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

Orthopaedic Surgery Orthopaedic Surgery

Resident Survival Guide Resident Survival Guide

2008 2008
Editor: Frank J. Frassica M.D. Editor: Frank J. Frassica M.D.
Asst. Editors: Kevin W. Farmer, M.D. & Brett M. Cascio, M.D. Asst. Editors: Kevin W. Farmer, M.D. & Brett M. Cascio, M.D.

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

Orthopaedic Surgery Orthopaedic Surgery
Resident Survival Guide Resident Survival Guide

2008 2008
Editor: Frank J. Frassica M.D. Editor: Frank J. Frassica M.D.
Asst. Editors: Kevin W. Farmer, M.D. & Brett M. Cascio, M.D. Asst. Editors: Kevin W. Farmer, M.D. & Brett M. Cascio, M.D.
Table of Contents: Table of Contents:
Compartment Syndrome 5 Compartment Syndrome 5
Cauda Equina 7 Cauda Equina 7
Pulmonary Embolism 8 Pulmonary Embolism 8
Deep Venous Thrombosis 9 Deep Venous Thrombosis 9
Labs 10 Labs 10
Narcotics 11 Narcotics 11
Chest Pain / Myocardial Infarction 12 Chest Pain / Myocardial Infarction 12
SICU Consult 12 SICU Consult 12
Hypotension 13 Hypotension 13
Stroke 13 Stroke 13
Fat Embolism 14 Fat Embolism 14
Epidural Hematoma 15 Epidural Hematoma 15
Physical Exam/Motor Grading 16 Physical Exam/Motor Grading 16
“Patient Safety Splinting 17 “Patient Safety Splinting 17
is Casting 19 is Casting 19
Rule Number 1.” Traction: Skeletal 21 Rule Number 1.” Traction: Skeletal 21
Traction: Skin 22 Traction: Skin 22
Aspirations & Injections 23 Aspirations & Injections 23
Preop Checklist 24 Preop Checklist 24
“Ask OR Safety (Bovie,Tourniquet) 25 “Ask OR Safety (Bovie,Tourniquet) 25
Radiology 28 Radiology 28
if you do not know.” Post Operative Care 31
if you do not know.” Post Operative Care 31
Medical Issues 32 Medical Issues 32
Consult Issues 33 Consult Issues 33
“Do not do anything Follow-Up Clinics 34 “Do not do anything Follow-Up Clinics 34
Ortho E-Learning 36 Ortho E-Learning 36
by yourself IMPORTANT NUMBERS 37 by yourself IMPORTANT NUMBERS 37
for the first time.” OPERATIVE NOTE FORMAT 42 for the first time.” OPERATIVE NOTE FORMAT 42

Table of Contents: Table of Contents:

Compartment Syndrome 5 Compartment Syndrome 5
Cauda Equina 7 Cauda Equina 7
Pulmonary Embolism 8 Pulmonary Embolism 8
Deep Venous Thrombosis 9 Deep Venous Thrombosis 9
Labs 10 Labs 10
Narcotics 11 Narcotics 11
Chest Pain / Myocardial Infarction 12 Chest Pain / Myocardial Infarction 12
SICU Consult 12 SICU Consult 12
Hypotension 13 Hypotension 13
Stroke 13 Stroke 13
Fat Embolism 14 Fat Embolism 14
Epidural Hematoma 15 Epidural Hematoma 15
Physical Exam/Motor Grading 16 Physical Exam/Motor Grading 16
“Patient Safety Splinting 17 “Patient Safety Splinting 17
is Casting 19 is Casting 19
Rule Number 1.” Traction: Skeletal 21 Rule Number 1.” Traction: Skeletal 21
Traction: Skin 22 Traction: Skin 22
Aspirations & Injections 23 Aspirations & Injections 23
Preop Checklist 24 Preop Checklist 24
“Ask OR Safety (Bovie,Tourniquet) 25 “Ask OR Safety (Bovie,Tourniquet) 25
Radiology 28 Radiology 28
if you do not know.” Post Operative Care 31
if you do not know.” Post Operative Care 31
Medical Issues 32 Medical Issues 32
Consult Issues 33 Consult Issues 33
“Do not do anything Follow-Up Clinics 34 “Do not do anything Follow-Up Clinics 34
Ortho E-Learning 36 Ortho E-Learning 36
by yourself IMPORTANT NUMBERS 37 by yourself IMPORTANT NUMBERS 37
for the first time.” OPERATIVE NOTE FORMAT 42 for the first time.” OPERATIVE NOTE FORMAT 42
 Contributors: Contributors:

Henry Boateng, M.D. Henry Boateng, M.D.

Mark Clough, M.D. Mark Clough, M.D.

Orthopaedic Orthopaedic
Phil Neubauer, M.D. Phil Neubauer, M.D.
Kevin Farmer, M.D. Kevin Farmer, M.D.
S u r g e r y Kris Alden, M.D. S u r g e r y Kris Alden, M.D.

Resident Michael Bahk, M.D.

Resident Michael Bahk, M.D.
Adam Farber, M.D. Adam Farber, M.D.
Sur vival Andrew Manista, 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. Henry Boateng, M.D.

Mark Clough, M.D. Mark Clough, M.D.

Orthopaedic Orthopaedic
Phil Neubauer, M.D. Phil Neubauer, M.D.
Kevin Farmer, M.D. Kevin Farmer, M.D.
S u r g e r y Kris Alden, M.D. S u r g e r y Kris Alden, M.D.

Resident Michael Bahk, M.D.

Resident Michael Bahk, M.D.
Adam Farber, M.D. Adam Farber, M.D.
Sur vival Andrew Manista, 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
 4 4

I I
ORTHOPAEDIC ORTHOPAEDIC
EMERGENCIES EMERGENCIES
Compartment Syndrome Compartment Syndrome
Cauda Equina Cauda Equina
Pulmonary Pulmonary
Embolism Embolism
Deep Venous Deep Venous
Thrombosis Thrombosis
“The price of safety is “The price of safety is
never-ending, unremitting Chest Pain / Myocardial Infarction never-ending, unremitting Chest Pain / Myocardial Infarction
vigilance.” vigilance.”
Hypotension Hypotension
“Check & Double Check.” “Check & Double Check.”
Stroke Stroke
“Never be afraid to ask.” “Never be afraid to ask.”
Fat Embolism Fat Embolism
Frank J. Frassica, M.D. Frank J. Frassica, M.D.
Epidural Hematoma Epidural Hematoma

4 4

I I
ORTHOPAEDIC ORTHOPAEDIC
EMERGENCIES EMERGENCIES
Compartment Syndrome Compartment Syndrome
Cauda Equina Cauda Equina
Pulmonary Pulmonary
Embolism Embolism
Deep Venous Deep Venous
Thrombosis Thrombosis
“The price of safety is “The price of safety is
never-ending, unremitting Chest Pain / Myocardial Infarction never-ending, unremitting Chest Pain / Myocardial Infarction
vigilance.” vigilance.”
Hypotension Hypotension
“Check & Double Check.” “Check & Double Check.”
Stroke Stroke
“Never be afraid to ask.” “Never be afraid to ask.”
Fat Embolism Fat Embolism
Frank J. Frassica, M.D. Frank J. Frassica, M.D.
Epidural Hematoma Epidural Hematoma
 5 5
Compartment Compartment
Level 1 case. Do not Delay!!!! Call chief resident with concerns. Level 1 case. Do not Delay!!!! Call chief resident with concerns.
Syndrome Syndrome
Have an extremely low threshold for Never hesitate to call the Have an extremely low threshold for Never hesitate to call the
concern. attending on call. concern. attending on call.
Can occur following any injury, and Can occur following any injury, and
in any extremity. Compartment measures? Measure in any extremity. Compartment measures? Measure
Don’t forget about well leg, can pressures if you can not decide if Don’t forget about well leg, can pressures if you can not decide if
LEVEL 2 occur in the non-injured extremity
due to positioning in OR.
a compartment syndrome is present.
Time is of the essence. Do not
LEVEL 2 occur in the non-injured extremity
due to positioning in OR.
a compartment syndrome is present.
Time is of the essence. Do not
delay! 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 side. DO NOT MISS A Numbness: Compare to other side. DO NOT MISS A
Compare to previous exams. Pain out of proportion to the 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? Shiny skin?
Tender to mild palpation? YOU MUST see the patient and Tender to mild palpation? YOU MUST see the patient and
Pulses: Compare to opposite side evaluate. Pulses: Compare to opposite side evaluate.

Pallor: Any color changes? Patients in severe pain will often try Pallor: Any color changes? Patients in severe pain will often try
to sleep to forget about pain. to sleep to forget about pain.
Diastolic Pressures: Document in Diastolic Pressures: Document in
case you check pressures. Compare exam to other side and to case you check pressures. Compare exam to other side and to
previous exams in chart!!!! previous exams in chart!!!!

5 5
Compartment Compartment
Level 1 case. Do not Delay!!!! Call chief resident with concerns. Level 1 case. Do not Delay!!!! Call chief resident with concerns.
Syndrome Syndrome
Have an extremely low threshold for Never hesitate to call the Have an extremely low threshold for Never hesitate to call the
concern. attending on call. concern. attending on call.
Can occur following any injury, and Can occur following any injury, and
in any extremity. Compartment measures? Measure in any extremity. Compartment measures? Measure
Don’t forget about well leg, can pressures if you can not decide if Don’t forget about well leg, can pressures if you can not decide if
LEVEL 2 occur in the non-injured extremity
due to positioning in OR.
a compartment syndrome is present.
Time is of the essence. Do not
LEVEL 2 occur in the non-injured extremity
due to positioning in OR.
a compartment syndrome is present.
Time is of the essence. Do not
delay! 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 side. DO NOT MISS A Numbness: Compare to other side. DO NOT MISS A
Compare to previous exams. Pain out of proportion to the 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? Shiny skin?
Tender to mild palpation? YOU MUST see the patient and Tender to mild palpation? YOU MUST see the patient and
Pulses: Compare to opposite side evaluate. Pulses: Compare to opposite side evaluate.

Pallor: Any color changes? Patients in severe pain will often try Pallor: Any color changes? Patients in severe pain will often try
to sleep to forget about pain. to sleep to forget about pain.
Diastolic Pressures: Document in Diastolic Pressures: Document in
case you check pressures. Compare exam to other side and to case you check pressures. Compare exam to other side and to
previous exams in chart!!!! previous exams in chart!!!!
 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 Whitemarsh - Clinic Office 2. The device needs to be adequately Have an assistant record these by
“charged” for accurate use. Depress each compartment. “charged” for accurate use. Depress each compartment.
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 Compartment Measurement needle. 8. Remove the needle and apply a
dressing. dressing.
1. Use the Stryker monitor in situations 3. Ask and receive verbal consent 1. Use the Stryker monitor in situations 3. Ask and receive verbal consent
where there is a question of for the procedure (potential benefit: 9. Inform chief of compartment where there is a question of for the procedure (potential benefit: 9. Inform chief of compartment
diagnosis of compartment syndrome in early diagnosis and prompt pressures. diagnosis of compartment syndrome in early diagnosis and prompt pressures.
a susceptible patient. treatment of compartment 10. Write a procedure note. Always a susceptible patient. treatment of compartment 10. Write a procedure note. Always
There is no need to stick a patient who syndrome vs. discomfort and remote use the compartment syndrome There is no need to stick a patient who syndrome vs. discomfort and remote use the compartment syndrome
clearly has or does not have compartment chance of infection, bleeding, damage stickers. Remember to compare the clearly has or does not have compartment chance of infection, bleeding, damage stickers. Remember to compare the
syndrome. to nerves). compartment pressure to the syndrome. to nerves). compartment pressure to the
2. Juniors must inform their chiefs 4. Prep the area to be tested with diastolic blood pressure. Perfusion 2. Juniors must inform their chiefs 4. Prep the area to be tested with diastolic blood pressure. Perfusion
prior to any compartment Betadine, and infiltrate the skin with pressure is the diastolic blood prior to any compartment Betadine, and infiltrate the skin with pressure is the diastolic blood
measurement. 1% lidocaine. Do not attempt to pressure minus the compartment measurement. 1% lidocaine. Do not attempt to pressure minus the compartment
pressure. pressure.

