amputation Phalanx fracture Compartmental syndromes involving phalange Shoulder dislocation Phalanx fracture Acromioclavicular Hip fracture fracture/dislocation Femur fracture Proximal humerus fracture Knee dislocation Distal humerus fracture Proximal tibia fracture Elbow fracture/dislocation Distal tibia fracture Forearm fracture Our hospital routinely transfers all Pilon fracture Distal radius fracture of these orthopaedic conditions.

32 Patzakis MJ, Harvey JP Jr, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg References Am. 1974;56:532-41. Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Introduction Database Syst Rev. 2004;1:CD003764. Resources for optimal care of the injured patient. American College of Surgeons Committee on Trauma, Patzakis MJ, Wilkins J. Factors influencing infection Rotondo MF, Cribari C, Smith RS, eds. 2014. rate in open fracture wounds. Clin Orthop Relat Res. 1989;243:36-40.

Patzakis MJ, Bains RS, Lee J, et al. Prospective, Triage and Transfer of randomized, double-blind study comparing single- Orthopaedic Injuries agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Transfer of the Orthopaedic Trauma Patient: Criteria Trauma. 2000;14:529-533. and Procedure. Health Policy Committee, Orthopaedic Trauma Association, approved Feb. 2007. Available Kindsfater K, Jonassen EA. Osteomyelitis in grade II and at: http://ota.org/media/77806/07-Trauma-and-the- III open tibia fractures with late debridement. J Orthop Transfer-Patient-Position-statement.pdf. Accessed Trauma. 1995;9:121-127. 4/15/2015. Hull, Jenkinson, et al. Delayed debridement of severe Resources for optimal care of the injured patient. open fractures is associated with a higher rate of deep American College of Surgeons Committee on Trauma, infection. Bone Joint J. 2014;96-B:379-384. Rotondo MF, Cribari C, Smith RS, eds. 2014. Rhee P, Nunley MK, Demetriades D, Velmahos G, Doucet Garwe, Cowen, et al. Survival benefit of transfer to JJ. Tetanus and trauma: A review and recommendations. tertiary trauma centers for major trauma patients J Trauma. 2005 May;58(5):1082-1088. initially presenting to nontertiary trauma centers. Acad Emerg Med. 2010 Nov;17(11):1223-32

Newguard, McConnell, et al. The benefit of higher level Damage Control of care transfer of injured patients from nontertiary Townsend RN, Lheureau T, Protech J, Riemer B, Simon hospital emergency departments. J Trauma. 2007 D. Timing fracture repair in patients with severe brain Nov;63(5):965-971. injury (Glasgow Coma Scale score <9). J Trauma. 1998 Jun;44(6):977-982; discussion 982-983.

Open Fractures Damage Control Orthopaedics. Roberts CS, Pape HC, Jones AL, et al. J Bone Joint Surg Am. 2005 Gustilo RB, Anderson JT. Prevention of infection in Feb;87(2):434-449. the treatment of 1,025 open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Nicola R. Early Total Care versus Damage Control: Surg Am. 1976;58:453-458. Current Concepts in the Orthopaedic Care of Polytrauma Patients. ISRN Orthopaedics. 2013; Bratzler DW, Houck PM, Surgical Infection Prevention ID329452. Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: An advisory statement from Carson JH. Damage Control Orthopaedics—When and the National Surgical Infection Prevention Project. Clin Why. J of Lancaster General Hosp. 2007;V2N3. Infect Dis. 2004;38:1706-1715. Boulton CL. Damage Control Orthopaedics. Pollak AN, Jones AL, Castillo RC, et al. The relationship Orthopaedic Knowledge Online Journal. 2013;V11N2. between time to surgical debridement and incidence of infection after open high-energy lower extremity Lichte P, Kobbe P, Dombroski D, Pape HC. Damage trauma. J Bone Joint Surg Am. 2010;92:7-15. Control Orthopaedics: Current Evidence. Curr Opin Crit Care. 2102;18:647-650. Jenkinson, et al. Delayed wound closure increases deep infection rate associated with lower grade open fractures. JBJS Am. March 5;96(5):380-386. Mangled Extremity Bhattacharyya T, Mehta P, Smith M, Pomahac B. Routine Higgins TF; Klatt JB; Beals TC. Lower Extremity use of wound vacuum-assisted closure does not allow Assessment Project (LEAP): The best available evidence coverage delay for open tibia fractures. Plast Reconstr on limb-threatening lower extremity trauma. Orthop Surg. 2008 Apr;121(4):1263-1266. Clin North Am. 2010; 41(2):233-239.

