Orthopaedic Surgery Resident Survival Guide Orthopaedic Surgery Resident Survival Guide

The James F. Wenz, M.D. The James F. Wenz, M.D.
Orthopaedic Surgery Orthopaedic Surgery

Resident Survival Guide Resident Survival Guide
2010 2010
Editor: Frank J. Frassica M.D. Editor: Frank J. Frassica M.D.
Asst. Editors: Addisu Mesfin, M.D., Joseph Gjolaj, M.D., Asst. Editors: Addisu Mesfin, M.D., Joseph Gjolaj, M.D.,
James Johnston, M.D. James Johnston, M.D.
The James F. Wenz, M.D. The James F. Wenz, M.D.

Orthopaedic Surgery Orthopaedic Surgery
Resident Survival Guide Resident Survival Guide
2010 2010
Editor: Frank J. Frassica M.D. Editor: Frank J. Frassica M.D.
Asst. Editors: Addisu Mesfin, M.D., Joseph Gjolaj, M.D., Asst. Editors: Addisu Mesfin, M.D., Joseph Gjolaj, M.D.,
James Johnston, M.D. James Johnston, M.D.
Table of Contents: Table of Contents:
Compartment Syndrome 5 Compartment Syndrome 5
Cauda Equina 7 Cauda Equina 7
Epidural Hematoma 8 Epidural Hematoma 8
Pulmonary Embolism 9 Pulmonary Embolism 9
Deep Venous Thrombosis 10 Deep Venous Thrombosis 10
Narcotics 11 Narcotics 11
Chest Pain / Myocardial Infarction 12 Chest Pain / Myocardial Infarction 12
SICU Consult 12 SICU Consult 12
Hypotension / Stroke 13 Hypotension / Stroke 13
Fat Embolism 14 Fat Embolism 14
Physical Exam/Motor Grading 15 Physical Exam/Motor Grading 15
Labs 16 Labs 16
Joint Reductions 17 Joint Reductions 17
Splinting 21 Splinting 21
“Patient Safety Casting 23 “Patient Safety Casting 23
is Traction: Skeletal 25 is Traction: Skeletal 25
Traction: Skin 26 Traction: Skin 26
Rule Number 1.” Aspirations 27 Rule Number 1.” Aspirations 27
Injections 28 Injections 28
Preop Checklist 29 Preop Checklist 29
OR Safety (Bovie,Tourniquet) 30 OR Safety (Bovie,Tourniquet) 30
“Ask Radiology 33
“Ask Radiology 33
if you do not know.” Post Operative Care 36 if you do not know.” Post Operative Care 36
Medical Issues 37 Medical Issues 37
Consult Issues 38 Consult Issues 38
Follow-Up Clinics/Insurance 39 Follow-Up Clinics/Insurance 39
“Do not do anything Ortho E-Learning 41 “Do not do anything Ortho E-Learning 41
by yourself IMPORTANT NUMBERS 42 by yourself IMPORTANT NUMBERS 42
for the first time.” Ultravisual, Sharepoint 47 for the first time.” Ultravisual, Sharepoint 47
OPERATIVE NOTE FORMAT 50 OPERATIVE NOTE FORMAT 50
Table of Contents: Table of Contents:

Compartment Syndrome 5 Compartment Syndrome 5
Cauda Equina 7 Cauda Equina 7
Epidural Hematoma 8 Epidural Hematoma 8
Pulmonary Embolism 9 Pulmonary Embolism 9
Deep Venous Thrombosis 10 Deep Venous Thrombosis 10
Narcotics 11 Narcotics 11
Chest Pain / Myocardial Infarction 12 Chest Pain / Myocardial Infarction 12
SICU Consult 12 SICU Consult 12
Hypotension / Stroke 13 Hypotension / Stroke 13
Fat Embolism 14 Fat Embolism 14
Physical Exam/Motor Grading 15 Physical Exam/Motor Grading 15
Labs 16 Labs 16
Joint Reductions 17 Joint Reductions 17
Splinting 21 Splinting 21
“Patient Safety Casting 23 “Patient Safety Casting 23
is Traction: Skeletal 25 is Traction: Skeletal 25
Traction: Skin 26 Traction: Skin 26
Rule Number 1.” Aspirations 27 Rule Number 1.” Aspirations 27
Injections 28 Injections 28
Preop Checklist 29 Preop Checklist 29
OR Safety (Bovie,Tourniquet) 30 OR Safety (Bovie,Tourniquet) 30
“Ask Radiology 33
“Ask Radiology 33
if you do not know.” Post Operative Care 36 if you do not know.” Post Operative Care 36
Medical Issues 37 Medical Issues 37
Consult Issues 38 Consult Issues 38
Follow-Up Clinics/Insurance 39 Follow-Up Clinics/Insurance 39
“Do not do anything Ortho E-Learning 41 “Do not do anything Ortho E-Learning 41
by yourself IMPORTANT NUMBERS 42 by yourself IMPORTANT NUMBERS 42
for the first time.” Ultravisual, Sharepoint 47 for the first time.” Ultravisual, Sharepoint 47
OPERATIVE NOTE FORMAT 50 OPERATIVE NOTE FORMAT 50
Contributors: Contributors:
Henry Boateng, M.D. Derek Papp, M.D. Henry Boateng, M.D. Derek Papp, M.D.
Mark Clough, M.D. Addisu Mesfin, M.D. Mark Clough, M.D. Addisu Mesfin, M.D.
Phil Neubauer, M.D. Payam Farjoodi, M.D. Phil Neubauer, M.D. Payam Farjoodi, M.D.
Orthopaedic Kevin Farmer, M.D. Jamie Johnson, M.D.
S u r g e r y Kris Alden, M.D. Joseph Gjolaj, M.D. S u r g e r y Kris Alden, M.D. Joseph Gjolaj, M.D.
Resident Michael Bahk, M.D.

Adam Farber, M.D. Adam Farber, M.D.
Sur vival Andrew Manista, M.D.
G u i d e Ted Manson, M.D. G u i d e Ted Manson, M.D.

Brett Cascio, M.D. Brett Cascio, M.D.
James F. Wenz, M.D. James F. Wenz, M.D.
Dennis Kramer, M.D. Dennis Kramer, M.D.
“This survival guide is dedicated to James F. Wenz, M.D., a true gentleman, scholar, “This survival guide is dedicated to James F. Wenz, M.D., a true gentleman, scholar,
and innovator. He was the type of patient and resident advocate that all of us and innovator. He was the type of patient and resident advocate that all of us
should strive to be.” should strive to be.”
Kevin Farmer, M.D. Kevin Farmer, M.D.
June, 2007 Class of 2008 June, 2007 Class of 2008
Contributors: Contributors:
Henry Boateng, M.D. Derek Papp, M.D. Henry Boateng, M.D. Derek Papp, M.D.
Mark Clough, M.D. Addisu Mesfin, M.D. Mark Clough, M.D. Addisu Mesfin, M.D.
Phil Neubauer, M.D. Payam Farjoodi, M.D. Phil Neubauer, M.D. Payam Farjoodi, M.D.
S u r g e r y Kris Alden, M.D. Joseph Gjolaj, M.D. S u r g e r y Kris Alden, M.D. Joseph Gjolaj, M.D.

Adam Farber, M.D. Adam Farber, M.D.
G u i d e Ted Manson, M.D. G u i d e Ted Manson, M.D.

Brett Cascio, M.D. Brett Cascio, M.D.
James F. Wenz, M.D. James F. Wenz, M.D.
Dennis Kramer, M.D. Dennis Kramer, M.D.
“This survival guide is dedicated to James F. Wenz, M.D., a true gentleman, scholar, “This survival guide is dedicated to James F. Wenz, M.D., a true gentleman, scholar,
and innovator. He was the type of patient and resident advocate that all of us and innovator. He was the type of patient and resident advocate that all of us
should strive to be.” should strive to be.”
Kevin Farmer, M.D. Kevin Farmer, M.D.
June, 2007 Class of 2008 June, 2007 Class of 2008
4 4
I I
“No patient should ever die on the orthopaedic service.” “No patient should ever die on the orthopaedic service.”
Payam Farjoodi, M.D. Payam Farjoodi, M.D.
EMERGENCIES EMERGENCIES
Compartment Syndrome Compartment Syndrome
Cauda Equina Cauda Equina
Epidural Hematoma Epidural Hematoma
Pulmonary Pulmonary
Embolism Embolism
“The price of safety is Deep Venous “The price of safety is Deep Venous
never-ending, unremitting Thrombosis never-ending, unremitting Thrombosis
vigilance.” vigilance.”
Chest Pain / Myocardial Infarction Chest Pain / Myocardial Infarction
“Check & Double Check.” “Check & Double Check.”
Hypotension Hypotension
“Never be afraid to ask.” “Never be afraid to ask.”
Stroke Stroke
Frank J. Frassica, M.D. Frank J. Frassica, M.D.
Fat Embolism Fat Embolism
4 4
I I
“No patient should ever die on the orthopaedic service.” “No patient should ever die on the orthopaedic service.”
Payam Farjoodi, M.D. Payam Farjoodi, M.D.
EMERGENCIES EMERGENCIES
Compartment Syndrome Compartment Syndrome
Pulmonary Pulmonary
Embolism Embolism
“The price of safety is Deep Venous “The price of safety is Deep Venous
never-ending, unremitting Thrombosis never-ending, unremitting Thrombosis
vigilance.” vigilance.”
Chest Pain / Myocardial Infarction Chest Pain / Myocardial Infarction
“Check & Double Check.” “Check & Double Check.”
“Never be afraid to ask.” “Never be afraid to ask.”
Stroke Stroke
Frank J. Frassica, M.D. Frank J. Frassica, M.D.
5 5
Compartment Compartment
Level 1A. Do not Delay!!!! Call chief resident with concerns ie: Level 1A. Do not Delay!!!! Call chief resident with concerns ie:
Syndrome change in exam. Syndrome change in exam.
Have an extremely low threshold for Have an extremely low threshold for
concern. Never hesitate to call the concern. Never hesitate to call the
attending on call. attending on call.
Can occur following any injury, and Can occur following any injury, and
in any extremity. Measure pressures if you can in any extremity. Measure pressures if you can
Don’t forget about well leg, not decide if a compartment Don’t forget about well leg, not decide if a compartment
LEVEL 1A can occur in the non-injured
extremity due to positioning in OR.
syndrome is present. Notify Chief
before measuring. Time is of the
essence. Do not delay! essence. Do not delay!
Pain: out of proportion to injury Pain: out of proportion to injury
Due to increased pressure within a Due to increased pressure within a
Pain on passive stretch: severe fascial compartment. Top priority!! Pain on passive stretch: severe fascial compartment. Top priority!!
pain with passive movement of toes, Pressure then impedes blood flow pain with passive movement of toes, Pressure then impedes blood flow
ankle, fingers, wrist, etc into compartment leading to If patient has compartment ankle, fingers, wrist, etc into compartment leading to If patient has compartment
potentially irreversible changes syndrome, it is a Level 1 OR case potentially irreversible changes syndrome, it is a Level 1 OR case
Weakness: 0-5 grading. Compare for fasciotomies. Weakness: 0-5 grading. Compare for fasciotomies.
to previous exam (nerve damage, muscle necrosis, etc). to previous exam (nerve damage, muscle necrosis, etc).
Numbness: Compare to other DO NOT MISS A Numbness: Compare to other DO NOT MISS A
side. Compare to previous exams. Pain out of proportion to the side. Compare to previous exams. Pain out of proportion to the
injury and the physical COMPARTMENT SYNDROME injury and the physical COMPARTMENT SYNDROME
examination is the most UNDER ANY examination is the most UNDER ANY
Tenseness: Tenseness:
sensitive indicator! CIRCUMSTANCES!!!! sensitive indicator! CIRCUMSTANCES!!!!
Feel compartments: Feel compartments:
Do they feel tight? Do they feel tight?
Shiny skin? Wrinkles? HIGHEST RISK FRACTURES Shiny skin? Wrinkles? HIGHEST RISK FRACTURES
Tender to mild palpation? YOU MUST see the patient and Tender to mild palpation? YOU MUST see the patient and
evaluate. Tibial shaft evaluate. Tibial shaft
Pulses: Compare to opposite side Calcaneus Pulses: Compare to opposite side Calcaneus
Compare exam to other side and Both bone forearm Compare exam to other side and Both bone forearm
Pallor: Any color changes? Pallor: Any color changes?
to previous exams in chart!!!! Anything casted to previous exams in chart!!!! Anything casted
Diastolic Pressures: Document in High energy mechanism Diastolic Pressures: Document in High energy mechanism
case you check pressures. Supracondylar Humerus FX case you check pressures. Supracondylar Humerus FX
5 5
Compartment Compartment
Level 1A. Do not Delay!!!! Call chief resident with concerns ie: Level 1A. Do not Delay!!!! Call chief resident with concerns ie:
Syndrome change in exam. Syndrome change in exam.
Have an extremely low threshold for Have an extremely low threshold for
concern. Never hesitate to call the concern. Never hesitate to call the
attending on call. attending on call.
Can occur following any injury, and Can occur following any injury, and
in any extremity. Measure pressures if you can in any extremity. Measure pressures if you can
Don’t forget about well leg, not decide if a compartment Don’t forget about well leg, not decide if a compartment
essence. Do not delay! essence. Do not delay!
Pain: out of proportion to injury Pain: out of proportion to injury
Due to increased pressure within a Due to increased pressure within a
Pain on passive stretch: severe fascial compartment. Top priority!! Pain on passive stretch: severe fascial compartment. Top priority!!
pain with passive movement of toes, Pressure then impedes blood flow pain with passive movement of toes, Pressure then impedes blood flow
ankle, fingers, wrist, etc into compartment leading to If patient has compartment ankle, fingers, wrist, etc into compartment leading to If patient has compartment
potentially irreversible changes syndrome, it is a Level 1 OR case potentially irreversible changes syndrome, it is a Level 1 OR case
Weakness: 0-5 grading. Compare for fasciotomies. Weakness: 0-5 grading. Compare for fasciotomies.
to previous exam (nerve damage, muscle necrosis, etc). to previous exam (nerve damage, muscle necrosis, etc).
Numbness: Compare to other DO NOT MISS A Numbness: Compare to other DO NOT MISS A
side. Compare to previous exams. Pain out of proportion to the side. Compare to previous exams. Pain out of proportion to the
injury and the physical COMPARTMENT SYNDROME injury and the physical COMPARTMENT SYNDROME
examination is the most UNDER ANY examination is the most UNDER ANY
Tenseness: Tenseness:
sensitive indicator! CIRCUMSTANCES!!!! sensitive indicator! CIRCUMSTANCES!!!!
Feel compartments: Feel compartments:
Do they feel tight? Do they feel tight?
Shiny skin? Wrinkles? HIGHEST RISK FRACTURES Shiny skin? Wrinkles? HIGHEST RISK FRACTURES
Tender to mild palpation? YOU MUST see the patient and Tender to mild palpation? YOU MUST see the patient and
evaluate. Tibial shaft evaluate. Tibial shaft
Pulses: Compare to opposite side Calcaneus Pulses: Compare to opposite side Calcaneus
Compare exam to other side and Both bone forearm Compare exam to other side and Both bone forearm
Pallor: Any color changes? Pallor: Any color changes?
to previous exams in chart!!!! Anything casted to previous exams in chart!!!! Anything casted
Diastolic Pressures: Document in High energy mechanism Diastolic Pressures: Document in High energy mechanism
case you check pressures. Supracondylar Humerus FX case you check pressures. Supracondylar Humerus FX
6 6
Measurement of Measurement of
3. This is a procedure and must be anesthetize any deeper as this may 3. This is a procedure and must be anesthetize any deeper as this may
Compartment taught to juniors by seniors prior to alter your compartment Compartment taught to juniors by seniors prior to alter your compartment
Pressures a junior performing the procedure measurements. Pressures a junior performing the procedure measurements.
alone. Prior experience at another alone. Prior experience at another
institution does not count. 5. After the system is purged with institution does not count. 5. After the system is purged with
some fluid, zero the monitor at the some fluid, zero the monitor at the
level of the compartment to be level of the compartment to be
Location of Stryker Monitors Use of the Stryker monitor tested. Location of Stryker Monitors Use of the Stryker monitor tested.
JHH – Main OR desk. 1. Preload a disposable syringe with 6. Using sterile gloves, insert the JHH – Main OR desk. 1. Preload a disposable syringe with 6. Using sterile gloves, insert the
JHOC - Chief’s Office, Laura’s Office fluid and connect to the measuring needle through the fascia keeping the JHOC - Chief’s Office, Laura’s Office fluid and connect to the measuring needle through the fascia keeping the
JHBMC – OR desk instrument. To the other end, add a unit parallel to the floor. JHBMC – OR desk instrument. To the other end, add a unit parallel to the floor.
disposable needle-catheter that disposable needle-catheter that
GSH – Page Nursing Supervisor. comes as part of the set. Check 9V 7. The numbers on the monitor GSH – Page Nursing Supervisor. comes as part of the set. Check 9V 7. The numbers on the monitor
They will bring it to you. Please return. screen fall reasonably rapidly, and as They will bring it to you. Please return. screen fall reasonably rapidly, and as
battery if the unit does not turn battery if the unit does not turn
GSS - Maria’s Office “On”. the descent levels off a reading of the GSS - Maria’s Office “On”. the descent levels off a reading of the
compartment pressure can be made. compartment pressure can be made.
Whitemarsh - Clinic Office 2. The device needs to be adequately Have an assistant record these by each Whitemarsh - Clinic Office 2. The device needs to be adequately Have an assistant record these by each
“charged” for accurate use. Depress compartment. MEASURE TWICE! “charged” for accurate use. Depress compartment. MEASURE TWICE!
Indications for syringe until saline fills the chamber & Indications for syringe until saline fills the chamber &
Compartment Measurement needle. 8. Remove the needle and apply a dressing. Compartment Measurement needle. 8. Remove the needle and apply a dressing.
1. Use the Stryker monitor in situations 3. Ask and receive verbal consent 9. Inform chief of compartment pressures. 1. Use the Stryker monitor in situations 3. Ask and receive verbal consent 9. Inform chief of compartment pressures.
where there is a question of for the procedure (potential benefit: 10. Write a procedure note. Always where there is a question of for the procedure (potential benefit: 10. Write a procedure note. Always
diagnosis of compartment syndrome in early diagnosis and prompt use the compartment syndrome diagnosis of compartment syndrome in early diagnosis and prompt use the compartment syndrome
a susceptible patient. treatment of compartment stickers. Compare compartment a susceptible patient. treatment of compartment stickers. Compare compartment
There is no need to stick a patient who syndrome vs. discomfort and remote pressure to the diastolic blood There is no need to stick a patient who syndrome vs. discomfort and remote pressure to the diastolic blood
clearly has or does not have compartment chance of infection, bleeding, damage pressure. Diastolic blood pressure clearly has or does not have compartment chance of infection, bleeding, damage pressure. Diastolic blood pressure
syndrome. to nerves). minus the compartment pressure is syndrome. to nerves). minus the compartment pressure is
2. Juniors must inform their chiefs 4. Prep the area to be tested with perfusion pressure. If perfusion 2. Juniors must inform their chiefs 4. Prep the area to be tested with perfusion pressure. If perfusion
prior to any compartment Betadine, and infiltrate the skin with pressure is less than 30, there is a prior to any compartment Betadine, and infiltrate the skin with pressure is less than 30, there is a
measurement. 1% lidocaine. Do not attempt to compartment syndrome. measurement. 1% lidocaine. Do not attempt to compartment syndrome.
6 6
Measurement of Measurement of
3. This is a procedure and must be anesthetize any deeper as this may 3. This is a procedure and must be anesthetize any deeper as this may
Compartment taught to juniors by seniors prior to alter your compartment Compartment taught to juniors by seniors prior to alter your compartment
Pressures a junior performing the procedure measurements. Pressures a junior performing the procedure measurements.
alone. Prior experience at another alone. Prior experience at another
institution does not count. 5. After the system is purged with institution does not count. 5. After the system is purged with
some fluid, zero the monitor at the some fluid, zero the monitor at the
level of the compartment to be level of the compartment to be
Location of Stryker Monitors Use of the Stryker monitor tested. Location of Stryker Monitors Use of the Stryker monitor tested.
JHH – Main OR desk. 1. Preload a disposable syringe with 6. Using sterile gloves, insert the JHH – Main OR desk. 1. Preload a disposable syringe with 6. Using sterile gloves, insert the
JHOC - Chief’s Office, Laura’s Office fluid and connect to the measuring needle through the fascia keeping the JHOC - Chief’s Office, Laura’s Office fluid and connect to the measuring needle through the fascia keeping the
JHBMC – OR desk instrument. To the other end, add a unit parallel to the floor. JHBMC – OR desk instrument. To the other end, add a unit parallel to the floor.
disposable needle-catheter that disposable needle-catheter that
GSH – Page Nursing Supervisor. comes as part of the set. Check 9V 7. The numbers on the monitor GSH – Page Nursing Supervisor. comes as part of the set. Check 9V 7. The numbers on the monitor
They will bring it to you. Please return. screen fall reasonably rapidly, and as They will bring it to you. Please return. screen fall reasonably rapidly, and as
battery if the unit does not turn battery if the unit does not turn
GSS - Maria’s Office “On”. the descent levels off a reading of the GSS - Maria’s Office “On”. the descent levels off a reading of the
compartment pressure can be made. compartment pressure can be made.
Whitemarsh - Clinic Office 2. The device needs to be adequately Have an assistant record these by each Whitemarsh - Clinic Office 2. The device needs to be adequately Have an assistant record these by each
“charged” for accurate use. Depress compartment. MEASURE TWICE! “charged” for accurate use. Depress compartment. MEASURE TWICE!
Indications for syringe until saline fills the chamber & Indications for syringe until saline fills the chamber &
Compartment Measurement needle. 8. Remove the needle and apply a dressing. Compartment Measurement needle. 8. Remove the needle and apply a dressing.
1. Use the Stryker monitor in situations 3. Ask and receive verbal consent 9. Inform chief of compartment pressures. 1. Use the Stryker monitor in situations 3. Ask and receive verbal consent 9. Inform chief of compartment pressures.
where there is a question of for the procedure (potential benefit: 10. Write a procedure note. Always where there is a question of for the procedure (potential benefit: 10. Write a procedure note. Always
diagnosis of compartment syndrome in early diagnosis and prompt use the compartment syndrome diagnosis of compartment syndrome in early diagnosis and prompt use the compartment syndrome
a susceptible patient. treatment of compartment stickers. Compare compartment a susceptible patient. treatment of compartment stickers. Compare compartment
There is no need to stick a patient who syndrome vs. discomfort and remote pressure to the diastolic blood There is no need to stick a patient who syndrome vs. discomfort and remote pressure to the diastolic blood
clearly has or does not have compartment chance of infection, bleeding, damage pressure. Diastolic blood pressure clearly has or does not have compartment chance of infection, bleeding, damage pressure. Diastolic blood pressure
syndrome. to nerves). minus the compartment pressure is syndrome. to nerves). minus the compartment pressure is
2. Juniors must inform their chiefs 4. Prep the area to be tested with perfusion pressure. If perfusion 2. Juniors must inform their chiefs 4. Prep the area to be tested with perfusion pressure. If perfusion
prior to any compartment Betadine, and infiltrate the skin with pressure is less than 30, there is a prior to any compartment Betadine, and infiltrate the skin with pressure is less than 30, there is a
measurement. 1% lidocaine. Do not attempt to compartment syndrome. measurement. 1% lidocaine. Do not attempt to compartment syndrome.
7 7
A True Surgical Emergency! Have a Low Threshold A True Surgical Emergency! Have a Low Threshold
Cauda equina syndrome occurs Examine any post-op spine Cauda equina syndrome occurs Examine any post-op spine
when the lumbosacral nerve patients with new complaints ie: when the lumbosacral nerve patients with new complaints ie:
roots are compressed, cutting incontinence, urinary retention, roots are compressed, cutting incontinence, urinary retention,
off sensation and motor parasthesias, weakness. off sensation and motor parasthesias, weakness.
function. Nerve roots that control function. Nerve roots that control
the function of the bladder and Always perform thorough motor, the function of the bladder and Always perform thorough motor,
NOTIFY SPINE FELLOW sensory (pin prick, light touch)
bowel are especially vulnerable to bowel are especially vulnerable to
& ATTENDING damage. rectal exam. & ATTENDING damage. rectal exam.
Bilateral buttock & lower extremity Compare exam to previous exams. Bilateral buttock & lower extremity Compare exam to previous exams.
pain. If you don’t get fast treatment to Any changes (weakness, sensory pain. If you don’t get fast treatment to Any changes (weakness, sensory
relieve the pressure, it may cause changes, decreased rectal tone) relieve the pressure, it may cause changes, decreased rectal tone)
Bowel/bladder dysfunction permanent paralysis, impaired Bowel/bladder dysfunction permanent paralysis, impaired
(especially urinary retention). should prompt immediate concern. (especially urinary retention). should prompt immediate concern.
bladder and/or bowel control, bladder and/or bowel control,
Saddle anesthesia. loss of sexual function and other Call spine fellow immediately. Do not Saddle anesthesia. loss of sexual function and other Call spine fellow immediately. Do not
problems. Even if the problem gets hesitate to call the spine attending on problems. Even if the problem gets hesitate to call the spine attending on
Lower extremity motor/sensory treatment right away, they may not call. Lower extremity motor/sensory treatment right away, they may not call.
changes. recover complete function. changes. recover complete function.
Make NPO. Make NPO.
Causes include: disc herniation, Will need stat CT Myelogram vs. MRI Causes include: disc herniation, Will need stat CT Myelogram vs. MRI
post-op hematoma/swelling, with Gadolinium vs. straight to OR post-op hematoma/swelling, with Gadolinium vs. straight to OR
tumor, infection, fracture or as Level 1. tumor, infection, fracture or as Level 1.
narrowing of the spinal canal. It narrowing of the spinal canal. It
may also happen because of a Any delays could be may also happen because of a Any delays could be
violent impact such as a car crash, catastrophic! violent impact such as a car crash, catastrophic!
fall from significant height or fall from significant height or
penetrating (i.e., gunshot, stab) injury. THIS IS A PRIORITY EVENT! penetrating (i.e., gunshot, stab) injury. THIS IS A PRIORITY EVENT!
Children may be born with Children may be born with
You can open up the checkbook You can open up the checkbook
abnormalities that cause CES. abnormalities that cause CES.
if it is missed!!! if it is missed!!!
7 7
A True Surgical Emergency! Have a Low Threshold A True Surgical Emergency! Have a Low Threshold
Cauda equina syndrome occurs Examine any post-op spine Cauda equina syndrome occurs Examine any post-op spine
when the lumbosacral nerve patients with new complaints ie: when the lumbosacral nerve patients with new complaints ie:
roots are compressed, cutting incontinence, urinary retention, roots are compressed, cutting incontinence, urinary retention,
off sensation and motor parasthesias, weakness. off sensation and motor parasthesias, weakness.
function. Nerve roots that control function. Nerve roots that control
the function of the bladder and Always perform thorough motor, the function of the bladder and Always perform thorough motor,
bowel are especially vulnerable to bowel are especially vulnerable to
& ATTENDING damage. rectal exam. & ATTENDING damage. rectal exam.
Bilateral buttock & lower extremity Compare exam to previous exams. Bilateral buttock & lower extremity Compare exam to previous exams.
pain. If you don’t get fast treatment to Any changes (weakness, sensory pain. If you don’t get fast treatment to Any changes (weakness, sensory
relieve the pressure, it may cause changes, decreased rectal tone) relieve the pressure, it may cause changes, decreased rectal tone)
Bowel/bladder dysfunction permanent paralysis, impaired Bowel/bladder dysfunction permanent paralysis, impaired
(especially urinary retention). should prompt immediate concern. (especially urinary retention). should prompt immediate concern.
bladder and/or bowel control, bladder and/or bowel control,
Saddle anesthesia. loss of sexual function and other Call spine fellow immediately. Do not Saddle anesthesia. loss of sexual function and other Call spine fellow immediately. Do not
problems. Even if the problem gets hesitate to call the spine attending on problems. Even if the problem gets hesitate to call the spine attending on
Lower extremity motor/sensory treatment right away, they may not call. Lower extremity motor/sensory treatment right away, they may not call.
changes. recover complete function. changes. recover complete function.
Make NPO. Make NPO.
Causes include: disc herniation, Will need stat CT Myelogram vs. MRI Causes include: disc herniation, Will need stat CT Myelogram vs. MRI
post-op hematoma/swelling, with Gadolinium vs. straight to OR post-op hematoma/swelling, with Gadolinium vs. straight to OR
tumor, infection, fracture or as Level 1. tumor, infection, fracture or as Level 1.
narrowing of the spinal canal. It narrowing of the spinal canal. It
may also happen because of a Any delays could be may also happen because of a Any delays could be
violent impact such as a car crash, catastrophic! violent impact such as a car crash, catastrophic!
fall from significant height or fall from significant height or
penetrating (i.e., gunshot, stab) injury. THIS IS A PRIORITY EVENT! penetrating (i.e., gunshot, stab) injury. THIS IS A PRIORITY EVENT!
Children may be born with Children may be born with
You can open up the checkbook You can open up the checkbook
abnormalities that cause CES. abnormalities that cause CES.
if it is missed!!! if it is missed!!!
8 8
Workup Declining neuro exam mandates stat Workup Declining neuro exam mandates stat
imaging or immediate operative imaging or immediate operative
Stat non-contrast head CT for exploration! Stat non-contrast head CT for exploration!
Presentation all possible head traumas. Presentation all possible head traumas.
This includes all patients who fall and Imaging options if concern for This includes all patients who fall and Imaging options if concern for
hit their head while in the hospital. postop hematoma: hit their head while in the hospital. postop hematoma:
Brain: Any unwitnessed falls should get Brain: Any unwitnessed falls should get
head CT. CT myelogram head CT. CT myelogram
Mental status changes after a fall Do not need radiologist approval for Need to speak with radiologist on call. Mental status changes after a fall Do not need radiologist approval for Need to speak with radiologist on call.
these tests. A radiology team will have to be called. these tests. A radiology team will have to be called.
May have a lucid interval MRI May have a lucid interval MRI
Don’t forget to check the results. Not as good,especially if hardware in place. Don’t forget to check the results. Not as good,especially if hardware in place.
Severe headache, vomiting, seizure Test should only take minutes! Severe headache, vomiting, seizure Test should only take minutes!
Postop Spine Patients Treatment: Postop Spine Patients Treatment:

