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: z All facilities should have in place appropriate pain management guidelines for those suffering from traumatic orthopaedic injury. z All patients with orthopaedic injuries should be preferentially placed in hospital units staffed by nurses who receive ongoing orthopaedic-specific in-service training. z For high-risk injuries, facilities should have guidelines ensuring ongoing neurovascular assessments prior to fixation. z 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 z 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 z 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 z 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. z 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 z 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 z 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 z Complex pelvic or orthopaedic injuries. Implementing acetabular fractures such protocols and procedures z 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 z Vertebral fractures or findings manage certain orthopaedic injuries. concerning for spinal cord injury Although hemodynamically stable z 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, z 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 z Bilateral pulmonary contusions best interests of the patient. Although with a PaO2:FiO2 ratio < 200 provider and institutional resources z 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: z Penetrating injuries or open fracture of the skull z Simple fractures without significant soft tissue injury or z Glasgow Coma Score (GCS) neurovascular compromise <14 or lateralizing physical examination findings z Patients without major medical comorbidities z 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: z Extremes of age, particularly with respect to the pediatric population z 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 z 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 z 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