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 Whitemarsh - Clinic Office 2. The device needs to be adequately Have an assistant record these by
“charged” for accurate use. Depress each compartment. “charged” for accurate use. Depress each compartment.
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 Compartment Measurement needle. 8. Remove the needle and apply a
dressing. dressing.
1. Use the Stryker monitor in situations 3. Ask and receive verbal consent 1. Use the Stryker monitor in situations 3. Ask and receive verbal consent
where there is a question of for the procedure (potential benefit: 9. Inform chief of compartment where there is a question of for the procedure (potential benefit: 9. Inform chief of compartment
diagnosis of compartment syndrome in early diagnosis and prompt pressures. diagnosis of compartment syndrome in early diagnosis and prompt pressures.
a susceptible patient. treatment of compartment 10. Write a procedure note. Always a susceptible patient. treatment of compartment 10. Write a procedure note. Always
There is no need to stick a patient who syndrome vs. discomfort and remote use the compartment syndrome There is no need to stick a patient who syndrome vs. discomfort and remote use the compartment syndrome
clearly has or does not have compartment chance of infection, bleeding, damage stickers. Remember to compare the clearly has or does not have compartment chance of infection, bleeding, damage stickers. Remember to compare the
syndrome. to nerves). compartment pressure to the syndrome. to nerves). compartment pressure to the
2. Juniors must inform their chiefs 4. Prep the area to be tested with diastolic blood pressure. Perfusion 2. Juniors must inform their chiefs 4. Prep the area to be tested with diastolic blood pressure. Perfusion
prior to any compartment Betadine, and infiltrate the skin with pressure is the diastolic blood prior to any compartment Betadine, and infiltrate the skin with pressure is the diastolic blood
measurement. 1% lidocaine. Do not attempt to pressure minus the compartment measurement. 1% lidocaine. Do not attempt to pressure minus the compartment
pressure. pressure.
 7 7
Cauda Equina Cauda Equina
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 patients Cauda equina syndrome occurs Examine any post-op spine patients
when the lumbosacral nerve with new complaints (incontinence, when the lumbosacral nerve with new complaints (incontinence,
roots are compressed and urinary retention, parasthesias, roots are compressed and urinary retention, parasthesias,
thereby injured, cutting off weakness). thereby injured, cutting off weakness).
sensation and motor function. sensation and motor function.
Nerve roots that control the Always perform thorough motor, Nerve roots that control the Always perform thorough motor,
LEVEL 2 function of the bladder and bowel sensory (pin prick, light touch) rectal
exam.
LEVEL 2 function of the bladder and bowel sensory (pin prick, light touch) rectal
exam.
are especially vulnerable to damage. are especially vulnerable to damage.
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
Cauda Equina Cauda Equina
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 patients Cauda equina syndrome occurs Examine any post-op spine patients
when the lumbosacral nerve with new complaints (incontinence, when the lumbosacral nerve with new complaints (incontinence,
roots are compressed and urinary retention, parasthesias, roots are compressed and urinary retention, parasthesias,
thereby injured, cutting off weakness). thereby injured, cutting off weakness).
sensation and motor function. sensation and motor function.
Nerve roots that control the Always perform thorough motor, Nerve roots that control the Always perform thorough motor,
LEVEL 2 function of the bladder and bowel sensory (pin prick, light touch) rectal
exam.
LEVEL 2 function of the bladder and bowel sensory (pin prick, light touch) rectal
exam.
are especially vulnerable to damage. are especially vulnerable to damage.
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
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 patient should be Check vital signs. SICU consult 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. until therapeutic.
Have a low threshold to EKG medicine consult?
Medicine consult for management.
Have a low threshold to EKG 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 and intramedullary to follow INR once discharged total joints and intramedullary to follow INR once discharged
Tachycardia rodding of a femur fracture. (primary care, coumadin clinic, etc). Tachycardia rodding of a femur fracture. (primary care, coumadin clinic, etc).
Hypoxia Hypoxia
Make sure patient does not have Let chief / attending know ASAP. Make sure patient does not have Let chief / attending know ASAP.
Tachypnea, or Tachypnea, or
kidney problems prior to kidney problems prior to
Pleuritic type chest pain. ordering spiral CT. It is much more acceptable to Pleuritic type chest pain. ordering spiral CT. It is much more acceptable to
over order spiral CT then to not over order spiral CT then to not
Consider mucormyst 600 my po order one in a patient who has a Consider mucormyst 600 my po order one in a patient who has a
BID before spiral CT and for 2 days PE !!! BID before spiral CT and for 2 days PE !!!
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).

8 8
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 patient should be Check vital signs. SICU consult 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. until therapeutic.
Have a low threshold to EKG medicine consult?
Medicine consult for management.
Have a low threshold to EKG 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 and intramedullary to follow INR once discharged total joints and intramedullary to follow INR once discharged
Tachycardia rodding of a femur fracture. (primary care, coumadin clinic, etc). Tachycardia rodding of a femur fracture. (primary care, coumadin clinic, etc).
Hypoxia Hypoxia
Make sure patient does not have Let chief / attending know ASAP. Make sure patient does not have Let chief / attending know ASAP.
Tachypnea, or Tachypnea, or
kidney problems prior to kidney problems prior to
Pleuritic type chest pain. ordering spiral CT. It is much more acceptable to Pleuritic type chest pain. ordering spiral CT. It is much more acceptable to
over order spiral CT then to not over order spiral CT then to not
Consider mucormyst 600 my po order one in a patient who has a Consider mucormyst 600 my po order one in a patient who has a
BID before spiral CT and for 2 days PE !!! BID before spiral CT and for 2 days PE !!!
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
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!!!
Must be treated! Must be treated!
Use the DVT protocol, please fill out Use the DVT protocol, please fill out
the pink form and put form in the Treatment: the pink form and put form in the Treatment:
front of the chart. Attending dependent. front of the chart. Attending dependent.

Do not do a Homan’s sign (low yield, Continue current pathway and Do not do a Homan’s sign (low yield, Continue current pathway and
Presentation potential to break off clot). recheck dopplers in 48 hours Presentation potential to break off clot). recheck dopplers in 48 hours
to look for propagation. to look for propagation.
Have a low threshold to order Have a low threshold to order
Calf pain/cramping bilateral lower extremity dopplers Calf pain/cramping bilateral lower extremity dopplers
for any patient with concerning Also possible to have DVT in upper for any patient with concerning Also possible to have DVT in upper
Leg swelling symptoms. extremity. Doppler if concerned. Leg swelling symptoms. extremity. Doppler if concerned.
Vascular lab better than radiology Vascular lab better than radiology
Palpable cords if possible. Palpable cords if possible.
Let your chief / attending know Let your chief / attending know
if positive for DVT!! 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.

9 9
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!!!
Must be treated! Must be treated!
Use the DVT protocol, please fill out Use the DVT protocol, please fill out
the pink form and put form in the Treatment: the pink form and put form in the Treatment:
front of the chart. Attending dependent. front of the chart. Attending dependent.

Do not do a Homan’s sign (low yield, Continue current pathway and Do not do a Homan’s sign (low yield, Continue current pathway and
Presentation potential to break off clot). recheck dopplers in 48 hours Presentation potential to break off clot). recheck dopplers in 48 hours
to look for propagation. to look for propagation.
Have a low threshold to order Have a low threshold to order
Calf pain/cramping bilateral lower extremity dopplers Calf pain/cramping bilateral lower extremity dopplers
for any patient with concerning Also possible to have DVT in upper for any patient with concerning Also possible to have DVT in upper
Leg swelling symptoms. extremity. Doppler if concerned. Leg swelling symptoms. extremity. Doppler if concerned.
Vascular lab better than radiology Vascular lab better than radiology
Palpable cords if possible. Palpable cords if possible.
Let your chief / attending know Let your chief / attending know
if positive for DVT!! 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
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
A.M. labs are usually back by 10 am. spinal, hip, knee and shoulder having an infection needs A.M. labs are usually back by 10 am. spinal, hip, knee and shoulder having an infection needs
procedures should get one in the these labs. procedures should get one in the these labs.
Midnight Labs can be ordered, recovery room. Midnight Labs can be ordered, recovery room.
especially on weekends. (1st draw AML) Blood Cx especially on weekends. (1st draw AML) 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
Don’t make a habit of signing out labs! (recognized by precipitous pressure Don’t make a habit of signing out labs! (recognized by precipitous pressure
part of our routine post op fever 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.
There are fewer labs to worry about There are fewer labs to worry about
in Orthopaedics. BMP in Orthopaedics. BMP
Watch the creatinine values Orthopaedic Tumor Consult? Watch the creatinine values Orthopaedic Tumor Consult?
A lab that is ordered on your on joint patients and patients A lab that is ordered on your on joint patients and patients
Order CBC, CRP, ESR, BMP, Order CBC, CRP, ESR, BMP,
patient is your responsibility to on gentamicin or patient is your responsibility to on gentamicin or
SPEP/UPEP, UA. SPEP/UPEP, UA.
check, no matter whom else vancomycin check, no matter whom else vancomycin
ordered it or is following the value. carefully. These have a tendency Dr. Frassica will ask for the calcium. ordered it or is following the value. carefully. These have a tendency Dr. Frassica will ask for the calcium.
to creep up. Keep potassium repleted. to creep up. Keep potassium repleted.
Get in the habit of looking through Pathology Reports Get in the habit of looking through Pathology Reports
EPR every day for rogue labs that PT/PTT Keep track of the patients you EPR every day for rogue labs that PT/PTT Keep track of the patients you
someone else ordered. Watch patients on coumadin have operated on, and review someone else ordered. Watch patients on coumadin have operated on, and review
like a hawk. Place it in bold their pathology reports. like a hawk. Place it in bold their pathology reports.
On the pediatrics service, ask On the pediatrics service, ask
letters on sign-out so that letters on sign-out so that
the attending before ordering the attending before ordering
other people know the patient is other people know the patient is
any labs. any labs.
on coumadin. on coumadin.
Often the kids don’t need them and Often the kids don’t need them and
the attendings will be miffed that Don’t let it jump up!! the attendings will be miffed that Don’t let it jump up!!
they were ordered. they were ordered.