Spine Brain Epidural Hematoma Spine Brain Epidural Hematoma
Usually post-op, especially if Full neuro exam – meticulous Usually post-op, especially if Full neuro exam – meticulous
documentation. Stat neurosurg consult. documentation. Stat neurosurg consult.
laminectomy laminectomy
Any post-op patient complaining of May need immediate evacuation Any post-op patient complaining of May need immediate evacuation
Unrelenting back pain in OR by neurosurg. Unrelenting back pain in OR by neurosurg.
severe back pain must be re-evaluated! severe back pain must be re-evaluated!
Progressive neurologic deficit ICU / NCCU transfer Progressive neurologic deficit ICU / NCCU transfer
Does deficit correspond with level of Does deficit correspond with level of
surgical site? surgical site?
What is it? Any neuro deficits, speak with Spinal Epidural Hematoma What is it? Any neuro deficits, speak with Spinal Epidural Hematoma
the spine fellow. ORTHOPAEDIC EMERGENCY ! the spine fellow. ORTHOPAEDIC EMERGENCY !
In Brain: hematoma between skull In Brain: hematoma between skull
and dural membrane. If can’t get in touch with spine and dural membrane. If can’t get in touch with spine
Needs stat decompression Needs stat decompression
fellow then call spine attending. in OR as level 1. fellow then call spine attending. in OR as level 1.
In Spine: hematoma compressing on In Spine: hematoma compressing on
spinal dura. If decide to observe, must do Q2-4h spinal dura. If decide to observe, must do Q2-4h
YOU MUST escort patient to YOU MUST escort patient to
neuro exams and document results. monitored setting. neuro exams and document results. monitored setting.
8 8
Workup Declining neuro exam mandates stat Workup Declining neuro exam mandates stat
imaging or immediate operative imaging or immediate operative
Stat non-contrast head CT for exploration! Stat non-contrast head CT for exploration!
Presentation all possible head traumas. Presentation all possible head traumas.
This includes all patients who fall and Imaging options if concern for This includes all patients who fall and Imaging options if concern for
hit their head while in the hospital. postop hematoma: hit their head while in the hospital. postop hematoma:
Brain: Any unwitnessed falls should get Brain: Any unwitnessed falls should get
head CT. CT myelogram head CT. CT myelogram
Mental status changes after a fall Do not need radiologist approval for Need to speak with radiologist on call. Mental status changes after a fall Do not need radiologist approval for Need to speak with radiologist on call.
these tests. A radiology team will have to be called. these tests. A radiology team will have to be called.
May have a lucid interval MRI May have a lucid interval MRI
Don’t forget to check the results. Not as good,especially if hardware in place. Don’t forget to check the results. Not as good,especially if hardware in place.
Severe headache, vomiting, seizure Test should only take minutes! Severe headache, vomiting, seizure Test should only take minutes!
Postop Spine Patients Treatment: Postop Spine Patients Treatment:

Spine Brain Epidural Hematoma Spine Brain Epidural Hematoma
Usually post-op, especially if Full neuro exam – meticulous Usually post-op, especially if Full neuro exam – meticulous
documentation. Stat neurosurg consult. documentation. Stat neurosurg consult.
laminectomy laminectomy
Any post-op patient complaining of May need immediate evacuation Any post-op patient complaining of May need immediate evacuation
Unrelenting back pain in OR by neurosurg. Unrelenting back pain in OR by neurosurg.
severe back pain must be re-evaluated! severe back pain must be re-evaluated!
Progressive neurologic deficit ICU / NCCU transfer Progressive neurologic deficit ICU / NCCU transfer
Does deficit correspond with level of Does deficit correspond with level of
surgical site? surgical site?
What is it? Any neuro deficits, speak with Spinal Epidural Hematoma What is it? Any neuro deficits, speak with Spinal Epidural Hematoma
the spine fellow. ORTHOPAEDIC EMERGENCY ! the spine fellow. ORTHOPAEDIC EMERGENCY !
In Brain: hematoma between skull In Brain: hematoma between skull
and dural membrane. If can’t get in touch with spine and dural membrane. If can’t get in touch with spine
Needs stat decompression Needs stat decompression
fellow then call spine attending. in OR as level 1. fellow then call spine attending. in OR as level 1.
In Spine: hematoma compressing on In Spine: hematoma compressing on
spinal dura. If decide to observe, must do Q2-4h spinal dura. If decide to observe, must do Q2-4h
YOU MUST escort patient to YOU MUST escort patient to
neuro exams and document results. monitored setting. neuro exams and document results. monitored setting.
9 9
Pulmonary Pulmonary
A potentially fatal event! Patient will need long term A potentially fatal event! Patient will need long term
Embolism therapeutic anti-coagulation. Embolism therapeutic anti-coagulation.
Check vital signs. SICU consult à patient should be Check vital signs. SICU consult à patient should be
Do a cardiac and lung exam in a monitored setting (IMC at least) Do a cardiac and lung exam in a monitored setting (IMC at least)
until therapeutic, if unstable. until therapeutic.
Have a low threshold to EKG à medicine consult?
Medicine consult for management.
order a spiral CT on any order a spiral CT on any
of these patients. Especially common following Make sure arrangements are made of these patients. Especially common following Make sure arrangements are made
total joints, intramedullary to follow INR once discharged total joints and intramedullary to follow INR once discharged
Tachycardia Febrile rodding of a femur fracture, (primary care, coumadin clinic, etc). Tachycardia Febrile rodding of a femur fracture. (primary care, coumadin clinic, etc).
Hypoxia pelvic fracture. Hypoxia
Let chief / attending know ASAP. Make sure patient does not have Let chief / attending know ASAP.
Tachypnea, or Tachypnea, or
Make sure patient does not have kidney problems prior to
Pleuritic type chest pain. kidney problems prior to It is much more acceptable to Pleuritic type chest pain. ordering spiral CT. It is much more acceptable to
ordering spiral CT. over order spiral CT then to not over order spiral CT then to not
order one in a patient who has a Consider mucormyst 600 my po order one in a patient who has a
Consider mucomyst 600 mg po PE !!! BID before spiral CT and for 2 days PE !!!
BID before spiral CT and for 2 days afterwards. Resuscitate them with
afterwards. Resuscitate them with normal saline IV before and after scan.
normal saline IV before and after scan.
Consider V/Q scan if patient a high
Consider V/Q scan if patient a high risk for renal failure.
risk for renal failure.
Will need a large bore peripheral IV
Will need a large bore peripheral IV for spiral CT (i.e. 18 gauge).
for spiral CT (i.e. 18 gauge).
9 9
Pulmonary Pulmonary
A potentially fatal event! Patient will need long term A potentially fatal event! Patient will need long term
Embolism therapeutic anti-coagulation. Embolism therapeutic anti-coagulation.
Check vital signs. SICU consult à patient should be Check vital signs. SICU consult à patient should be
Do a cardiac and lung exam in a monitored setting (IMC at least) Do a cardiac and lung exam in a monitored setting (IMC at least)
until therapeutic, if unstable. until therapeutic.
order a spiral CT on any order a spiral CT on any
of these patients. Especially common following Make sure arrangements are made of these patients. Especially common following Make sure arrangements are made
total joints, intramedullary to follow INR once discharged total joints and intramedullary to follow INR once discharged
Tachycardia Febrile rodding of a femur fracture, (primary care, coumadin clinic, etc). Tachycardia Febrile rodding of a femur fracture. (primary care, coumadin clinic, etc).
Hypoxia pelvic fracture. Hypoxia
Let chief / attending know ASAP. Make sure patient does not have Let chief / attending know ASAP.
Tachypnea, or Tachypnea, or
Make sure patient does not have kidney problems prior to
Pleuritic type chest pain. kidney problems prior to It is much more acceptable to Pleuritic type chest pain. ordering spiral CT. It is much more acceptable to
ordering spiral CT. over order spiral CT then to not over order spiral CT then to not
order one in a patient who has a Consider mucormyst 600 my po order one in a patient who has a
Consider mucomyst 600 mg po PE !!! BID before spiral CT and for 2 days PE !!!
BID before spiral CT and for 2 days afterwards. Resuscitate them with
afterwards. Resuscitate them with normal saline IV before and after scan.
normal saline IV before and after scan.
Consider V/Q scan if patient a high
Consider V/Q scan if patient a high risk for renal failure.
risk for renal failure.
Will need a large bore peripheral IV
Will need a large bore peripheral IV for spiral CT (i.e. 18 gauge).
for spiral CT (i.e. 18 gauge).
10 10
Deep Venous Deep Venous
Make sure all patients have Below the knee DVT: Make sure all patients have Below the knee DVT:
Thrombosis anticoagulation plan!!! Thrombosis anticoagulation plan!!!
Treatment: Must be treated!
Do not do a Homan’s sign (low yield, Attending dependent. Use the DVT protocol, please fill out
potential to break off clot). the pink form and put form in the Treatment:
Continue current pathway and front of the chart. Attending dependent.
Have a low threshold to order recheck dopplers in 48 hours
bilateral lower extremity dopplers to look for propagation. Do not do a Homan’s sign (low yield, Continue current pathway and
Presentation for any patient with concerning Presentation potential to break off clot). recheck dopplers in 48 hours
symptoms. to look for propagation.
Vascular lab better than radiology Also possible to have DVT in upper Have a low threshold to order
Calf pain/cramping if possible. extremity. Doppler if concerned. Calf pain/cramping bilateral lower extremity dopplers
for any patient with concerning Also possible to have DVT in upper
Leg swelling Leg swelling symptoms. extremity. Doppler if concerned.
Let your chief / attending know Vascular lab better than radiology
Palpable cords if positive for DVT!! Palpable cords if possible. Let your chief / attending know
if positive for DVT!!
Above the knee DVT: Above the knee DVT:
Must be treated! Must be treated!
Medicine consult. Medicine consult.
Will need arrangements to have Will need arrangements to have
coumadin and INR followed once coumadin and INR followed once
discharged, preferably by primary discharged, preferably by primary
care physician. care physician.
10 10
Deep Venous Deep Venous
Make sure all patients have Below the knee DVT: Make sure all patients have Below the knee DVT:
Thrombosis anticoagulation plan!!! Thrombosis anticoagulation plan!!!
Treatment: Must be treated!
Do not do a Homan’s sign (low yield, Attending dependent. Use the DVT protocol, please fill out
potential to break off clot). the pink form and put form in the Treatment:
Continue current pathway and front of the chart. Attending dependent.
Have a low threshold to order recheck dopplers in 48 hours
bilateral lower extremity dopplers to look for propagation. Do not do a Homan’s sign (low yield, Continue current pathway and
Presentation for any patient with concerning Presentation potential to break off clot). recheck dopplers in 48 hours
symptoms. to look for propagation.
Vascular lab better than radiology Also possible to have DVT in upper Have a low threshold to order
Calf pain/cramping if possible. extremity. Doppler if concerned. Calf pain/cramping bilateral lower extremity dopplers
for any patient with concerning Also possible to have DVT in upper
Leg swelling Leg swelling symptoms. extremity. Doppler if concerned.
Let your chief / attending know Vascular lab better than radiology
Palpable cords if positive for DVT!! Palpable cords if possible. Let your chief / attending know
if positive for DVT!!
Above the knee DVT: Above the knee DVT:
Must be treated! Must be treated!
Medicine consult. Medicine consult.
Will need arrangements to have Will need arrangements to have
coumadin and INR followed once coumadin and INR followed once
discharged, preferably by primary discharged, preferably by primary
care physician. care physician.
11 11
Narcotics Narcotics
Treatment of Narcotic Do not prescribe narcotics on Treatment of Narcotic Do not prescribe narcotics on
Overdose the weekends or evenings. Overdose the weekends or evenings.
A: Maintain Airway Call the chief resident or A: Maintain Airway Call the chief resident or
Call anesthesia if needed attending and let them handle Call anesthesia if needed attending and let them handle
the problem (FJF). the problem (FJF).
B: Maintain Breathing B: Maintain Breathing
Oxygen supplementation Oxygen supplementation
Signs of Narcotic Signs of Narcotic
Overdose C: Circulatory Support Constipation Overdose C: Circulatory Support Constipation
Place patient on monitor Place patient on monitor
Colace 100 mg po bid Colace 100 mg po bid
Respiratory depression D: Call code if necessary Respiratory depression D: Call code if necessary
Senna 2 tabs qDay (increases GI Senna 2 tabs qDay (increases GI
CNS depression E: Stop all narcotic medications motility) CNS depression E: Stop all narcotic medications motility)
Miosis F: Naloxone (e.g. Narcan) Miosis F: Naloxone (e.g. Narcan)
Hypotension 0.4mg-2mg q 2-3 min PRN. Pediatric patients should have Hypotension 0.4mg-2mg q 2-3 min PRN. Pediatric patients should have
Has short half-life / will likely need their narcotics managed by the Has short half-life / will likely need their narcotics managed by the
to be re-dosed. Patient should pediatric pain service. to be re-dosed. Patient should pediatric pain service.
remain on monitor. remain on monitor.
Appropriate Post-Operative G: Inform team and transport Appropriate Post-Operative G: Inform team and transport
Pain Management to monitored setting if clinically Pain Management to monitored setting if clinically
indicated. indicated.
1mg Morphine 1mg Morphine
= =
0.2 mg Dilaudid 0.2 mg Dilaudid
= =
Be wary of the narcotic naïve. Be wary of the narcotic naïve.
100 mcg of Fentanyl 100 mcg of Fentanyl
Be wary of the narcotic seeking. Be wary of the narcotic seeking.
They have differing half-lives They have differing half-lives
Dilaudid > Morphine > Fentanyl Dilaudid > Morphine > Fentanyl
11 11
Narcotics Narcotics
Treatment of Narcotic Do not prescribe narcotics on Treatment of Narcotic Do not prescribe narcotics on
Overdose the weekends or evenings. Overdose the weekends or evenings.
A: Maintain Airway Call the chief resident or A: Maintain Airway Call the chief resident or
Call anesthesia if needed attending and let them handle Call anesthesia if needed attending and let them handle
the problem (FJF). the problem (FJF).
B: Maintain Breathing B: Maintain Breathing
Oxygen supplementation Oxygen supplementation
Signs of Narcotic Signs of Narcotic
Overdose C: Circulatory Support Constipation Overdose C: Circulatory Support Constipation
Place patient on monitor Place patient on monitor
Colace 100 mg po bid Colace 100 mg po bid
Respiratory depression D: Call code if necessary Respiratory depression D: Call code if necessary
Senna 2 tabs qDay (increases GI Senna 2 tabs qDay (increases GI
CNS depression E: Stop all narcotic medications motility) CNS depression E: Stop all narcotic medications motility)
Miosis F: Naloxone (e.g. Narcan) Miosis F: Naloxone (e.g. Narcan)
Hypotension 0.4mg-2mg q 2-3 min PRN. Pediatric patients should have Hypotension 0.4mg-2mg q 2-3 min PRN. Pediatric patients should have
Has short half-life / will likely need their narcotics managed by the Has short half-life / will likely need their narcotics managed by the
to be re-dosed. Patient should pediatric pain service. to be re-dosed. Patient should pediatric pain service.
remain on monitor. remain on monitor.
Appropriate Post-Operative G: Inform team and transport Appropriate Post-Operative G: Inform team and transport
Pain Management to monitored setting if clinically Pain Management to monitored setting if clinically
indicated. indicated.
1mg Morphine 1mg Morphine
= =
0.2 mg Dilaudid 0.2 mg Dilaudid
= =
Be wary of the narcotic naïve. Be wary of the narcotic naïve.
100 mcg of Fentanyl 100 mcg of Fentanyl
Be wary of the narcotic seeking. Be wary of the narcotic seeking.
They have differing half-lives They have differing half-lives
Dilaudid > Morphine > Fentanyl Dilaudid > Morphine > Fentanyl
12 12
Chest Pain / Chest Pain /
Top priority!! If any concerns with story or if Top priority!! If any concerns with story or if
Myocardial any EKG changes: Myocardial any EKG changes:
YOU MUST see all patients with YOU MUST see all patients with
Infarction complaints of chest pain. 1. Send off Cardiac enzymes x 3, first one
stat. stat.
Pertinent questions Pertinent questions
2. If at night, take EKG and show 2. If at night, take EKG and show
Radiation? Nausea? Diaphoresis? SICU fellow. Have a convincing story Radiation? Nausea? Diaphoresis? SICU fellow. Have a convincing story
Let chief / attending know Type of pain? Shortness of Breath? Let chief / attending know Type of pain? Shortness of Breath?
as to why you’re concerned. as to why you’re concerned.
immediately. immediately.
3. If able to, call cardiology for 3. If able to, call cardiology for
Physical Exam consult for acute MI if EKG changes Physical Exam consult for acute MI if EKG changes
Check vitals. or enzymes positive. Check vitals. or enzymes positive.
Cardiac/Lung Exam. 4. MONA - morphine, oxygen, Cardiac/Lung Exam. 4. MONA - morphine, oxygen,
Check EKG nitroglycerin tablets, aspirin. Check EKG nitroglycerin tablets, aspirin.
Compare to old EKG. 5. If patient is having an acute MI, Compare to old EKG. 5. If patient is having an acute MI,
If story not concerning, and your job is to transfer them from If story not concerning, and your job is to transfer them from
EKG unchanged: our service and into a monitored EKG unchanged: our service and into a monitored
May stop there and monitor. setting ASAP- SICU, Cards. May stop there and monitor. setting ASAP- SICU, Cards.
Order: Order:
STAT CHEST X-Ray We should not be STAT CHEST X-Ray We should not be
Evaluate: PE, pneumonia, managing a MI ! Evaluate: PE, pneumonia, managing a MI !
pneumothorax, etc. pneumothorax, etc.
Talk to SICU fellow for any patients necessary work-up and you have Talk to SICU fellow for any patients necessary work-up and you have
SICU Consult with concerns. Don’t try to be a legitimate concerns. If they are not SICU Consult with concerns. Don’t try to be a legitimate concerns. If they are not
hero!! Bump it up if you have a worry. receptive, talk to your chief or hero!! Bump it up if you have a worry. receptive, talk to your chief or
Take EKG, labs, etc. with you to the attending about the situation. Take EKG, labs, etc. with you to the attending about the situation.
fellow. They are usually willing to help fellow. They are usually willing to help
Same situation for the PICU fellow. Same situation for the PICU fellow.
you out if you present it to them in you out if you present it to them in
way that shows you have done all the way that shows you have done all the
12 12
Chest Pain / Chest Pain /
Top priority!! If any concerns with story or if Top priority!! If any concerns with story or if
Myocardial any EKG changes: Myocardial any EKG changes:
YOU MUST see all patients with YOU MUST see all patients with
stat. stat.
Pertinent questions Pertinent questions
2. If at night, take EKG and show 2. If at night, take EKG and show
Radiation? Nausea? Diaphoresis? SICU fellow. Have a convincing story Radiation? Nausea? Diaphoresis? SICU fellow. Have a convincing story
Let chief / attending know Type of pain? Shortness of Breath? Let chief / attending know Type of pain? Shortness of Breath?
as to why you’re concerned. as to why you’re concerned.
immediately. immediately.
3. If able to, call cardiology for 3. If able to, call cardiology for
Physical Exam consult for acute MI if EKG changes Physical Exam consult for acute MI if EKG changes
Check vitals. or enzymes positive. Check vitals. or enzymes positive.
Cardiac/Lung Exam. 4. MONA - morphine, oxygen, Cardiac/Lung Exam. 4. MONA - morphine, oxygen,
Check EKG nitroglycerin tablets, aspirin. Check EKG nitroglycerin tablets, aspirin.
Compare to old EKG. 5. If patient is having an acute MI, Compare to old EKG. 5. If patient is having an acute MI,
If story not concerning, and your job is to transfer them from If story not concerning, and your job is to transfer them from
EKG unchanged: our service and into a monitored EKG unchanged: our service and into a monitored
May stop there and monitor. setting ASAP- SICU, Cards. May stop there and monitor. setting ASAP- SICU, Cards.
Order: Order:
STAT CHEST X-Ray We should not be STAT CHEST X-Ray We should not be
Evaluate: PE, pneumonia, managing a MI ! Evaluate: PE, pneumonia, managing a MI !
pneumothorax, etc. pneumothorax, etc.
Talk to SICU fellow for any patients necessary work-up and you have Talk to SICU fellow for any patients necessary work-up and you have
SICU Consult with concerns. Don’t try to be a legitimate concerns. If they are not SICU Consult with concerns. Don’t try to be a legitimate concerns. If they are not
hero!! Bump it up if you have a worry. receptive, talk to your chief or hero!! Bump it up if you have a worry. receptive, talk to your chief or
Take EKG, labs, etc. with you to the attending about the situation. Take EKG, labs, etc. with you to the attending about the situation.
fellow. They are usually willing to help fellow. They are usually willing to help
Same situation for the PICU fellow. Same situation for the PICU fellow.
you out if you present it to them in you out if you present it to them in
way that shows you have done all the way that shows you have done all the
13 13
Make sure patient is stable. Treatment Make sure patient is stable. Treatment
Check pulse, Urine output. Start with IV fluid bolus Check pulse, Urine output. Start with IV fluid bolus
Is patient alert? D/C any hypertensive meds if patient Is patient alert? D/C any hypertensive meds if patient
is unstable (unresponsive). is unstable (unresponsive).
If urine output is low, bolus with Stat SICU consult (they will want to If urine output is low, bolus with Stat SICU consult (they will want to
1 Liter Normal Saline know EKG, Hct, WBC, ABG etc). 1 Liter Normal Saline know EKG, Hct, WBC, ABG etc).
Let chief / attending know. Check Hct Have blood available. Let chief / attending know. Check Hct Have blood available.
Blood > Normal Saline > ½ NS ABC’s. Blood > Normal Saline > ½ NS ABC’s.
for intravascular resuscitation. Call code if concerned. for intravascular resuscitation. Call code if concerned.
Be careful with CHF. Consider Be careful with CHF. Consider
bolusing 500 cc. bolusing 500 cc.
Differential Diagnosis Differential Diagnosis

Highàhypovolemia? Sepsis? PE? A-fib? Highàhypovolemia? Sepsis? PE? A-fib?
Lowà heart failure? Lowà heart failure?
Meds:Beta blocker,calcium channel blocker? Meds:Beta blocker,calcium channel blocker?
Check EKGàmedicine consult? Check EKGàmedicine consult?
Cards consult for arrythmia. Cards consult for arrythmia.
Stroke Document your Neuro Exam

as thoroughly as possible.
JHH:
410.283.7777
JHH:
410.283.7777
Check for asymetry. Bayview: Check for asymetry. Bayview:
Head CT without contrast. 410.283.8810 Head CT without contrast. 410.283.8810
Neurology Consult: Good Samaritan: Neurology Consult: Good Samaritan:
Call the Stroke pager ASAP. 443.444.4040 Call the Stroke pager ASAP. 443.444.4040
13 13
Make sure patient is stable. Treatment Make sure patient is stable. Treatment
Check pulse, Urine output. Start with IV fluid bolus Check pulse, Urine output. Start with IV fluid bolus
Is patient alert? D/C any hypertensive meds if patient Is patient alert? D/C any hypertensive meds if patient
is unstable (unresponsive). is unstable (unresponsive).
If urine output is low, bolus with Stat SICU consult (they will want to If urine output is low, bolus with Stat SICU consult (they will want to
1 Liter Normal Saline know EKG, Hct, WBC, ABG etc). 1 Liter Normal Saline know EKG, Hct, WBC, ABG etc).
Let chief / attending know. Check Hct Have blood available. Let chief / attending know. Check Hct Have blood available.
Blood > Normal Saline > ½ NS ABC’s. Blood > Normal Saline > ½ NS ABC’s.
for intravascular resuscitation. Call code if concerned. for intravascular resuscitation. Call code if concerned.
Be careful with CHF. Consider Be careful with CHF. Consider
bolusing 500 cc. bolusing 500 cc.
Differential Diagnosis Differential Diagnosis

Highàhypovolemia? Sepsis? PE? A-fib? Highàhypovolemia? Sepsis? PE? A-fib?
Lowà heart failure? Lowà heart failure?
Meds:Beta blocker,calcium channel blocker? Meds:Beta blocker,calcium channel blocker?
Check EKGàmedicine consult? Check EKGàmedicine consult?
Cards consult for arrythmia. Cards consult for arrythmia.