33 Gregory RT, Gould RJ, Peclet M, et al. The mangled Gould MK, Garcia DA, Wren SM, et al; American extremity syndrome (MES): A severity grading system College of Chest Physicians. Prevention of VTE in of multisystem injury of the extremity. J Trauma. nonorthopaedic surgical patients: antithrombotic 25(12);1985:1147-1150. therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based Lange RH. Limb reconstruction versus amputation clinical practice guidelines. 2012;141(5):1369. Chest. decision making in massive lower extremity trauma. 2012;141(2). CORR 243. June 1989:92-99 Kanaan AO, SilvaMA, Donovan JL, Roy T, Al-Homsi AS. Dagum AB, Best AK, Schemitsch EH, et al. Salvage after Meta-analysis of venous thromboembolism prophylaxis severe lower-extremity trauma: Are the outcomes in medically ill patients. Clin Ther. 2007;29(11):2395- worth the means? Plast Reconstr Surg. 1999;103(4):1212- 2405. 1220. Slobogean, GP, Lefaivre KA, Nicolaou S, O’Brien PJ. A Systematic Review of Thromboprophylaxis for Compartment Syndrome Pelvic and Acetabular Fractures. J Orthop Trauma. 2009;23(5):379-384. Blaisdell FW. The pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: A review. Steele N, Dodenhoff RM, Ward AJ, et al. Cardiovasc Surg. 2002;10:620-630. Thromboprophylaxis in pelvic and acetabular trauma surgery. The role of early treatment with low-molecular- Sanderson RA, Foley RK, McIvor GWD, et al. Histological weight heparin. J Bone Joint Surg Br. 2005;87:209-212. Response on Skeletal Muscle to Ischemia. Clin Orthopaedics. 1975;113:27-34.

Shuler FD, DietzMJ. Physicians’ ability to manually Geriatric Hip Fracture detect isolated elevations in leg intracompartmental Management of Hip Fractures in the Elderly Evidence- pressure. J Bone Joint Surg Am. 2010;92:361-367. Based Clinical Practice Guideline. American Academy of Orthopaedic Surgeons, 2014. Available at: http://www. Whitesides TE Jr, Haney TC, Morimoto K, Harada H. aaos.org/research/guidelines/GuidelineHipFracture.asp. Tissue pressure measurements as a determinant for the need of fasciotomy. Clin Orthop. 1975;113:43-51. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. J Am Blick SS, Brumback RJ, Poka A, Burgess AR, Ebraheim Coll Surg. 2015 February;220(2):136-148.e1 NA. Compartment syndrome in open tibial fractures. J Bone Joint Surg [Am]. 1986;68-A:1348-1353. Radcliff, L, Young K. Reducing mortality from hip fractures: A systematic quality improvement Hargens AR, Akeson WH, Mubarak SJ, et al. Tissue programme. 2011. Available at: http://qir.bmj.com/ fluid pressures: From basic research tools to clinical content/3/1/u205006.w2103.full. applications. J Orthop Res. 1989;7:902-909. Sircar P, Godkar D, Mahgerefteh S, Chambers K, Niranjan Matsen FA III, Winquist RA, Krugmire RB Jr. Diagnosis S, Cucco R. Morbidity and mortality among patients and management of compartmental syndromes. J Bone with hip fractures surgically repaired within and after 48 Joint Surg Am. 1980;62:286-291. hours. Am J Ther. 2007 Nov-Dec;14(6):508-513.

McQueen MM, Court-Brown CM: Compartment monitoring in tibial fractures: The pressure threshold for decompression. J Bone Joint Surg Br. 1996;78:99-104. Management of Pediatric Supracondylar Humerus Fractures Little K. Elbow Fractures and Dislocations. Orthop Clin N Management of Pelvic Fractures Am. July 2014;45(3):327-340. with Associated Hemorrhage American Academy of Orthopaedic Surgeons Biffl WL, Fox CJ, Moore EE. The role of REBOA in the Clinical Practice Guidelines Unit: The Treatment of control of exsanguinating torso hemorrhage. J Trauma Pediatric Supracondylar Humerus Fractures. Released Acute Care Surg. 2015 May;78(5):1054-1058. September 2011. Available at: http://www.aaos. org/research/guidelines/SupracondylarFracture/ Eastridge BJ, Starr A, Minei JP, O’Keefe GE, Scalea SupConFullGuideline.pdf. TM. The importance of fracture pattern in guiding therapeutic decision-making in patients with hemorrhagic shock and pelvic ring disruptions. J Trauma. 2002;53:446-451

Flint L, Cryer HG. Pelvic Fracture: The last 50 years. J Trauma. 2010 Sep;69(3):483-438

34 Rehabilitation of the Multisystem Trauma Patient Resources for Optimal Care of the Injured Patient. Chapter 12. American College of Surgeons Committee on Trauma, Rotondo MF, Cribari C, Smith RS, eds. 2014.