10 10
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
A.M. labs are usually back by 10 am. spinal, hip, knee and shoulder having an infection needs A.M. labs are usually back by 10 am. spinal, hip, knee and shoulder having an infection needs
procedures should get one in the these labs. procedures should get one in the these labs.
Midnight Labs can be ordered, recovery room. Midnight Labs can be ordered, recovery room.
especially on weekends. (1st draw AML) Blood Cx especially on weekends. (1st draw AML) 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
Don’t make a habit of signing out labs! (recognized by precipitous pressure Don’t make a habit of signing out labs! (recognized by precipitous pressure
part of our routine post op fever 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.
There are fewer labs to worry about There are fewer labs to worry about
in Orthopaedics. BMP in Orthopaedics. BMP
Watch the creatinine values Orthopaedic Tumor Consult? Watch the creatinine values Orthopaedic Tumor Consult?
A lab that is ordered on your on joint patients and patients A lab that is ordered on your on joint patients and patients
Order CBC, CRP, ESR, BMP, Order CBC, CRP, ESR, BMP,
patient is your responsibility to on gentamicin or patient is your responsibility to on gentamicin or
SPEP/UPEP, UA. SPEP/UPEP, UA.
check, no matter whom else vancomycin check, no matter whom else vancomycin
ordered it or is following the value. carefully. These have a tendency Dr. Frassica will ask for the calcium. ordered it or is following the value. carefully. These have a tendency Dr. Frassica will ask for the calcium.
to creep up. Keep potassium repleted. to creep up. Keep potassium repleted.
Get in the habit of looking through Pathology Reports Get in the habit of looking through Pathology Reports
EPR every day for rogue labs that PT/PTT Keep track of the patients you EPR every day for rogue labs that PT/PTT Keep track of the patients you
someone else ordered. Watch patients on coumadin have operated on, and review someone else ordered. Watch patients on coumadin have operated on, and review
like a hawk. Place it in bold their pathology reports. like a hawk. Place it in bold their pathology reports.
On the pediatrics service, ask On the pediatrics service, ask
letters on sign-out so that letters on sign-out so that
the attending before ordering the attending before ordering
other people know the patient is other people know the patient is
any labs. any labs.
on coumadin. on coumadin.
Often the kids don’t need them and Often the kids don’t need them and
the attendings will be miffed that Don’t let it jump up!! the attendings will be miffed that Don’t let it jump up!!
they were ordered. they were ordered.
 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 if you Overdose the weekends or evenings if you
feel the patients are seeking feel the patients are seeking
A: Maintain Airway drugs. A: Maintain Airway drugs.
Call anesthesia if needed Call anesthesia if needed
Call the chief resident or Call the chief resident or
B: Maintain Breathing attending and let them handle B: Maintain Breathing attending and let them handle
Oxygen supplementation Oxygen supplementation
Signs of Narcotic the problem (FJF). Signs of Narcotic the problem (FJF).
Overdose C: Circulatory Support Overdose C: Circulatory Support
Place patient on monitor Place patient on monitor
Respiratory depression Constipation Respiratory depression Constipation
D: Call code if necessary D: Call code if necessary
CNS depression Colace 100 mg po bid CNS depression Colace 100 mg po bid
E: Stop all narcotic medications E: Stop all narcotic medications
Miosis Senna 2 tabs qDay (increases GI Miosis Senna 2 tabs qDay (increases GI
F: Naloxone (e.g. Narcan) motility) F: Naloxone (e.g. Narcan) motility)
Hypotension 0.4mg-2mg q 2-3 min PRN. Hypotension 0.4mg-2mg q 2-3 min PRN.
Has short half-life / will likely need Has short half-life / will likely need
to be re-dosed. Patient should to be re-dosed. Patient should
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
They have differing half-lives Be wary of the narcotic seeking. They have differing half-lives Be wary of the narcotic seeking.
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 if you Overdose the weekends or evenings if you
feel the patients are seeking feel the patients are seeking
A: Maintain Airway drugs. A: Maintain Airway drugs.
Call anesthesia if needed Call anesthesia if needed
Call the chief resident or Call the chief resident or
B: Maintain Breathing attending and let them handle B: Maintain Breathing attending and let them handle
Oxygen supplementation Oxygen supplementation
Signs of Narcotic the problem (FJF). Signs of Narcotic the problem (FJF).
Overdose C: Circulatory Support Overdose C: Circulatory Support
Place patient on monitor Place patient on monitor
Respiratory depression Constipation Respiratory depression Constipation
D: Call code if necessary D: Call code if necessary
CNS depression Colace 100 mg po bid CNS depression Colace 100 mg po bid
E: Stop all narcotic medications E: Stop all narcotic medications
Miosis Senna 2 tabs qDay (increases GI Miosis Senna 2 tabs qDay (increases GI
F: Naloxone (e.g. Narcan) motility) F: Naloxone (e.g. Narcan) motility)
Hypotension 0.4mg-2mg q 2-3 min PRN. Hypotension 0.4mg-2mg q 2-3 min PRN.
Has short half-life / will likely need Has short half-life / will likely need
to be re-dosed. Patient should to be re-dosed. Patient should
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
They have differing half-lives Be wary of the narcotic seeking. They have differing half-lives Be wary of the narcotic seeking.
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:
Infarction YOU MUST see all patients with
complaints of chest pain. 1. Send off Cardiac enzymes x 3, first one
Infarction YOU MUST see all patients with
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.
if situation is bad. if situation is bad.
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,
nitroglycerin tablets, aspirin. nitroglycerin tablets, aspirin.
Check EKG Check EKG
Compare to old EKG. 5. If patient is having an acute MI, Compare to old EKG. 5. If patient is having an acute MI,
your job is to transfer them from your job is to transfer them from
If story not concerning, and our service and into a monitored If story not concerning, and our service and into a monitored
EKG unchanged: setting ASAP- SICU, Cards. EKG unchanged: setting ASAP- SICU, Cards.
May stop there and monitor. May stop there and monitor.
Do not forget about: We should not be Do not forget about: We should not be
PE, pneumonia, pneumothorax, etc. managing a MI ! PE, pneumonia, pneumothorax, etc. managing a MI !
Consider STAT CHEST X-ray. Consider STAT CHEST X-ray.

Talk to SICU fellow for any patients you have done all the necessary work- Talk to SICU fellow for any patients you have done all the necessary work-
SICU Consult with concerns. Don’t try to be a up and you have legitimate concerns. If SICU Consult with concerns. Don’t try to be a up and you have legitimate concerns. If
hero!! Bump it up if you have a worry. they are not receptive, talk to your hero!! Bump it up if you have a worry. they are not receptive, talk to your
Have a good story. Take EKG, labs, etc. chief or attending about the situation. Have a good story. Take EKG, labs, etc. chief or attending about the situation.
with you to the fellow. They are with you to the fellow. They are
Same situation for the PICU fellow. Same situation for the PICU fellow.
usually willing to help you out if you usually willing to help you out if you
present it to them in way that shows present it to them in way that shows

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:
Infarction YOU MUST see all patients with
complaints of chest pain. 1. Send off Cardiac enzymes x 3, first one
Infarction YOU MUST see all patients with
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.
if situation is bad. if situation is bad.
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,
nitroglycerin tablets, aspirin. nitroglycerin tablets, aspirin.
Check EKG Check EKG
Compare to old EKG. 5. If patient is having an acute MI, Compare to old EKG. 5. If patient is having an acute MI,
your job is to transfer them from your job is to transfer them from
If story not concerning, and our service and into a monitored If story not concerning, and our service and into a monitored
EKG unchanged: setting ASAP- SICU, Cards. EKG unchanged: setting ASAP- SICU, Cards.
May stop there and monitor. May stop there and monitor.
Do not forget about: We should not be Do not forget about: We should not be
PE, pneumonia, pneumothorax, etc. managing a MI ! PE, pneumonia, pneumothorax, etc. managing a MI !
Consider STAT CHEST X-ray. Consider STAT CHEST X-ray.

Talk to SICU fellow for any patients you have done all the necessary work- Talk to SICU fellow for any patients you have done all the necessary work-
SICU Consult with concerns. Don’t try to be a up and you have legitimate concerns. If SICU Consult with concerns. Don’t try to be a up and you have legitimate concerns. If
hero!! Bump it up if you have a worry. they are not receptive, talk to your hero!! Bump it up if you have a worry. they are not receptive, talk to your
Have a good story. Take EKG, labs, etc. chief or attending about the situation. Have a good story. Take EKG, labs, etc. chief or attending about the situation.
with you to the fellow. They are with you to the fellow. They are
Same situation for the PICU fellow. Same situation for the PICU fellow.
usually willing to help you out if you usually willing to help you out if you
present it to them in way that shows present it to them in way that shows
 13 13
Hypotension Hypotension
Make sure patient is stable. If patient in unstable Make sure patient is stable. If patient in unstable
(unresponsive, etc): (unresponsive, etc):
Check pulse, Urine output. Stat IV bolus NS. Check pulse, Urine output. Stat IV bolus NS.
Is patient alert? Stat SICU consult (they will want to Is patient alert? Stat SICU consult (they will want to
know EKG, Hct, WBC, ABG etc). know EKG, Hct, WBC, ABG etc).
If urine output is low, bolus with Have blood available. If urine output is low, bolus with Have blood available.
1 Liter Normal Saline ABC’s. 1 Liter Normal Saline ABC’s.
Let chief / attending know Check Hct Call code if concerned enough - ACLS? Let chief / attending know Check Hct Call code if concerned enough - ACLS?
if situation is bad. Blood > Normal Saline > ½ NS if situation is bad. Blood > Normal Saline > ½ NS
for intravascular resuscitation. for intravascular resuscitation.

Pulse Pulse
High hypovolemia? Sepsis? PE? A-fib? High hypovolemia? Sepsis? PE? A-fib?
Low heart failure? Low heart failure?
Meds:Beta blocker, calcium channel blocker? Meds:Beta blocker, calcium channel blocker?
Check EKG medicine consult? Check EKG medicine consult?
Cards consult for arrythmia. Cards consult for arrythmia.

Stroke Document your Neuro Exam

as thoroughly as possible.
JHH:
410.283.7777
Stroke Document your Neuro Exam
as thoroughly as possible.
JHH:
410.283.7777
Neurology Consult: Bayview: Neurology Consult: Bayview:
Call the Stroke pager ASAP. 410.283.8810 Call the Stroke pager ASAP. 410.283.8810
Good Samaritan: Good Samaritan:
410.532.4040 410.532.4040

13 13
Hypotension Hypotension
Make sure patient is stable. If patient in unstable Make sure patient is stable. If patient in unstable
(unresponsive, etc): (unresponsive, etc):
Check pulse, Urine output. Stat IV bolus NS. Check pulse, Urine output. Stat IV bolus NS.
Is patient alert? Stat SICU consult (they will want to Is patient alert? Stat SICU consult (they will want to
know EKG, Hct, WBC, ABG etc). know EKG, Hct, WBC, ABG etc).
If urine output is low, bolus with Have blood available. If urine output is low, bolus with Have blood available.
1 Liter Normal Saline ABC’s. 1 Liter Normal Saline ABC’s.
Let chief / attending know Check Hct Call code if concerned enough - ACLS? Let chief / attending know Check Hct Call code if concerned enough - ACLS?
if situation is bad. Blood > Normal Saline > ½ NS if situation is bad. Blood > Normal Saline > ½ NS
for intravascular resuscitation. for intravascular resuscitation.