JHH:
410.283.7777
JHH:
410.283.7777
Check for asymetry. Bayview: Check for asymetry. Bayview:
Head CT without contrast. 410.283.8810 Head CT without contrast. 410.283.8810
Neurology Consult: Good Samaritan: Neurology Consult: Good Samaritan:
Call the Stroke pager ASAP. 443.444.4040 Call the Stroke pager ASAP. 443.444.4040
14 14
What is it ? Workup: What is it ? Workup:
Fat embolism is a release of fat Stat portable CXR Fat embolism is a release of fat Stat portable CXR
droplets into systemic circulation May see diffuse bilat infiltrates droplets into systemic circulation May see diffuse bilat infiltrates
after a traumatic event. after a traumatic event.
ABG ABG
Fat embolism syndrome is a rare Increased Aa gradient Fat embolism syndrome is a rare Increased Aa gradient
clinical consequence of the above. clinical consequence of the above.
Presentation CBC, platelets, fibrinogen. Presentation CBC, platelets, fibrinogen.
Pathophysiology unclear. Anemia, thrombocytopenia, Pathophysiology unclear. Anemia, thrombocytopenia,
low fibrinogen low fibrinogen
Pulmonary distress – ARDS-like Continuous O2 monitor. Pulmonary distress – ARDS-like Continuous O2 monitor.
Risk factors Risk factors
Mental status changes Spiral CT to rule out PE when Mental status changes Spiral CT to rule out PE when
Increased risk with increased stable. Increased risk with increased stable.
Petechial rash number of long bone fractures. Petechial rash number of long bone fractures.
Occur transiently in 50% Non contrast head CT if mental Occur transiently in 50% Non contrast head CT if mental
Reddish-brown spots in upper body Femur fractures especially. status changes. Reddish-brown spots in upper body Femur fractures especially. status changes.
and axilla or subconjunctival and axilla or subconjunctival
Non-op treatment has highest risk. Non-op treatment has highest risk.
Fever >38.5 Treatment: Fever >38.5 Treatment:
IM nailing? Controversial! IM nailing? Controversial!
Tachycardia >110 Early supportive pulmonary therapy. Tachycardia >110 Early supportive pulmonary therapy.
24-72 hrs after long bone Diagnosis 100% O2 on non-rebreather if on floor 24-72 hrs after long bone Diagnosis 100% O2 on non-rebreather if on floor
fracture or pelvic fracture Continuous O2 monitoring fracture or pelvic fracture Continuous O2 monitoring
CLINICAL DIAGNOSIS!! May need to be intubated CLINICAL DIAGNOSIS!! May need to be intubated
Lab and XR findings are non-specific. ICU or IMC transfer. Lab and XR findings are non-specific. ICU or IMC transfer.
SICU fellow consult stat SICU fellow consult stat
Notes: Mortality 10-20% Notes: Mortality 10-20%
14 14
What is it ? Workup: What is it ? Workup:
Fat embolism is a release of fat Stat portable CXR Fat embolism is a release of fat Stat portable CXR
droplets into systemic circulation May see diffuse bilat infiltrates droplets into systemic circulation May see diffuse bilat infiltrates
after a traumatic event. after a traumatic event.
ABG ABG
Fat embolism syndrome is a rare Increased Aa gradient Fat embolism syndrome is a rare Increased Aa gradient
clinical consequence of the above. clinical consequence of the above.
Presentation CBC, platelets, fibrinogen. Presentation CBC, platelets, fibrinogen.
Pathophysiology unclear. Anemia, thrombocytopenia, Pathophysiology unclear. Anemia, thrombocytopenia,
low fibrinogen low fibrinogen
Pulmonary distress – ARDS-like Continuous O2 monitor. Pulmonary distress – ARDS-like Continuous O2 monitor.
Risk factors Risk factors
Mental status changes Spiral CT to rule out PE when Mental status changes Spiral CT to rule out PE when
Increased risk with increased stable. Increased risk with increased stable.
Petechial rash number of long bone fractures. Petechial rash number of long bone fractures.
Occur transiently in 50% Non contrast head CT if mental Occur transiently in 50% Non contrast head CT if mental
Reddish-brown spots in upper body Femur fractures especially. status changes. Reddish-brown spots in upper body Femur fractures especially. status changes.
and axilla or subconjunctival and axilla or subconjunctival
Non-op treatment has highest risk. Non-op treatment has highest risk.
Fever >38.5 Treatment: Fever >38.5 Treatment:
IM nailing? Controversial! IM nailing? Controversial!
Tachycardia >110 Early supportive pulmonary therapy. Tachycardia >110 Early supportive pulmonary therapy.
24-72 hrs after long bone Diagnosis 100% O2 on non-rebreather if on floor 24-72 hrs after long bone Diagnosis 100% O2 on non-rebreather if on floor
fracture or pelvic fracture Continuous O2 monitoring fracture or pelvic fracture Continuous O2 monitoring
CLINICAL DIAGNOSIS!! May need to be intubated CLINICAL DIAGNOSIS!! May need to be intubated
Lab and XR findings are non-specific. ICU or IMC transfer. Lab and XR findings are non-specific. ICU or IMC transfer.
SICU fellow consult stat SICU fellow consult stat
Notes: Mortality 10-20% Notes: Mortality 10-20%

15 15
A patient with a tibial fracture is not Children with supracondylar humerus A patient with a tibial fracture is not Children with supracondylar humerus
II going to have 5/5 strength in his foot,
even though the nerves may be fine.
fractures are often hard to assess.
Check that anterior interosseous &
Document what you see. Document what you see.
P H Y S I C A L ulnar nerves are in when you see them
in the ER.
in the ER.
Adult spine surgery NOS notes should Adult spine surgery NOS notes should
E X A M also include rectal tone, wink & EPL tests the radial nerve. E X A M also include rectal tone, wink & EPL tests the radial nerve.
perianal sensation for all Index finger DIP flexion tests the Anterior perianal sensation for all Index finger DIP flexion tests the Anterior
Motor Exam thoracolumbar cases & extensive Interosseous Nerve (Branch of median) Motor Exam thoracolumbar cases & extensive Interosseous Nerve (Branch of median)
cervical cases. Small finger DIP flexion tests Ulnar Nerve cervical cases. Small finger DIP flexion tests Ulnar Nerve
Motor exams are critical in orthopaedics. Motor exams are critical in orthopaedics.
Document your findings accurately. Do the rectal with a nurse present and Patients with an active nerve block Document your findings accurately. Do the rectal with a nurse present and Patients with an active nerve block
Compare to previous exams. warn the patient. ACDF’s do NOT from anesthesia should be reassessed Compare to previous exams. warn the patient. ACDF’s do NOT from anesthesia should be reassessed
typically need a rectal. when their block wears off. typically need a rectal. when their block wears off.
Every patient’s NOS note or H+P Every patient’s NOS note or H+P
should have a motor exam written Pediatric spine patients do NOT need Sensory exam-Document abnormal should have a motor exam written Pediatric spine patients do NOT need Sensory exam-Document abnormal
out so that we can track progress or a rectal. sensation as to area, light touch & out so that we can track progress or a rectal. sensation as to area, light touch &
decline. You should be able to pinprick (paperclip). Compare to decline. You should be able to pinprick (paperclip). Compare to
explain every deficit you find, or you Spine surgery patients, adult and other side!!! explain every deficit you find, or you Spine surgery patients, adult and other side!!!
should notify someone senior. peds should also be tested for should notify someone senior. peds should also be tested for
clonus. Preop History and Physical clonus. Preop History and Physical
Motor Grades Must include Cardiac, lung, & Motor Grades Must include Cardiac, lung, &
(Not a perfect system!) Spine Surgery Notes abdomen to be considered complete!! (Not a perfect system!) Spine Surgery Notes abdomen to be considered complete!!
Designed for Spinal Cord Injury and joints Designed for Spinal Cord Injury and joints
with full range of motion, not for orthopaedic UPPER Biceps WristExt Triceps Grip FingerAbd with full range of motion, not for orthopaedic UPPER Biceps WristExt Triceps Grip FingerAbd
trauma. EXT C5 C6 C7 C8 T1 trauma. EXT C5 C6 C7 C8 T1
Right Right
Grade 0:Nothing, Grade 0:Nothing,
Grade 1:Flicker Left Grade 1:Flicker Left
Grade 2:Full range of motion-gravity LOWER HipFlex KneeExt FootDorsi ToeExt FootPlant Grade 2:Full range of motion-gravity LOWER HipFlex KneeExt FootDorsi ToeExt FootPlant
removed EXT L2 L3 L4 L5 S1 removed EXT L2 L3 L4 L5 S1
Grade 3:Full range of motion-against Grade 3:Full range of motion-against
gravity Right gravity Right
Grade 4-weak (only grade with +, -) Grade 4-weak (only grade with +, -)
Left Left
Grade 5-normal Grade 5-normal
15 15
A patient with a tibial fracture is not Children with supracondylar humerus A patient with a tibial fracture is not Children with supracondylar humerus
Document what you see. Document what you see.
in the ER.
in the ER.
Adult spine surgery NOS notes should Adult spine surgery NOS notes should
E X A M also include rectal tone, wink & EPL tests the radial nerve. E X A M also include rectal tone, wink & EPL tests the radial nerve.
perianal sensation for all Index finger DIP flexion tests the Anterior perianal sensation for all Index finger DIP flexion tests the Anterior
Motor Exam thoracolumbar cases & extensive Interosseous Nerve (Branch of median) Motor Exam thoracolumbar cases & extensive Interosseous Nerve (Branch of median)
cervical cases. Small finger DIP flexion tests Ulnar Nerve cervical cases. Small finger DIP flexion tests Ulnar Nerve
Motor exams are critical in orthopaedics. Motor exams are critical in orthopaedics.
Document your findings accurately. Do the rectal with a nurse present and Patients with an active nerve block Document your findings accurately. Do the rectal with a nurse present and Patients with an active nerve block
Compare to previous exams. warn the patient. ACDF’s do NOT from anesthesia should be reassessed Compare to previous exams. warn the patient. ACDF’s do NOT from anesthesia should be reassessed
typically need a rectal. when their block wears off. typically need a rectal. when their block wears off.
Every patient’s NOS note or H+P Every patient’s NOS note or H+P
should have a motor exam written Pediatric spine patients do NOT need Sensory exam-Document abnormal should have a motor exam written Pediatric spine patients do NOT need Sensory exam-Document abnormal
out so that we can track progress or a rectal. sensation as to area, light touch & out so that we can track progress or a rectal. sensation as to area, light touch &
decline. You should be able to pinprick (paperclip). Compare to decline. You should be able to pinprick (paperclip). Compare to
explain every deficit you find, or you Spine surgery patients, adult and other side!!! explain every deficit you find, or you Spine surgery patients, adult and other side!!!
should notify someone senior. peds should also be tested for should notify someone senior. peds should also be tested for
clonus. Preop History and Physical clonus. Preop History and Physical
Motor Grades Must include Cardiac, lung, & Motor Grades Must include Cardiac, lung, &
(Not a perfect system!) Spine Surgery Notes abdomen to be considered complete!! (Not a perfect system!) Spine Surgery Notes abdomen to be considered complete!!
Designed for Spinal Cord Injury and joints Designed for Spinal Cord Injury and joints
with full range of motion, not for orthopaedic UPPER Biceps WristExt Triceps Grip FingerAbd with full range of motion, not for orthopaedic UPPER Biceps WristExt Triceps Grip FingerAbd
trauma. EXT C5 C6 C7 C8 T1 trauma. EXT C5 C6 C7 C8 T1
Right Right
Grade 0:Nothing, Grade 0:Nothing,
Grade 1:Flicker Left Grade 1:Flicker Left
Grade 2:Full range of motion-gravity LOWER HipFlex KneeExt FootDorsi ToeExt FootPlant Grade 2:Full range of motion-gravity LOWER HipFlex KneeExt FootDorsi ToeExt FootPlant
removed EXT L2 L3 L4 L5 S1 removed EXT L2 L3 L4 L5 S1
Grade 3:Full range of motion-against Grade 3:Full range of motion-against
gravity Right gravity Right
Grade 4-weak (only grade with +, -) Grade 4-weak (only grade with +, -)
Left Left
Grade 5-normal Grade 5-normal
16 16
Labs Labs
Pertinent Labs: UA Pertinent Labs: UA
Every hip fracture should have a Every hip fracture should have a
Hematocrit UA on admission. Others as Hematocrit UA on admission. Others as
Most post op patients get one appropriate. Most post op patients get one appropriate.
the first day after surgery. the first day after surgery.
CRP/ESR CRP/ESR
Femur fractures and large Every patient suspected of Femur fractures and large Every patient suspected of
Early AM Labs can be ordered, spinal, hip, knee and shoulder having an infection needs Early AM Labs can be ordered, spinal, hip, knee and shoulder having an infection needs
especially on weekends. (1st draw AML) procedures should get one in the these labs. especially on weekends. (1st draw AML) procedures should get one in the these labs.
recovery room. recovery room.
Don’t make a habit of signing out labs! Blood Cx Don’t make a habit of signing out labs! Blood Cx
If the patient is actively losing blood Less useful in orthopaedics. Not If the patient is actively losing blood Less useful in orthopaedics. Not
(recognized by precipitous pressure part of our routine post op fever (recognized by precipitous pressure part of our routine post op fever
drop or heavy drain output), order workup unless the fever is high or drop or heavy drain output), order workup unless the fever is high or
a post-transfusion hematocrit. patient has documented infection. a post-transfusion hematocrit. patient has documented infection.
A lab that is ordered on your A lab that is ordered on your
patient is your responsibility to BMP patient is your responsibility to BMP
check, no matter whom else Watch the creatinine values Orthopaedic Tumor Consult? check, no matter whom else Watch the creatinine values Orthopaedic Tumor Consult?
ordered it or is following the value. on joint patients and patients Order CBC, CRP, ESR, BMP, ordered it or is following the value. on joint patients and patients Order CBC, CRP, ESR, BMP,
on gentamicin or vancomycin SPEP/UPEP, UA. on gentamicin or vancomycin SPEP/UPEP, UA.
Get in the habit of looking through carefully. These have a tendency Get in the habit of looking through carefully. These have a tendency
EPR every day for rogue labs that to creep up. Keep potassium repleted Dr. Frassica will ask for the calcium. EPR every day for rogue labs that to creep up. Keep potassium repleted Dr. Frassica will ask for the calcium.
someone else ordered. above 3.5. someone else ordered. above 3.5.
On the pediatrics service, ask PT/PTT Pathology Reports On the pediatrics service, ask PT/PTT Pathology Reports
the attending before ordering Watch patients on coumadin Keep track of the patients you the attending before ordering Watch patients on coumadin Keep track of the patients you
any labs. like a hawk. Place it in bold have operated on, and review any labs. like a hawk. Place it in bold have operated on, and review
Often the kids don’t need them and letters on sign-out so that their pathology reports. Often the kids don’t need them and letters on sign-out so that their pathology reports.
the attendings will be upset that other people know the patient is the attendings will be upset that other people know the patient is
they were ordered. on coumadin. they were ordered. on coumadin.
Don’t let it jump up!! Don’t let it jump up!!
16 16
Labs Labs
Pertinent Labs: UA Pertinent Labs: UA
Every hip fracture should have a Every hip fracture should have a
Hematocrit UA on admission. Others as Hematocrit UA on admission. Others as
Most post op patients get one appropriate. Most post op patients get one appropriate.
the first day after surgery. the first day after surgery.
CRP/ESR CRP/ESR
Femur fractures and large Every patient suspected of Femur fractures and large Every patient suspected of
Early AM Labs can be ordered, spinal, hip, knee and shoulder having an infection needs Early AM Labs can be ordered, spinal, hip, knee and shoulder having an infection needs
especially on weekends. (1st draw AML) procedures should get one in the these labs. especially on weekends. (1st draw AML) procedures should get one in the these labs.
recovery room. recovery room.
Don’t make a habit of signing out labs! Blood Cx Don’t make a habit of signing out labs! Blood Cx
If the patient is actively losing blood Less useful in orthopaedics. Not If the patient is actively losing blood Less useful in orthopaedics. Not
(recognized by precipitous pressure part of our routine post op fever (recognized by precipitous pressure part of our routine post op fever
drop or heavy drain output), order workup unless the fever is high or drop or heavy drain output), order workup unless the fever is high or
a post-transfusion hematocrit. patient has documented infection. a post-transfusion hematocrit. patient has documented infection.
A lab that is ordered on your A lab that is ordered on your
patient is your responsibility to BMP patient is your responsibility to BMP
check, no matter whom else Watch the creatinine values Orthopaedic Tumor Consult? check, no matter whom else Watch the creatinine values Orthopaedic Tumor Consult?
ordered it or is following the value. on joint patients and patients Order CBC, CRP, ESR, BMP, ordered it or is following the value. on joint patients and patients Order CBC, CRP, ESR, BMP,
on gentamicin or vancomycin SPEP/UPEP, UA. on gentamicin or vancomycin SPEP/UPEP, UA.
Get in the habit of looking through carefully. These have a tendency Get in the habit of looking through carefully. These have a tendency
EPR every day for rogue labs that to creep up. Keep potassium repleted Dr. Frassica will ask for the calcium. EPR every day for rogue labs that to creep up. Keep potassium repleted Dr. Frassica will ask for the calcium.
someone else ordered. above 3.5. someone else ordered. above 3.5.
On the pediatrics service, ask PT/PTT Pathology Reports On the pediatrics service, ask PT/PTT Pathology Reports
the attending before ordering Watch patients on coumadin Keep track of the patients you the attending before ordering Watch patients on coumadin Keep track of the patients you
any labs. like a hawk. Place it in bold have operated on, and review any labs. like a hawk. Place it in bold have operated on, and review
Often the kids don’t need them and letters on sign-out so that their pathology reports. Often the kids don’t need them and letters on sign-out so that their pathology reports.
the attendings will be upset that other people know the patient is the attendings will be upset that other people know the patient is
they were ordered. on coumadin. they were ordered. on coumadin.
Don’t let it jump up!! Don’t let it jump up!!
17 17
III III
Glenohumeral Joint Reduction Place sheet around flexed forearm and Glenohumeral Joint Reduction Place sheet around flexed forearm and
PROCEDURES (Anterior Dislocation 95%) tie same sheet around your waist PROCEDURES (Anterior Dislocation 95%) tie same sheet around your waist
snugly. Gently pull on forearm wile snugly. Gently pull on forearm wile
Traction-Countertraction Method leaning your weight back on sheet and Traction-Countertraction Method leaning your weight back on sheet and
Requires an assistant. Supine patient. rotate arm. Requires an assistant. Supine patient. rotate arm.
Assistant: Stands on opposite side of Assistant: Stands on opposite side of

Joint Reductions pt. Place sheet under pt’s affected Stimson/Gravity Technique Joint Reductions pt. Place sheet under pt’s affected Stimson/Gravity Technique
axilla/upper trunk and pull/provide axilla/upper trunk and pull/provide
GOAL: countertraction. Patient is prone. Hang arm down at GOAL: countertraction. Patient is prone. Hang arm down at
To reduce ASAP without side of bed. To reduce ASAP without side of bed.
causing additional damage Resident: Pulls arm gently opposite causing additional damage Resident: Pulls arm gently opposite
axis of countertraction while Tie weight (10lb) to distal forearm. axis of countertraction while Tie weight (10lb) to distal forearm.
rotating OR flexes elbow of affected You may place weight in stockinette rotating OR flexes elbow of affected You may place weight in stockinette
arm to 90°. and wrap around distal forearm. arm to 90°. and wrap around distal forearm.
May take several hours to reduce. May take several hours to reduce.
Post-Reduction Post-Reduction
Document NV exam. Obtain axillary Document NV exam. Obtain axillary
view to ensure reduction. view to ensure reduction.
17 17
III III
Glenohumeral Joint Reduction Place sheet around flexed forearm and Glenohumeral Joint Reduction Place sheet around flexed forearm and
PROCEDURES (Anterior Dislocation 95%) tie same sheet around your waist PROCEDURES (Anterior Dislocation 95%) tie same sheet around your waist
snugly. Gently pull on forearm wile snugly. Gently pull on forearm wile
Traction-Countertraction Method leaning your weight back on sheet and Traction-Countertraction Method leaning your weight back on sheet and
Requires an assistant. Supine patient. rotate arm. Requires an assistant. Supine patient. rotate arm.
Assistant: Stands on opposite side of Assistant: Stands on opposite side of

Joint Reductions pt. Place sheet under pt’s affected Stimson/Gravity Technique Joint Reductions pt. Place sheet under pt’s affected Stimson/Gravity Technique
axilla/upper trunk and pull/provide axilla/upper trunk and pull/provide
GOAL: countertraction. Patient is prone. Hang arm down at GOAL: countertraction. Patient is prone. Hang arm down at
To reduce ASAP without side of bed. To reduce ASAP without side of bed.
causing additional damage Resident: Pulls arm gently opposite causing additional damage Resident: Pulls arm gently opposite
axis of countertraction while Tie weight (10lb) to distal forearm. axis of countertraction while Tie weight (10lb) to distal forearm.
rotating OR flexes elbow of affected You may place weight in stockinette rotating OR flexes elbow of affected You may place weight in stockinette
arm to 90°. and wrap around distal forearm. arm to 90°. and wrap around distal forearm.
May take several hours to reduce. May take several hours to reduce.
Document NV exam. Obtain axillary Document NV exam. Obtain axillary
view to ensure reduction. view to ensure reduction.
Elbow Reduction 18 Elbow Reduction 18
(Posterior/Posterolateral 80%) (Posterior/Posterolateral 80%)
Beware of terrible triad: fx of coranoid, Beware of terrible triad: fx of coranoid,
fx of radial head, elbow dislocation. fx of radial head, elbow dislocation.
Document NV exam. Consent Document NV exam. Consent
patient. Provide pt with conscious patient. Provide pt with conscious
sedation/analgesia. sedation/analgesia.
Pt is supine, elbow extended, use Pt is supine, elbow extended, use
assistant if available. assistant if available.
Assistant: Pulls countertraction on Assistant: Pulls countertraction on
humerus. humerus.
Resident: Pulls gentle longitudinal Resident: Pulls gentle longitudinal
traction. Corrects medial/lateral traction. Corrects medial/lateral
displacement. Use gentle flexion. displacement. Use gentle flexion.
Should hear clunk if reduced. Should hear clunk if reduced.
Distal Radius Fx-Reduction/Splinting Technique Distal Radius Fx-Reduction/Splinting Technique
Document NV exam. X-Ray AP/ Document NV exam. X-Ray AP/
Lateral of elbow to confirm Lateral of elbow to confirm
reduction. reduction.
Perform range of motion of elbow to Perform range of motion of elbow to
ensure stability. ensure stability.
With elbow at 90° place in well With elbow at 90° place in well
padded posterior splint. Sling. padded posterior splint. Sling.
Elbow Reduction 18 Elbow Reduction 18

(Posterior/Posterolateral 80%) (Posterior/Posterolateral 80%)
Beware of terrible triad: fx of coranoid, Beware of terrible triad: fx of coranoid,
fx of radial head, elbow dislocation. fx of radial head, elbow dislocation.
Document NV exam. Consent Document NV exam. Consent
patient. Provide pt with conscious patient. Provide pt with conscious
sedation/analgesia. sedation/analgesia.
Pt is supine, elbow extended, use Pt is supine, elbow extended, use
assistant if available. assistant if available.
Assistant: Pulls countertraction on Assistant: Pulls countertraction on
humerus. humerus.
Resident: Pulls gentle longitudinal Resident: Pulls gentle longitudinal
traction. Corrects medial/lateral traction. Corrects medial/lateral
displacement. Use gentle flexion. displacement. Use gentle flexion.
Should hear clunk if reduced. Should hear clunk if reduced.
Distal Radius Fx-Reduction/Splinting Technique Distal Radius Fx-Reduction/Splinting Technique
Document NV exam. X-Ray AP/ Document NV exam. X-Ray AP/
Lateral of elbow to confirm Lateral of elbow to confirm
reduction. reduction.
Perform range of motion of elbow to Perform range of motion of elbow to
ensure stability. ensure stability.
With elbow at 90° place in well With elbow at 90° place in well
padded posterior splint. Sling. padded posterior splint. Sling.
19 19
Hip Dislocation Hip Dislocation

(Native Posterior more common than East Baltimore Lift (Invented at (Native Posterior more common than East Baltimore Lift (Invented at
Anterior) Hopkins) (not commonly used) Anterior) Hopkins) (not commonly used)
Leg will be flexed/IR/Adducted Leg will be flexed/IR/Adducted
Patient is supine on bed. Patient is supine on bed.
Must be reduced within 6 hrs of Must be reduced within 6 hrs of
injury. Resident: stands at side of dislocation injury. Resident: stands at side of dislocation
at level of pat’s pelvis. at level of pat’s pelvis.
Assistant: Pushes down on pelvis at ASIS. Assistant: Pushes down on pelvis at ASIS.
Document NV exam. (To see if Document NV exam. (To see if
sciatic nerve injury is present. Assistant: stands across bed. sciatic nerve injury is present. Assistant: stands across bed.
Resident: Pulls inline traction gently. Resident: Pulls inline traction gently.
Peroneal section of sciatic nerve is Flex hip to 60-90° while pulling up on Resident: Places arm under pt’s calf Peroneal section of sciatic nerve is Flex hip to 60-90° while pulling up on Resident: Places arm under pt’s calf
most commonly injured). pt’s calf with right arm. and places arm on assistant’s most commonly injured). pt’s calf with right arm. and places arm on assistant’s
Perform knee ligamentous exam. shoulder. Uses free hand to stabilize Perform knee ligamentous exam. shoulder. Uses free hand to stabilize
Rotational movement of hip along with Rotational movement of hip along with
pt’s ankle. pt’s ankle.
adduction. Should hear clunk when adduction. Should hear clunk when
Consent patient. Consciously sedate reduced. Consent patient. Consciously sedate reduced.
(ask for Etomidate). Ask for an Assistant: Places arm under pt’s calf (ask for Etomidate). Ask for an Assistant: Places arm under pt’s calf
assistant. and places arm on resident’s assistant. and places arm on resident’s
If not successful with 2 closed If not successful with 2 closed
shoulder. Uses free hand on pelvis shoulder. Uses free hand on pelvis
reductions then take to OR for reductions then take to OR for
for countertraction. for countertraction.
reduction under general anesthesia. reduction under general anesthesia.
Allis Technique (Can also be used Allis Technique (Can also be used
for dislocated THA) Both resident and assistant stand up for dislocated THA) Both resident and assistant stand up
on toes and use arms as fulcrum for on toes and use arms as fulcrum for
Requires an assistant. reduction. Requires an assistant. reduction.
Supine patient (on bed or on ground Post-Reduction Supine patient (on bed or on ground Post-Reduction
with a backboard). with a backboard).
Document NV exam. Range hip to Document NV exam. Range hip to
ensure stability. CT to ensure no ensure stability. CT to ensure no
intraarticular fragments/congruence. intraarticular fragments/congruence.
If acetabulum fx (usually posterior If acetabulum fx (usually posterior
wall) pt will need femoral traction wall) pt will need femoral traction
pin otherwise place in abduction pin otherwise place in abduction
pillow. pillow.
19 19
Hip Dislocation Hip Dislocation

