Guidelines for Orthopaedic Trauma

Educational Objectives

The goals of this program are to improve management of orthopedic trauma and postoperative infections and to im­prove risk management practices. After hearing and assimilating this program, the clinician will be better able to:

1.   Prioritize orthopedic trauma calls and assess which types of injuries require the most urgent attention.

2.   Determine whether patients suffering orthopedic trauma should be treated in a community hospital or trans­ferred to a trauma center.

3.   Recognize infected orthopedic hardware and evaluate whether it can be salvaged.

4.   Comply with Emergency Medical Treatment and Active Labor Act (EMTALA) regulations governing emer­gency treatment and patient transfers.

5.   Identify the most common causes of medical malpractice claims, and take proactive steps to prevent them.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Schmidt has financial relationships with Smith and Nephew, Thieme, Medtronic, Twin Star Medical, and Conventus. Drs. Wiss and Trafton, Mr. Goodman, and the planning committee reported nothing to disclose.  

Acknowledgments

Drs. Wiss,  Trafton,  and Schmidt, and  Mr. Goodman were recorded at the 4th Annual San Francisco Orthopaedic Trauma Course, held April 30 to May 2, 2009, in San Francisco, CA, and presented by the Department of Orthopaedic Surgery of the University of California, San Francisco, School of Medicine and San Francisco General Hospital. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Surviving Emergency Call: Tips for theNon-Traumatologist

Donald A. Wiss, MD, Clinical Professor, Department of Orthopaedic Surgery, Keck School of Medicine at the University of Southern California, and Director of Orthopaedic Trauma, Cedars-Sinai Medical Center, Los An­geles, CA

Introduction: calls frequently interrupt procedures or arrive at night or on weekends; calls increase malpractice risk

Emergency call guidelines: live reasonably close to primary call hospital; avoid alcohol consumption when on call, even on typically low-volume shifts; avoid using multiple consultants; transfer patients only after thorough assess­ment and stabilization; establish preferred call hours far in advance; remote access  —  remotely viewing patient data (eg, x-rays) critical; remote data provides basis for decisions about patient priority and condition; preparedness   —  have reference books available; do not hesitate to pause and consult online references for issues or anatomy not regularly encountered; keep specializations of colleagues in mind for referrals and assistance; prioritizing  —  know reliability of information provided in calls; diagnostic and treatment skill varies greatly among initial providers; lack of experience may bias assessment of severity, causing under- or over-emphasis

24-hr trauma room: designated for cases that present at night; cost-effective; improves patient care and fracture out­comes; few absolute orthopedic emergencies, but do not procrastinate

Damage-control orthopedics: treatment philosophy emphasizes stabilization and injury control over primary repair; 1) resuscitate and stabilize, 2) eliminate urgent case component, 3) transport to intensive care unit (ICU)

Absolute emergencies: compartment syndrome  —  among most severe orthopedic emergencies; conduct clinical exam with even slight suspicion; always measure compartments in presence of obfuscating factors (eg, head injury, alcohol intoxication); predominantly clinical diagnosis; surgically releasing even borderline compartment advis­able; failure to promptly treat compartment syndrome among most common causes of malpractice lawsuits; vascu­lar injuries  —  associated with fractures and dislocations; relatively uncommon; typically occurs around knee, distal femur, proximal tibia, or elbow; irreducible major joint dislocations  —  typically occur in hip and knee, occasion­ally shoulder; general anesthetic facilitates reduction and appropriate imaging; mangled extremity  —  physician to patient dialogue typically unproductive; attempting salvage of obviously unsalvageable limbs may expose patients to higher risks of sepsis and mortality; unsuccessful limb salvage associated with increased costs and psychosocial morbidity; hemodynamically unstable displaced pelvic fracture  —  focus on controlling bleeding; sheet or pelvic binder to control pelvic volume may help temporize; pelvic C-clamp useful in selected cases; at minimum, learn how to attach simple pelvic reduction resuscitation frame (placing pins to stabilize pelvis for transfer or definitive fixation)

Relative emergences: low-grade open fractures  —  often consist of small puncture wounds; can typically wait several hours (but requires timely treatment); displaced femoral neck fracture  —  no absolute guidelines, but earlier treat­ment preferred; anterior or anterolateral approach necessary if fracture remains irreducible; secure time and assis­tance in advance; high-energy fractures  —  apply damage control approach; with displacement, delay definitive fixation; conduct thorough examination, assess neurovascular health, check for compartment syndrome, apply rapid damage control frame; tibial pilon injury  —  high-energy fracture treatment guidelines apply; serious injury requiring spanning external fixation; fractured dislocation  —  most dislocations do not fracture; exclusions necessi­tate reduction and repair

Care of the Trauma Patient: What Does it Take?