Pulse Pulse
High hypovolemia? Sepsis? PE? A-fib? High hypovolemia? Sepsis? PE? A-fib?
Low heart failure? Low heart failure?
Meds:Beta blocker, calcium channel blocker? Meds:Beta blocker, calcium channel blocker?
Check EKG medicine consult? Check EKG medicine consult?
Cards consult for arrythmia. Cards consult for arrythmia.

Stroke Document your Neuro Exam

as thoroughly as possible.
JHH:
410.283.7777
Stroke Document your Neuro Exam
as thoroughly as possible.
JHH:
410.283.7777
Neurology Consult: Bayview: Neurology Consult: Bayview:
Call the Stroke pager ASAP. 410.283.8810 Call the Stroke pager ASAP. 410.283.8810
Good Samaritan: Good Samaritan:
410.532.4040 410.532.4040
 14 14
Fat Embolism Fat Embolism
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
Fat Embolism Fat Embolism
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
Epidural Hematoma Epidural Hematoma
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
chief & spine fellow. ORTHOPAEDIC EMERGENCY ! chief & 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.

15 15
Epidural Hematoma Epidural Hematoma
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
chief & spine fellow. ORTHOPAEDIC EMERGENCY ! chief & 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.
 16 16
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 &
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.
P H Y S I C A L ulnar nerves are in when you see them
in the ER.
E X A M Adult spine surgery NOS notes should
also include rectal tone, wink & EPL tests the radial nerve. E X A M Adult spine surgery NOS notes should
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 Motor exams are critical in
orthopaedics. Document your Do the rectal with a nurse present and Patients with an active nerve block orthopaedics. Document your Do the rectal with a nurse present and Patients with an active nerve block
findings accurately. warn the patient. ACDF’s do NOT from anesthesia should be reassessed findings accurately. 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
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 &
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.
P H Y S I C A L ulnar nerves are in when you see them
in the ER.
E X A M Adult spine surgery NOS notes should
also include rectal tone, wink & EPL tests the radial nerve. E X A M Adult spine surgery NOS notes should
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 Motor exams are critical in
orthopaedics. Document your Do the rectal with a nurse present and Patients with an active nerve block orthopaedics. Document your Do the rectal with a nurse present and Patients with an active nerve block
findings accurately. warn the patient. ACDF’s do NOT from anesthesia should be reassessed findings accurately. 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
 17 17

III plaster and 1 layer of soft roll on the

superficial side of the plaster so that
it doesn’t stick to the ACE wrap. Do
For fractures that can balloon with
swelling, use Robert Jones cotton for
extra padding. Overwrap with a
III plaster and 1 layer of soft roll on the
superficial side of the plaster so that
it doesn’t stick to the ACE wrap. Do
For fractures that can balloon with
swelling, use Robert Jones cotton for
extra padding. Overwrap with a
PROCEDURES not pull the softroll or ACE wrap. Kerlix to help apply gentle PROCEDURES not pull the softroll or ACE wrap. Kerlix to help apply gentle
This is too tight & patients will be compression to control the swelling. This is too tight & patients will be compression to control the swelling.
calling you in a few hours for blue or Fractures that require this are often calling you in a few hours for blue or Fractures that require this are often
tingling fingers. Just roll it on. high energy or have significant tingling fingers. Just roll it on. high energy or have significant
comminution – dusted elbows, comminution – dusted elbows,
Pad bony prominences well! This pilons, tibial plateau fractures. We Pad bony prominences well! This pilons, tibial plateau fractures. We
means putting on extra padding at also tend to splint tibial shaft means putting on extra padding at also tend to splint tibial shaft
the elbow joint for sugar tongs or on fractures with Robert Jones cotton the elbow joint for sugar tongs or on fractures with Robert Jones cotton
the heel for AO splints. Dr. Campbell and Kerlix here as well. the heel for AO splints. Dr. Campbell and Kerlix here as well.
often uses ABD pads for the heel. often uses ABD pads for the heel.
Splinting Make sure no plaster or thinly
However, too much padding may not Splinting Make sure no plaster or thinly
However, too much padding may not
provide enough support to maintain provide enough support to maintain
padded plaster touches the skin. a reduction. A distal radius needs padded plaster touches the skin. a reduction. A distal radius needs
Adult This is especially true at the ends Adult This is especially true at the ends
just enough soft roll to protect the just enough soft roll to protect the
of splints. skin without losing reduction. of splints. skin without losing reduction.
Adults do not get casts acutely, Adults do not get casts acutely,
the one exception may be cylinder Make sure your posterior slab for an the one exception may be cylinder Make sure your posterior slab for an
When holding a reduction as a splint When holding a reduction as a splint
casts for patella fractures (very ankle fracture does not dig into the casts for patella fractures (very ankle fracture does not dig into the
hardens, use broad surfaces to apply hardens, use broad surfaces to apply
rarely, Dr. Frassica prefers padded popliteal fossa. You will be amazed rarely, Dr. Frassica prefers padded popliteal fossa. You will be amazed
forces, use the palm of the hand. Do forces, use the palm of the hand. Do
splint). Only splint acute fractures how fast an ulcer can develop. splint). Only splint acute fractures how fast an ulcer can develop.
not use fingers or the plaster will not use fingers or the plaster will
with plaster to accommodate with plaster to accommodate
Upper extremity often requires 10- pick up the grooves and cause an Upper extremity often requires 10- pick up the grooves and cause an
swelling. No fiberglass. A splint swelling. No fiberglass. A splint
12 layers of plaster. Lower extremity ulcer. 12 layers of plaster. Lower extremity ulcer.
should generally try to immobilize should generally try to immobilize
the joint above and the joint below a often requires 12-14 layers. However, the joint above and the joint below a often requires 12-14 layers. However,
fracture. modify as necessary. A big person 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 general, use at least 3 layers of soft
roll to protect the skin from the roll to protect the skin from the

17 17

III plaster and 1 layer of soft roll on the

superficial side of the plaster so that
it doesn’t stick to the ACE wrap. Do
For fractures that can balloon with
swelling, use Robert Jones cotton for
extra padding. Overwrap with a
III plaster and 1 layer of soft roll on the
superficial side of the plaster so that
it doesn’t stick to the ACE wrap. Do
For fractures that can balloon with
swelling, use Robert Jones cotton for
extra padding. Overwrap with a
PROCEDURES not pull the softroll or ACE wrap. Kerlix to help apply gentle PROCEDURES not pull the softroll or ACE wrap. Kerlix to help apply gentle
This is too tight & patients will be compression to control the swelling. This is too tight & patients will be compression to control the swelling.
calling you in a few hours for blue or Fractures that require this are often calling you in a few hours for blue or Fractures that require this are often
tingling fingers. Just roll it on. high energy or have significant tingling fingers. Just roll it on. high energy or have significant
comminution – dusted elbows, comminution – dusted elbows,
Pad bony prominences well! This pilons, tibial plateau fractures. We Pad bony prominences well! This pilons, tibial plateau fractures. We
means putting on extra padding at also tend to splint tibial shaft means putting on extra padding at also tend to splint tibial shaft
the elbow joint for sugar tongs or on fractures with Robert Jones cotton the elbow joint for sugar tongs or on fractures with Robert Jones cotton
the heel for AO splints. Dr. Campbell and Kerlix here as well. the heel for AO splints. Dr. Campbell and Kerlix here as well.
often uses ABD pads for the heel. often uses ABD pads for the heel.
Splinting Make sure no plaster or thinly
However, too much padding may not Splinting Make sure no plaster or thinly
However, too much padding may not
provide enough support to maintain provide enough support to maintain
padded plaster touches the skin. a reduction. A distal radius needs padded plaster touches the skin. a reduction. A distal radius needs
Adult This is especially true at the ends Adult This is especially true at the ends
just enough soft roll to protect the just enough soft roll to protect the
of splints. skin without losing reduction. of splints. skin without losing reduction.
Adults do not get casts acutely, Adults do not get casts acutely,
the one exception may be cylinder Make sure your posterior slab for an the one exception may be cylinder Make sure your posterior slab for an
When holding a reduction as a splint When holding a reduction as a splint
casts for patella fractures (very ankle fracture does not dig into the casts for patella fractures (very ankle fracture does not dig into the
hardens, use broad surfaces to apply hardens, use broad surfaces to apply
rarely, Dr. Frassica prefers padded popliteal fossa. You will be amazed rarely, Dr. Frassica prefers padded popliteal fossa. You will be amazed
forces, use the palm of the hand. Do forces, use the palm of the hand. Do
splint). Only splint acute fractures how fast an ulcer can develop. splint). Only splint acute fractures how fast an ulcer can develop.
not use fingers or the plaster will not use fingers or the plaster will
with plaster to accommodate with plaster to accommodate
Upper extremity often requires 10- pick up the grooves and cause an Upper extremity often requires 10- pick up the grooves and cause an
swelling. No fiberglass. A splint swelling. No fiberglass. A splint
12 layers of plaster. Lower extremity ulcer. 12 layers of plaster. Lower extremity ulcer.
should generally try to immobilize should generally try to immobilize
the joint above and the joint below a often requires 12-14 layers. However, the joint above and the joint below a often requires 12-14 layers. However,
fracture. modify as necessary. A big person 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 general, use at least 3 layers of soft
roll to protect the skin from the roll to protect the skin from the
 18 18
Fracture Splint Tips Fracture Splint Tips
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

18 18
Fracture Splint Tips Fracture Splint Tips
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

 19 19
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 90°. Pediatrics Volarly do not extend the cast distal to Cast with the ankle dorsiflexed to 90°.
the distal transverse palmar crease so Make sure the tips of the toes are the distal transverse palmar crease so 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 for the short arm cast. In addition, cast with the knee flexed at As above for the short arm cast. In addition, cast with the knee flexed at
Take care to avoid pressure points addition, cast with the elbow flexed at 30°. This prevents kids from being able Take care to avoid pressure points addition, cast with the elbow flexed at 30°. This prevents kids from being able
which may cause cast sores. 90°. Apply a supracondylar mold. to weight-bear. Apply a supracondylar which may cause cast sores. 90°. Apply a supracondylar mold. to weight-bear. Apply a supracondylar
Extend the cast as proximal as mold (M to L). Extend the cast as Extend the cast as proximal as mold (M to L). Extend the cast as
Bivalve all casts unless there is possible, but avoid impinging on the proximal as possible (it is never as high Bivalve all casts unless there is possible, but avoid impinging on the proximal as possible (it is never as high
minimal swelling and a low-energy axilla. Make sure you wrap the soft roll as you think). It often helps to abduct minimal swelling and a low-energy axilla. Make sure you wrap the soft roll as you think). It often helps to abduct
mechanism with little potential for with the elbow flexed at 90°, so that the hip off of the bed to obtain space mechanism with little potential for with the elbow flexed at 90°, so that the hip off of the bed to obtain space
swelling (i.e. buckle fracture), or a wrinkles do not develop. under the proximal thigh. Make sure swelling (i.e. buckle fracture), or a wrinkles do not develop. under the proximal thigh. Make sure
significant time has elapsed since the you wrap the soft roll with the knee significant time has elapsed since the you wrap the soft roll with the knee
injuring event (i.e.> 2 days). Indicated for unstable forearm flexed so that wrinkles do not develop. injuring event (i.e.> 2 days). Indicated for unstable forearm flexed so that wrinkles do not develop.
fractures, forearm fractures which Indicated for tibial shaft fractures and fractures, forearm fractures which Indicated for tibial shaft fractures and
Ask a child his or her color preference! required reduction, and pediatric ankle fractures which required Ask a child his or her color preference! required reduction, and pediatric ankle fractures which required
elbow fractures using neutral rotation. reduction. elbow fractures using neutral rotation. reduction.