(Native Posterior more common than East Baltimore Lift (Invented at (Native Posterior more common than East Baltimore Lift (Invented at
Anterior) Hopkins) (not commonly used( Anterior) Hopkins) (not commonly used)
Leg will be flexed/IR/Adducted Leg will be flexed/IR/Adducted
Patient is supine on bed. Patient is supine on bed.
Must be reduced within 6 hrs of Must be reduced within 6 hrs of
injury. Resident: stands at side of dislocation injury. Resident: stands at side of dislocation
at level of pat’s pelvis. at level of pat’s pelvis.
Assistant: Pushes down on pelvis at ASIS. Assistant: Pushes down on pelvis at ASIS.
Document NV exam. (To see if Document NV exam. (To see if
sciatic nerve injury is present. Assistant: stands across bed. sciatic nerve injury is present. Assistant: stands across bed.
Resident: Pulls inline traction gently. Resident: Pulls inline traction gently.
Peroneal section of sciatic nerve is Flex hip to 60-90° while pulling up on Resident: Places arm under pt’s calf Peroneal section of sciatic nerve is Flex hip to 60-90° while pulling up on Resident: Places arm under pt’s calf
most commonly injured). pt’s calf with right arm. and places arm on assistant’s most commonly injured). pt’s calf with right arm. and places arm on assistant’s
Perform knee ligamentous exam. shoulder. Uses free hand to stabilize Perform knee ligamentous exam. shoulder. Uses free hand to stabilize
Rotational movement of hip along with Rotational movement of hip along with
pt’s ankle. pt’s ankle.
adduction. Should hear clunk when adduction. Should hear clunk when
Consent patient. Consciously sedate reduced. Consent patient. Consciously sedate reduced.
(ask for Etomidate). Ask for an Assistant: Places arm under pt’s calf (ask for Etomidate). Ask for an Assistant: Places arm under pt’s calf
assistant. and places arm on resident’s assistant. and places arm on resident’s
If not successful with 2 closed If not successful with 2 closed
shoulder. Uses free hand on pelvis shoulder. Uses free hand on pelvis
reductions then take to OR for reductions then take to OR for
for countertraction. for countertraction.
reduction under general anesthesia. reduction under general anesthesia.
Allis Technique (Can also be used Allis Technique (Can also be used
for dislocated THA) Both resident and assistant stand up for dislocated THA) Both resident and assistant stand up
on toes and use arms as fulcrum for on toes and use arms as fulcrum for
Requires an assistant. reduction. Requires an assistant. reduction.
Supine patient (on bed or on ground Post-Reduction Supine patient (on bed or on ground Post-Reduction
with a backboard). with a backboard).
Document NV exam. Range hip to Document NV exam. Range hip to
ensure stability. CT to ensure no ensure stability. CT to ensure no
intraarticular fragments/congruence. intraarticular fragments/congruence.
If acetabulum fx (usually posterior If acetabulum fx (usually posterior
wall) pt will need femoral traction wall) pt will need femoral traction
pin otherwise place in abduction pin otherwise place in abduction
pillow. pillow.
20 20
Knee Dislocation Anterior Dislocation Reduction Displaced Ankle Fracture Knee Dislocation Anterior Dislocation Reduction Displaced Ankle Fracture
(Anterior most common) (Anterior most common)
Requires an assistant. Reduction/Splinting Set-Up Requires an assistant. Reduction/Splinting Set-Up
(Beware of popliteal artery & (Beware of popliteal artery &
peroneal nerve injury) Consent patient. Conscious sedation. peroneal nerve injury) Consent patient. Conscious sedation.
Kennedy Classification: position of Assistant: Provides counter traction Kennedy Classification: position of Assistant: Provides counter traction
tibia in relation to femur: anterior/ on femur. tibia in relation to femur: anterior/ on femur.
posterior/med/lateral. Resident: Pulls gently longitudinal posterior/med/lateral. Resident: Pulls gently longitudinal
Schatzker IV is considered a knee traction on tibia and pulls up. Schatzker IV is considered a knee traction on tibia and pulls up.
dislocation variant. Posterior Dislocation Reduction dislocation variant. Posterior Dislocation Reduction
Dimple Sign: posterolateral Requires an assistant. Dimple Sign: posterolateral Requires an assistant.
dislocation: medial femoral condyle dislocation: medial femoral condyle
buttonholes through anteromedial Consent patient. Conscious sedation. buttonholes through anteromedial Consent patient. Conscious sedation.
capsule. Medial structures become capsule. Medial structures become
entrapped. Requires open reduction. Assistant: Provides counter traction entrapped. Requires open reduction. Assistant: Provides counter traction
on femur. on femur.
Document pulses/peroneal nerve Document pulses/peroneal nerve
function/compartment of affected Resident: Pulls gently longitudinal function/compartment of affected Resident: Pulls gently longitudinal
extremity. traction on tibia and lifts up on tibia. extremity. traction on tibia and lifts up on tibia.
Perform ABI: Hand-held Doppler and Post-Reduction Perform ABI: Hand-held Doppler and Post-Reduction
BP cuff. Check UE systolic, ankle Document NV exam. BP cuff. Check UE systolic, ankle Document NV exam.
systolic of DP & PT (use the one that systolic of DP & PT (use the one that
is higher. LE systolic/UE systolic=ABI. X-Ray: post-reduction AP/lateral is higher. LE systolic/UE systolic=ABI. X-Ray: post-reduction AP/lateral
Nmle “I”. knee. Nmle “I”. knee.
If ABI <0.9 or No Pulses cool foot. Knee immobilizer: Long bulky splint. If ABI <0.9 or No Pulses cool foot. Knee immobilizer: Long bulky splint.
Consult Vascular surgery. CT angio. Consult Vascular surgery. CT angio.
Serial compartment checks. Serial compartment checks.
MRI MRI
20 20
Knee Dislocation Anterior Dislocation Reduction Displaced Ankle Fracture Knee Dislocation Anterior Dislocation Reduction Displaced Ankle Fracture
(Anterior most common) (Anterior most common)
Requires an assistant. Reduction/Splinting Set-Up Requires an assistant. Reduction/Splinting Set-Up
(Beware of popliteal artery & (Beware of popliteal artery &
peroneal nerve injury) Consent patient. Conscious sedation. peroneal nerve injury) Consent patient. Conscious sedation.
Kennedy Classification: position of Assistant: Provides counter traction Kennedy Classification: position of Assistant: Provides counter traction
tibia in relation to femur: anterior/ on femur. tibia in relation to femur: anterior/ on femur.
posterior/med/lateral. Resident: Pulls gently longitudinal posterior/med/lateral. Resident: Pulls gently longitudinal
Schatzker IV is considered a knee traction on tibia and pulls up on. Schatzker IV is considered a knee traction on tibia and pulls up.
dislocation variant. Posterior Dislocation Reduction dislocation variant. Posterior Dislocation Reduction
Dimple Sign: posterolateral Requires an assistant. Dimple Sign: posterolateral Requires an assistant.
dislocation: medial femoral condyle dislocation: medial femoral condyle
buttonholes through anteromedial Consent patient. Conscious sedation. buttonholes through anteromedial Consent patient. Conscious sedation.
capsule. Medial structures become capsule. Medial structures become
entrapped. Requires open reduction. Assistant: Provides counter traction entrapped. Requires open reduction. Assistant: Provides counter traction
on femur. on femur.
Document pulses/peroneal nerve Document pulses/peroneal nerve
function/compartment of affected Resident: Pulls gently longitudinal function/compartment of affected Resident: Pulls gently longitudinal
extremity. traction on tibia and lifts up on tibia. extremity. traction on tibia and lifts up on tibia.
Perform ABI: Hand-held Doppler and Post-Reduction Perform ABI: Hand-held Doppler and Post-Reduction
BP cuff. Check UE systolic, ankle Document NV exam. BP cuff. Check UE systolic, ankle Document NV exam.
systolic of DP & PT (use the one that systolic of DP & PT (use the one that
is higher. LE systolic/UE systolic=ABI. X-Ray: post-reduction AP/lateral is higher. LE systolic/UE systolic=ABI. X-Ray: post-reduction AP/lateral
Nmle “I”. knee. Nmle “I”. knee.
If ABI <0.9 or No Pulses cool foot. Knee immobilizer: Long bulky splint. If ABI <0.9 or No Pulses cool foot. Knee immobilizer: Long bulky splint.
Consult Vascular surgery. CT angio. Consult Vascular surgery. CT angio.
Serial compartment checks. Serial compartment checks.
MRI MRI
21 21
This is too tight & patients will be Fractures that require this are often This is too tight & patients will be Fractures that require this are often
calling you in a few hours for blue or high energy or have significant calling you in a few hours for blue or high energy or have significant
tingling fingers. Just roll it on. comminution – dusted elbows, tingling fingers. Just roll it on. comminution – dusted elbows,
pilons, tibial plateau fractures. We pilons, tibial plateau fractures. We
Pad bony prominences well! This also tend to splint tibial shaft Pad bony prominences well! This also tend to splint tibial shaft
means putting on extra padding at fractures with Robert Jones cotton means putting on extra padding at fractures with Robert Jones cotton
the elbow joint for sugar tongs or on and Kerlex here as well. the elbow joint for sugar tongs or on and Kerlex here as well.
the heel for AO splints. Can use the heel for AO splints. Can use
ABD pads for the heel. However, too much padding may not ABD pads for the heel. However, too much padding may not
provide enough support to maintain provide enough support to maintain
Make sure no plaster or thinly a reduction. A distal radius needs Make sure no plaster or thinly a reduction. A distal radius needs
padded plaster touches the skin. just enough soft roll to protect the padded plaster touches the skin. just enough soft roll to protect the
This is especially true at the ends skin without losing reduction. This is especially true at the ends skin without losing reduction.
Splinting of splints.
When holding a reduction as a splint
Make sure your posterior slab for an hardens, use broad surfaces to apply Make sure your posterior slab for an hardens, use broad surfaces to apply
Adult ankle fracture does not dig into the forces, use the palm of the hand. Adult ankle fracture does not dig into the forces, use the palm of the hand.
popliteal fossa. You will be amazed popliteal fossa. You will be amazed
Adults do not get casts acutely. how fast an ulcer can develop. Adults do not get casts acutely. how fast an ulcer can develop.
Only splint acute fractures with Only splint acute fractures with
plaster to accommodate swelling. A Upper extremity often requires 10- Do not use fingers or the plaster will plaster to accommodate swelling. A Upper extremity often requires 10- Do not use fingers or the plaster will
splint should generally try to 12 layers of plaster. Lower extremity pick up the grooves and cause an splint should generally try to 12 layers of plaster. Lower extremity pick up the grooves and cause an
immobilize the joint above and the often requires 12-14 layers. However, ulcer. immobilize the joint above and the often requires 12-14 layers. However, ulcer.
joint below a fracture. modify as necessary. A big person joint below a fracture. modify as necessary. A big person
may require more layers. Measure off may require more layers. Measure off
A good splint stabilizes the fracture the good limb. A good splint stabilizes the fracture the good limb.
without causing a pressure ulcer. In without causing a pressure ulcer. In
general, use at least 3 layers of soft For fractures that can balloon with general, use at least 3 layers of soft For fractures that can balloon with
roll to protect the skin from the swelling, use Robert Jones cotton for roll to protect the skin from the swelling, use Robert Jones cotton for
plaster and 1 layer of soft roll on the extra padding. Overwrap with a plaster and 1 layer of soft roll on the extra padding. Overwrap with a
superficial side of the plaster so that Kerlex to help apply gentle superficial side of the plaster so that Kerlex to help apply gentle
it doesn’t stick to the ACE wrap. Do compression to control the swelling. it doesn’t stick to the ACE wrap. Do compression to control the swelling.
not pull the softroll or ACE wrap. not pull the softroll or ACE wrap.
21 21
This is too tight & patients will be Fractures that require this are often This is too tight & patients will be Fractures that require this are often
calling you in a few hours for blue or high energy or have significant calling you in a few hours for blue or high energy or have significant
tingling fingers. Just roll it on. comminution – dusted elbows, tingling fingers. Just roll it on. comminution – dusted elbows,
pilons, tibial plateau fractures. We pilons, tibial plateau fractures. We
Pad bony prominences well! This also tend to splint tibial shaft Pad bony prominences well! This also tend to splint tibial shaft
means putting on extra padding at fractures with Robert Jones cotton means putting on extra padding at fractures with Robert Jones cotton
the elbow joint for sugar tongs or on and Kerlex here as well. the elbow joint for sugar tongs or on and Kerlex here as well.
the heel for AO splints. Can use the heel for AO splints. Can use
ABD pads for the heel. However, too much padding may not ABD pads for the heel. However, too much padding may not
provide enough support to maintain provide enough support to maintain
Make sure no plaster or thinly a reduction. A distal radius needs Make sure no plaster or thinly a reduction. A distal radius needs
padded plaster touches the skin. just enough soft roll to protect the padded plaster touches the skin. just enough soft roll to protect the
This is especially true at the ends skin without losing reduction. This is especially true at the ends skin without losing reduction.
Make sure your posterior slab for an hardens, use broad surfaces to apply Make sure your posterior slab for an hardens, use broad surfaces to apply
Adult ankle fracture does not dig into the forces, use the palm of the hand. Adult ankle fracture does not dig into the forces, use the palm of the hand.
popliteal fossa. You will be amazed popliteal fossa. You will be amazed
Adults do not get casts acutely. how fast an ulcer can develop. Adults do not get casts acutely. how fast an ulcer can develop.
Only splint acute fractures with Only splint acute fractures with
plaster to accommodate swelling. A Upper extremity often requires 10- Do not use fingers or the plaster will plaster to accommodate swelling. A Upper extremity often requires 10- Do not use fingers or the plaster will
splint should generally try to 12 layers of plaster. Lower extremity pick up the grooves and cause an splint should generally try to 12 layers of plaster. Lower extremity pick up the grooves and cause an
immobilize the joint above and the often requires 12-14 layers. However, ulcer. immobilize the joint above and the often requires 12-14 layers. However, ulcer.
joint below a fracture. modify as necessary. A big person joint below a fracture. modify as necessary. A big person
may require more layers. Measure off may require more layers. Measure off
A good splint stabilizes the fracture the good limb. A good splint stabilizes the fracture the good limb.
without causing a pressure ulcer. In without causing a pressure ulcer. In
general, use at least 3 layers of soft For fractures that can balloon with general, use at least 3 layers of soft For fractures that can balloon with
roll to protect the skin from the swelling, use Robert Jones cotton for roll to protect the skin from the swelling, use Robert Jones cotton for
plaster and 1 layer of soft roll on the extra padding. Overwrap with a plaster and 1 layer of soft roll on the extra padding. Overwrap with a
superficial side of the plaster so that Kerlex to help apply gentle superficial side of the plaster so that Kerlex to help apply gentle
it doesn’t stick to the ACE wrap. Do compression to control the swelling. it doesn’t stick to the ACE wrap. Do compression to control the swelling.
not pull the softroll or ACE wrap. not pull the softroll or ACE wrap.
22 22
Fracture Splint Tips Fracture Splint Tips
Proximal Humerus Sling Dr. Trice prefers shoulder immobilizer Proximal Humerus Sling Dr. Trice prefers shoulder immobilizer
Humeral shaft Coaptation splint Pad the axilla extension well Humeral shaft Coaptation splint Pad the axilla extension well
with ABD’s, carry the shoulder with ABD’s, carry the shoulder
extension high, pad the elbow extension high, pad the elbow
Elbow Posterior slab with Buttress The buttress gives support Elbow Posterior slab with Buttress The buttress gives support
consider Jones cotton if dusted consider Jones cotton if dusted
Distal radius Sugar tong Pad the elbow well, keep splint Distal radius Sugar tong Pad the elbow well, keep splint
proximal to MCP’s proximal to MCP’s
Boxer’s Fracture Ulnar gutter Mild wrist extension with as Boxer’s Fracture Ulnar gutter Mild wrist extension with as
much MCP flexion much MCP flexion
Thumb / scaphoid Thumb spica Thumb / scaphoid Thumb spica
Tibial plateau Long posterior slab Use Robert Jones cotton Tibial plateau Long posterior slab Use Robert Jones cotton
with 2 side slabs with 2 side slabs
Tibial Shaft Long posterior slab including Use Robert Jones cotton Tibial Shaft Long posterior slab including Use Robert Jones cotton
foot with long stirrup foot with long stirrup
Ankle Posterior slab with stirrup Start applying plaster at calf Ankle Posterior slab with stirrup Start applying plaster at calf
and then double over on foot and then double over on foot
plate if excess. Apply 1 layer of plate if excess. Apply 1 layer of
soft roll in between slab & stirrup soft roll in between slab & stirrup
Foot Posterior slab Foot Posterior slab
22 22
Fracture Splint Tips Fracture Splint Tips
Proximal Humerus Sling Dr. Trice prefers shoulder immobilizer Proximal Humerus Sling Dr. Trice prefers shoulder immobilizer
Humeral shaft Coaptation splint Pad the axilla extension well Humeral shaft Coaptation splint Pad the axilla extension well
with ABD’s, carry the shoulder with ABD’s, carry the shoulder
extension high, pad the elbow extension high, pad the elbow
Elbow Posterior slab with Buttress The buttress gives support Elbow Posterior slab with Buttress The buttress gives support
consider Jones cotton if dusted consider Jones cotton if dusted
Distal radius Sugar tong Pad the elbow well, keep splint Distal radius Sugar tong Pad the elbow well, keep splint
proximal to MCP’s proximal to MCP’s
Boxer’s Fracture Ulnar gutter Mild wrist extension with as Boxer’s Fracture Ulnar gutter Mild wrist extension with as
much MCP flexion much MCP flexion
Thumb / scaphoid Thumb spica Thumb / scaphoid Thumb spica
Tibial plateau Long posterior slab Use Robert Jones cotton Tibial plateau Long posterior slab Use Robert Jones cotton
with 2 side slabs with 2 side slabs
Tibial Shaft Long posterior slab including Use Robert Jones cotton Tibial Shaft Long posterior slab including Use Robert Jones cotton
foot with long stirrup foot with long stirrup
Ankle Posterior slab with stirrup Start applying plaster at calf Ankle Posterior slab with stirrup Start applying plaster at calf
and then double over on foot and then double over on foot
plate if excess. Apply 1 layer of plate if excess. Apply 1 layer of
soft roll in between slab & stirrup soft roll in between slab & stirrup
Foot Posterior slab Foot Posterior slab
23 23
Casting Casting
Short Arm Cast Short Leg Cast Short Arm Cast Short Leg Cast
Pediatrics Volarly do not extend the cast distal to Cast with the ankle dorsiflexed to Pediatrics Volarly do not extend the cast distal to Cast with the ankle dorsiflexed to
the distal transverse palmar crease so 90°. Make sure the tips of the toes are the distal transverse palmar crease so 90°. Make sure the tips of the toes are
In general, fiberglass casts are applied that MCP flexion may occur; dorsally visible. Apply ample soft roll to the In general, fiberglass casts are applied that MCP flexion may occur; dorsally visible. Apply ample soft roll to the
with the following layers in sequential the cast should extend to the heel to avoid a heel ulcer at all costs. with the following layers in sequential the cast should extend to the heel to avoid a heel ulcer at all costs.
order: metacarpal heads. Leave ample room Mold the cast in the shape of the tibia order: metacarpal heads. Leave ample room Mold the cast in the shape of the tibia
- Stockinette (cut out creases); around the thumb. Obtain a good (i.e. triangular shape with crest anteriorly). - Stockinette (cut out creases); around the thumb. Obtain a good (i.e. triangular shape with crest anteriorly).
- Soft roll (at least 2 layers thick); interosseous (A to P) and ulnar mold. - Soft roll (at least 2 layers thick); interosseous (A to P) and ulnar mold.
- Fiberglass (at least 2 layers thick). Long Leg Cast - Fiberglass (at least 2 layers thick). Long Leg Cast
- Over-wrap with ACE wrap after Long Arm Cast - Over-wrap with ACE wrap after Long Arm Cast
bivalving the cast. Same as for short leg cast. In bivalving the cast. Same as for short leg cast. In
As above, but cast with the elbow addition, cast with the knee flexed at As above, but cast with the elbow addition, cast with the knee flexed at
Take care to avoid pressure points flexed at 90°. Do not bend elbow 30°. This prevents kids from being able Take care to avoid pressure points flexed at 90°. Do not bend elbow 30°. This prevents kids from being able
which may cause cast sores. >90°. Do not bend elbow after rolling to weight-bear. Apply a supracondylar which may cause cast sores. >90°. Do not bend elbow after rolling to weight-bear. Apply a supracondylar
fiberglass. Apply a supracondylar mold. mold (M to L). Extend the cast as fiberglass. Apply a supracondylar mold. mold (M to L). Extend the cast as
Bivalve all casts unless there is Extend the cast as proximal as proximal as possible (it is never as high Bivalve all casts unless there is Extend the cast as proximal as proximal as possible (it is never as high
minimal swelling and a low-energy possible, but avoid impinging on the as you think). It often helps to abduct minimal swelling and a low-energy possible, but avoid impinging on the as you think). It often helps to abduct
mechanism with little potential for axilla. Make sure you wrap the soft roll the hip off of the bed to obtain space mechanism with little potential for axilla. Make sure you wrap the soft roll the hip off of the bed to obtain space
swelling (i.e. buckle fracture), or a with the elbow flexed at 90°, so that under the proximal thigh. Make sure swelling (i.e. buckle fracture), or a with the elbow flexed at 90°, so that under the proximal thigh. Make sure
significant time has elapsed since the wrinkles do not develop. you wrap the soft roll with the knee significant time has elapsed since the wrinkles do not develop. you wrap the soft roll with the knee
injuring event (i.e.> 2 days). flexed so that wrinkles do not develop. injuring event (i.e.> 2 days). flexed so that wrinkles do not develop.
For unstable forearm fxs, forearm fxs Indicated for tibial shaft fractures and For unstable forearm fxs, forearm fxs Indicated for tibial shaft fractures and
Ask a child his or her color preference! which required reduction, & pediatric ankle fractures which required Ask a child his or her color preference! which required reduction, & pediatric ankle fractures which required
elbow frxs using neutral rotation. reduction. elbow frxs using neutral rotation. reduction.
23 23
Casting Casting
Short Arm Cast Short Leg Cast Short Arm Cast Short Leg Cast
Pediatrics Volarly do not extend the cast distal to Cast with the ankle dorsiflexed to Pediatrics Volarly do not extend the cast distal to Cast with the ankle dorsiflexed to
the distal transverse palmar crease so 90°. Make sure the tips of the toes are the distal transverse palmar crease so 90°. Make sure the tips of the toes are
In general, fiberglass casts are applied that MCP flexion may occur; dorsally visible. Apply ample soft roll to the In general, fiberglass casts are applied that MCP flexion may occur; dorsally visible. Apply ample soft roll to the
with the following layers in sequential the cast should extend to the heel to avoid a heel ulcer at all costs. with the following layers in sequential the cast should extend to the heel to avoid a heel ulcer at all costs.
order: metacarpal heads. Leave ample room Mold the cast in the shape of the tibia order: metacarpal heads. Leave ample room Mold the cast in the shape of the tibia
- Stockinette (cut out creases); around the thumb. Obtain a good (i.e. triangular shape with crest anteriorly). - Stockinette (cut out creases); around the thumb. Obtain a good (i.e. triangular shape with crest anteriorly).
- Soft roll (at least 2 layers thick); interosseous (A to P) and ulnar mold. - Soft roll (at least 2 layers thick); interosseous (A to P) and ulnar mold.
- Fiberglass (at least 2 layers thick). Long Leg Cast - Fiberglass (at least 2 layers thick). Long Leg Cast
- Over-wrap with ACE wrap after Long Arm Cast - Over-wrap with ACE wrap after Long Arm Cast
bivalving the cast. Same as for short leg cast. In bivalving the cast. Same as for short leg cast. In
As above, but cast with the elbow addition, cast with the knee flexed at As above, but cast with the elbow addition, cast with the knee flexed at
Take care to avoid pressure points flexed at 90°. Do not bend elbow 30°. This prevents kids from being able Take care to avoid pressure points flexed at 90°. Do not bend elbow 30°. This prevents kids from being able
which may cause cast sores. >90°. Do not bend elbow after rolling to weight-bear. Apply a supracondylar which may cause cast sores. >90°. Do not bend elbow after rolling to weight-bear. Apply a supracondylar
fiberglass. Apply a supracondylar mold. mold (M to L). Extend the cast as fiberglass. Apply a supracondylar mold. mold (M to L). Extend the cast as
Bivalve all casts unless there is Extend the cast as proximal as proximal as possible (it is never as high Bivalve all casts unless there is Extend the cast as proximal as proximal as possible (it is never as high
minimal swelling and a low-energy possible, but avoid impinging on the as you think). It often helps to abduct minimal swelling and a low-energy possible, but avoid impinging on the as you think). It often helps to abduct
mechanism with little potential for axilla. Make sure you wrap the soft roll the hip off of the bed to obtain space mechanism with little potential for axilla. Make sure you wrap the soft roll the hip off of the bed to obtain space
swelling (i.e. buckle fracture), or a with the elbow flexed at 90°, so that under the proximal thigh. Make sure swelling (i.e. buckle fracture), or a with the elbow flexed at 90°, so that under the proximal thigh. Make sure
significant time has elapsed since the wrinkles do not develop. you wrap the soft roll with the knee significant time has elapsed since the wrinkles do not develop. you wrap the soft roll with the knee
injuring event (i.e.> 2 days). flexed so that wrinkles do not develop. injuring event (i.e.> 2 days). flexed so that wrinkles do not develop.
For unstable forearm fxs, forearm fxs Indicated for tibial shaft fractures and For unstable forearm fxs, forearm fxs Indicated for tibial shaft fractures and
Ask a child his or her color preference! which required reduction, & pediatric ankle fractures which required Ask a child his or her color preference! which required reduction, & pediatric ankle fractures which required
elbow frxs using neutral rotation. reduction. elbow frxs using neutral rotation. reduction.
24 24
SPICA Cast for Femur Fractures SPICA Cast for Femur Fractures
Requires conscious sedation, Insert towel(s) into abdomen to allow Requires conscious sedation, Insert towel(s) into abdomen to allow
the spica table, and usually 2 appropriate space for breathing and the spica table, and usually 2 appropriate space for breathing and
additional people. abdominal distension. Leave ample additional people. abdominal distension. Leave ample
perineal space for hygiene; use of safety perineal space for hygiene; use of safety
Usually the unaffected extremity is pins on the stockinette is key. Usually the unaffected extremity is pins on the stockinette is key.
casted to include the thigh only and casted to include the thigh only and
the affected extremity is casted distally: Wrap soft roll and fiberglass in spica the affected extremity is casted distally: Wrap soft roll and fiberglass in spica
Dr. Sponseller includes the foot and pattern at hips and around perineum. Dr. Sponseller includes the foot and pattern at hips and around perineum.
ankle; Dr. Leet likes to stop the cast ankle; Dr. Leet likes to stop the cast
above the ankle (make sure you pad Apply a strut of fiberglass over the above the ankle (make sure you pad Apply a strut of fiberglass over the
this area well to avoid heel ulcer). inguinal crease from the thigh to the Cast Saws this area well to avoid heel ulcer). inguinal crease from the thigh to the Cast Saws
abdomen on the affected side to abdomen on the affected side to
The goal position includes 90°of knee reinforce this weak area. Petal cast at Can still cut and burn skin. The goal position includes 90°of knee reinforce this weak area. Petal cast at Can still cut and burn skin.
flexion on the affected extremity, completion (Nurses will usually do Use two hands: one to hold the saw, and flexion on the affected extremity, completion (Nurses will usually do Use two hands: one to hold the saw, and
30-45° of hip abduction, and 45-60° of this). one to prevent diving in. 30-45° of hip abduction, and 45-60° of this). one to prevent diving in.
hip flexion. Use of the mini-C-arm to hip flexion. Use of the mini-C-arm to
check reduction before and during cast Alignment of Femur: Use up and down motion only. check reduction before and during cast Alignment of Femur: Use up and down motion only.
application will prevent the need for No more than 2 cm shortening, application will prevent the need for No more than 2 cm shortening,
recasting and save significant time. 15 degrees var/valg Can wet cast saw with alcohol pad to recasting and save significant time. 15 degrees var/valg Can wet cast saw with alcohol pad to
20 degrees sagittal plane prevent overheating. 20 degrees sagittal plane prevent overheating.
DO NOT MOVE THE SAW DO NOT MOVE THE SAW
DISTALLY WHEN ON THE SKIN! DISTALLY WHEN ON THE SKIN!
That is how cuts are made. Use up and That is how cuts are made. Use up and
down, and only move distally/proximally down, and only move distally/proximally
when on cast surface. when on cast surface.
Bivalve entire cast, not just part of it. Bivalve entire cast, not just part of it.
24 24
SPICA Cast for Femur Fractures SPICA Cast for Femur Fractures
Requires conscious sedation, Insert towel(s) into abdomen to allow Requires conscious sedation, Insert towel(s) into abdomen to allow
the spica table, and usually 2 appropriate space for breathing and the spica table, and usually 2 appropriate space for breathing and
additional people. abdominal distension. Leave ample additional people. abdominal distension. Leave ample
perineal space for hygiene; use of safety perineal space for hygiene; use of safety
Usually the unaffected extremity is pins on the stockinette is key. Usually the unaffected extremity is pins on the stockinette is key.
casted to include the thigh only and casted to include the thigh only and
the affected extremity is casted distally: Wrap soft roll and fiberglass in spica the affected extremity is casted distally: Wrap soft roll and fiberglass in spica
Dr. Sponseller includes the foot and pattern at hips and around perineum. Dr. Sponseller includes the foot and pattern at hips and around perineum.
ankle; Dr. Leet likes to stop the cast ankle; Dr. Leet likes to stop the cast
above the ankle (make sure you pad Apply a strut of fiberglass over the above the ankle (make sure you pad Apply a strut of fiberglass over the
this area well to avoid heel ulcer). inguinal crease from the thigh to the Cast Saws this area well to avoid heel ulcer). inguinal crease from the thigh to the Cast Saws
abdomen on the affected side to abdomen on the affected side to
The goal position includes 90°of knee reinforce this weak area. Petal cast at Can still cut and burn skin. The goal position includes 90°of knee reinforce this weak area. Petal cast at Can still cut and burn skin.
flexion on the affected extremity, completion (Nurses will usually do Use two hands: one to hold the saw, and flexion on the affected extremity, completion (Nurses will usually do Use two hands: one to hold the saw, and
30-45° of hip abduction, and 45-60° of this). one to prevent diving in. 30-45° of hip abduction, and 45-60° of this). one to prevent diving in.
hip flexion. Use of the mini-C-arm to hip flexion. Use of the mini-C-arm to
check reduction before and during cast Alignment of Femur: Use up and down motion only. check reduction before and during cast Alignment of Femur: Use up and down motion only.
application will prevent the need for No more than 2 cm shortening, application will prevent the need for No more than 2 cm shortening,
recasting and save significant time. 15 degrees var/valg Can wet cast saw with alcohol pad to recasting and save significant time. 15 degrees var/valg Can wet cast saw with alcohol pad to
20 degrees sagittal plane prevent overheating. 20 degrees sagittal plane prevent overheating.
DO NOT MOVE THE SAW DO NOT MOVE THE SAW
DISTALLY WHEN ON THE SKIN! DISTALLY WHEN ON THE SKIN!
That is how cuts are made. Use up and That is how cuts are made. Use up and
down, and only move distally/proximally down, and only move distally/proximally
when on cast surface. when on cast surface.
Bivalve entire cast, not just part of it. Bivalve entire cast, not just part of it.
25 25
Traction: Skeletal Traction: Skeletal
Steinman pin trays are kept in both Distal Femoral Steinman pin trays are kept in both Distal Femoral
the Bayview (pyxis) and JHH ER in the Bayview (pyxis) and JHH ER in
the supply room. Also in supply Distal femoral traction pins are the supply room. Also in supply Distal femoral traction pins are
closet in Nelson 8 or 6 Surg (Bay). inserted on medial side to avoid closet in Nelson 8 or 6 Surg (Bay). inserted on medial side to avoid
Bows in the OR at Bayview. injury to the femoral artery. Bows in the OR at Bayview. injury to the femoral artery.
Proximal Tibia It is best to flex the knee and thigh Proximal Tibia It is best to flex the knee and thigh
on several folded sheets to facilitate on several folded sheets to facilitate
Proximal tibial pins are more pin insertion from the opposite side Proximal tibial pins are more pin insertion from the opposite side
commonly used, and are helpful in a of the bed and go from medial to commonly used, and are helpful in a of the bed and go from medial to
femoral shaft fracture in order to lateral. This also facilitates obtaining a femoral shaft fracture in order to lateral. This also facilitates obtaining a
keep the patient out to length, and lateral radiographic view. keep the patient out to length, and lateral radiographic view.
to relieve pain prior to going to the to relieve pain prior to going to the
OR. The entry site is just proximal to the OR. The entry site is just proximal to the
adductor tubercle (proximal to adductor tubercle (proximal to
Contraindications include ligament medial epicondyle and/or growth Contraindications include ligament medial epicondyle and/or growth
injury to ipsilateral knee and should plate ~ 1 finger breadth above injury to ipsilateral knee and should plate ~ 1 finger breadth above
Traction serves several purposes: never be used in children. These pins superior pole of patella when leg in Traction serves several purposes: never be used in children. These pins superior pole of patella when leg in
it aligns the ends of a fracture are inserted from lateral side to extension. it aligns the ends of a fracture are inserted from lateral side to extension.
by pulling the limb into a avoid damaging peroneal nerve. by pulling the limb into a avoid damaging peroneal nerve.
straight position; it ends muscle Distal pin placement risks entering straight position; it ends muscle Distal pin placement risks entering
spasm and relieves pain. The pin insertion site is 2.5 cm joint at intercondylar notch, and spasm and relieves pain. The pin insertion site is 2.5 cm joint at intercondylar notch, and
posterior to and 2.5 cm distal to more proximal pin insertion risks posterior to and 2.5 cm distal to more proximal pin insertion risks
Skeletal Traction tibial tubercle. Make a skin incision injury to femoral artery at Hunter’s Skeletal Traction tibial tubercle. Make a skin incision injury to femoral artery at Hunter’s
about 1 cm in length, placed about 3 canal. about 1 cm in length, placed about 3 canal.
Skeletal traction is performed when cm below the tibial tubercle. Skeletal traction is performed when cm below the tibial tubercle.
more force is needed than can be As the short longitudinal incision is more force is needed than can be As the short longitudinal incision is
withstood by skin traction. Skeletal Use smooth pins. Protect the cut made, turn the knife 90 deg (once it withstood by skin traction. Skeletal Use smooth pins. Protect the cut made, turn the knife 90 deg (once it
traction uses weights of 25-40 ends of the pins with test tubes or is buried under the skin) in order to traction uses weights of 25-40 ends of the pins with test tubes or is buried under the skin) in order to
pounds. balls supplied. make a small transverse nick in the pounds. balls supplied. make a small transverse nick in the
IT band. Place pin perpendicular to IT band. Place pin perpendicular to
This is an invasive procedure that is knee joint rather than perpendicular This is an invasive procedure that is knee joint rather than perpendicular
done either in an operating room or to femoral shaft. done either in an operating room or to femoral shaft.
in the E.R. with local anesthesia. in the E.R. with local anesthesia.
25 25
Steinman pin trays are kept in both Distal Femoral Steinman pin trays are kept in both Distal Femoral
the Bayview (pyxis) and JHH ER in the Bayview (pyxis) and JHH ER in
the supply room. Also in supply Distal femoral traction pins are the supply room. Also in supply Distal femoral traction pins are
closet in Nelson 8 or 6 Surg (Bay). inserted on medial side to avoid closet in Nelson 8 or 6 Surg (Bay). inserted on medial side to avoid
Bows in the OR at Bayview. injury to the femoral artery. Bows in the OR at Bayview. injury to the femoral artery.
Proximal Tibia It is best to flex the knee and thigh Proximal Tibia It is best to flex the knee and thigh
on several folded sheets to facilitate on several folded sheets to facilitate
Proximal tibial pins are more pin insertion from the opposite side Proximal tibial pins are more pin insertion from the opposite side
commonly used, and are helpful in a of the bed and go from medial to commonly used, and are helpful in a of the bed and go from medial to
femoral shaft fracture in order to lateral. This also facilitates obtaining a femoral shaft fracture in order to lateral. This also facilitates obtaining a
keep the patient out to length, and lateral radiographic view. keep the patient out to length, and lateral radiographic view.
to relieve pain prior to going to the to relieve pain prior to going to the
OR. The entry site is just proximal to the OR. The entry site is just proximal to the
adductor tubercle (proximal to adductor tubercle (proximal to
Contraindications include ligament medial epicondyle and/or growth Contraindications include ligament medial epicondyle and/or growth
injury to ipsilateral knee and should plate ~ 1 finger breadth above injury to ipsilateral knee and should plate ~ 1 finger breadth above
Traction serves several purposes: never be used in children. These pins superior pole of patella when leg in Traction serves several purposes: never be used in children. These pins superior pole of patella when leg in
it aligns the ends of a fracture are inserted from lateral side to extension. it aligns the ends of a fracture are inserted from lateral side to extension.
by pulling the limb into a avoid damaging peroneal nerve. by pulling the limb into a avoid damaging peroneal nerve.
straight position; it ends muscle Distal pin placement risks entering straight position; it ends muscle Distal pin placement risks entering
spasm and relieves pain. The pin insertion site is 2.5 cm joint at intercondylar notch, and spasm and relieves pain. The pin insertion site is 2.5 cm joint at intercondylar notch, and
posterior to and 2.5 cm distal to more proximal pin insertion risks posterior to and 2.5 cm distal to more proximal pin insertion risks
Skeletal Traction tibial tubercle. Make a skin incision injury to femoral artery at Hunter’s Skeletal Traction tibial tubercle. Make a skin incision injury to femoral artery at Hunter’s
about 1 cm in length, placed about 3 canal. about 1 cm in length, placed about 3 canal.
Skeletal traction is performed when cm below the tibial tubercle. Skeletal traction is performed when cm below the tibial tubercle.
more force is needed than can be As the short longitudinal incision is more force is needed than can be As the short longitudinal incision is
withstood by skin traction. Skeletal Use smooth pins. Protect the cut made, turn the knife 90 deg (once it withstood by skin traction. Skeletal Use smooth pins. Protect the cut made, turn the knife 90 deg (once it
traction uses weights of 25-40 ends of the pins with test tubes or is buried under the skin) in order to traction uses weights of 25-40 ends of the pins with test tubes or is buried under the skin) in order to
pounds. balls supplied. make a small transverse nick in the pounds. balls supplied. make a small transverse nick in the
IT band. Place pin perpendicular to IT band. Place pin perpendicular to
This is an invasive procedure that is knee joint rather than perpendicular This is an invasive procedure that is knee joint rather than perpendicular
done either in an operating room or to femoral shaft. done either in an operating room or to femoral shaft.
in the E.R. with local anesthesia. in the E.R. with local anesthesia.
26 26
cont. The pulley system is adjusted to
obtain the necessary angle of
traction. Hip flexion is secured with a traction. Hip flexion is secured with a
folded blanket posterior to the thigh folded blanket posterior to the thigh
or a sling about the thigh attached to or a sling about the thigh attached to
a weight through a pulley system. a weight through a pulley system.
The contra-lateral extremity is The contra-lateral extremity is
Preparation likewise padded, wrapped, and placed Preparation likewise padded, wrapped, and placed
in traction. in traction.
Prep the area well with betadine and Prep the area well with betadine and
have all of your equipment ready in Elevate the foot of the bed to have all of your equipment ready in Elevate the foot of the bed to
order to keep things sterile. Traction: Skin prevent a child from sliding down the order to keep things sterile. Traction: Skin prevent a child from sliding down the
bed because of the traction. bed because of the traction.
Inject 1% lidocaine into the skin and The skin should be cleansed and Inject 1% lidocaine into the skin and The skin should be cleansed and
down to bone around the areas then prepared with a non-allergenic Skin traction uses five-to seven down to bone around the areas then prepared with a non-allergenic Skin traction uses five-to seven
where your insertion and exit sites adherent dressing to prevent skin pound weights depending on the size where your insertion and exit sites adherent dressing to prevent skin pound weights depending on the size
will be. irritation. Make sure that the leg and and weight of the child. will be. irritation. Make sure that the leg and and weight of the child.
Make your incision as above and bony prominences of the malleoli and The amount of weight that can be Make your incision as above and bony prominences of the malleoli and The amount of weight that can be
place pin medial to lateral. heel are well protected with cast applied through skin traction is place pin medial to lateral. heel are well protected with cast applied through skin traction is
padding, and that the leg is wrapped. limited because excessive weight will padding, and that the leg is wrapped. limited because excessive weight will
Finally, check an x-ray after you are irritate the skin and cause it to Finally, check an x-ray after you are irritate the skin and cause it to
finished to make certain you are in Apply adhesive straps to the cotton finished to make certain you are in Apply adhesive straps to the cotton
padding both medially and laterally slough off. padding both medially and laterally slough off.
bone and not in the joint. bone and not in the joint.
and secure with an overwrap of an and secure with an overwrap of an
Keep the pin sites covered with ace wrap. The straps are attached to Keep the pin sites covered with ace wrap. The straps are attached to
sterile guaze or xeroform until going a footplate, which is connected to sterile guaze or xeroform until going a footplate, which is connected to
to the OR, where the pin will likely the desired weights through a pulley to the OR, where the pin will likely the desired weights through a pulley
be removed. system. be removed. system.
26 26
traction. Hip flexion is secured with a traction. Hip flexion is secured with a
folded blanket posterior to the thigh folded blanket posterior to the thigh
or a sling about the thigh attached to or a sling about the thigh attached to
a weight through a pulley system. a weight through a pulley system.
The contra-lateral extremity is The contra-lateral extremity is
Preparation likewise padded, wrapped, and placed Preparation likewise padded, wrapped, and placed
in traction. in traction.
Prep the area well with betadine and Prep the area well with betadine and
have all of your equipment ready in Elevate the foot of the bed to have all of your equipment ready in Elevate the foot of the bed to
order to keep things sterile. Traction: Skin prevent a child from sliding down the order to keep things sterile. Traction: Skin prevent a child from sliding down the
bed because of the traction. bed because of the traction.
Inject 1% lidocaine into the skin and The skin should be cleansed and Inject 1% lidocaine into the skin and The skin should be cleansed and
down to bone around the areas then prepared with a non-allergenic Skin traction uses five-to seven down to bone around the areas then prepared with a non-allergenic Skin traction uses five-to seven
where your insertion and exit sites adherent dressing to prevent skin pound weights depending on the size where your insertion and exit sites adherent dressing to prevent skin pound weights depending on the size
will be. irritation. Make sure that the leg and and weight of the child. will be. irritation. Make sure that the leg and and weight of the child.
Make your incision as above and bony prominences of the malleoli and The amount of weight that can be Make your incision as above and bony prominences of the malleoli and The amount of weight that can be
place pin medial to lateral. heel are well protected with cast applied through skin traction is place pin medial to lateral. heel are well protected with cast applied through skin traction is
padding, and that the leg is wrapped. limited because excessive weight will padding, and that the leg is wrapped. limited because excessive weight will
Finally, check an x-ray after you are irritate the skin and cause it to Finally, check an x-ray after you are irritate the skin and cause it to
finished to make certain you are in Apply adhesive straps to the cotton finished to make certain you are in Apply adhesive straps to the cotton
padding both medially and laterally slough off. padding both medially and laterally slough off.
bone and not in the joint. bone and not in the joint.
and secure with an overwrap of an and secure with an overwrap of an
Keep the pin sites covered with ace wrap. The straps are attached to Keep the pin sites covered with ace wrap. The straps are attached to
sterile guaze or xeroform until going a footplate, which is connected to sterile guaze or xeroform until going a footplate, which is connected to
to the OR, where the pin will likely the desired weights through a pulley to the OR, where the pin will likely the desired weights through a pulley
be removed. system. be removed. system.
27 27
Aspirations Aspirations
General: Bursa Ankle General: Bursa Ankle
1. Sterile technique: alcohol prep, Olecranon, prepatellar: Needle only; Mark out relevant anatomy (anterior 1. Sterile technique: alcohol prep, Olecranon, prepatellar: Needle only; Mark out relevant anatomy (anterior
then betadine or chlorhexidine. may leave an angio cath 16 ga for tibial tendon, extensor hallucis then betadine or chlorhexidine. may leave an angio cath 16 ga for tibial tendon, extensor hallucis
daily lavage if pt is being admitted. longus, dorsalis pedis, medial daily lavage if pt is being admitted. longus, dorsalis pedis, medial
2. Lidocaine local. malleolus). 2. Lidocaine local. malleolus).
Do not I & D: they drain forever!! Do not I & D: they drain forever!!
3. Aspirate with at least 1 ½ inch 20 Anteromedial Approach: Identify soft 3. Aspirate with at least 1 ½ inch 20 Anteromedial Approach: Identify soft
ga, preferably 19 ga, consider spinal spot medial to anterior tibial tendon. ga, preferably 19 ga, consider spinal spot medial to anterior tibial tendon.
needles. needles.
Elbow Prep area (see General) Elbow Prep area (see General)
4. Tap until dry. Document neurovascular exam prior 4. Tap until dry. Document neurovascular exam prior
to aspiration. Aspirate with 18/19 gauge needle to aspiration. Aspirate with 18/19 gauge needle
5. Send Red and Green tops, sterile until dry. 5. Send Red and Green tops, sterile until dry.
collecting cup/tube for culture. Mark out relevant anatomy (lateral collecting cup/tube for culture. Mark out relevant anatomy (lateral
Be careful with transferring fluid to tubes. epicondyle, radial head, olecranon). Post aspiration, document Be careful with transferring fluid to tubes. epicondyle, radial head, olecranon). Post aspiration, document
neurovascular exam. neurovascular exam.
6. Place order in POE. Midlateral/Direct lateral Approach: 6. Place order in POE. Midlateral/Direct lateral Approach:
Draw triangle connecting lateral Draw triangle connecting lateral
7. Print labels & place in biohazard epicondyle, radial head & olecranon 7. Print labels & place in biohazard epicondyle, radial head & olecranon
bag with specimen. and identify soft spot at center of Hips and shoulders should be bag with specimen. and identify soft spot at center of Hips and shoulders should be
triangle. done with fluoro guidance to triangle. done with fluoro guidance to
ensure that it is intraarticular. ensure that it is intraarticular.
Gram Stain Prep area (see General). Talk to radiology. Gram Stain Prep area (see General). Talk to radiology.
Cultures-aerobic/anaerobic Cultures-aerobic/anaerobic
(add fungal if immunocomp) Aspirate with 18/19 gauge needle (add fungal if immunocomp) Aspirate with 18/19 gauge needle
until dry. until dry.
Cell Count and Differential Cell Count and Differential
Crystals Post aspiration, document Crystals Post aspiration, document
Sometimes glucose neurovascular exam. Sometimes glucose neurovascular exam.
7. Walk it down to lab yourself!!! 7. Walk it down to lab yourself!!!
27 27
Aspirations Aspirations
General: Bursa Ankle General: Bursa Ankle
1. Sterile technique: alcohol prep, Olecranon, prepatellar: Needle only; Mark out relevant anatomy (anterior 1. Sterile technique: alcohol prep, Olecranon, prepatellar: Needle only; Mark out relevant anatomy (anterior
then betadine or chlorhexidine. may leave an angio cath 16 ga for tibial tendon, extensor hallucis then betadine or chlorhexidine. may leave an angio cath 16 ga for tibial tendon, extensor hallucis
daily lavage if pt is being admitted. longus, dorsalis pedis, medial daily lavage if pt is being admitted. longus, dorsalis pedis, medial
2. Lidocaine local. malleolus). 2. Lidocaine local. malleolus).
Do not I & D: they drain forever!! Do not I & D: they drain forever!!
3. Aspirate with at least 1 ½ inch 20 Anteromedial Approach: Identify soft 3. Aspirate with at least 1 ½ inch 20 Anteromedial Approach: Identify soft
ga, preferably 19 ga, consider spinal spot medial to anterior tibial tendon. ga, preferably 19 ga, consider spinal spot medial to anterior tibial tendon.
needles. needles.
Elbow Prep area (see General) Elbow Prep area (see General)
4. Tap until dry. Document neurovascular exam prior 4. Tap until dry. Document neurovascular exam prior
to aspiration. Aspirate with 18/19 gauge needle to aspiration. Aspirate with 18/19 gauge needle
5. Send Red and Green tops, sterile until dry. 5. Send Red and Green tops, sterile until dry.
collecting cup/tube for culture. Mark out relevant anatomy (lateral collecting cup/tube for culture. Mark out relevant anatomy (lateral
Be careful with transferring fluid to tubes. epicondyle, radial head, olecranon). Post aspiration, document Be careful with transferring fluid to tubes. epicondyle, radial head, olecranon). Post aspiration, document
neurovascular exam. neurovascular exam.
6. Place order in POE. Midlateral/Direct lateral Approach: 6. Place order in POE. Midlateral/Direct lateral Approach:
Draw triangle connecting lateral Draw triangle connecting lateral
7. Print labels & place in biohazard epicondyle, radial head & olecranon 7. Print labels & place in biohazard epicondyle, radial head & olecranon
bag with specimen. and identify soft spot at center of Hips and shoulders should be bag with specimen. and identify soft spot at center of Hips and shoulders should be
triangle. done with fluoro guidance to triangle. done with fluoro guidance to
ensure that it is intraarticular. ensure that it is intraarticular.
Gram Stain Prep area (see General). Talk to radiology. Gram Stain Prep area (see General). Talk to radiology.
Cultures-aerobic/anaerobic Cultures-aerobic/anaerobic
(add fungal if immunocomp) Aspirate with 18/19 gauge needle (add fungal if immunocomp) Aspirate with 18/19 gauge needle
until dry. until dry.
Cell Count and Differential Cell Count and Differential
Crystals Post aspiration, document Crystals Post aspiration, document
Sometimes glucose neurovascular exam. Sometimes glucose neurovascular exam.
7. Walk it down to lab yourself!!! 7. Walk it down to lab yourself!!!