Peter G. Trafton, MD, Professor of Orthopaedic Surgery, Alpert Medical School, Brown University, Provi­dence, RI

Patient care: majority of trauma patients not treated in trauma centers; very small number of severely injured pa­tients, very large number of “walking wounded”; most moderate injuries treated in community hospitals, few of which employ dedicated trauma teams; severely injured patients typically experience better outcomes when treated at trauma centers; regional trauma systems  —  organize care within local area and bring right patient to right hospi­tal at right time; include opportunities for quality assessment and improvement via case review process

Triaging trauma patients: isolated fractures constitute lowest priority; multiple fractures must be evaluated individ­ually; number of fractures does not increase injury severity score (ISS); ISS based on individual assessment of 3 bodily systems with most severe injuries; patients with multiple fractures meeting ISS and physiologic criteria for significant trauma ideally routed to trauma centers

Preparedness: focus on generalist practice; refine diagnostic skills; having latest medical technology not critical; emphasize basics; personal preparation  —  no substitute for visiting community hospitals and trauma centers; wit­nessing colleagues perform familiar procedures often highly educational; communication with patient (or family member) critical; Advanced Trauma Life Support (ALTS) training program highly beneficial (as student or instruc­tor); institutional preparation  —  form transfer agreements dividing specific types of patients between neighboring hospitals; develop concrete protocols specifying patient care, but recognize that each patient and situation unique

Postoperative Infections: Acute Management

Andrew H. Schmidt, MD, Associate Professor, Department of Orthopaedic surgery, University of Minnesota, Medical School, and Hennepin County Medical Center, Minneapolis, MN

Infections: occur in £5% of closed fractures; infection rates reach 50% among specific populations of patients with open fractures; postoperative infections treated by orthopedists typically related to implants

Biofilms: in nature, bacteria form mixed-species communities capable of surface adhesion; surfaces of metal im­plants electrochemically active and rapidly absorb proteins; absorbed proteins stimulate both host tissue ingrowth and bacterial proliferation; biofilms  —  organized structures with 3-dimensional morphology; contain fluid channels that allow transportation of nutrients and signaling molecules; actions  —  1) enhance bacterial nutrition, 2) interfere with phagocytosis, 3) influence host antibody functioning, 4) promote increased bacterial aggregation; antibiotic resistance increases and specific antibiotic sensitivities decrease; induce genetic changes in resident bacteria (sub­populations display reduced growth rates and increased levels of resistance or persistence); persister cells  — do not grow or die (even in presence of antibiotics); capable of reverting to normal phenotype when antibiotics stopped

Fracture stability: foreign bodies typically increase risk for infection, yet internal fixation of open fractures reduces infection rates; Association for the Study of Internal Fixation (AO) Institute Study  —  tibial fractures induced in rab­bits, then stabilized rigidly (with plate) or loosely (with undersized intramedullary pin); fractures subsequently in­oculated with Staphylococcus aureus; infection rates doubled in loosely stabilized subjects; mechanism undetermined; stable fixation may promote rapid vascular invasion and host tissue ingrowth, creating less hospita­ble surface for bacterial growth

Clinical aspects: postoperative infections typically difficult to diagnose; associated with persistent pain, wound in­flammation, occasionally abscess with draining; patients frequently display no symptoms beyond unexpected loos­ening; confirmation diagnostics  —  studies by several authors cite prolonged culturing and sonication as methods for increasing yields; imaging studies typically unreliable (especially with early postoperative infections); labora­tory studies helpful, particularly C-reactive protein (CRP) assays; CRP typically peaks 2 days after surgery and subsequently falls; in study, rise in CRP >4 days postoperatively predictive of septic complications