19 19
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 90°. Pediatrics Volarly do not extend the cast distal to Cast with the ankle dorsiflexed to 90°.
the distal transverse palmar crease so Make sure the tips of the toes are the distal transverse palmar crease so 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 for the short arm cast. In addition, cast with the knee flexed at As above for the short arm cast. In addition, cast with the knee flexed at
Take care to avoid pressure points addition, cast with the elbow flexed at 30°. This prevents kids from being able Take care to avoid pressure points addition, cast with the elbow flexed at 30°. This prevents kids from being able
which may cause cast sores. 90°. Apply a supracondylar mold. to weight-bear. Apply a supracondylar which may cause cast sores. 90°. Apply a supracondylar mold. to weight-bear. Apply a supracondylar
Extend the cast as proximal as mold (M to L). Extend the cast as Extend the cast as proximal as mold (M to L). Extend the cast as
Bivalve all casts unless there is possible, but avoid impinging on the proximal as possible (it is never as high Bivalve all casts unless there is possible, but avoid impinging on the proximal as possible (it is never as high
minimal swelling and a low-energy axilla. Make sure you wrap the soft roll as you think). It often helps to abduct minimal swelling and a low-energy axilla. Make sure you wrap the soft roll as you think). It often helps to abduct
mechanism with little potential for with the elbow flexed at 90°, so that the hip off of the bed to obtain space mechanism with little potential for with the elbow flexed at 90°, so that the hip off of the bed to obtain space
swelling (i.e. buckle fracture), or a wrinkles do not develop. under the proximal thigh. Make sure swelling (i.e. buckle fracture), or a wrinkles do not develop. under the proximal thigh. Make sure
significant time has elapsed since the you wrap the soft roll with the knee significant time has elapsed since the you wrap the soft roll with the knee
injuring event (i.e.> 2 days). Indicated for unstable forearm flexed so that wrinkles do not develop. injuring event (i.e.> 2 days). Indicated for unstable forearm flexed so that wrinkles do not develop.
fractures, forearm fractures which Indicated for tibial shaft fractures and fractures, forearm fractures which Indicated for tibial shaft fractures and
Ask a child his or her color preference! required reduction, and pediatric ankle fractures which required Ask a child his or her color preference! required reduction, and pediatric ankle fractures which required
elbow fractures using neutral rotation. reduction. elbow fractures using neutral rotation. reduction.
 20 20

SPICA Cast for Femur Fractures SPICA Cast for Femur Fractures
Requires conscious sedation, Insert towel into abdomen to allow Requires conscious sedation, Insert towel 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 Use up and down motion only. check reduction before and during cast Use up and down motion only.
application will prevent the need for application will prevent the need for
recasting and save significant time. DO NOT MOVE THE SAW recasting and save significant time. 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.
No clamshelling here. No clamshelling here.

20 20

SPICA Cast for Femur Fractures SPICA Cast for Femur Fractures
Requires conscious sedation, Insert towel into abdomen to allow Requires conscious sedation, Insert towel 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 Use up and down motion only. check reduction before and during cast Use up and down motion only.
application will prevent the need for application will prevent the need for
recasting and save significant time. DO NOT MOVE THE SAW recasting and save significant time. 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.
No clamshelling here. No clamshelling here.
 21 21
Traction: Skeletal Traction: Skeletal
This is an invasive procedure that is Distal Femoral This is an invasive procedure that is Distal Femoral
done either in an operating room or done either in an operating room or
in the E.R. with local anesthesia. Distal femoral traction pins are in the E.R. with local anesthesia. Distal femoral traction pins are
Steinman pin trays are kept in both inserted on medial side to avoid Steinman pin trays are kept in both inserted on medial side to avoid
the Bayview (pyxis) and JHH ER in injury to the femoral artery. the Bayview (pyxis) and JHH ER in injury to the femoral artery.
the supply room. It is best to flex the knee and thigh the supply room. It is best to flex the knee and thigh
Traction can be set up once the on several folded sheets to facilitate Traction can be set up once the on several folded sheets to facilitate
patient gets a bed on the floor. Call pin insertion from the opposite side patient gets a bed on the floor. Call pin insertion from the opposite side
central supply to have them deliver of the bed and go from medial to central supply to have them deliver of the bed and go from medial to
the traction cart to the floor where lateral. This also facilitates obtaining a the traction cart to the floor where lateral. This also facilitates obtaining a
you will need it. lateral radiographic view. you will need it. lateral radiographic view.

Proximal Tibia The entry site is just proximal to the Proximal Tibia The entry site is just proximal to the
adductor tubercle (proximal to adductor tubercle (proximal to
Proximal tibial pins are more medial epicondyle and/or growth Proximal tibial pins are more medial epicondyle and/or growth
commonly used, and are helpful in a plate ~ 1 finger breadth above commonly used, and are helpful in a plate ~ 1 finger breadth above
Traction is the use of a pulling femoral shaft fracture in order to superior pole of patella when leg in Traction is the use of a pulling femoral shaft fracture in order to superior pole of patella when leg in
force to treat long bone keep the patient out to length, and extension. force to treat long bone keep the patient out to length, and extension.
fractures prior to operative to relieve pain prior to going to the fractures prior to operative to relieve pain prior to going to the
fixation. Traction serves several OR. Distal pin placement risks entering fixation. Traction serves several OR. Distal pin placement risks entering
purposes: it aligns the ends of a joint at intercondylar notch, and purposes: it aligns the ends of a joint at intercondylar notch, and
fracture by pulling the limb into a Contraindications include ligament more proximal pin insertion risks fracture by pulling the limb into a Contraindications include ligament more proximal pin insertion risks
straight position; it ends muscle injury to ipsilateral knee and should injury to femoral artery at Hunter’s straight position; it ends muscle injury to ipsilateral knee and should injury to femoral artery at Hunter’s
spasm and relieves pain. never be used in children. These pins canal. spasm and relieves pain. never be used in children. These pins canal.
are inserted from lateral side to are inserted from lateral side to
Skeletal Traction avoid damaging peroneal nerve. As the short longitudinal incision is Skeletal Traction avoid damaging peroneal nerve. As the short longitudinal incision is
made, turn the knife 90 deg (once it made, turn the knife 90 deg (once it
Skeletal traction is performed when The pin insertion site is 2.5 cm is buried under the skin) in order to Skeletal traction is performed when The pin insertion site is 2.5 cm is buried under the skin) in order to
more pulling force is needed than posterior to and 2.5 cm distal to make a small transverse nick in the more pulling force is needed than posterior to and 2.5 cm distal to make a small transverse nick in the
can be withstood by skin traction. tibial tubercle. Make a skin incision IT band. Place pin perpendicular to can be withstood by skin traction. tibial tubercle. Make a skin incision IT band. Place pin perpendicular to
Skeletal traction uses weights of 25- about 1 cm in length, placed about 3 knee joint rather than perpendicular Skeletal traction uses weights of 25- about 1 cm in length, placed about 3 knee joint rather than perpendicular
40 pounds. cm below the lesser tuberosity. to femoral shaft. 40 pounds. cm below the lesser tuberosity. to femoral shaft.

21 21
Traction: Skeletal Traction: Skeletal
This is an invasive procedure that is Distal Femoral This is an invasive procedure that is Distal Femoral
done either in an operating room or done either in an operating room or
in the E.R. with local anesthesia. Distal femoral traction pins are in the E.R. with local anesthesia. Distal femoral traction pins are
Steinman pin trays are kept in both inserted on medial side to avoid Steinman pin trays are kept in both inserted on medial side to avoid
the Bayview (pyxis) and JHH ER in injury to the femoral artery. the Bayview (pyxis) and JHH ER in injury to the femoral artery.
the supply room. It is best to flex the knee and thigh the supply room. It is best to flex the knee and thigh
Traction can be set up once the on several folded sheets to facilitate Traction can be set up once the on several folded sheets to facilitate
patient gets a bed on the floor. Call pin insertion from the opposite side patient gets a bed on the floor. Call pin insertion from the opposite side
central supply to have them deliver of the bed and go from medial to central supply to have them deliver of the bed and go from medial to
the traction cart to the floor where lateral. This also facilitates obtaining a the traction cart to the floor where lateral. This also facilitates obtaining a
you will need it. lateral radiographic view. you will need it. lateral radiographic view.

Proximal Tibia The entry site is just proximal to the Proximal Tibia The entry site is just proximal to the
adductor tubercle (proximal to adductor tubercle (proximal to
Proximal tibial pins are more medial epicondyle and/or growth Proximal tibial pins are more medial epicondyle and/or growth
commonly used, and are helpful in a plate ~ 1 finger breadth above commonly used, and are helpful in a plate ~ 1 finger breadth above
Traction is the use of a pulling femoral shaft fracture in order to superior pole of patella when leg in Traction is the use of a pulling femoral shaft fracture in order to superior pole of patella when leg in
force to treat long bone keep the patient out to length, and extension. force to treat long bone keep the patient out to length, and extension.
fractures prior to operative to relieve pain prior to going to the fractures prior to operative to relieve pain prior to going to the
fixation. Traction serves several OR. Distal pin placement risks entering fixation. Traction serves several OR. Distal pin placement risks entering
purposes: it aligns the ends of a joint at intercondylar notch, and purposes: it aligns the ends of a joint at intercondylar notch, and
fracture by pulling the limb into a Contraindications include ligament more proximal pin insertion risks fracture by pulling the limb into a Contraindications include ligament more proximal pin insertion risks
straight position; it ends muscle injury to ipsilateral knee and should injury to femoral artery at Hunter’s straight position; it ends muscle injury to ipsilateral knee and should injury to femoral artery at Hunter’s
spasm and relieves pain. never be used in children. These pins canal. spasm and relieves pain. never be used in children. These pins canal.
are inserted from lateral side to are inserted from lateral side to
Skeletal Traction avoid damaging peroneal nerve. As the short longitudinal incision is Skeletal Traction avoid damaging peroneal nerve. As the short longitudinal incision is
made, turn the knife 90 deg (once it made, turn the knife 90 deg (once it
Skeletal traction is performed when The pin insertion site is 2.5 cm is buried under the skin) in order to Skeletal traction is performed when The pin insertion site is 2.5 cm is buried under the skin) in order to
more pulling force is needed than posterior to and 2.5 cm distal to make a small transverse nick in the more pulling force is needed than posterior to and 2.5 cm distal to make a small transverse nick in the
can be withstood by skin traction. tibial tubercle. Make a skin incision IT band. Place pin perpendicular to can be withstood by skin traction. tibial tubercle. Make a skin incision IT band. Place pin perpendicular to
Skeletal traction uses weights of 25- about 1 cm in length, placed about 3 knee joint rather than perpendicular Skeletal traction uses weights of 25- about 1 cm in length, placed about 3 knee joint rather than perpendicular
40 pounds. cm below the lesser tuberosity. to femoral shaft. 40 pounds. cm below the lesser tuberosity. to femoral shaft.
 22 22
Traction: Skin Traction: Skin
Preparation Apply adhesive straps to the cotton Preparation Apply adhesive straps to the cotton
padding both medially and laterally padding both medially and laterally
Prep the area well with betadine and and secure with an overwrap of an Prep the area well with betadine and and secure with an overwrap of an
have all of your equipment ready in ace wrap. The straps are attached to have all of your equipment ready in ace wrap. The straps are attached to
order to keep things sterile. a footplate, which is connected to order to keep things sterile. a footplate, which is connected to
Inject 1% lidocaine into the skin and the desired weights through a pulley Inject 1% lidocaine into the skin and the desired weights through a pulley
down to bone around the areas system. down to bone around the areas system.
where your insertion and exit sites The pulley system is adjusted to where your insertion and exit sites The pulley system is adjusted to
will be. obtain the necessary angle of will be. obtain the necessary angle of
Make your incision as above and traction. Hip flexion is secured with a Make your incision as above and traction. Hip flexion is secured with a
place pin medial to lateral. folded blanket posterior to the thigh place pin medial to lateral. folded blanket posterior to the thigh
or a sling about the thigh attached to or a sling about the thigh attached to
Finally, check an x-ray after you are a weight through a pulley system. Finally, check an x-ray after you are a weight through a pulley system.
finished to make certain you are in finished to make certain you are in
bone and not in the joint. The contra-lateral extremity is bone and not in the joint. The contra-lateral extremity is
likewise padded, wrapped, and placed likewise padded, wrapped, and placed
Keep the pin sites covered with in traction. Keep the pin sites covered with in traction.
sterile guaze or xeroform until going sterile guaze or xeroform until going
to the OR, where the pin will likely Elevate the foot of the bed to to the OR, where the pin will likely Elevate the foot of the bed to
be removed. prevent a child from sliding down the be removed. prevent a child from sliding down the
bed because of the traction. bed because of the traction.