28 28
Injections Injections
Joint: Abcess Joint: Abcess
Prep the area with betadine and Prep the area with betadine and
alcohol. IVDA: Need x-rays and CT scan w alcohol. IVDA: Need x-rays and CT scan w
contrast minimum prior to cutting contrast minimum prior to cutting
Knee-supralateral or supramedial. skin. Knee-supralateral or supramedial. skin.
Can also go anterolateral/medial, but Can also go anterolateral/medial, but
need to flex knee close to 90°. need to flex knee close to 90°.
Shoulder Gas Gangrene? Needs OR Shoulder Gas Gangrene? Needs OR
Subacromial bursa: Posterolateral debridement. Call General Surgery. Subacromial bursa: Posterolateral debridement. Call General Surgery.
aspect of acromion. Slide under aspect of acromion. Slide under
bone. Be wary of mycotic aneurysms in bone. Be wary of mycotic aneurysms in
Joint IVDA patients. Joint IVDA patients.
Tough to know if you are really in. Consider dopplers if concerned. Tough to know if you are really in. Consider dopplers if concerned.
Can go from posterolateral shoulder Sterilely prep area. Incise skin along Can go from posterolateral shoulder Sterilely prep area. Incise skin along
or anterior between coracoid and Langer’s lines. or anterior between coracoid and Langer’s lines.
AC joint. Discuss with Chief/ AC joint. Discuss with Chief/
Attending. Send cultures. Attending. Send cultures.
Pack and dress wound. Pack and dress wound.
IV antibiotics vs. po (see if patient IV antibiotics vs. po (see if patient
can go to EACU). can go to EACU).
28 28
Injections Injections
Joint: Abcess Joint: Abcess
Prep the area with betadine and Prep the area with betadine and
alcohol. IVDA: Need x-rays and CT scan w alcohol. IVDA: Need x-rays and CT scan w
contrast minimum prior to cutting contrast minimum prior to cutting
Knee-supralateral or supramedial. skin. Knee-supralateral or supramedial. skin.
Can also go anterolateral/medial, but Can also go anterolateral/medial, but
need to flex knee close to 90°. need to flex knee close to 90°.
Shoulder Gas Gangrene? Needs OR Shoulder Gas Gangrene? Needs OR
Subacromial bursa: Posterolateral debridement. Call General Surgery. Subacromial bursa: Posterolateral debridement. Call General Surgery.
aspect of acromion. Slide under aspect of acromion. Slide under
bone. Be wary of mycotic aneurysms in bone. Be wary of mycotic aneurysms in
Joint IVDA patients. Joint IVDA patients.
Tough to know if you are really in. Consider dopplers if concerned. Tough to know if you are really in. Consider dopplers if concerned.
Can go from posterolateral shoulder Sterilely prep area. Incise skin along Can go from posterolateral shoulder Sterilely prep area. Incise skin along
or anterior between coracoid and Langer’s lines. or anterior between coracoid and Langer’s lines.
AC joint. Discuss with Chief/ AC joint. Discuss with Chief/
Attending. Send cultures. Attending. Send cultures.
Pack and dress wound. Pack and dress wound.
IV antibiotics vs. po (see if patient IV antibiotics vs. po (see if patient
can go to EACU). can go to EACU).
29 29
Preop Checklist Preop Checklist
IV History Films IV History Films
PREOPERATIVE Physical Should be printed for all operative PREOPERATIVE Physical Should be printed for all operative
cases, and box brought to Board. cases, and box brought to Board.
C A R E NEED heart and lung exam C A R E NEED heart and lung exam
Chest Xray, EKG Chest Xray, EKG
Consent Consent
Labs Labs
Attending is not listed as “staff”. List CBC Type & Cross Attending is not listed as “staff”. List CBC Type & Cross
an attending (Adult, Peds, Shock Chemistry - 2 Units an attending (Adult, Peds, Shock Chemistry - 2 Units
Trauma, Fellows). List all possible Coags BHC-G Trauma, Fellows). List all possible Coags BHC-G
procedures including fasciotomy. UA Type & Screen procedures including fasciotomy. UA Type & Screen
Standard Risks & Specific Risks Mark Site Standard Risks & Specific Risks Mark Site
Bleeding, infection, non-union, D/C Blood Thinners Bleeding, infection, non-union, D/C Blood Thinners
malunion, injury to nerves or vessels, Lovenox, Coumadin, ASA, Plavix... malunion, injury to nerves or vessels, Lovenox, Coumadin, ASA, Plavix...
weakness, numbness, pain, hardware weakness, numbness, pain, hardware
failure, breakage, loosening, NPO failure, breakage, loosening, NPO
compartment syndrome, loss of compartment syndrome, loss of
function, arthritis, need for additional Consults function, arthritis, need for additional Consults
procedures, limp, cosmetic deformity, Medicine Anesthesia procedures, limp, cosmetic deformity, Medicine Anesthesia
leg length discrepancy (total hip, Posted leg length discrepancy (total hip, Posted
femoral nail etc.), reflex sympathetic femoral nail etc.), reflex sympathetic
dystrophy, stiffness. Patients discharged to follow up. dystrophy, stiffness. Patients discharged to follow up.
Peds Risks Preop fully - including contact Peds Risks Preop fully - including contact
numbers numbers
Growth plate injury causing leg Growth plate injury causing leg
length discrepancy Level 1A: must stay with patient length discrepancy Level 1A: must stay with patient
and personally bring to O.R. and personally bring to O.R.
Blood consent Blood consent
29 29
Preop Checklist Preop Checklist
IV History Films IV History Films
PREOPERATIVE Physical Should be printed for all operative PREOPERATIVE Physical Should be printed for all operative
cases, and box brought to Board. cases, and box brought to Board.
C A R E NEED heart and lung exam C A R E NEED heart and lung exam
Chest Xray, EKG Chest Xray, EKG
Consent Consent
Labs Labs
Attending is not listed as “staff”. List CBC Type & Cross Attending is not listed as “staff”. List CBC Type & Cross
an attending (Adult, Peds, Shock Chemistry - 2 Units an attending (Adult, Peds, Shock Chemistry - 2 Units
Trauma, Fellows). List all possible Coags BHC-G Trauma, Fellows). List all possible Coags BHC-G
procedures including fasciotomy. UA Type & Screen procedures including fasciotomy. UA Type & Screen
Standard Risks & Specific Risks Mark Site Standard Risks & Specific Risks Mark Site
Bleeding, infection, non-union, D/C Blood Thinners Bleeding, infection, non-union, D/C Blood Thinners
malunion, injury to nerves or vessels, Lovenox, Coumadin, ASA, Plavix... malunion, injury to nerves or vessels, Lovenox, Coumadin, ASA, Plavix...
weakness, numbness, pain, hardware weakness, numbness, pain, hardware
failure, breakage, loosening, NPO failure, breakage, loosening, NPO
compartment syndrome, loss of compartment syndrome, loss of
function, arthritis, need for additional Consults function, arthritis, need for additional Consults
procedures, limp, cosmetic deformity, Medicine Anesthesia procedures, limp, cosmetic deformity, Medicine Anesthesia
leg length discrepancy (total hip, Posted leg length discrepancy (total hip, Posted
femoral nail etc.), reflex sympathetic femoral nail etc.), reflex sympathetic
dystrophy, stiffness. Patients discharged to follow up. dystrophy, stiffness. Patients discharged to follow up.
Peds Risks Preop fully - including contact Peds Risks Preop fully - including contact
numbers numbers
Growth plate injury causing leg Growth plate injury causing leg
length discrepancy Level 1A: must stay with patient length discrepancy Level 1A: must stay with patient
and personally bring to O.R. and personally bring to O.R.
Blood consent Blood consent
30 30
Electrocautery Electrocautery
V (Bovie) V (Bovie)
O P E R AT I N G The Bovie should not be used in the
presence of any flammable liquid
ROOM SAFETY (alcohol or tincture based agents). ROOM SAFETY (alcohol or tincture based agents).
Make sure the patient is not in Make sure the patient is not in
contact with any metal parts of the contact with any metal parts of the
table. table.
Once bovie pad has been placed on Once bovie pad has been placed on
body do not remove it and replace it body do not remove it and replace it
on the skin, once it is removed a new on the skin, once it is removed a new
pad should be opened. pad should be opened.
When not in use the active electrode When not in use the active electrode
(the bovie pencil) should be placed in (the bovie pencil) should be placed in
a clean, dry , nonconductive plastic a clean, dry , nonconductive plastic
container within the surgical field. container within the surgical field.
The electrode gel pad should be The electrode gel pad should be
placed on the positioned patient, on placed on the positioned patient, on
clean dry skin over a large muscle clean dry skin over a large muscle
mass as close to the operative field mass as close to the operative field
as possible, limbs with metal implants as possible, limbs with metal implants
should be avoided. should be avoided.
The skin should be inspected before The skin should be inspected before
and after removal of the pad. Keep and after removal of the pad. Keep
area dry avoid allowing liquids area dry avoid allowing liquids
especially prep solutions from especially prep solutions from
coming in contact with pad site. coming in contact with pad site.
30 30
Electrocautery Electrocautery
V (Bovie) V (Bovie)
ROOM SAFETY (alcohol or tincture based agents). ROOM SAFETY (alcohol or tincture based agents).
Make sure the patient is not in Make sure the patient is not in
contact with any metal parts of the contact with any metal parts of the
table. table.
Once bovie pad has been placed on Once bovie pad has been placed on
body do not remove it and replace it body do not remove it and replace it
on the skin, once it is removed a new on the skin, once it is removed a new
pad should be opened. pad should be opened.
When not in use the active electrode When not in use the active electrode
(the bovie pencil) should be placed in (the bovie pencil) should be placed in
a clean, dry , nonconductive plastic a clean, dry , nonconductive plastic
container within the surgical field. container within the surgical field.
The electrode gel pad should be The electrode gel pad should be
placed on the positioned patient, on placed on the positioned patient, on
clean dry skin over a large muscle clean dry skin over a large muscle
mass as close to the operative field mass as close to the operative field
as possible, limbs with metal implants as possible, limbs with metal implants
should be avoided. should be avoided.
The skin should be inspected before The skin should be inspected before
and after removal of the pad. Keep and after removal of the pad. Keep
area dry avoid allowing liquids area dry avoid allowing liquids
especially prep solutions from especially prep solutions from
coming in contact with pad site. coming in contact with pad site.
31 31
Tourniquet Tourniquet
When placing a tourniquet on an Tourniquet pressures depend on the When placing a tourniquet on an Tourniquet pressures depend on the
extremity the tourniquet should patient’s age, blood pressure and extremity the tourniquet should patient’s age, blood pressure and
overlap at least 3 inches, but no more limb size, but should never exceed overlap at least 3 inches, but no more limb size, but should never exceed
than 6 inches. 400mm Hg. than 6 inches. 400mm Hg.
The cuff should be placed at the Normal settings are 100mm Hg over The cuff should be placed at the Normal settings are 100mm Hg over
point of maximum limb circumference the patients SBP. point of maximum limb circumference the patients SBP.
( i.e. the proximal thigh). ( i.e. the proximal thigh).
Do not leave the tourniquet cuff Do not leave the tourniquet cuff
Padding in the form of stockinet inflated on an arm for greater Padding in the form of stockinet inflated on an arm for greater
supplied with cuff of web role should than 2 hours or on a thigh greater supplied with cuff of web role should than 2 hours or on a thigh greater
be applied prior to cuff positioning than 2 hours. be applied prior to cuff positioning than 2 hours.
this should be wrinkle free. this should be wrinkle free.
Prior to inflating the tourniquet the Prior to inflating the tourniquet the
Once applied a cuff should not be limb should be exsanguinated using Once applied a cuff should not be limb should be exsanguinated using
rotated to a new position. an ace wrap or esmarch. rotated to a new position. an ace wrap or esmarch.
Liquids and skin preparations should Liquids and skin preparations should
not be allowed to collect or pool not be allowed to collect or pool
under the cuff. under the cuff.
A U drape should be applied one A U drape should be applied one
inch below the distal edge of the cuff inch below the distal edge of the cuff
prior to the use of skin prep prior to the use of skin prep
solutions. solutions.
31 31
Tourniquet Tourniquet
When placing a tourniquet on an Tourniquet pressures depend on the When placing a tourniquet on an Tourniquet pressures depend on the
extremity the tourniquet should patient’s age, blood pressure and extremity the tourniquet should patient’s age, blood pressure and
overlap at least 3 inches, but no more limb size, but should never exceed overlap at least 3 inches, but no more limb size, but should never exceed
than 6 inches. 400mm Hg. than 6 inches. 400mm Hg.
The cuff should be placed at the Normal settings are 100mm Hg over The cuff should be placed at the Normal settings are 100mm Hg over
point of maximum limb circumference the patients SBP. point of maximum limb circumference the patients SBP.
( i.e. the proximal thigh). ( i.e. the proximal thigh).
Do not leave the tourniquet cuff Do not leave the tourniquet cuff
Padding in the form of stockinet inflated on an arm for greater Padding in the form of stockinet inflated on an arm for greater
supplied with cuff of web role should than 2 hours or on a thigh greater supplied with cuff of web role should than 2 hours or on a thigh greater
be applied prior to cuff positioning than 2 hours. be applied prior to cuff positioning than 2 hours.
this should be wrinkle free. this should be wrinkle free.
Prior to inflating the tourniquet the Prior to inflating the tourniquet the
Once applied a cuff should not be limb should be exsanguinated using Once applied a cuff should not be limb should be exsanguinated using
rotated to a new position. an ace wrap or esmarch. rotated to a new position. an ace wrap or esmarch.
Liquids and skin preparations should Liquids and skin preparations should
not be allowed to collect or pool not be allowed to collect or pool
under the cuff. under the cuff.
A U drape should be applied one A U drape should be applied one
inch below the distal edge of the cuff inch below the distal edge of the cuff
prior to the use of skin prep prior to the use of skin prep
solutions. solutions.
32 32
Surgical Site Marking Surgical Site Marking
The surgeon (At Bayview: this is the The circulating nurse will use the The surgeon (At Bayview: this is the The circulating nurse will use the
attending, Downtown: it is the resident consent form and verbally verify with attending, Downtown: it is the resident consent form and verbally verify with
who consented the patient or who is the attending surgeon, and the who consented the patient or who is the attending surgeon, and the
doing the surgery) should identify anesthesia care provider, as well as doing the surgery) should identify anesthesia care provider, as well as
the patient and confirm the any scrub personnel caring for the the patient and confirm the any scrub personnel caring for the
operative side and level. patient, that the patient’s name, operative side and level. patient, that the patient’s name,
surgical side, site, and level are surgical side, site, and level are
Once this is done he/she MUST correct. Once this is done he/she MUST correct.
mark that side and or level with his mark that side and or level with his
or her initials in the center of or her initials in the center of
the surgical field, as close to the the surgical field, as close to the
middle of where the patient will be middle of where the patient will be
prepped and draped, and so that, Post-Op Orders prepped and draped, and so that, Post-Op Orders
once draped, the initials can be once draped, the initials can be
visible prior to making the incision. Need PT/OT consult. visible prior to making the incision. Need PT/OT consult.
The Informed Consent must be Need WB status & ROM. The Informed Consent must be Need WB status & ROM.
complete and must include the complete and must include the
patient’s name, the description of the Order DVT prophylaxis. patient’s name, the description of the Order DVT prophylaxis.
procedure and must include the side/ procedure and must include the side/
site and level of the surgery. Post-Op Labs site and level of the surgery. Post-Op Labs
A time out MUST be performed Post-Op Antibiotics A time out MUST be performed Post-Op Antibiotics
prior to incision. This is carried out prior to incision. This is carried out
by the attending physician, the nurse Don’t Forget 3 A’s: by the attending physician, the nurse Don’t Forget 3 A’s:
and the anesthesiologist together in and the anesthesiologist together in
a controlled and organized manner. Activity a controlled and organized manner. Activity
Antibiotics Antibiotics
Anticoagulation Anticoagulation
32 32
Surgical Site Marking Surgical Site Marking
The surgeon (At Bayview: this is the The circulating nurse will use the The surgeon (At Bayview: this is the The circulating nurse will use the
attending, Downtown: it is the resident consent form and verbally verify with attending, Downtown: it is the resident consent form and verbally verify with
who consented the patient or who is the attending surgeon, and the who consented the patient or who is the attending surgeon, and the
doing the surgery) should identify anesthesia care provider, as well as doing the surgery) should identify anesthesia care provider, as well as
the patient and confirm the any scrub personnel caring for the the patient and confirm the any scrub personnel caring for the
operative side and level. patient, that the patient’s name, operative side and level. patient, that the patient’s name,
surgical side, site, and level are surgical side, site, and level are
Once this is done he/she MUST correct. Once this is done he/she MUST correct.
mark that side and or level with his mark that side and or level with his
or her initials in the center of or her initials in the center of
the surgical field, as close to the the surgical field, as close to the
middle of where the patient will be middle of where the patient will be
prepped and draped, and so that, Post-Op Orders prepped and draped, and so that, Post-Op Orders
once draped, the initials can be once draped, the initials can be
visible prior to making the incision. Need PT/OT consult. visible prior to making the incision. Need PT/OT consult.
The Informed Consent must be Need WB status & ROM. The Informed Consent must be Need WB status & ROM.
complete and must include the complete and must include the
patient’s name, the description of the Order DVT prophylaxis. patient’s name, the description of the Order DVT prophylaxis.
procedure and must include the side/ procedure and must include the side/
site and level of the surgery. Post-Op Labs site and level of the surgery. Post-Op Labs
A time out MUST be performed Post-Op Antibiotics A time out MUST be performed Post-Op Antibiotics
prior to incision. This is carried out prior to incision. This is carried out
by the attending physician, the nurse Don’t Forget 3 A’s: by the attending physician, the nurse Don’t Forget 3 A’s:
and the anesthesiologist together in and the anesthesiologist together in
a controlled and organized manner. Activity a controlled and organized manner. Activity
Antibiotics Antibiotics
Anticoagulation Anticoagulation
33 33
VI Fluoroscopy
Must have lead on prior to operating
Plain Xray
Always x-ray the joint above and
VI Fluoroscopy
Plain Xray
RADIOLOGY Fluoro. below the injury!!! RADIOLOGY Fluoro. below the injury!!!
Make sure every one in room is At least 2 views of all extremities: Make sure every one in room is At least 2 views of all extremities:
covered prior to fluoroscopy – AP & Lateral. Insist on perfect covered prior to fluoroscopy – AP & Lateral. Insist on perfect
announce that fluoro is being used. laterals, otherwise they will be announce that fluoro is being used. laterals, otherwise they will be
oblique, and YOU, not the XR tech oblique, and YOU, not the XR tech
6 feet minimum safe distance to will be spanked at AM board rounds. 6 feet minimum safe distance to will be spanked at AM board rounds.
avoid radiation if not wearing avoid radiation if not wearing
protection. On Hip xrays obtain cross table protection. On Hip xrays obtain cross table
lateral of affected side. lateral of affected side.
Make sure that you have informed Make sure that you have informed
anesthesia prior to fluoro use so that anesthesia prior to fluoro use so that
they are protected. Special Views they are protected. Special Views
Axillary views on all shoulder Axillary views on all shoulder
Mini C arm films, except, if CT scan shows Mini C arm films, except, if CT scan shows
glenohumeral joint reduced, no need glenohumeral joint reduced, no need
1 foot min safe distance. for axillary. 1 foot min safe distance. for axillary.
Should use xray gown if available. If tech unwilling, you will have to Should use xray gown if available. If tech unwilling, you will have to
Mini C arm is located in Peds ER. position the arm for the film. Mini C arm is located in Peds ER. position the arm for the film.
Make sure you return it after use. Pelvis: Judet views. Evaluate for all Make sure you return it after use. Pelvis: Judet views. Evaluate for all
possible acetabular fx. possible acetabular fx.
Inlet Outlet View if there is Inlet Outlet View if there is
possible disruption of pelvic ring. possible disruption of pelvic ring.
33 33
VI Fluoroscopy
Plain Xray
VI Fluoroscopy
Plain Xray
RADIOLOGY Fluoro. below the injury!!! RADIOLOGY Fluoro. below the injury!!!
Make sure every one in room is At least 2 views of all extremities: Make sure every one in room is At least 2 views of all extremities:
covered prior to fluoroscopy – AP & Lateral. Insist on perfect covered prior to fluoroscopy – AP & Lateral. Insist on perfect
announce that fluoro is being used. laterals, otherwise they will be announce that fluoro is being used. laterals, otherwise they will be
oblique, and YOU, not the XR tech oblique, and YOU, not the XR tech
6 feet minimum safe distance to will be spanked at AM board rounds. 6 feet minimum safe distance to will be spanked at AM board rounds.
avoid radiation if not wearing avoid radiation if not wearing
protection. On Hip xrays obtain cross table protection. On Hip xrays obtain cross table
lateral of affected side. lateral of affected side.
Make sure that you have informed Make sure that you have informed
anesthesia prior to fluoro use so that anesthesia prior to fluoro use so that
they are protected. Special Views they are protected. Special Views
Axillary views on all shoulder Axillary views on all shoulder
Mini C arm films, except, if CT scan shows Mini C arm films, except, if CT scan shows
glenohumeral joint reduced, no need glenohumeral joint reduced, no need
1 foot min safe distance. for axillary. 1 foot min safe distance. for axillary.
Should use xray gown if available. If tech unwilling, you will have to Should use xray gown if available. If tech unwilling, you will have to
Mini C arm is located in Peds ER. position the arm for the film. Mini C arm is located in Peds ER. position the arm for the film.
Make sure you return it after use. Pelvis: Judet views. Evaluate for all Make sure you return it after use. Pelvis: Judet views. Evaluate for all
possible acetabular fx. possible acetabular fx.
Inlet Outlet View if there is Inlet Outlet View if there is
possible disruption of pelvic ring. possible disruption of pelvic ring.
34 34
Radiographic Views for Orthopaedic Trauma Radiographic Views for Orthopaedic Trauma
SPINE: Fracture in one area necessitates x-rays or CT of the whole spine!!! SPINE: Fracture in one area necessitates x-rays or CT of the whole spine!!!
C-SPINE 1. AP/LAT/ODONTOID 2. Flex/Ext views only 3. CT scan for any frx or C-SPINE 1. AP/LAT/ODONTOID 2. Flex/Ext views only 3. CT scan for any frx or
after talking to senior first non-visualized area (C7-T1) after talking to senior first non-visualized area (C7-T1)
T/L-SPINE 1. AP/LAT 2. CT scan for fracture 3. Obliques if you suspect T/L-SPINE 1. AP/LAT 2. CT scan for fracture 3. Obliques if you suspect
traumatic spondylolisthesis. traumatic spondylolisthesis.
SHOULDER 1. AP/AXILLARY VIEW 2. Can get Int/Ext 3. Get CT scan for 4. 40 degree cephalad SHOULDER 1. AP/AXILLARY VIEW 2. Can get Int/Ext 3. Get CT scan for 4. 40 degree cephalad
Do not present a shoulder rotation views operative proximal x-ray & CT scan for Do not present a shoulder rotation views operative proximal x-ray & CT scan for
consult w/o an axillary humerus fractures if SC joint dislocation consult w/o an axillary humerus fractures if SC joint dislocation
view!! If tech unwilling, you intraarticular view!! If tech unwilling, you intraarticular
will have to position the will have to position the
arm for the film. arm for the film.
HUMERAL 1. AP/LAT HUMERAL 1. AP/LAT
SHAFT SHAFT
FOREARM 1. AP/LAT FOREARM 1. AP/LAT
ELBOW 1. AP/LAT Lateral must 2. Obliques & possibly 3. Traction views for 4. Get films of wrist ELBOW 1. AP/LAT Lateral must 2. Obliques & possibly 3. Traction views for 4. Get films of wrist
be dead on for pediatric CT for difficult injuries comminuted frx for radial head frxs be dead on for pediatric CT for difficult injuries comminuted frx for radial head frxs
SC humerus frx SC humerus frx
WRIST 1. AP/LAT/OBLIQUE 2. Traction views for 3. Scaphoid view WRIST 1. AP/LAT/OBLIQUE 2. Traction views for 3. Scaphoid view
ALL distal radius frxs (ulnar deviation AP) ALL distal radius frxs (ulnar deviation AP)
& ALL wrist injuries if indicated & ALL wrist injuries if indicated
HAND 1. 3 views with spot HAND 1. 3 views with spot
view of fingers if you view of fingers if you
need it need it
34 34
Radiographic Views for Orthopaedic Trauma Radiographic Views for Orthopaedic Trauma
SPINE: Fracture in one area necessitates x-rays or CT of the whole spine!!! SPINE: Fracture in one area necessitates x-rays or CT of the whole spine!!!
C-SPINE 1. AP/LAT/ODONTOID 2. Flex/Ext views only 3. CT scan for any frx or C-SPINE 1. AP/LAT/ODONTOID 2. Flex/Ext views only 3. CT scan for any frx or
after talking to senior first non-visualized area (C7-T1) after talking to senior first non-visualized area (C7-T1)
T/L-SPINE 1. AP/LAT 2. CT scan for fracture 3. Obliques if you suspect T/L-SPINE 1. AP/LAT 2. CT scan for fracture 3. Obliques if you suspect
traumatic spondylolisthesis. traumatic spondylolisthesis.
SHOULDER 1. AP/AXILLARY VIEW 2. Can get Int/Ext 3. Get CT scan for 4. 40 degree cephalad SHOULDER 1. AP/AXILLARY VIEW 2. Can get Int/Ext 3. Get CT scan for 4. 40 degree cephalad
Do not present a shoulder rotation views operative proximal x-ray & CT scan for Do not present a shoulder rotation views operative proximal x-ray & CT scan for
consult w/o an axillary humerus fractures if SC joint dislocation consult w/o an axillary humerus fractures if SC joint dislocation
view!! If tech unwilling, you intraarticular view!! If tech unwilling, you intraarticular
will have to position the will have to position the
arm for the film. arm for the film.
HUMERAL 1. AP/LAT HUMERAL 1. AP/LAT
SHAFT SHAFT
FOREARM 1. AP/LAT FOREARM 1. AP/LAT
ELBOW 1. AP/LAT Lateral must 2. Obliques & possibly 3. Traction views for 4. Get films of wrist ELBOW 1. AP/LAT Lateral must 2. Obliques & possibly 3. Traction views for 4. Get films of wrist
be dead on for pediatric CT for difficult injuries comminuted frx for radial head frxs be dead on for pediatric CT for difficult injuries comminuted frx for radial head frxs
SC humerus frx SC humerus frx
WRIST 1. AP/LAT/OBLIQUE 2. Traction views for 3. Scaphoid view WRIST 1. AP/LAT/OBLIQUE 2. Traction views for 3. Scaphoid view
ALL distal radius frxs (ulnar deviation AP) ALL distal radius frxs (ulnar deviation AP)
& ALL wrist injuries if indicated & ALL wrist injuries if indicated
HAND 1. 3 views with spot HAND 1. 3 views with spot
view of fingers if you view of fingers if you
need it need it
35 35
PELVIS 1. AP PELVIS 2. Inlet/Outlet views if 3. Judet views for any PELVIS 1. AP PELVIS 2. Inlet/Outlet views if 3. Judet views for any
there is possible disruption acetabular fracture there is possible disruption acetabular fracture
of pelvic ring (including - Obturator oblique of pelvic ring (including - Obturator oblique
pelvic rami) shows anterior column pelvic rami) shows anterior column
- Inlet shows hemipelvis & posterior wall - Inlet shows hemipelvis & posterior wall
rotation (ie. open book) - Iliac oblique shows rotation (ie. open book) - Iliac oblique shows
- Outlet shows hemipelvis posterior column & - Outlet shows hemipelvis posterior column &
vertical translation anterior wall vertical translation anterior wall
HIP 1. DEDICATED AP & LATERAL OF HIP + AP PELVIS HIP 1. DEDICATED AP & LATERAL OF HIP + AP PELVIS
- AP Pelvis is not an AP of the hip. Get a dedicated view. - AP Pelvis is not an AP of the hip. Get a dedicated view.
- Best AP of femoral neck is a 15 degree internal rotation AP. You often have to hold for these. - Best AP of femoral neck is a 15 degree internal rotation AP. You often have to hold for these.
- Get femur films for templating / looking for distal lesions. - Get femur films for templating / looking for distal lesions.
FEMORAL 1. AP/LAT 2. A/P & lateral of hip to FEMORAL 1. AP/LAT 2. A/P & lateral of hip to
SHAFT rule out concomitant SHAFT rule out concomitant
femoral neck fractures femoral neck fractures
KNEE 1. AP/LAT 2. Obliques for tibial 3. CT scan for all 4. Traction views & KNEE 1. AP/LAT 2. Obliques for tibial 3. CT scan for all 4. Traction views &
plateau fracture tibial plateau frxs CT scan for displaced plateau fracture tibial plateau frxs CT scan for displaced
distal femur frx distal femur frx
TIBIAL 1. AP/LAT TIBIAL 1. AP/LAT
SHAFT SHAFT
ANKLE 1. AP/LAT/MORTISE 2. CT scan for 3. Stress views for 4.Tib/Fib for 5. Foot films ANKLE 1. AP/LAT/MORTISE 2. CT scan for 3. Stress views for 4.Tib/Fib for 5. Foot films
Pilon fractures isolated lateral malleolus Maisonneuve frx if if tender in foot Pilon fractures isolated lateral malleolus Maisonneuve frx if if tender in foot
fractures (lidocaine block) tender over prox fib fractures (lidocaine block) tender over prox fib
FOOT 1. AP/LAT/OBLIQUE 2. CT scan for all 3. Harris (axial 4. Weight-bearing FOOT 1. AP/LAT/OBLIQUE 2. CT scan for all 3. Harris (axial 4. Weight-bearing
hindfoot & midfoot calcaneus) for AP if you suspect hindfoot & midfoot calcaneus) for AP if you suspect
fractures calcaneus frx Lisfranc injury fractures calcaneus frx Lisfranc injury
35 35
PELVIS 1. AP PELVIS 2. Inlet/Outlet views if 3. Judet views for any PELVIS 1. AP PELVIS 2. Inlet/Outlet views if 3. Judet views for any
there is possible disruption acetabular fracture there is possible disruption acetabular fracture
of pelvic ring (including - Obturator oblique of pelvic ring (including - Obturator oblique
pelvic rami) shows anterior column pelvic rami) shows anterior column
- Inlet shows hemipelvis & posterior wall - Inlet shows hemipelvis & posterior wall
rotation (ie. open book) - Iliac oblique shows rotation (ie. open book) - Iliac oblique shows
- Outlet shows hemipelvis posterior column & - Outlet shows hemipelvis posterior column &
vertical translation anterior wall vertical translation anterior wall
HIP 1. DEDICATED AP & LATERAL OF HIP + AP PELVIS HIP 1. DEDICATED AP & LATERAL OF HIP + AP PELVIS
- AP Pelvis is not an AP of the hip. Get a dedicated view. - AP Pelvis is not an AP of the hip. Get a dedicated view.
- Best AP of femoral neck is a 15 degree internal rotation AP. You often have to hold for these. - Best AP of femoral neck is a 15 degree internal rotation AP. You often have to hold for these.
- Get femur films for templating / looking for distal lesions. - Get femur films for templating / looking for distal lesions.
FEMORAL 1. AP/LAT 2. A/P & lateral of hip to FEMORAL 1. AP/LAT 2. A/P & lateral of hip to
SHAFT rule out concomitant SHAFT rule out concomitant
femoral neck fractures femoral neck fractures
KNEE 1. AP/LAT 2. Obliques for tibial 3. CT scan for all 4. Traction views & KNEE 1. AP/LAT 2. Obliques for tibial 3. CT scan for all 4. Traction views &
plateau fracture tibial plateau frxs CT scan for displaced plateau fracture tibial plateau frxs CT scan for displaced
distal femur frx distal femur frx
TIBIAL 1. AP/LAT TIBIAL 1. AP/LAT
SHAFT SHAFT
ANKLE 1. AP/LAT/MORTISE 2. CT scan for 3. Stress views for 4.Tib/Fib for 5. Foot films ANKLE 1. AP/LAT/MORTISE 2. CT scan for 3. Stress views for 4.Tib/Fib for 5. Foot films
Pilon fractures isolated lateral malleolus Maisonneuve frx if if tender in foot Pilon fractures isolated lateral malleolus Maisonneuve frx if if tender in foot
fractures (lidocaine block) tender over prox fib fractures (lidocaine block) tender over prox fib
FOOT 1. AP/LAT/OBLIQUE 2. CT scan for all 3. Harris (axial 4. Weight-bearing FOOT 1. AP/LAT/OBLIQUE 2. CT scan for all 3. Harris (axial 4. Weight-bearing
hindfoot & midfoot calcaneus) for AP if you suspect hindfoot & midfoot calcaneus) for AP if you suspect
fractures calcaneus frx Lisfranc injury fractures calcaneus frx Lisfranc injury
36 36
VII Night of Surgery Notes (NOS)