Infected fracture: acute phase  —  may present with nonunion and loose or unstable hardware; options  —  1) suppress infection until fracture unifies, then remove hardware, 2) eradicate infection by implant removal or debridement, then obtain unification; paradox  —  infected implants act as bacterial reservoirs, support biofilm, and suppress im­mune response; however, rigidly stabilized implants combat infection and promote healing; choice  —  depends on clinical situation, including host characteristics, whether bone healing and callus forming, health of soft tissues, acuity of infection; type of organisms, type of implant;  treatment  —  depends on maintaining stability, but balanced against possible need to remove colonized hardware

Study data: German implant study  —  protocol of debriding infected fracture sites every 48 hr, combined with local and systemic antibiotics; all infections eventually eradicated; implants salvaged in only one-third of patients; every patient with history of diabetes, vascular disease, alcoholism, or tobacco use failed protocol and required hardware removal; Southeast Fracture Consortium  —  protocol specified debridement, retention of implant, and prolonged an­tibiotic suppression; hardware salvaged in three-quarters of patients, but of these, more than one-third suffered re­currence of infection and required implant removal; predictors of failure included open fractures and intramedullary nail placement

Infected intramedullary nail: theoretically capable of causing wide-spread intramedullary infection; Court-Brown study  —determined exchange nailing with reaming of intramedullary canal typically sufficient to treat infections; antibiotic-impregnated-cement nail  —  rapidly gaining favor with diaphyseal infections; in study, cement nails with culture-specific antibiotics successfully eradicated implant infections in 18 of 19 patients; summary  —  when im­plant exchange necessary, consider brief “hardware holiday” (»1 wk ) with alternative fixation

EMTALA: What Does it Mean to Me?

Dr. Schmidt

Emergency Medical Treatment and Active Labor Act (EMTALA): colloquially referred to as “antidumping stat­ute”; passed by congress in 1986; places significant financial burden on hospitals and physicians; considered one of primary causes of ER overcrowding and diversion

What is EMTALA? places requirements on hospitals that participate in Medicare and offer emergency services; re­quirements enforced regardless of whether patients enrolled in qualifying federal programs; EMTALA forbids de­lays in screening or stabilization of patients for purposes of assessing ability to pay or seek authorization; laws require hospitals to report inappropriate transfer of patients; signs required throughout hospital indicating patients’ right to treatment; hospitals must maintain on-call logs; if found negligent in providing care mandated by EM­TALA, civil penalties apply

EMTALA regulations and precedents: 600 to 700 EMTALA violations annually; 13 hospitals banned from Medi­care system for repeated violations; “the final rule”  —  issued in 2003 by Centers for Medicare and Medicaid Ser­vices; expanded definition of emergency department (ED) to include any part of hospital affiliated with ED; clarifications of on-call policy  —  physicians now allowed on-call status at multiple hospitals and permitted to work in clinics or surgery while on-call; physicians are not required to be on-call at all times, but hospitals must establish protocols for when specialists unavailable; EMTALA obligations end when patient stable, appropriately trans­ferred, or admitted; hospitals with specialized capabilities (participating in Medicare) violate EMTALA by refusing transfers; physicians automatically subject to EMTALA when name on on-call list; EMTALA forbids physicians not listed as on-call from selectively accepting patients; physician’s assistants may respond to calls from EDs, but require supervision of on-call physician; hospitals may refuse transfers if certain transferring hospital capable of providing care; receiving hospital can sue transferring hospital for cost of care if transfer inappropriate

Personal requirements: manage patients according to hospital privileges, not scope of practice; respond to ED when called and evaluate patient; if required treatment beyond physician’s skills, physician must personally arrange and document referrals; gray areas remain, involving scope of practice, core competencies, hospital privileges, and fol­low-up care; maintain core competencies in initial fracture management; physicians employed in trauma centers are frequently willing to help, but preferable to find associates in community who can provide assistance

How Do I Avoid a Lawsuit?