Skin Traction Skin traction uses five-to seven Skin Traction Skin traction uses five-to seven
pound weights depending on the size pound weights depending on the size
The skin should be cleansed and and weight of the child. The skin should be cleansed and and weight of the child.
then prepared with a non-allergenic then prepared with a non-allergenic
adherent dressing to prevent skin The amount of weight that can be adherent dressing to prevent skin The amount of weight that can be
irritation. Make sure that the leg and applied through skin traction is irritation. Make sure that the leg and applied through skin traction is
bony prominences of the malleoli and limited because excessive weight will bony prominences of the malleoli and limited because excessive weight will
heel are well protected with cast irritate the skin and cause it to heel are well protected with cast irritate the skin and cause it to
padding, and that the leg is wrapped. slough off. padding, and that the leg is wrapped. slough off.

22 22
Traction: Skin Traction: Skin
Preparation Apply adhesive straps to the cotton Preparation Apply adhesive straps to the cotton
padding both medially and laterally padding both medially and laterally
Prep the area well with betadine and and secure with an overwrap of an Prep the area well with betadine and and secure with an overwrap of an
have all of your equipment ready in ace wrap. The straps are attached to have all of your equipment ready in ace wrap. The straps are attached to
order to keep things sterile. a footplate, which is connected to order to keep things sterile. a footplate, which is connected to
Inject 1% lidocaine into the skin and the desired weights through a pulley Inject 1% lidocaine into the skin and the desired weights through a pulley
down to bone around the areas system. down to bone around the areas system.
where your insertion and exit sites The pulley system is adjusted to where your insertion and exit sites The pulley system is adjusted to
will be. obtain the necessary angle of will be. obtain the necessary angle of
Make your incision as above and traction. Hip flexion is secured with a Make your incision as above and traction. Hip flexion is secured with a
place pin medial to lateral. folded blanket posterior to the thigh place pin medial to lateral. folded blanket posterior to the thigh
or a sling about the thigh attached to or a sling about the thigh attached to
Finally, check an x-ray after you are a weight through a pulley system. Finally, check an x-ray after you are a weight through a pulley system.
finished to make certain you are in finished to make certain you are in
bone and not in the joint. The contra-lateral extremity is bone and not in the joint. The contra-lateral extremity is
likewise padded, wrapped, and placed likewise padded, wrapped, and placed
Keep the pin sites covered with in traction. Keep the pin sites covered with in traction.
sterile guaze or xeroform until going sterile guaze or xeroform until going
to the OR, where the pin will likely Elevate the foot of the bed to to the OR, where the pin will likely Elevate the foot of the bed to
be removed. prevent a child from sliding down the be removed. prevent a child from sliding down the
bed because of the traction. bed because of the traction.

Skin Traction Skin traction uses five-to seven Skin Traction Skin traction uses five-to seven
pound weights depending on the size pound weights depending on the size
The skin should be cleansed and and weight of the child. The skin should be cleansed and and weight of the child.
then prepared with a non-allergenic then prepared with a non-allergenic
adherent dressing to prevent skin The amount of weight that can be adherent dressing to prevent skin The amount of weight that can be
irritation. Make sure that the leg and applied through skin traction is irritation. Make sure that the leg and applied through skin traction is
bony prominences of the malleoli and limited because excessive weight will bony prominences of the malleoli and limited because excessive weight will
heel are well protected with cast irritate the skin and cause it to heel are well protected with cast irritate the skin and cause it to
padding, and that the leg is wrapped. slough off. padding, and that the leg is wrapped. slough off.
 23 23
Aspirations Aspirations
5. Send Red and Green tops, sterile Hips and shoulders should be 5. Send Red and Green tops, sterile Hips and shoulders should be
General: collecting cup/tube for culture. done with fluoro guidance to General: collecting cup/tube for culture. done with fluoro guidance to
1. Sterile technique: alcohol prep, Be careful with transferring fluid to tubes. ensure that it is intraarticular. 1. Sterile technique: alcohol prep, Be careful with transferring fluid to tubes. ensure that it is intraarticular.
then betadine or chlorhexidine. Talk to radiology. then betadine or chlorhexidine. Talk to radiology.
6. Send for: (Make sure it is marked 6. Send for: (Make sure it is marked
2. Lidocaine local. “Stat” on pink pathology form) Bursa 2. Lidocaine local. “Stat” on pink pathology form) Bursa
Olecranon, prepatellar: Needle only; Olecranon, prepatellar: Needle only;
3. Aspirate with at least 1 ½ inch 20 Gram Stain may leave an angio cath 16 ga for 3. Aspirate with at least 1 ½ inch 20 Gram Stain may leave an angio cath 16 ga for
ga, preferably 19 ga, consider spinal Cultures-aerobic/anaerobic daily lavage if pt is being admitted. ga, preferably 19 ga, consider spinal Cultures-aerobic/anaerobic daily lavage if pt is being admitted.
needles. (add fungal if immunocomp) needles. (add fungal if immunocomp)
Do not I & D: they drain forever!! Do not I & D: they drain forever!!
4. Tap until dry. Cell Count and Differential 4. Tap until dry. Cell Count and Differential
Crystals Crystals
Sometimes glucose Sometimes glucose
7. Walk it down to lab yourself!!! 7. Walk it down to lab yourself!!!

Injections Injections
Joint: Tough to know if you are really Be wary of mycotic aneurysms in Joint: Tough to know if you are really Be wary of mycotic aneurysms in
Joint in. Can go from posterolateral IVDA patients. Joint in. Can go from posterolateral IVDA patients.
shoulder or anterior between Consider dopplers if concerned. shoulder or anterior between Consider dopplers if concerned.
Prep the area with betadine and coracoid and AC joint. Prep the area with betadine and coracoid and AC joint.
alcohol. Sterilely prep area. Incise skin along alcohol. Sterilely prep area. Incise skin along
Abcess Langer’s lines. Abcess Langer’s lines.
Knee-supralateral or supramedial. Knee-supralateral or supramedial.
Can also go anterolateral/medial, but IVDA: Need x-rays and CT scan w Send cultures. Can also go anterolateral/medial, but IVDA: Need x-rays and CT scan w Send cultures.
need to flex knee close to 90°. contrast minimum prior to cutting need to flex knee close to 90°. contrast minimum prior to cutting
skin. Pack and dress wound. skin. Pack and dress wound.
Shoulder Shoulder
Gas Gangrene? Needs OR IV antibiotics vs. po (see if patient Gas Gangrene? Needs OR IV antibiotics vs. po (see if patient
Subacromial bursa: Posterolateral debridement. can go to EACU). Subacromial bursa: Posterolateral debridement. can go to EACU).
aspect of acromion. Slide under aspect of acromion. Slide under
bone. bone.

23 23
Aspirations Aspirations
5. Send Red and Green tops, sterile Hips and shoulders should be 5. Send Red and Green tops, sterile Hips and shoulders should be
General: collecting cup/tube for culture. done with fluoro guidance to General: collecting cup/tube for culture. done with fluoro guidance to
1. Sterile technique: alcohol prep, Be careful with transferring fluid to tubes. ensure that it is intraarticular. 1. Sterile technique: alcohol prep, Be careful with transferring fluid to tubes. ensure that it is intraarticular.
then betadine or chlorhexidine. Talk to radiology. then betadine or chlorhexidine. Talk to radiology.
6. Send for: (Make sure it is marked 6. Send for: (Make sure it is marked
2. Lidocaine local. “Stat” on pink pathology form) Bursa 2. Lidocaine local. “Stat” on pink pathology form) Bursa
Olecranon, prepatellar: Needle only; Olecranon, prepatellar: Needle only;
3. Aspirate with at least 1 ½ inch 20 Gram Stain may leave an angio cath 16 ga for 3. Aspirate with at least 1 ½ inch 20 Gram Stain may leave an angio cath 16 ga for
ga, preferably 19 ga, consider spinal Cultures-aerobic/anaerobic daily lavage if pt is being admitted. ga, preferably 19 ga, consider spinal Cultures-aerobic/anaerobic daily lavage if pt is being admitted.
needles. (add fungal if immunocomp) needles. (add fungal if immunocomp)
Do not I & D: they drain forever!! Do not I & D: they drain forever!!
4. Tap until dry. Cell Count and Differential 4. Tap until dry. Cell Count and Differential
Crystals Crystals
Sometimes glucose Sometimes glucose
7. Walk it down to lab yourself!!! 7. Walk it down to lab yourself!!!