Vital Signs. Pain.
document your exam. Check rectal
tone/sensation and rule out saddle
anesthesia in spine patients.
Vital Signs. Pain.
POSTOPERATIVE Any concern for compartment POSTOPERATIVE Any concern for compartment
syndrome? Review I&O’s, check BUN/Cr for syndrome? Review I&O’s, check BUN/Cr for
C A R E kidney status. Evaluate nephrotoxic C A R E kidney status. Evaluate nephrotoxic
Appropriate exams: drugs such as aminoglycoside or Appropriate exams: drugs such as aminoglycoside or
Spine Exam vancomycin. Spine Exam vancomycin.
Fever: Respond to all temps > 38.5. Fever: Respond to all temps > 38.5.
Neurovascular exam for extremities Neurovascular exam for extremities
Low grade fever within first 24-48 Look at op note Evaluate patient for distention. In Low grade fever within first 24-48 Look at op note Evaluate patient for distention. In
hours of surgery is normal, but do pediatric patients may be more hours of surgery is normal, but do pediatric patients may be more
Make sure dressing/splints/VACs are conservative about cathing. Consider Make sure dressing/splints/VACs are conservative about cathing. Consider
not let that fool you. not let that fool you.
intact. checking post void residuals. intact. checking post void residuals.
UA is the most sensitive test for UA is the most sensitive test for
PACU x-rays / Hgb PACU x-rays / Hgb
fever work-up during first 48 hours VAC Dressings fever work-up during first 48 hours VAC Dressings
(due to foley, etc). Send C&S as well. Let chief know about any Must act if suction is not (due to foley, etc). Send C&S as well. Let chief know about any Must act if suction is not
concerns. holding. Cover any openings with concerns. holding. Cover any openings with
Check vitals make sure pt is stable. Check vitals make sure pt is stable.
op-site etc. op-site etc.
Examine incision. Constipation / Ileus Examine incision. Constipation / Ileus
All patients on colace. Dulcolax, fleets, Non-working VAC sponge is a All patients on colace. Dulcolax, fleets, Non-working VAC sponge is a
Check for calf tenderness. If positive or soap suds, Mag Citrate, etc as needed. broth for badness!! Don’t let Check for calf tenderness. If positive or soap suds, Mag Citrate, etc as needed. broth for badness!! Don’t let
suspicious for DVT, order Ultrasound. someone get toxic shock suspicious for DVT, order Ultrasound. someone get toxic shock
Urinary Retention syndrome because you didn’t Urinary Retention syndrome because you didn’t
Chest Xray to eval for Atelectasis check the VAC!!! Chest Xray to eval for Atelectasis check the VAC!!!
Check post void residuals on all Check post void residuals on all
and Pneumonia (if lungs sound junky). and Pneumonia (if lungs sound junky).
spine patients. Cauda Equina? spine patients. Cauda Equina?
Cultures/Infectious Disease Cultures/Infectious Disease
Send blood cultures x 2 if concern Consultations Send blood cultures x 2 if concern Consultations
Straight cath if it’s been greater that Straight cath if it’s been greater that
for sepsis. for sepsis.
8 hours, leave in if output > 300 cc. 8 hours, leave in if output > 300 cc.
Pathology Pathology
Remember: Remember:
Remove foley next am to let Remove foley next am to let
Wind ,Water, Wound, Keep an eye on all cultures and Wind ,Water, Wound, Keep an eye on all cultures and
detrusor muscle relax. detrusor muscle relax.
Walking, Wonder Drug specimens sent from OR!!! Don’t Walking, Wonder Drug specimens sent from OR!!! Don’t
If you straight cath a spine patient miss an infection or other badness!! If you straight cath a spine patient miss an infection or other badness!!
downtown, perform rectal and downtown, perform rectal and
36 36