James M. Goodman, Esq, Hassard Bonnington, LLP, San Francisco, CA

Causes of litigation: many patients with just cause choose not to file claims; speaker has identified 2 critical points where lawsuits typically foment, 1) patient considers lawsuit and decides to consult lawyer, 2) lawyer chooses to accept case; if lawyer accepts case, claims almost certainly follow; decision to consult lawyer is typically difficult for patient; patients with favorable physician relationships likely to regard complications as acceptable; amicable relationship with patients critical; physicians with unfavorable attitudes at higher risk for lawsuits; sudden changes in demeanor following complications typically not appreciated

Patient categories: with specific subgroups, any negative outcome likely to result in malpractice claims; speaker la­bels these individuals “problem patients”; problem patients  —   laws (eg, EMTALA) prevent screening problem pa­tients out of practice; learn to recognize problem patients while providing care in hospital settings; increase documentation of treatment accordingly; catastrophic loss  —  occurs when patient suffers life-altering conse­quences, eg, paralysis, loss of limb; patients with amicable physician relationships may feel forced to sue based on economic pressures

Lawyer’s decision: many lawyers hire independent experts to evaluate merits of potential claims; if accused physi­cian demonstrates consistent quality care (eg, in patient evaluation, indications for surgery, technique applied, at­taining informed consent, postoperative care) attorney may refuse case; altering documentation  —  never attempt covert revision of old records; even when absolutely certain of documentation errors (taking place before complica­tions occurred), resist going back to amend; changes easily found by document examiners

Proactive response: with potential lawsuits, physicians should inform their liability insurers and risk manager; phy­sician’s legal representation occasionally able to dissuade other parties from filing claim (successful in »10% of cases); respond cooperatively to records requests and other inquiries; never submit to interview with lawyer for other side; talking with patient or patient’s family permissible; catastrophic loss cases  —  infrequently dropped; typ­ically high-value cases; lawyers frequently accept catastrophic loss cases with insubstantial evidence; in states with tort reform, lawyers seldom take nuisance value cases

Ineffective tactics: written waivers  —  states do not allow physicians to obtain waivers for medical negligence; threats  —ineffective whether issued by lawyer or physician;  arbitration agreements  in opinion of speaker, they “simply do not work” and increase costs dramatically; juries exonerate physicians in >85% of contested trials; arbi­trators frequently rule against physicians and hospitals

Suggested Reading

Roberts CS et al: Damage Control Orthopaedics: Evolving Concepts in the Treatment of Patients Who Have Sustained Orthopae­dic Trauma. The Journal of Bone and Joint Surgery (American) 87:434, 2005; Tobias JD Hoernschemeyer DG: Near-infrared spectroscopy identifies compartment syndrome in an infant. J Pediatr Orthop 27:311, 2007; Sadri H et al: Control of severe hem­orrhage using C-clamp and arterial embolization in hemodynamically unstable patients with pelvic ring disruption.  Archives of Or­thopaedic and Trauma Surgery 125:443, 2005; Sutherland AG et al: The New Injury Severity Score: Better Prediction of Functional Recovery after Musculoskeletal Injury. Value in Health 9:24, 2006; Pape HC et al: Timing of Fixation of Major Frac­tures in Blunt Polytrauma: Role of Conventional Indicators in Clinical Decision Making. Journal of Orthopaedic Trauma 19:551, 2005; Parks J et al: Systemic hypotension is a late marker of shock after trauma: a validation study of Advanced Trauma Life Sup­port principles in a large national sample. The American Journal of Surgery 192:727, 2006; Subbiahdoss G et al: Microbial biofilm growth vs. tissue integration: “The race for the surface” experimentally studied. Acta Biomaterialia 5:1399, 2009; Esteban J et al: Evaluation of Quantitative Analysis of Cultures from Sonicated Retrieved Orthopedic Implants in Diagnosis of Orthopedic Infec­tion. Journal of Clinical Microbiology 46:488, 2008; Bhandari M et al: Randomized Trial of Reamed and Unreamed Intramedul­lary Nailing of Tibial Shaft Fractures. The Journal of Bone and Joint Surgery (American) 91:1274, 2009; Bitterman R: EMTALA and the Ethical Delivery of Hospital Emergency Services. Emergency Medicine Clinics of North America 24:557, 2006; Ballard D et al: EMTALA, two decades later: a descriptive review of fiscal year 2000 violations. The American Journal of Emergency Medi­cine 24:197, 2006; Cone D et al: EMTALA knowledge among on-call specialists at an academic medical center. Journal of Emer­gency Medicine 30:444, 2006; Sacopulos M Segal JJ: Limiting Exposure to Medical Malpractice Claims and Defamatory Cyber Postings via Patient Contracts. Clinical Orthopaedics and Related Research 467:427, 2008; Studdert DM et al: Claims, Errors, and Compensation Payments in Medical Malpractice Litigation. New England Journal of Medicine 354:2024, 2006.