Injections Injections
Joint: Tough to know if you are really Be wary of mycotic aneurysms in Joint: Tough to know if you are really Be wary of mycotic aneurysms in
Joint in. Can go from posterolateral IVDA patients. Joint in. Can go from posterolateral IVDA patients.
shoulder or anterior between Consider dopplers if concerned. shoulder or anterior between Consider dopplers if concerned.
Prep the area with betadine and coracoid and AC joint. Prep the area with betadine and coracoid and AC joint.
alcohol. Sterilely prep area. Incise skin along alcohol. Sterilely prep area. Incise skin along
Abcess Langer’s lines. Abcess Langer’s lines.
Knee-supralateral or supramedial. Knee-supralateral or supramedial.
Can also go anterolateral/medial, but IVDA: Need x-rays and CT scan w Send cultures. Can also go anterolateral/medial, but IVDA: Need x-rays and CT scan w Send cultures.
need to flex knee close to 90°. contrast minimum prior to cutting need to flex knee close to 90°. contrast minimum prior to cutting
skin. Pack and dress wound. skin. Pack and dress wound.
Shoulder Shoulder
Gas Gangrene? Needs OR IV antibiotics vs. po (see if patient Gas Gangrene? Needs OR IV antibiotics vs. po (see if patient
Subacromial bursa: Posterolateral debridement. can go to EACU). Subacromial bursa: Posterolateral debridement. can go to EACU).
aspect of acromion. Slide under aspect of acromion. Slide under
bone. bone.
 24 24
Preop Checklist Preop Checklist
IV History Chest Xray IV History Chest Xray

PREOPERATIVE Physical EKG PREOPERATIVE Physical EKG

C A R E NEED heart and lung exam Labs C A R E NEED heart and lung exam Labs
CBC T2S or T2C CBC T2S or T2C
Consent Chemistry Consent Chemistry
Attending is not listed as “staff”. List Coags Attending is not listed as “staff”. List Coags
some of the most likely attendings Mark Site some of the most likely attendings Mark Site
(Adult, Peds, Shock Trauma, Fellows). (Adult, Peds, Shock Trauma, Fellows).
D/C Blood Thinners D/C Blood Thinners
Standard Risks & Specific Risks Lovenox, Coumadin, ASA, Plavix... Standard Risks & Specific Risks Lovenox, Coumadin, ASA, Plavix...
Bleeding, infection, non-union, NPO Bleeding, infection, non-union, NPO
malunion, injury to nerves or vessels, malunion, injury to nerves or vessels,
weakness, numbness, pain, hardware Consults weakness, numbness, pain, hardware Consults
failure, breakage, loosening, Medicine failure, breakage, loosening, Medicine
compartment syndrome, loss of Anesthesia compartment syndrome, loss of Anesthesia
function, arthritis, need for additional function, arthritis, need for additional
procedures, limp, cosmetic deformity, Posted procedures, limp, cosmetic deformity, Posted
leg length discrepancy (total hip, Patients discharged to follow up leg length discrepancy (total hip, Patients discharged to follow up
femoral nail etc.), reflex sympathetic in Chiefs clinic. femoral nail etc.), reflex sympathetic in Chiefs clinic.
dystrophy, stiffness. dystrophy, stiffness.
Preop fully - including contact Preop fully - including contact
Peds Risks numbers Peds Risks numbers
Growth plate injury causing leg Growth plate injury causing leg
length discrepancy length discrepancy
Level 1 posting: must stay with Level 1 posting: must stay with
Blood consent patient and personally bring to Blood consent patient and personally bring to
Films O.R. Films O.R.

24 24
Preop Checklist Preop Checklist
IV History Chest Xray IV History Chest Xray

PREOPERATIVE Physical EKG PREOPERATIVE Physical EKG

C A R E NEED heart and lung exam Labs C A R E NEED heart and lung exam Labs
CBC T2S or T2C CBC T2S or T2C
Consent Chemistry Consent Chemistry
Attending is not listed as “staff”. List Coags Attending is not listed as “staff”. List Coags
some of the most likely attendings Mark Site some of the most likely attendings Mark Site
(Adult, Peds, Shock Trauma, Fellows). (Adult, Peds, Shock Trauma, Fellows).
D/C Blood Thinners D/C Blood Thinners
Standard Risks & Specific Risks Lovenox, Coumadin, ASA, Plavix... Standard Risks & Specific Risks Lovenox, Coumadin, ASA, Plavix...
Bleeding, infection, non-union, NPO Bleeding, infection, non-union, NPO
malunion, injury to nerves or vessels, malunion, injury to nerves or vessels,
weakness, numbness, pain, hardware Consults weakness, numbness, pain, hardware Consults
failure, breakage, loosening, Medicine failure, breakage, loosening, Medicine
compartment syndrome, loss of Anesthesia compartment syndrome, loss of Anesthesia
function, arthritis, need for additional function, arthritis, need for additional
procedures, limp, cosmetic deformity, Posted procedures, limp, cosmetic deformity, Posted
leg length discrepancy (total hip, Patients discharged to follow up leg length discrepancy (total hip, Patients discharged to follow up
femoral nail etc.), reflex sympathetic in Chiefs clinic. femoral nail etc.), reflex sympathetic in Chiefs clinic.
dystrophy, stiffness. dystrophy, stiffness.
Preop fully - including contact Preop fully - including contact
Peds Risks numbers Peds Risks numbers
Growth plate injury causing leg Growth plate injury causing leg
length discrepancy length discrepancy
Level 1 posting: must stay with Level 1 posting: must stay with
Blood consent patient and personally bring to Blood consent patient and personally bring to
Films O.R. Films O.R.
 25 25
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
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.

25 25
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
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.
 26 26
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 one hour or on a thigh supplied with cuff of web role should than one hour or on a thigh
be applied prior to cuff positioning greater than 1.5 hrs. be applied prior to cuff positioning greater than 1.5 hrs.
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 of es-marc. rotated to a new position. an ace wrap of es-marc.
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.

26 26
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. 400 mmHg. 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 one hour or on a thigh supplied with cuff of web role should than one hour or on a thigh
be applied prior to cuff positioning greater than 1.5 hrs. be applied prior to cuff positioning greater than 1.5 hrs.
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 of es-marc. rotated to a new position. an ace wrap of es-marc.
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.
 27 27
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

27 27
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
 28 28

VI Fluoroscopy
Must have lead prior to operating
On Hip xrays obtain cross table
lateral of affected side. VI Fluoroscopy
Must have lead prior to operating
On Hip xrays obtain cross table
lateral of affected side.

RADIOLOGY Fluoro. Always x-ray the joint above and RADIOLOGY Fluoro. Always x-ray the joint above and
below the injury!!! below the injury!!!
Make sure every one in room is Make sure every one in room is
covered prior to fluoroscopy – covered prior to fluoroscopy –
announce that fluoro is being used. Special Views announce that fluoro is being used. Special Views
6 feet minimum safe distance to Axillary views on all shoulder 6 feet minimum safe distance to Axillary views on all shoulder
avoid radiation if not wearing films. If tech unwilling, you will have to avoid radiation if not wearing films. If tech unwilling, you will have to
protection. position the arm for the film. protection. position the arm for the film.
Make sure that you have informed Pelvis: Judet views. Evaluate for all Make sure that you have informed Pelvis: Judet views. Evaluate for all
anesthesia prior to fluoro use so that possible acetabular fx. anesthesia prior to fluoro use so that possible acetabular fx.
they are protected. they are protected.
Inlet Outlet View if there is Inlet Outlet View if there is
possible disruption of pelvic ring. possible disruption of pelvic ring.
Mini C arm Mini C arm
1 foot min safe distance. CT Scans for 1 foot min safe distance. CT Scans for
Should use xray gown if available. Tibial Plateau fractures Should use xray gown if available. Tibial Plateau fractures
Mini C arm located in Urgent care: Pelvic fractures Mini C arm located in Urgent care: Pelvic fractures
Make sure you return it after use. Pilon fractures Make sure you return it after use. Pilon fractures
Spine fractures Spine fractures
Calcaneal fractures Calcaneal fractures
Plain Xray Plain Xray
At least 2 views of all extremities: At least 2 views of all extremities:
AP & Lateral. Insist on perfect AP & Lateral. Insist on perfect
laterals, otherwise they will be laterals, otherwise they will be
oblique, and YOU, not the XR tech oblique, and YOU, not the XR tech
will be spanked at AM board rounds. will be spanked at AM board rounds.

28 28

VI Fluoroscopy
Must have lead prior to operating
On Hip xrays obtain cross table
lateral of affected side. VI Fluoroscopy
Must have lead prior to operating
On Hip xrays obtain cross table
lateral of affected side.

RADIOLOGY Fluoro. Always x-ray the joint above and RADIOLOGY Fluoro. Always x-ray the joint above and
below the injury!!! below the injury!!!
Make sure every one in room is Make sure every one in room is
covered prior to fluoroscopy – covered prior to fluoroscopy –
announce that fluoro is being used. Special Views announce that fluoro is being used. Special Views
6 feet minimum safe distance to Axillary views on all shoulder 6 feet minimum safe distance to Axillary views on all shoulder
avoid radiation if not wearing films. If tech unwilling, you will have to avoid radiation if not wearing films. If tech unwilling, you will have to
protection. position the arm for the film. protection. position the arm for the film.
Make sure that you have informed Pelvis: Judet views. Evaluate for all Make sure that you have informed Pelvis: Judet views. Evaluate for all
anesthesia prior to fluoro use so that possible acetabular fx. anesthesia prior to fluoro use so that possible acetabular fx.
they are protected. they are protected.
Inlet Outlet View if there is Inlet Outlet View if there is
possible disruption of pelvic ring. possible disruption of pelvic ring.
Mini C arm Mini C arm
1 foot min safe distance. CT Scans for 1 foot min safe distance. CT Scans for
Should use xray gown if available. Tibial Plateau fractures Should use xray gown if available. Tibial Plateau fractures
Mini C arm located in Urgent care: Pelvic fractures Mini C arm located in Urgent care: Pelvic fractures
Make sure you return it after use. Pilon fractures Make sure you return it after use. Pilon fractures
Spine fractures Spine fractures
Calcaneal fractures Calcaneal fractures
Plain Xray Plain Xray
At least 2 views of all extremities: At least 2 views of all extremities:
AP & Lateral. Insist on perfect AP & Lateral. Insist on perfect
laterals, otherwise they will be laterals, otherwise they will be
oblique, and YOU, not the XR tech oblique, and YOU, not the XR tech
will be spanked at AM board rounds. will be spanked at AM board rounds.
 29 29
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

29 29
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
 30 30

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

30 30

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
 31 31

VII Night of Surgery Notes (NOS)

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

31 31

VII Night of Surgery Notes (NOS)