Vital Signs. Pain.
Vital Signs. Pain.
POSTOPERATIVE Any concern for compartment POSTOPERATIVE Any concern for compartment
syndrome? Review I&O’s, check BUN/Cr for syndrome? Review I&O’s, check BUN/Cr for
C A R E kidney status. Evaluate nephrotoxic C A R E kidney status. Evaluate nephrotoxic
Appropriate exams: drugs such as aminoglycoside or Appropriate exams: drugs such as aminoglycoside or
Spine Exam vancomycin. Spine Exam vancomycin.
Fever: Respond to all temps > 38.5. Fever: Respond to all temps > 38.5.
Neurovascular exam for extremities Neurovascular exam for extremities
Low grade fever within first 24-48 Look at op note Evaluate patient for distention. In Low grade fever within first 24-48 Look at op note Evaluate patient for distention. In
hours of surgery is normal, but do pediatric patients may be more hours of surgery is normal, but do pediatric patients may be more
Make sure dressing/splints/VACs are conservative about cathing. Consider Make sure dressing/splints/VACs are conservative about cathing. Consider
not let that fool you. not let that fool you.
intact. checking post void residuals. intact. checking post void residuals.
UA is the most sensitive test for UA is the most sensitive test for
PACU x-rays / Hgb PACU x-rays / Hgb
fever work-up during first 48 hours VAC Dressings fever work-up during first 48 hours VAC Dressings
(due to foley, etc). Send C&S as well. Let chief know about any Must act if suction is not (due to foley, etc). Send C&S as well. Let chief know about any Must act if suction is not
concerns. holding. Cover any openings with concerns. holding. Cover any openings with
Check vitals make sure pt is stable. Check vitals make sure pt is stable.
op-site etc. op-site etc.
Examine incision. Constipation / Ileus Examine incision. Constipation / Ileus
All patients on colace. Dulcolax, fleets, Non-working VAC sponge is a All patients on colace. Dulcolax, fleets, Non-working VAC sponge is a
Check for calf tenderness. If positive or soap suds, Mag Citrate, etc as needed. broth for badness!! Don’t let Check for calf tenderness. If positive or soap suds, Mag Citrate, etc as needed. broth for badness!! Don’t let
suspicious for DVT, order Ultrasound. someone get toxic shock suspicious for DVT, order Ultrasound. someone get toxic shock
Urinary Retention syndrome because you didn’t Urinary Retention syndrome because you didn’t
Chest Xray to eval for Atelectasis check the VAC!!! Chest Xray to eval for Atelectasis check the VAC!!!
Check post void residuals on all Check post void residuals on all
and Pneumonia (if lungs sound junky). and Pneumonia (if lungs sound junky).
spine patients. Cauda Equina? spine patients. Cauda Equina?
Cultures/Infectious Disease Cultures/Infectious Disease
Send blood cultures x 2 if concern Consultations Send blood cultures x 2 if concern Consultations
Straight cath if it’s been greater that Straight cath if it’s been greater that
for sepsis. for sepsis.
8 hours, leave in if output > 300 cc. 8 hours, leave in if output > 300 cc.
Pathology Pathology
Remember: Remember:
Remove foley next am to let Remove foley next am to let
Wind ,Water, Wound, Keep an eye on all cultures and Wind ,Water, Wound, Keep an eye on all cultures and
detrusor muscle relax. detrusor muscle relax.
Walking, Wonder Drug specimens sent from OR!!! Don’t Walking, Wonder Drug specimens sent from OR!!! Don’t
If you straight cath a spine patient miss an infection or other badness!! If you straight cath a spine patient miss an infection or other badness!!
downtown, perform rectal and downtown, perform rectal and
37 37
VIII W/u should include albumin,

prealbumin, transferrin. Ensure
shakes/pudding TID.
Open Fractures:
Type I or II: 1st generation
shakes/pudding TID.
Open Fractures:
M E D I C A L cephalosporin. M E D I C A L cephalosporin.
On discharge recommend On discharge recommend
I S S U E S osteoporosis/osteopenia work up & Type IIIA: 1st generation I S S U E S osteoporosis/osteopenia work up & Type IIIA: 1st generation
calcium supplementation. Nutrition cephalosporin + aminoglycoside; add calcium supplementation. Nutrition cephalosporin + aminoglycoside; add
consult. penicillin for grossly contaminated consult. penicillin for grossly contaminated
Decubitus ulcers Decubitus ulcers
wounds. wounds.
Air mattress, heels off bed, heels Air mattress, heels off bed, heels
Colchicine Always check levels on nephrotoxic Colchicine Always check levels on nephrotoxic
protected, turn q2 hours, wound care protected, turn q2 hours, wound care
drugs especially on patient with drugs especially on patient with
nurse. nurse.
No ortho resident should preexisting renal insufficiency or No ortho resident should preexisting renal insufficiency or
Check daily. prescribe colchicine. diabetes. (i.e. Gent or Vanc levels). Check daily. prescribe colchicine. diabetes. (i.e. Gent or Vanc levels).
Waffle boots/heel protectors. Rheumatology consult to medically Cultures from infections should be Waffle boots/heel protectors. Rheumatology consult to medically Cultures from infections should be
manage. checked for sensitivities and manage. checked for sensitivities and
For consults: consider osteomyelitis. Infectious Disease recommendations For consults: consider osteomyelitis. Infectious Disease recommendations
W/u should include xray, CT scan, should be followed for proper W/u should include xray, CT scan, should be followed for proper
inflammatory markers (ESR, CRP), Antibiotics antibiotic coverage. inflammatory markers (ESR, CRP), Antibiotics antibiotic coverage.
local wound care-local debridement, local wound care-local debridement,
Post Op: Post Op:
wet to dry dressing changes/ wet to dry dressing changes/
Silvadene. Ancef one gram IV Q8hr x 24hr. Lack of peripheral I.V. Access Silvadene. Ancef one gram IV Q8hr x 24hr. Lack of peripheral I.V. Access
If PCN allergic Clinda 600mg IV Do not put in central lines or A. If PCN allergic Clinda 600mg IV Do not put in central lines or A.
Nutrition Q8hr or Vanc one gram IV Q12hr. lines. 24 hour stop on I.V. team Nutrition Q8hr or Vanc one gram IV Q12hr. lines. 24 hour stop on I.V. team
Nutritional status: always an issue for Revision surgery and prior infection Femoral, radial, brachial vein/arter Nutritional status: always an issue for Revision surgery and prior infection Femoral, radial, brachial vein/arter
wound healing and preventing will dictate coverage and may be sticks for labs, if needed. Discuss wound healing and preventing will dictate coverage and may be sticks for labs, if needed. Discuss
infection. Very important in elderly attending dependant. with senior resident first. infection. Very important in elderly attending dependant. with senior resident first.
hip fractures. hip fractures.
Make sure patient is not on Make sure patient is not on
anticoagulation!!!! anticoagulation!!!!
37 37

shakes/pudding TID.
Open Fractures:
st
Type I or II: 1 generation
shakes/pudding TID.
Open Fractures:
M E D I C A L cephalosporin. M E D I C A L cephalosporin.
On discharge recommend On discharge recommend
I S S U E S osteoporosis/osteopenia work up & Type IIIA: 1st generation I S S U E S osteoporosis/osteopenia work up & Type IIIA: 1st generation
calcium supplementation. Nutrition cephalosporin + aminoglycoside; add calcium supplementation. Nutrition cephalosporin + aminoglycoside; add
consult. penicillin for grossly contaminated consult. penicillin for grossly contaminated
Decubitus ulcers Decubitus ulcers
wounds. wounds.
Air mattress, heels off bed, heels Air mattress, heels off bed, heels
Colchicine Always check levels on nephrotoxic Colchicine Always check levels on nephrotoxic
protected, turn q2 hours, wound care protected, turn q2 hours, wound care
drugs especially on patient with drugs especially on patient with
nurse. nurse.
No ortho resident should preexisting renal insufficiency or No ortho resident should preexisting renal insufficiency or
Check daily. prescribe colchicine. diabetes. (i.e. Gent or Vanc levels). Check daily. prescribe colchicine. diabetes. (i.e. Gent or Vanc levels).
Waffle boots/heel protectors. Rheumatology consult to medically Cultures from infections should be Waffle boots/heel protectors. Rheumatology consult to medically Cultures from infections should be
manage. checked for sensitivities and manage. checked for sensitivities and
For consults: consider osteomyelitis. Infectious Disease recommendations For consults: consider osteomyelitis. Infectious Disease recommendations
W/u should include xray, CT scan, should be followed for proper W/u should include xray, CT scan, should be followed for proper
inflammatory markers (ESR, CRP), Antibiotics antibiotic coverage. inflammatory markers (ESR, CRP), Antibiotics antibiotic coverage.
local wound care-local debridement, local wound care-local debridement,
Post Op: Post Op:
wet to dry dressing changes/ wet to dry dressing changes/
Silvadene. Ancef one gram IV Q8hr x 24hr. Lack of peripheral I.V. Access Silvadene. Ancef one gram IV Q8hr x 24hr. Lack of peripheral I.V. Access
If PCN allergic Clinda 600mg IV Do not put in central lines or A. If PCN allergic Clinda 600mg IV Do not put in central lines or A.
Nutrition Q8hr or Vanc one gram IV Q12hr. lines. 24 hour stop on I.V. team Nutrition Q8hr or Vanc one gram IV Q12hr. lines. 24 hour stop on I.V. team
Nutritional status: always an issue for Revision surgery and prior infection Femoral, radial, brachial vein/arter Nutritional status: always an issue for Revision surgery and prior infection Femoral, radial, brachial vein/arter
wound healing and preventing will dictate coverage and may be sticks for labs, if needed. Discuss wound healing and preventing will dictate coverage and may be sticks for labs, if needed. Discuss
infection. Very important in elderly attending dependant. with senior resident first. infection. Very important in elderly attending dependant. with senior resident first.
hip fractures. hip fractures.
Make sure patient is not on Make sure patient is not on
anticoagulation!!!! anticoagulation!!!!
38 38
IX ON-CALL (410.283.1254) SPINE à Spine Fellow

C O N S U L T
All ER 7am-5pm Day Adult: Shared with neurosurgery.
C O N S U L T
All ER After Hrs Only see spine consults without All ER After Hrs Only see spine consults without
I S S U E S All InPatient & Wkend neuro changes. Any neuro changes I S S U E S All InPatient & Wkend neuro changes. Any neuro changes
àneurosurgery!!! àneurosurgery!!!
ADULT ORTHO TEAM (rotating pager) Peds: Basically all spine. ADULT ORTHO TEAM (rotating pager) Peds: Basically all spine.
Discuss case with attending to Discuss case with attending to
Day Adult InPatient 7am-5pm see if NUS should be involved also. Day Adult InPatient 7am-5pm see if NUS should be involved also.
PEDIATRIC ORTHOTEAM (410.283.4505) PEDIATRIC ORTHOTEAM (410.283.4505)

RESPONSE TIME RESPONSE TIME
Day Pediatric InPatient 7am-5pm Call back within 10 minutes! Day Pediatric InPatient 7am-5pm Call back within 10 minutes!
(Tell OR nurses that you’re on call (Tell OR nurses that you’re on call
HAND and ask them to return pages). HAND and ask them to return pages).
Rotates weekly with Plastics. See patients as soon as possible! Rotates weekly with Plastics. See patients as soon as possible!
If we’re not on, we don’t want it!!! If we’re not on, we don’t want it!!!
Hand includes: PRIORITIZE!!! Hand includes: PRIORITIZE!!!
Soft tissue distal to elbow. Soft tissue distal to elbow.
Bone distal to distal radius. See the emergencies first. Bone distal to distal radius. See the emergencies first.
Distal radius is always Ortho. Distal radius is always Ortho.
Compartment Syndrome, Cauda Equina, Compartment Syndrome, Cauda Equina,
Any microvascular repair goes Open Fractures, Septic joint, etc. Any microvascular repair goes Open Fractures, Septic joint, etc.
to Plastics. to Plastics.
The clavicle fractures, etc can wait until The clavicle fractures, etc can wait until
the emergencies are handled. the emergencies are handled.
38 38

C O N S U L T
C O N S U L T
All ER After Hrs Only see spine consults without All ER After Hrs Only see spine consults without
I S S U E S All InPatient & Wkend neuro changes. Any neuro changes I S S U E S All InPatient & Wkend neuro changes. Any neuro changes
àneurosurgery!!! àneurosurgery!!!
ADULT ORTHO TEAM (rotating pager) Peds: Basically all spine. ADULT ORTHO TEAM (rotating pager) Peds: Basically all spine.
Discuss case with attending to Discuss case with attending to
Day Adult InPatient 7am-5pm see if NUS should be involved also. Day Adult InPatient 7am-5pm see if NUS should be involved also.
PEDIATRIC ORTHOTEAM (410.283.4505) PEDIATRIC ORTHOTEAM (410.283.4505)

RESPONSE TIME RESPONSE TIME
Day Pediatric InPatient 7am-5pm Call back within 10 minutes! Day Pediatric InPatient 7am-5pm Call back within 10 minutes!
(Tell OR nurses that you’re on call (Tell OR nurses that you’re on call
HAND and ask them to return pages). HAND and ask them to return pages).
Rotates weekly with Plastics. See patients as soon as possible! Rotates weekly with Plastics. See patients as soon as possible!
If we’re not on, we don’t want it!!! If we’re not on, we don’t want it!!!
Hand includes: PRIORITIZE!!! Hand includes: PRIORITIZE!!!
Soft tissue distal to elbow. Soft tissue distal to elbow.
Bone distal to distal radius. See the emergencies first. Bone distal to distal radius. See the emergencies first.
Distal radius is always Ortho. Distal radius is always Ortho.
Compartment Syndrome, Cauda Equina, Compartment Syndrome, Cauda Equina,
Any microvascular repair goes Open Fractures, Septic joint, etc. Any microvascular repair goes Open Fractures, Septic joint, etc.
to Plastics. to Plastics.
The clavicle fractures, etc can wait until The clavicle fractures, etc can wait until
the emergencies are handled. the emergencies are handled.
39 39
X JHOC X JHOC
F O L L O W- U P F O L L O W- U P
C L I N I C S In the past, patients in the JHHED C L I N I C S In the past, patients in the JHHED
have been told to, “Follow up in clinic.” have been told to, “Follow up in clinic.”
This has created substantial This has created substantial
confusion, and has resulted in follow- confusion, and has resulted in follow-
ups at inappropriate times. ups at inappropriate times.
BAYVIEW When residents see patients in the ED, BAYVIEW When residents see patients in the ED,
patients should be given the pink patients should be given the pink
1. Fracture Clinic follow-up appointment card with 1. Fracture Clinic follow-up appointment card with
Thursday PM, Friday AM the name of the clinic (can be Dr’s Thursday PM, Friday AM the name of the clinic (can be Dr’s
All fractures name or specialty), with the date. All fractures name or specialty), with the date.
SELF-PAY and those (Children are sent to clinic of the SELF-PAY and those (Children are sent to clinic of the
UNDER the medical assistance attending who was on call the day the UNDER the medical assistance attending who was on call the day the
umbrella (see chart). patient was seen in ED.) umbrella (see chart). patient was seen in ED.)
Bayview Residents’ Coordinator Each day residents who see ED patients Bayview Residents’ Coordinator Each day residents who see ED patients
April Lindenmuth (01504) also need to provide a list of ED April Lindenmuth (01504) also need to provide a list of ED
patients given follow-up appts patients given follow-up appts
(pink cards) to the JHOC (pink cards) to the JHOC
Residents’ Coordinator (57296) Residents’ Coordinator (57296)
for next-day scheduling (list needs for next-day scheduling (list needs
to include patient name, JHH#, and to include patient name, JHH#, and
follow-up date). follow-up date).
39 39
X JHOC X JHOC
F O L L O W- U P F O L L O W- U P
C L I N I C S In the past, patients in the JHHED C L I N I C S In the past, patients in the JHHED
have been told to, “Follow up in clinic.” have been told to, “Follow up in clinic.”
This has created substantial This has created substantial
confusion, and has resulted in follow- confusion, and has resulted in follow-
ups at inappropriate times. ups at inappropriate times.
BAYVIEW When residents see patients in the ED, BAYVIEW When residents see patients in the ED,
patients should be given the pink patients should be given the pink
1. Fracture Clinic follow-up appointment card with 1. Fracture Clinic follow-up appointment card with
Thursday PM, Friday AM the name of the clinic (can be Dr’s Thursday PM, Friday AM the name of the clinic (can be Dr’s
All fractures name or specialty), with the date. All fractures name or specialty), with the date.
SELF-PAY and those (Children are sent to clinic of the SELF-PAY and those (Children are sent to clinic of the
UNDER the medical assistance attending who was on call the day the UNDER the medical assistance attending who was on call the day the
umbrella (see chart). patient was seen in ED.) umbrella (see chart). patient was seen in ED.)
Bayview Residents’ Coordinator Each day residents who see ED patients Bayview Residents’ Coordinator Each day residents who see ED patients
April Lindenmuth (01504) also need to provide a list of ED April Lindenmuth (01504) also need to provide a list of ED
patients given follow-up appts patients given follow-up appts
(pink cards) to the JHOC (pink cards) to the JHOC
Residents’ Coordinator (57296) Residents’ Coordinator (57296)
for next-day scheduling (list needs for next-day scheduling (list needs
to include patient name, JHH#, and to include patient name, JHH#, and
follow-up date). follow-up date).
40 40
Insurances Under the Medical Assistance Insurances Under the Medical Assistance
Umbrella Umbrella
Medicaid (does not require referral) Medicaid (does not require referral)
Amerigroup MCO/Americaid (only Ortho does not require referral) Amerigroup MCO/Americaid (only Ortho does not require referral)
Patients should be instructed to obtain a referral from their primary Patients should be instructed to obtain a referral from their primary
care doctor’s office for: care doctor’s office for:
JAI MCO JAI MCO
Maryland Physicians Care Maryland Physicians Care
The referral MUST be physically here in the office (fax accepted) before we The referral MUST be physically here in the office (fax accepted) before we
can proceed with scheduling a follow-up appointment. can proceed with scheduling a follow-up appointment.
Fax JHOC 410-955-0180 Fax line for referrals only! Fax JHOC 410-955-0180 Fax line for referrals only!
Fax BAYVIEW 410-550-0622 Fax line for referrals only! Fax BAYVIEW 410-550-0622 Fax line for referrals only!
We do not participate with the following insurances, We do not participate with the following insurances,
however, a patient can be seen by our Chief Resident Follow-Up Clinic if seen first in ED, however, a patient can be seen by our Chief Resident Follow-Up Clinic if seen first in ED,
but must have authorization # from insurer to be scheduled in the Chiefs’ Clinic. but must have authorization # from insurer to be scheduled in the Chiefs’ Clinic.
Diamond Plan MCO Diamond Plan MCO

Helix MCO Helix MCO
United Heath Care MCO United Heath Care MCO
40 40
Insurances Under the Medical Assistance Insurances Under the Medical Assistance
Umbrella Umbrella
Medicaid (does not require referral) Medicaid (does not require referral)
Amerigroup MCO/Americaid (only Ortho does not require referral) Amerigroup MCO/Americaid (only Ortho does not require referral)
Patients should be instructed to obtain a referral from their primary Patients should be instructed to obtain a referral from their primary
care doctor’s office for: care doctor’s office for:
JAI MCO JAI MCO
Maryland Physicians Care Maryland Physicians Care
The referral MUST be physically here in the office (fax accepted) before we The referral MUST be physically here in the office (fax accepted) before we
can proceed with scheduling a follow-up appointment. can proceed with scheduling a follow-up appointment.
Fax JHOC 410-955-0180 Fax line for referrals only! Fax JHOC 410-955-0180 Fax line for referrals only!
Fax BAYVIEW 410-550-0622 Fax line for referrals only! Fax BAYVIEW 410-550-0622 Fax line for referrals only!
We do not participate with the following insurances, We do not participate with the following insurances,
however, a patient can be seen by our Chief Resident Follow-Up Clinic if seen first in ED, however, a patient can be seen by our Chief Resident Follow-Up Clinic if seen first in ED,
but must have authorization # from insurer to be scheduled in the Chiefs’ Clinic. but must have authorization # from insurer to be scheduled in the Chiefs’ Clinic.
Diamond Plan MCO Diamond Plan MCO

Helix MCO Helix MCO
United Heath Care MCO United Heath Care MCO
41 41
XII NetOrthoDoc Website

NetOrthoDoc is a password-
O R T H O protected e-learning website of O R T H O protected e-learning website of
the Johns Hopkins Department of the Johns Hopkins Department of
E-LEARNING Orthopaedic Surgery. E-LEARNING Orthopaedic Surgery.
The site is for resident education, The site is for resident education,
and contains an ever-expanding and contains an ever-expanding
http://www.netorthodoc.org library of talks with sound and http://www.netorthodoc.org library of talks with sound and
visuals from Grand Rounds, faculty visuals from Grand Rounds, faculty
LOGIN: jhuortho lectures, the JHOrthopaedic Review LOGIN: jhuortho lectures, the JHOrthopaedic Review
PW: resident Course, and other specialty courses. PW: resident Course, and other specialty courses.
(the Hopkins firewall may ask for these NetOrthoDoc also has video clips (the Hopkins firewall may ask for these NetOrthoDoc also has video clips
twice, just enter them a second time and from anatomy courses created by Dr. twice, just enter them a second time and from anatomy courses created by Dr.
disregard the request for a “domain” David Hungerford: “Anatomy of the disregard the request for a “domain” David Hungerford: “Anatomy of the
name) Knee,” and “Anatomy of the Hip.” name) Knee,” and “Anatomy of the Hip.”
The syllabi for rotations can also be The syllabi for rotations can also be
found at the site. Some have weekly found at the site. Some have weekly
objectives and reading assignments. objectives and reading assignments.
The yearly lecture schedule is also The yearly lecture schedule is also
posted at NetOrthoDoc. posted at NetOrthoDoc.
From NetOrthoDoc you can link to From NetOrthoDoc you can link to
sets of tutorials and questions on sets of tutorials and questions on
various topics. Pediatrics has over various topics. Pediatrics has over
200 questions, and Dr. Frassica will 200 questions, and Dr. Frassica will
Contact for Ortho E-Learning: Contact for Ortho E-Learning:
be including weekly current topics be including weekly current topics
for review. Each resident will have a Gail Richter-Nelson for review. Each resident will have a Gail Richter-Nelson
personalized login for this feature. (o) 410.502.5885, (c) 443.629.3848 personalized login for this feature. (o) 410.502.5885, (c) 443.629.3848
JHOC #5240 JHOC #5240
41 41

O R T H O protected e-learning website of O R T H O protected e-learning website of
the Johns Hopkins Department of the Johns Hopkins Department of
E-LEARNING Orthopaedic Surgery. E-LEARNING Orthopaedic Surgery.
The site is for resident education, The site is for resident education,
and contains an ever-expanding and contains an ever-expanding
http://www.netorthodoc.org library of talks with sound and http://www.netorthodoc.org library of talks with sound and
visuals from Grand Rounds, faculty visuals from Grand Rounds, faculty
LOGIN: jhuortho lectures, the JHOrthopaedic Review LOGIN: jhuortho lectures, the JHOrthopaedic Review
PW: resident Course, and other specialty courses. PW: resident Course, and other specialty courses.
(the Hopkins firewall may ask for these NetOrthoDoc also has video clips (the Hopkins firewall may ask for these NetOrthoDoc also has video clips
twice, just enter them a second time and from anatomy courses created by Dr. twice, just enter them a second time and from anatomy courses created by Dr.
disregard the request for a “domain” David Hungerford: “Anatomy of the disregard the request for a “domain” David Hungerford: “Anatomy of the
name) Knee,” and “Anatomy of the Hip.” name) Knee,” and “Anatomy of the Hip.”
The syllabi for rotations can also be The syllabi for rotations can also be
found at the site. Some have weekly found at the site. Some have weekly
objectives and reading assignments. objectives and reading assignments.
The yearly lecture schedule is also The yearly lecture schedule is also
posted at NetOrthoDoc. posted at NetOrthoDoc.
From NetOrthoDoc you can link to From NetOrthoDoc you can link to
sets of tutorials and questions on sets of tutorials and questions on
various topics. Pediatrics has over various topics. Pediatrics has over
200 questions, and Dr. Frassica will 200 questions, and Dr. Frassica will
Contact for Ortho E-Learning: Contact for Ortho E-Learning:
be including weekly current topics be including weekly current topics
for review. Each resident will have a Gail Richter-Nelson for review. Each resident will have a Gail Richter-Nelson
personalized login for this feature. (o) 410.502.5885, (c) 443.629.3848 personalized login for this feature. (o) 410.502.5885, (c) 443.629.3848
JHOC #5240 JHOC #5240
47 47
BAYVIEW SHAREPOINT BAYVIEW SHAREPOINT