Engels PT et al. Physical rehabilitation of the critically ill trauma patient in the ICU. Crit Care Med. 2013;41:1790- 1801.

Khan F, et al. Systematic review of multidisciplinary rehabilitation in patients with multiple trauma. British J Surg. 2012;99:88-96.

Strasser DC, Uomoto JM, Smits SJ. The interdisciplinary team and polytrauma rehabilitation: Prescription for partnership. Arch Phys Med Rehabil. 2008;89(1):179-181.

Notes

35 Expert Panel Matthew L. Davis, MD, FACS (Co-Chair) Rosemary Kozar MD, FACS Assistant Professor of Surgery, Texas A&M COM Director of Translational Research, Professor of Trauma Program Director, Baylor Scott and White Surgery, Division of Trauma/Surgical Critical Care, RA Health care, Temple, TX Cowley Shock Trauma Center, Baltimore, MD

Gregory J. Della Rocca, MD, PhD, FACS (Co-Chair) Avery B. Nathens, MD, PhD FACS Associate Professor, Co-Director, Orthopaedic Surgeon in Chief, Sunnybrook Health Sciences Centre Trauma Service, Department of Orthopaedic Surgery Professor of Surgery, University of Toronto, University of Missouri, Columbia, MO Toronto, ON

Megan Brenner, MD, MS, RPVI, FACS Steven A. Olson, MD, FACS Associate Professor of Surgery, Division of Trauma/ Professor, Department of Orthopaedic Surgery Surgical Critical Care, RA Cowley Shock Trauma Duke University Medical Center, Durham, NC Center, Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, MD Mike Wandling, MD Clinical Scholar, American College of Surgeons Chris Cribari, MD, FACS Post-Doctoral Research Fellow, Northwestern Medical Director of Acute Care Surgery Medical University, General Surgery Resident, Northwestern Center of the Rockies, University of Colorado Health University, Chicago, IL Denver, CO Katie Wiggins-Dohlvik, MD H. Gill Cryer, MD, FACS Resident Physician, General Surgery, Baylor Scott and Professor of Surgery, Chief of the Trauma/Emergency White Health care, Temple, TX Surgery and Critical Care Program , UCLA Los Angeles, CA Philip Wolinsky, MD Professor of Orthopaedic Surgery, Chief Orthopaedic James R. Ficke, MD, FACS Trauma , Vice Chair Department Orthopaedic Robert A. Robinson Professor, Director, Department Surgery, University of California, Davis Medical of Orthopaedic Surgery, Orthopaedic Surgeon-in- Center, Sacramento, CA Chief, The Johns Hopkins HospitalBaltimore, MD Bruce H. Ziran, MD, FACS Langdon Hartsock, MD, FACS Director of Orthopaedic Trauma Professor and Director of Orthopaedic Trauma The Hughston Clinic at Gwinnett Medical Center Medical University of South Carolina Lawrenceville, GA Charleston, SC

M. Bradford Henley, MD, MBA Professor of Orthopaedic Surgery Harborview Medical Center, Seattle, WA

Patrick D.G. Henry, MD, FRCSC Assistant Professor of Surgery, University of Toronto Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, Toronto, ON

Donald H. Jenkins, MD Consultant, Division of Trauma, Critical Care and General Surgery Professor of Surgery, College of Medicine , Medical Director, Trauma Center Rochester, MN

Jorie Klein, BSN, RN Director, Trauma Program, Rees-Jones Trauma Center, Parkland Memorial Hospital, Dallas, TX

36 These Best Practices Orthopaedic Guidelines are dedicated to

Matthew L. Davis, MD, FACS Chair, TQIP Best Practices Project Team 1974–2015

A skilled surgeon, an inspiring leader, and a great friend. Matt, we miss you.

The intent of the ACS TQIP Best Practices Guidelines is to provide health care professionals with evidence-based recommendations regarding care of the trauma patient. The Best Practices Guidelines do not include all potential options for prevention, diagnosis, and treatment and are not intended as a substitute for the provider’s clinical judgment and experience. The responsible provider must make all treatment decisions based upon his or her independent judgment and the patient’s individual clinical presentation. The ACS shall not be liable for any direct, indirect, special, incidental, or consequential damages related to the use of the information contained herein. The ACS may modify the TQIP Best Practices Guidelines at any time without notice.

Notes

37