Vital Signs
Review I&O’s, check BUN/Cr for
kidney status. Evaluate nephrotoxic
drugs such as aminoglycoside or
VII Night of Surgery Notes (NOS)
Vital Signs
Review I&O’s, check BUN/Cr for
kidney status. Evaluate nephrotoxic
drugs such as aminoglycoside or
POSTOPERATIVE See how pain is. vancomycin. POSTOPERATIVE See how pain is. vancomycin.
C A R E Any concern for compartment Evaluate patient for distention. In C A R E Any concern for compartment Evaluate patient for distention. In
syndrome? pediatric patients may be more syndrome? pediatric patients may be more
Fever: Respond to all temps > 38.5. Appropriate exams: conservative about cathing. Consider Fever: Respond to all temps > 38.5. Appropriate exams: conservative about cathing. Consider
Spine Exam checking post void residuals. Spine Exam checking post void residuals.
Low grade fever within first 24-48 Low grade fever within first 24-48
Neurovascular exam for extremities Potential for cauda equine syndrome Neurovascular exam for extremities Potential for cauda equine syndrome
hours of surgery is normal, but do hours of surgery is normal, but do
Look at op note in post op spine patients. Check Look at op note in post op spine patients. Check
not let that fool you. not let that fool you.
Make sure dressing/splints/VACs are rectal tone/sensation and rule out Make sure dressing/splints/VACs are rectal tone/sensation and rule out
UA is the most sensitive test for saddle anesthesia in spine patients. UA is the most sensitive test for saddle anesthesia in spine patients.
intact. intact.
fever work-up during first 48 hours fever work-up during first 48 hours
(due to foley, etc). Send C&S as well. PACU x-rays / Hgb VAC Dressings (due to foley, etc). Send C&S as well. PACU x-rays / Hgb VAC Dressings
Must act if suction is not Must act if suction is not
Check vitals make sure pt is stable. Let chief know about any Check vitals make sure pt is stable. Let chief know about any
holding. Cover any openings with holding. Cover any openings with
concerns. op-site etc. concerns. op-site etc.
Examine incision. Examine incision.
Check for calf tenderness. If positive or Constipation / Ileus Non-working VAC sponge is a Check for calf tenderness. If positive or Constipation / Ileus Non-working VAC sponge is a
suspicious for DVT, order Ultrasound. All patients on colace. Dulcolax, fleets, broth for badness!! Don’t let suspicious for DVT, order Ultrasound. All patients on colace. Dulcolax, fleets, broth for badness!! Don’t let
soap suds, Mag Citrate, etc as needed. someone get toxic shock soap suds, Mag Citrate, etc as needed. someone get toxic shock
Chest Xray to eval for Atelectasis syndrome because you didn’t Chest Xray to eval for Atelectasis syndrome because you didn’t
and Pneumonia (if lungs sound junky). Urinary Retention check the VAC!!! and Pneumonia (if lungs sound junky). Urinary Retention check the VAC!!!
Have concern if a spine patient. Have concern if a spine patient.
Send blood cultures x 2 (if valid Cultures/Infectious Disease Send blood cultures x 2 (if valid Cultures/Infectious Disease
Cauda Equina? Check post void Cauda Equina? Check post void
concern for sepsis). Consultations concern for sepsis). Consultations
residuals on all spine patients. residuals on all spine patients.
Remember: Pathology Remember: Pathology
Straight cath if it’s been greater that Straight cath if it’s been greater that
Wind ,Water, Wound, Walking, Wind ,Water, Wound, Walking,
8 hours, leave in if output > 300 cc. 8 hours, leave in if output > 300 cc.
Wonder Drug Keep an eye on all cultures and Wonder Drug Keep an eye on all cultures and
Remove foley next am to let specimens sent from OR!!! Don’t Remove foley next am to let specimens sent from OR!!! Don’t
detrusor muscle relax. miss an infection or other badness!! detrusor muscle relax. miss an infection or other badness!!
 32 32

VIII W/u should include albumin,

prealbumin, transferrin. Ensure
shakes/pudding TID.
Open Fractures:
Type I or II: 1st generation
VIII W/u should include albumin,
prealbumin, transferrin. Ensure
shakes/pudding TID.
Open Fractures:
Type I or II: 1st generation
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 colchicines. diabetes. (i.e. Gent or Vanc levels). Check daily. prescribe colchicines. 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!!!!

32 32

VIII W/u should include albumin,

prealbumin, transferrin. Ensure
shakes/pudding TID.
Open Fractures:
Type I or II: 1 generation
st
VIII W/u should include albumin,
prealbumin, transferrin. Ensure
shakes/pudding TID.
Open Fractures:
Type I or II: 1st generation
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 colchicines. diabetes. (i.e. Gent or Vanc levels). Check daily. prescribe colchicines. 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!!!!
 33 33

IX ON-CALL (410.283.1254) SPINE Spine Fellow

IX ON-CALL (410.283.1254) SPINE 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 7am-5pm Day Adult: Shared with neurosurgery.

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
neurosurgery!!! neurosurgery!!!

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 clavical fractures, etc can wait until The clavical fractures, etc can wait until
the emergencies are handled. the emergencies are handled.

33 33

IX ON-CALL (410.283.1254) SPINE Spine Fellow

IX ON-CALL (410.283.1254) SPINE 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 7am-5pm Day Adult: Shared with neurosurgery.

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
neurosurgery!!! neurosurgery!!!

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 clavical fractures, etc can wait until The clavical fractures, etc can wait until
the emergencies are handled. the emergencies are handled.
 34 34

X JHOC X JHOC
F O L L O W- U P 1. Pediatric Chief Resident Clinic
JHOC
F O L L O W- U P 1. Pediatric Chief Resident Clinic
JHOC
C L I N I C S Every Monday.
All fractures in children <4 yrs In the past, patients in the JHHED C L I N I C S Every Monday.
All fractures in children <4 yrs In the past, patients in the JHHED
Complicated fractures <16 yrs have been told to, “Follow up in clinic”, Complicated fractures <16 yrs have been told to, “Follow up in clinic”,
UNDER the medical assistance or “Follow up in Chief Clinic.” This has UNDER the medical assistance or “Follow up in Chief Clinic.” This has
umbrella (see chart). created substantial confusion, and umbrella (see chart). created substantial confusion, and
has resulted in follow-ups at has resulted in follow-ups at
BAYVIEW 2. Pediatric Attending Clinic
Mon: Sponseller
inappropriate times. BAYVIEW 2. Pediatric Attending Clinic
Mon: Sponseller
inappropriate times.

Tues: Ain; Leet When residents see patients in the ED, Tues: Ain; Leet When residents see patients in the ED,
1. Chief Resident Clinic Thurs: Sponseller patients should be given the pink 1. Chief Resident Clinic Thurs: Sponseller patients should be given the pink
Every Wednesday AM. Fri: Ain follow-up appointment card with Every Wednesday AM. Fri: Ain follow-up appointment card with
All fractures All fractures in children <16 yrs. the name of the clinic (can be Dr’s All fractures All fractures in children <16 yrs. the name of the clinic (can be Dr’s
SELF-PAY and those NOT under the medical name or specialty), with the date. SELF-PAY and those NOT under the medical name or specialty), with the date.
UNDER the medical assistance assistance umbrella (see chart). (Children are sent to clinic of the UNDER the medical assistance assistance umbrella (see chart). (Children are sent to clinic of the
umbrella (see chart). Child is sent to clinic of attending on attending who was on call the day the umbrella (see chart). Child is sent to clinic of attending on attending who was on call the day the
Bayview Residents’ Coordinator call the day patient was seen in ED. patient was seen in ED.) Bayview Residents’ Coordinator call the day patient was seen in ED. patient was seen in ED.)
April Lindenmuth (01504) Each day residents who see ED patients April Lindenmuth (01504) Each day residents who see ED patients
3. Trauma Fracture Clinic 3. Trauma Fracture Clinic
Every Wednesday. also need to provide a list of ED Every Wednesday. also need to provide a list of ED
All other fractures. patients given follow-up appts All other fractures. patients given follow-up appts
UNDER the medical assistance (pink cards) to the JHOC UNDER the medical assistance (pink cards) to the JHOC
umbrella (see chart). Residents’ Coordinator (57296) umbrella (see chart). Residents’ Coordinator (57296)
for next-day scheduling (list needs for next-day scheduling (list needs
4. Private Fracture Clinic to include patient name, JHH#, and 4. Private Fracture Clinic to include patient name, JHH#, and
Every Thursday afternoon. follow-up date). Every Thursday afternoon. follow-up date).
All other fractures All other fractures
NOT under the medical assistance NOT under the medical assistance
umbrella (see chart). umbrella (see chart).

34 34

X JHOC X JHOC
F O L L O W- U P 1. Pediatric Chief Resident Clinic
JHOC
F O L L O W- U P 1. Pediatric Chief Resident Clinic
JHOC
C L I N I C S Every Monday.
All fractures in children <4 yrs In the past, patients in the JHHED C L I N I C S Every Monday.
All fractures in children <4 yrs In the past, patients in the JHHED
Complicated fractures <16 yrs have been told to, “Follow up in clinic”, Complicated fractures <16 yrs have been told to, “Follow up in clinic”,
UNDER the medical assistance or “Follow up in Chief Clinic.” This has UNDER the medical assistance or “Follow up in Chief Clinic.” This has
umbrella (see chart). created substantial confusion, and umbrella (see chart). created substantial confusion, and
has resulted in follow-ups at has resulted in follow-ups at
BAYVIEW 2. Pediatric Attending Clinic
Mon: Sponseller
inappropriate times. BAYVIEW 2. Pediatric Attending Clinic
Mon: Sponseller
inappropriate times.

Tues: Ain; Leet When residents see patients in the ED, Tues: Ain; Leet When residents see patients in the ED,
1. Chief Resident Clinic Thurs: Sponseller patients should be given the pink 1. Chief Resident Clinic Thurs: Sponseller patients should be given the pink
Every Wednesday AM. Fri: Ain follow-up appointment card with Every Wednesday AM. Fri: Ain follow-up appointment card with
All fractures All fractures in children <16 yrs. the name of the clinic (can be Dr’s All fractures All fractures in children <16 yrs. the name of the clinic (can be Dr’s
SELF-PAY and those NOT under the medical name or specialty), with the date. SELF-PAY and those NOT under the medical name or specialty), with the date.
UNDER the medical assistance assistance umbrella (see chart). (Children are sent to clinic of the UNDER the medical assistance assistance umbrella (see chart). (Children are sent to clinic of the
umbrella (see chart). Child is sent to clinic of attending on attending who was on call the day the umbrella (see chart). Child is sent to clinic of attending on attending who was on call the day the
Bayview Residents’ Coordinator call the day patient was seen in ED. patient was seen in ED.) Bayview Residents’ Coordinator call the day patient was seen in ED. patient was seen in ED.)
April Lindenmuth (01504) Each day residents who see ED patients April Lindenmuth (01504) Each day residents who see ED patients
3. Trauma Fracture Clinic 3. Trauma Fracture Clinic
Every Wednesday. also need to provide a list of ED Every Wednesday. also need to provide a list of ED
All other fractures. patients given follow-up appts All other fractures. patients given follow-up appts
UNDER the medical assistance (pink cards) to the JHOC UNDER the medical assistance (pink cards) to the JHOC
umbrella (see chart). Residents’ Coordinator (57296) umbrella (see chart). Residents’ Coordinator (57296)
for next-day scheduling (list needs for next-day scheduling (list needs
4. Private Fracture Clinic to include patient name, JHH#, and 4. Private Fracture Clinic to include patient name, JHH#, and
Every Thursday afternoon. follow-up date). Every Thursday afternoon. follow-up date).
All other fractures All other fractures
NOT under the medical assistance NOT under the medical assistance
umbrella (see chart). umbrella (see chart).
 35 35

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

35 35

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
 36 36

XII NetOrthoDoc Website

NetOrthoDoc is a password-
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

36 36

XII NetOrthoDoc Website

NetOrthoDoc is a password-
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
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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

42 42
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) - Diagnoses/Problems
- Diagnoses/Problems Complaint) - Indications for Surgery
- Procedures - History of Present Illness (may
- Indications for Surgery - History of Present Illness (may include past medical/surgical, family
- Procedures - Pre-Operative/Post-Operative
- 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,
- Adverse Drug Reactions, Allergies, Complications of - Major Findings (including PE,
Pathological, or other) - Major Findings (including PE, pertinent lab or imaging study
Allergies, Complications of - Prosthetic Device / Implant Procedures
- 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,
- Discharge Instructions (Diet, Activity, Other Follow-Up Car - Problems/Diagnoses
prep, incision, closure, drains etc.) - Problems/Diagnoses - Description of Findings
- Description of Findings Activity, Other Follow-Up Car - Stage of Cancer - Procedures & Immunizations
CC List (include address of non-
- 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 (clinic notes are linked to an outpatient
- Indication of dual Attendings
- Indication of dual Attendings (clinic notes are linked to an outpatient episode of care
episode of care