TO CREATE A FILM LIST IN https://collaborate.johns hopkins.edu/ TO CREATE A FILM LIST IN https://collaborate.johns hopkins.edu/
ULTRAVISUAL sites/Orthosignoutsheet/ ULTRAVISUAL sites/Orthosignoutsheet/
- Site is password protected with your - Site is password protected with your
JHED ID and Password JHED ID and Password
- Click EXAM LIST - Click EXAM LIST
- The reading calendar has embedded - The reading calendar has embedded
- Click NEW EXAM LIST .pdf files that we read for - Click NEW EXAM LIST .pdf files that we read for
- Click ADD TO PRIVATE FOLDERS - Joint Conference,Tues AM - Click ADD TO PRIVATE FOLDERS - Joint Conference,Tues AM
- Give a NAME to the LIST - Trauma Conference, Fri AM - Give a NAME to the LIST - Trauma Conference, Fri AM
- Change the DAY on STUDIES - Change the DAY on STUDIES

ACQUIRED to 2 DAYS - List of Patients is saved to the shared ACQUIRED to 2 DAYS - List of Patients is saved to the shared
files daily and can be opened from the files daily and can be opened from the
- Click ADD site. - Click ADD site.
- Click COMPOSITE and/or NODE - Every consult seen in ED, but not - Click COMPOSITE and/or NODE - Every consult seen in ED, but not
and Click OK admitted should be added to the “TASK” and Click OK admitted should be added to the “TASK”
section. section.
- Click on PATIENT ID - Patient’s Name, Phone, Bayview #, - Click on PATIENT ID - Patient’s Name, Phone, Bayview #,
- In VALUE Box, type in PTS MR# Diagnosis - In VALUE Box, type in PTS MR# Diagnosis
without the check digit and no - After showing films at board to an without the check digit and no - After showing films at board to an
spaces. Press OK. attending, task should be updated as to spaces. Press OK. attending, task should be updated as to
- To add another patient repeat from whether this is operative or non-op, and - To add another patient repeat from whether this is operative or non-op, and
Click ADD to end. where they should follow up. Click ADD to end. where they should follow up.
- The secretaries at Bayview have access - The secretaries at Bayview have access
to this site and will use this information to this site and will use this information
to schedule appointments. MAKE SURE to schedule appointments. MAKE SURE
INFO IS CORRECT. INFO IS CORRECT.
47 47
BAYVIEW SHAREPOINT BAYVIEW SHAREPOINT

TO CREATE A FILM LIST IN https://collaborate.johns hopkins.edu/ TO CREATE A FILM LIST IN https://collaborate.johns hopkins.edu/
ULTRAVISUAL sites/Orthosignoutsheet/ ULTRAVISUAL sites/Orthosignoutsheet/
- Site is password protected with your - Site is password protected with your
JHED ID and Password JHED ID and Password
- Click EXAM LIST - Click EXAM LIST
- The reading calendar has embedded - The reading calendar has embedded
- Click NEW EXAM LIST .pdf files that we read for - Click NEW EXAM LIST .pdf files that we read for
- Click ADD TO PRIVATE FOLDERS - Joint Conference,Tues AM - Click ADD TO PRIVATE FOLDERS - Joint Conference,Tues AM
- Give a NAME to the LIST - Trauma Conference, Fri AM - Give a NAME to the LIST - Trauma Conference, Fri AM
- Change the DAY on STUDIES - Change the DAY on STUDIES

ACQUIRED to 2 DAYS - List of Patients is saved to the shared ACQUIRED to 2 DAYS - List of Patients is saved to the shared
files daily and can be opened from the files daily and can be opened from the
- Click ADD site. - Click ADD site.
- Click COMPOSITE and/or NODE - Every consult seen in ED, but not - Click COMPOSITE and/or NODE - Every consult seen in ED, but not
and Click OK admitted should be added to the “TASK” and Click OK admitted should be added to the “TASK”
section. section.
- Click on PATIENT ID - Patient’s Name, Phone, Bayview #, - Click on PATIENT ID - Patient’s Name, Phone, Bayview #,
- In VALUE Box, type in PTS MR# Diagnosis - In VALUE Box, type in PTS MR# Diagnosis
without the check digit and no - After showing films at board to an without the check digit and no - After showing films at board to an
spaces. Press OK. attending, task should be updated as to spaces. Press OK. attending, task should be updated as to
- To add another patient repeat from whether this is operative or non-op, and - To add another patient repeat from whether this is operative or non-op, and
Click ADD to end. where they should follow up. Click ADD to end. where they should follow up.
- The secretaries at Bayview have access - The secretaries at Bayview have access
to this site and will use this information to this site and will use this information
to schedule appointments. MAKE SURE to schedule appointments. MAKE SURE
INFO IS CORRECT. INFO IS CORRECT.
48 48
JHH ORTHO SHAREPOINT DAILY LISTS: ADULT INTERN or ON-CALL RESIDENT JHH ORTHO SHAREPOINT DAILY LISTS: ADULT INTERN or ON-CALL RESIDENT
http://ortho.jhu.edu http://ortho.jhu.edu
A copy of list should be uploaded to sharepoint each AM after list is A copy of list should be uploaded to sharepoint each AM after list is
updated with labs BEFORE ROUNDS. updated with labs BEFORE ROUNDS.
- DOCUMENTS: - Click Daily Lists icon under Documents List - DOCUMENTS: - Click Daily Lists icon under Documents List
Trauma Postings - Click Upload Trauma Postings - Click Upload
Documents & Resources - Select Upload a document from your computer to this Documents & Resources - Select Upload a document from your computer to this
Daily Lists library Daily Lists library
- LISTS: - Upload list - LISTS: - Upload list
Trauma Schedule Calendar, Trauma Schedule Calendar,
Patient Phone Calls & Requests Patient Phone Calls & Requests
RETURNING PHONE CALLS: CHIEF,TRAUMA 2, & ON CALL PA RETURNING PHONE CALLS: CHIEF,TRAUMA 2, & ON CALL PA
- Discussions: - Discussions:
Trauma Patients (Pending Laronda Johnson (Dr. Osgood’s assistant) lists these phone calls on Trauma Patients (Pending Laronda Johnson (Dr. Osgood’s assistant) lists these phone calls on
Surgery), website. Should be handled daily. Surgery), website. Should be handled daily.
Morbidity & Mortality List - Click Patient Phone Calls & Requests under Lists Morbidity & Mortality List - Click Patient Phone Calls & Requests under Lists
- ON CALL RESIDENT RESPONSIBILITIES - Click on any pending phone call issues - ON CALL RESIDENT RESPONSIBILITIES - Click on any pending phone call issues
- Update ALL Adult Consults that - If request is for narcotics, make sure there are no notes in EPR - Update ALL Adult Consults that - If request is for narcotics, make sure there are no notes in EPR
need or may need surgery prohibiting. If not, write script. Leave note in EPR using the need or may need surgery prohibiting. If not, write script. Leave note in EPR using the
“Prescribing Meds” note type. “Prescribing Meds” note type.
- Click Trauma Patients icon under - DELETE the discussion from sharepoint, so only one Rx is written. - Click Trauma Patients icon under - DELETE the discussion from sharepoint, so only one Rx is written.
Discussions List - Leave script on Laronda’s desk JHOC 5 Discussions List - Leave script on Laronda’s desk JHOC 5
- Click NEW, CREATE NEW DISCUSSION - Click NEW, CREATE NEW DISCUSSION
- In subject, list patient’s name, mrn, - In subject, list patient’s name, mrn,
and injury. Include treatment (nonop, ORIF) and injury. Include treatment (nonop, ORIF)
- Provide: who saw, treatment, dispo, contact - Provide: who saw, treatment, dispo, contact
Subject: Doe, John MR# 1-234-56-789. Subject: Doe, John MR# 1-234-56-789.
Left bimalleolar ankle fx requiring ORIF Left bimalleolar ankle fx requiring ORIF
Body: seen by ortho doc on 1/28/2010 and treated Body: seen by ortho doc on 1/28/2010 and treated
with closed reduction & splinting. with closed reduction & splinting.
D/C home with plan for OR next wk. D/C home with plan for OR next wk.
Contact (cell): 410-867-5309 Contact (cell): 410-867-5309
If consented for surgery FAX CONSENT If consented for surgery FAX CONSENT
to MMF (1-866-341-2834) to MMF (1-866-341-2834)
48 48
JHH ORTHO SHAREPOINT DAILY LISTS: ADULT INTERN or ON-CALL RESIDENT JHH ORTHO SHAREPOINT DAILY LISTS: ADULT INTERN or ON-CALL RESIDENT
http://ortho.jhu.edu http://ortho.jhu.edu
A copy of list should be uploaded to sharepoint each AM after list is A copy of list should be uploaded to sharepoint each AM after list is
updated with labs BEFORE ROUNDS. updated with labs BEFORE ROUNDS.
- DOCUMENTS: - Click Daily Lists icon under Documents List - DOCUMENTS: - Click Daily Lists icon under Documents List
Trauma Postings - Click Upload Trauma Postings - Click Upload
Documents & Resources - Select Upload a document from your computer to this Documents & Resources - Select Upload a document from your computer to this
Daily Lists library Daily Lists library
- LISTS: - Upload list - LISTS: - Upload list
Trauma Schedule Calendar, Trauma Schedule Calendar,
Patient Phone Calls & Requests Patient Phone Calls & Requests
RETURNING PHONE CALLS: CHIEF,TRAUMA 2, & ON CALL PA RETURNING PHONE CALLS: CHIEF,TRAUMA 2, & ON CALL PA
- Discussions: - Discussions:
Trauma Patients (Pending Laronda Johnson (Dr. Osgood’s assistant) lists these phone calls on Trauma Patients (Pending Laronda Johnson (Dr. Osgood’s assistant) lists these phone calls on
Surgery), website. Should be handled daily. Surgery), website. Should be handled daily.
Morbidity & Mortality List - Click Patient Phone Calls & Requests under Lists Morbidity & Mortality List - Click Patient Phone Calls & Requests under Lists
- ON CALL RESIDENT RESPONSIBILITIES - Click on any pending phone call issues - ON CALL RESIDENT RESPONSIBILITIES - Click on any pending phone call issues
- Update ALL Adult Consults that - If request is for narcotics, make sure there are no notes in EPR - Update ALL Adult Consults that - If request is for narcotics, make sure there are no notes in EPR
need or may need surgery prohibiting. If not, write script. Leave note in EPR using the need or may need surgery prohibiting. If not, write script. Leave note in EPR using the
“Prescribing Meds” note type. “Prescribing Meds” note type.
- Click Trauma Patients icon under - DELETE the discussion from sharepoint, so only one Rx is written. - Click Trauma Patients icon under - DELETE the discussion from sharepoint, so only one Rx is written.
Discussions List - Leave script on Laronda’s desk JHOC 5 Discussions List - Leave script on Laronda’s desk JHOC 5
- In subject, list patient’s name, mrn, - In subject, list patient’s name, mrn,
and injury. Include treatment (nonop, ORIF) and injury. Include treatment (nonop, ORIF)
- Provide: who saw, treatment, dispo, contact - Provide: who saw, treatment, dispo, contact
Subject: Doe, John MR# 1-234-56-789. Subject: Doe, John MR# 1-234-56-789.
Left bimalleolar ankle fx requiring ORIF Left bimalleolar ankle fx requiring ORIF
Body: seen by ortho doc on 1/28/2010 and treated Body: seen by ortho doc on 1/28/2010 and treated
with closed reduction & splinting. with closed reduction & splinting.
D/C home with plan for OR next wk. D/C home with plan for OR next wk.
Contact (cell): 410-867-5309 Contact (cell): 410-867-5309
If consented for surgery FAX CONSENT If consented for surgery FAX CONSENT
to MMF (1-866-341-2834) to MMF (1-866-341-2834)
49 49
POSTING CASES: CHIEF & TRAUMA PGY-2 MORBIDITY & MORTALITY: CHIEF & TRAUMA PGY-2 POSTING CASES: CHIEF & TRAUMA PGY-2 MORBIDITY & MORTALITY: CHIEF & TRAUMA PGY-2
- Scheduled surgery, but NOT next or same day - Add patients to M&M list after case discussed with - Scheduled surgery, but NOT next or same day - Add patients to M&M list after case discussed with
( these must be called in) Dr. Osgood. ( these must be called in) Dr. Osgood.
- Posting sheet must be created so Laronda can post - Cases should be removed or archived once - Posting sheet must be created so Laronda can post - Cases should be removed or archived once
the case for us. Once she has posted it, it will show presented at M&M the case for us. Once she has posted it, it will show presented at M&M
up on OR schedule. up on OR schedule.
- Even if date is not known, posting MUST BE - Click on Morbidity & Mortality List icon under - Even if date is not known, posting MUST BE - Click on Morbidity & Mortality List icon under
CREATED at time patient is consented. Discussions List CREATED at time patient is consented. Discussions List
COMPLETING A POSTING SHEET: - Subject: Patient’s Name, MR#,Treatment, COMPLETING A POSTING SHEET: - Subject: Patient’s Name, MR#,Treatment,
Complication Complication
- Open Ortho Posting Sheet Brief (if no template - Body: Any additional information - Open Ortho Posting Sheet Brief (if no template - Body: Any additional information
exists for your surgery. exists for your surgery.
- Save file to I drive with header of Patient’s Name, - Save file to I drive with header of Patient’s Name,
MR#, Procedure, MR#, Procedure,
and date and date
- Subject: Doe, John MR# 1-234-56-789. Left bimalleolar - Subject: Doe, John MR# 1-234-56-789. Left bimalleolar
ankle fx, ORIF for 1/11/11 ankle fx, ORIF for 1/11/11
- Fill out posting sheet general info: name, MR#, ICD- - Fill out posting sheet general info: name, MR#, ICD-
9, CPT codes. 9, CPT codes.
- True trauma cases are posted to our room: OR15 - True trauma cases are posted to our room: OR15
- All other cases to ANY OR (e.g. ROH) - All other cases to ANY OR (e.g. ROH)
- Outpatients should be seen in PEC center and - Outpatients should be seen in PEC center and
box: CALL PATIENT should be checked (not box: CALL PATIENT should be checked (not
Patient To Call) Patient To Call)
- Under EQUIPMENT, add what’s needed: fluoro, - Under EQUIPMENT, add what’s needed: fluoro,
ortho basic, table type, ortho minor, bump, lateral ortho basic, table type, ortho minor, bump, lateral
positioning, etc. If you include all info in this section positioning, etc. If you include all info in this section
you do not need to fill in boxes on form. you do not need to fill in boxes on form.
49 49
POSTING CASES: CHIEF & TRAUMA PGY-2 MORBIDITY & MORTALITY: CHIEF & TRAUMA PGY-2 POSTING CASES: CHIEF & TRAUMA PGY-2 MORBIDITY & MORTALITY: CHIEF & TRAUMA PGY-2
- Scheduled surgery, but NOT next or same day - Add patients to M&M list after case discussed with - Scheduled surgery, but NOT next or same day - Add patients to M&M list after case discussed with
( these must be called in) Dr. Osgood. ( these must be called in) Dr. Osgood.
- Posting sheet must be created so Laronda can post - Cases should be removed or archived once - Posting sheet must be created so Laronda can post - Cases should be removed or archived once
the case for us. Once she has posted it, it will show presented at M&M the case for us. Once she has posted it, it will show presented at M&M
up on OR schedule. up on OR schedule.
- Even if date is not known, posting MUST BE - Click on Morbidity & Mortality List icon under - Even if date is not known, posting MUST BE - Click on Morbidity & Mortality List icon under
CREATED at time patient is consented. Discussions List CREATED at time patient is consented. Discussions List
COMPLETING A POSTING SHEET: - Subject: Patient’s Name, MR#,Treatment, COMPLETING A POSTING SHEET: - Subject: Patient’s Name, MR#,Treatment,
Complication Complication
- Open Ortho Posting Sheet Brief (if no template - Body: Any additional information - Open Ortho Posting Sheet Brief (if no template - Body: Any additional information
exists for your surgery. exists for your surgery.
- Save file to I drive with header of Patient’s Name, - Save file to I drive with header of Patient’s Name,
MR#, Procedure, MR#, Procedure,
and date and date
- Subject: Doe, John MR# 1-234-56-789. Left bimalleolar - Subject: Doe, John MR# 1-234-56-789. Left bimalleolar
ankle fx, ORIF for 1/11/11 ankle fx, ORIF for 1/11/11
- Fill out posting sheet general info: name, MR#, ICD- - Fill out posting sheet general info: name, MR#, ICD-
9, CPT codes. 9, CPT codes.
- True trauma cases are posted to our room: OR15 - True trauma cases are posted to our room: OR15
- All other cases to ANY OR (e.g. ROH) - All other cases to ANY OR (e.g. ROH)
- Outpatients should be seen in PEC center and - Outpatients should be seen in PEC center and
box: CALL PATIENT should be checked (not box: CALL PATIENT should be checked (not
Patient To Call) Patient To Call)
- Under EQUIPMENT, add what’s needed: fluoro, - Under EQUIPMENT, add what’s needed: fluoro,
ortho basic, table type, ortho minor, bump, lateral ortho basic, table type, ortho minor, bump, lateral
positioning, etc. If you include all info in this section positioning, etc. If you include all info in this section
you do not need to fill in boxes on form. you do not need to fill in boxes on form.
50 50
OPERATIVE NOTE FORMAT DISCHARGE SUMMARY FORMAT CLINIC NOTE FORMAT OPERATIVE NOTE FORMAT DISCHARGE SUMMARY FORMAT CLINIC NOTE FORMAT
- Your name, Patient Name, - Your name, Patient Name, - Your name, Patient Name, - Your name, Patient Name, - Your name, Patient Name, - Your name, Patient Name,
7-digit History #, Attending 7-digit History #, Admission & 7-digit History #, Date of Clinic 7-digit History #, Attending 7-digit History #, Admission & 7-digit History #, Date of Clinic
Surgeon, Assistants or other Discharge Dates, Attending Visit, Clinic #, Attending Surgeon, Assistants or other Discharge Dates, Attending Visit, Clinic #, Attending
surgeons present in OR incl. Physician, other Physicians (spell Physician, other Physicians (spell surgeons present in OR incl. Physician, other Physicians (spell Physician, other Physicians (spell
residents (spell names) names) names) residents (spell names) names) names)
- Date of Procedure, Title of - Condition on Discharge - Reason for Visit (Chief - Date of Procedure, Title of - Condition on Discharge - Reason for Visit (Chief
Operation (include Codes) Complaint) Operation (include Codes) Complaint)
- Diagnoses/Problems - Diagnoses/Problems
- Indications for Surgery - History of Present Illness (may - Indications for Surgery - History of Present Illness (may
- Procedures - Procedures
- Pre-Operative/Post-Operative include past medical/surgical, family - Pre-Operative/Post-Operative include past medical/surgical, family
Diagnoses (include Codes) - Brief History, Major Findings, history, social history, immunization) Diagnoses (include Codes) - Brief History, Major Findings, history, social history, immunization)
Hospital Course (500 wds or less) Hospital Course (500 wds or less)
- Anesthesia (Specify type) - Medications - Anesthesia (Specify type) - Medications
- Reportable Diseases - Reportable Diseases
- Specimen (Bacteriological, - Allergies - Specimen (Bacteriological, - Allergies
Pathological, or other) - Adverse Drug Reactions, Pathological, or other) - Adverse Drug Reactions,
Allergies, Complications of - Major Findings (including PE, Allergies, Complications of - Major Findings (including PE,
- Prosthetic Device / Implant Procedures pertinent lab or imaging study - Prosthetic Device / Implant Procedures pertinent lab or imaging study
results) results)
- Narrative: - Discharge Medications - Narrative: - Discharge Medications
- Technical Procedures (incl skin - Assessments - Technical Procedures (incl skin - Assessments
prep, incision, closure, drains etc.) - Discharge Instructions (Diet, prep, incision, closure, drains etc.) - Discharge Instructions (Diet,
Activity, Other Follow-Up Car - Problems/Diagnoses Activity, Other Follow-Up Car - Problems/Diagnoses
- Description of Findings - Description of Findings
- Stage of Cancer CC List (include address of non- - Procedures & Immunizations - Stage of Cancer CC List (include address of non- - Procedures & Immunizations
- Clinical size of tumor JHH doctors) - Plans - Clinical size of tumor JHH doctors) - Plans
- Clinical nodal size - Clinical nodal size
- Evidence of Metastasis - Medication Changes - Evidence of Metastasis - Medication Changes
- Estimated Blood Loss/Given - Estimated Blood Loss/Given
- Fluids Given - CC List (include address of non- - Fluids Given - CC List (include address of non-
- Sponge count JHH doctors) - Sponge count JHH doctors)
- Post-Operative Condition Patient MUST be registered - Post-Operative Condition Patient MUST be registered
- Indication of dual Attendings (clinic notes are linked to an outpatient - Indication of dual Attendings (clinic notes are linked to an outpatient
episode of care episode of care
50 50
OPERATIVE NOTE FORMAT DISCHARGE SUMMARY FORMAT CLINIC NOTE FORMAT OPERATIVE NOTE FORMAT DISCHARGE SUMMARY FORMAT CLINIC NOTE FORMAT
- Your name, Patient Name, - Your name, Patient Name, - Your name, Patient Name, - Your name, Patient Name, - Your name, Patient Name, - Your name, Patient Name,
7-digit History #, Attending 7-digit History #, Admission & 7-digit History #, Date of Clinic 7-digit History #, Attending 7-digit History #, Admission & 7-digit History #, Date of Clinic
Surgeon, Assistants or other Discharge Dates, Attending Visit, Clinic #, Attending Surgeon, Assistants or other Discharge Dates, Attending Visit, Clinic #, Attending
surgeons present in OR incl. Physician, other Physicians (spell Physician, other Physicians (spell surgeons present in OR incl. Physician, other Physicians (spell Physician, other Physicians (spell
residents (spell names) names) names) residents (spell names) names) names)
- Date of Procedure, Title of - Condition on Discharge - Reason for Visit (Chief - Date of Procedure, Title of - Condition on Discharge - Reason for Visit (Chief
Operation (include Codes) Complaint) Operation (include Codes) Complaint)
- Diagnoses/Problems - Diagnoses/Problems
- Indications for Surgery - History of Present Illness (may - Indications for Surgery - History of Present Illness (may
- Procedures - Procedures
- Pre-Operative/Post-Operative include past medical/surgical, family - Pre-Operative/Post-Operative include past medical/surgical, family
Diagnoses (include Codes) - Brief History, Major Findings, history, social history, immunization) Diagnoses (include Codes) - Brief History, Major Findings, history, social history, immunization)
Hospital Course (500 wds or less) Hospital Course (500 wds or less)
- Anesthesia (Specify type) - Medications - Anesthesia (Specify type) - Medications
- Reportable Diseases - Reportable Diseases
- Specimen (Bacteriological, - Allergies - Specimen (Bacteriological, - Allergies
Pathological, or other) - Adverse Drug Reactions, Pathological, or other) - Adverse Drug Reactions,
Allergies, Complications of - Major Findings (including PE, Allergies, Complications of - Major Findings (including PE,
- Prosthetic Device / Implant Procedures pertinent lab or imaging study - Prosthetic Device / Implant Procedures pertinent lab or imaging study
results) results)
- Narrative: - Discharge Medications - Narrative: - Discharge Medications
- Technical Procedures (incl skin - Assessments - Technical Procedures (incl skin - Assessments
prep, incision, closure, drains etc.) - Discharge Instructions (Diet, prep, incision, closure, drains etc.) - Discharge Instructions (Diet,
Activity, Other Follow-Up Car - Problems/Diagnoses Activity, Other Follow-Up Car - Problems/Diagnoses
- Description of Findings - Description of Findings
- Stage of Cancer CC List (include address of non- - Procedures & Immunizations - Stage of Cancer CC List (include address of non- - Procedures & Immunizations
- Clinical size of tumor JHH doctors) - Plans - Clinical size of tumor JHH doctors) - Plans
- Clinical nodal size - Clinical nodal size
- Evidence of Metastasis - Medication Changes - Evidence of Metastasis - Medication Changes
- Estimated Blood Loss/Given - Estimated Blood Loss/Given
- Fluids Given - CC List (include address of non- - Fluids Given - CC List (include address of non-
- Sponge count JHH doctors) - Sponge count JHH doctors)
- Post-Operative Condition Patient MUST be registered - Post-Operative Condition Patient MUST be registered
- Indication of dual Attendings (clinic notes are linked to an outpatient - Indication of dual Attendings (clinic notes are linked to an outpatient
episode of care episode of care

Orthopaedic Surgery Resident Survival Guide Orthopaedic Surgery Resident Survival Guide

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Orthopaedic Surgery Resident Survival Guide Orthopaedic Surgery Resident Survival Guide

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The James F. Wenz, M.D. The James F. Wenz, M.D.

Orthopaedic Surgery Orthopaedic Surgery

The James F. Wenz, M.D. The James F. Wenz, M.D.

Table of Contents: Table of Contents:

Resident Michael Bahk, M.D.

G u i d e Ted Manson, M.D. G u i d e Ted Manson, M.D.

Resident Michael Bahk, M.D.

G u i d e Ted Manson, M.D. G u i d e Ted Manson, M.D.

Postop Spine Patients Treatment: Postop Spine Patients Treatment:

Postop Spine Patients Treatment: Postop Spine Patients Treatment:

Differential Diagnosis Differential Diagnosis

Stroke Document your Neuro Exam

Differential Diagnosis Differential Diagnosis

Stroke Document your Neuro Exam

Notes: Mortality 10-20% Notes: Mortality 10-20%

Notes: Mortality 10-20% Notes: Mortality 10-20%

Assistant: Stands on opposite side of Assistant: Stands on opposite side of

Assistant: Stands on opposite side of Assistant: Stands on opposite side of

Elbow Reduction 18 Elbow Reduction 18

Hip Dislocation Hip Dislocation

Hip Dislocation Hip Dislocation

7. Walk it down to lab yourself!!! 7. Walk it down to lab yourself!!!

7. Walk it down to lab yourself!!! 7. Walk it down to lab yourself!!!

VII Night of Surgery Notes (NOS)

VII Night of Surgery Notes (NOS)

VIII W/u should include albumin,

VIII W/u should include albumin,

IX ON-CALL (410.283.1254) SPINE à Spine Fellow

PEDIATRIC ORTHOTEAM (410.283.4505) PEDIATRIC ORTHOTEAM (410.283.4505)

IX ON-CALL (410.283.1254) SPINE à Spine Fellow

PEDIATRIC ORTHOTEAM (410.283.4505) PEDIATRIC ORTHOTEAM (410.283.4505)

Diamond Plan MCO Diamond Plan MCO

Diamond Plan MCO Diamond Plan MCO

XII NetOrthoDoc Website

XII NetOrthoDoc Website

BAYVIEW SHAREPOINT BAYVIEW SHAREPOINT

- Change the DAY on STUDIES - Change the DAY on STUDIES

BAYVIEW SHAREPOINT BAYVIEW SHAREPOINT

- Change the DAY on STUDIES - Change the DAY on STUDIES

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