General guidelines for orthopaedic injuries and initial evaluation

 

General Guidelines for Orthopaedic Injuries

Overall Guide

• As a Level 1 Trauma Center, Kentucky Children’s Hospital accepts all referrals/transfers related to orthopaedic emergencies.
• ALL pelvic and acetabular fractures are treated at UKHeathCare 
• See pelvic fracture algorithms – stable & unstable
• Long bone fractures, isolated or multiply injured, are taken to the operating room for initial or definitive fixation within 24 hours of presentation to UKHealthCare unless not medically cleared.
• See “Determining priority in emergency orthopaedic and non-orthopaedic injuries” for damage control priorities (Below).
• Open fractures are evaluated for proper management and are taken to the operating room for surgical irrigation & debridement within 24 hours of presentation to UKHealthCare unless not medically cleared. Initial washout may be performed at bedside as needed.  Open fractures receive the first dose of antibiotics within 60 minutes of arrival at UKHealthCare. 
• Refer to “Open Fracture” guideline and “Determining Priority in Emergency Non-Ortho and Ortho Injuries"
• Supracondylar humerus fractures, Gartland type III or greater, are taken for repair within 18 hours of injury. Occasionally, some cases may be referred to Shriner’s Hospital for outpatient OR to optimize minimal time to operative repair.

Consulting Orthopaedic Surgery 

The Orthopaedic Trauma team is readily available after consultation requested by the surgical team leader for multiply injured patients with these time-sensitive injuries

• Fractures or dislocations with
• Neurovascular compromise
• Risk of avascular necrosis
• Pelvic fractures with hemodynamic instability
• Suspected compartment syndrome

        OR at the discretion of the trauma surgeon

General initial assessment, interventions, diagnostics and pain management of pediatric extremity fractures

Assessment 

• Document time, mechanism of injury and any associated injuries. 

• Note obvious swelling, deformity, tissue integrity, dislocation, or inability to bear weight or move affected extremity.  And compare to uninjured extremity. 

• Assess and document quality and severity of pain using age-appropriate tools 

 

Children >12years of age: 5P’s	Children 0-11 years: 3 A’s
Pain	Analgesia
Paralysis	Anxiety
Pulses	Agitation
Paresthesia
Pallor

• Perform serial assessments for compartment syndrome (CS). Assess for: 

Taut, firm extremity compartments 

Pain unrelieved by narcotics – often the first noted indication of CS 

Extreme pain elicited by passive stretch 

Paresthesia 

Loss of pulse is the LAST clinical finding in developing CS 

• Determine relevant history, including previous fracture or injury; possible pregnancy status in females; tetanus immunization status; last meal; medications received. 

• Document treatment PTA – self-treatment, at outlying facility, or by pre-hospital personnel. 

 

Interventions: 

• Remove jewelry and/or constrictive clothing as soon as possible. 

• RICE – rest, ice, compression, elevation. 

• Irrigate, clean, and dress open wounds (See Open Fracture guideline) – give Td as indicated 

• Splint injured site to prevent further injury or allow patient to hold extremity in position of comfort 

• Reevaluate neurovascular status proximal to injury before and after any interventions. 

 

Diagnostics 

• Image affected limb with joints above and below the injury site 

• Consult orthopaedics for abnormality noted on imaging or concern for compartment syndrome. 

• Consider CTA, angiogram, and/or vascular consult if vascular injury suspected. Hard signs are:  

• expanding/pulsatile hematoma 

• presence of bruit/thrill 

• absence of Doppler signals 

• signs of limb ischemia 

• ABI < 0.9 

• Refer to Mangled Extremity Guideline or Extremity Vascular Injury Guideline for further care of these injuries.   

 

Pain management recommendations for the orthopaedically injured child 

• Acetaminophen 15mg/kg/dose q 4h PRN 

• Ibuprofen 10 mg/kg/dose q 6h PRN pain 

• Acetaminophen/Hydrocodone, Hydrocodone 0.1 - 0.2 mg/kg/dose q 4h PRN pain 

• Oxycodone 0.1 – 0.2 mg/kg/dose q 4h PRN pain 

• Morphine Inj.  0.05 to 0.2 mg/kg/dose q 2h PRN pain 

• Diazepam 0.05 – 0.1 mg/kg/dose q 6h PRN spasms 

Determining Priority in Emergency Non-orthopaedic and Orthopaedic Injuries

 Disclaimer

These guidelines are not intended as a directive or to present a definitive statement of the applicable standard of patient care.  They are offered as an approach for quality assurance and risk management and are subject to (1) revision as warranted by the continuing evaluation of technology and practice; (2) the overall individual professional discretion and judgment of the treating provider in a given patient circumstance; and (3) the patient’s willingness to follow the recommended treatment.