Frustrated learning orthopedic fractures ED disposition

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plick

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Which fractures need ortho consult in the ED? Which ones can be discharged to see ortho later (referral)?

I'm doing a "deep-dive" of this topic, since I feel that my residency program didn't really prepare us well for ortho fx topics. I thought this was pretty straightforward to learn, as I just started being an attending. However... Anyone out there feel that learning ED dispositions of ortho fractures can sometimes be more difficult than it should be?? I say this because different sources sometimes have different recommendations.

Some examples... (given that fx are not open, and without neurovasc compromise):

DISPLACED OLECRANON:
1) First Aid for EM Boards: consult ortho in ED
2) Tintinalli's: ortho referral
3) Uptodate: consult ortho in ED

DISPLACED PROXIMAL HUMERUS FX:
1) First Aid for EM Boards: ortho referral
2) Tintinalli's: consult ortho in ED
3) Uptodate: ortho referral

DISPLACED SUPRACONDYLAR:
1) First Aid for EM Boards: ortho referral
2) Tintinalli's: consult ortho in ED
3) Uptodate: consult ortho in ED

GALEAZZI FX:
1) First Aid for EM Boards: ortho referral
2) Tintinalli's: consult ortho in ED
3) Uptodate: "likely" consult ortho in ED

I was hoping Orthobullets would clarify, unfortunately many times it only answers which are "Operative" and "Nonoperative" but doesn't usually answer the questions above. I realize that some practice differences may be due to local ED agreements with local orthopods.

Anyone would like to offer suggestions?

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Supracondylars that are displaced/type II/III, olecranons with any signs of ulnar neuropathy, galeazzi/monteggia etc I will call and ask for in ED consult. Most fractures that have NV compromise I reduce acutely then I usually call ortho and they go to OR. if you work in the community, and you have a fracture you are thinking likely needs ORIF for definitive treatment then you can do what I do - call ortho and say something to the effect of "I know you guys like to operate on this kind of thing sooner than later, can they see you in the clinic in the am, that way if you decide they are surgical candidate you can do them in the afternoon or next couple days?" typically this has good results and they are fine with it, and I just document their recommendation. Sometimes textbooks are a little conservative, and truly most fractures don't need an urgent in ED consult, but if you have an ortho group that is on the ball, they will usually see your ED patients quickly as an outpatient and decide if they are surgical candidates, that is my experience working at 4-5 different places/hospital systems in the community. Obviously if you are in academics this is different.
 
It can't ever be done in a format like you want. It's too location dependent.
Learn what they do where you work. Ask the other docs. Call ortho more than you feel you should. Explain "in residency we called on these" or whatever. Don't feel bad if they get bitchy about doing their job. You're only calling once for each type probably, so it's not a big deal.
 
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Just call until you get a feel for it. If nothing else, it's a reminder of who is buttering their bread. Except the hand/plastics guys, they hate you because you send them a bunch of uninsured and Medicaid patients. Not sure what it is about the inverse correlation between payor status and need for a hand surgeon.
 
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If in doubt, call your on-call Orthopod, and start like this, "Hey [name], got a patient I think can go home for outpatient Ortho follow up, calling you to run my plan by you as our specialist and to see if the patient can follow up with you in your clinic..."

Say this line before the specialist has a chance to open his mouth and before you go into the diagnosis, treatment, etc. That is the key.

I feel like consultants' fangs usually withdraw when you say the magic words "I think the patient can go home"... Their greatest fear in life is coming in to the hospital, so as soon as you say this, it usually leads to a pleasant conversation.
 
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A very wise Orthopedist once said to me "the first thing I want to know when I get a page from the ER is whether I need to come to the hospital." So, I lead with that (as Angry Birds suggested above). Once they hear that they don't need to come in, they can start listening to understand, rather than listening to disagree.

That said, sometimes Ortho does need to come in - this is when there is an open fracture, neurovascular compromise, or a handful of very specific fracture patterns. So, in these cases, lead with "I need you to come see..." and follow with the specific condition that necessitates ED consultation.

As for resources - I agree with McNinja that this is highly site-specific, but of all the texts I find Tintinalli to accord best with my real-life experience.
 
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I just look at ortho bullets quickly every time i have an ortho complaint. It is an amazing resource, and helps put things in the orthopedists mindset so youre speaking the same lingo if/when you need to call.

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I can send clavicle fractures to the OR same day. It all depends on where you work and the access you have to surgeons who want to work. When in doubt give them a ring and ask them what they want to do with it.
 
This probably varies by shop. During residency, we always admitted bimalleolar and trimalleolar fractures. Where I work now, we reduce and send out. Tib/fib's usually are admitted (watch for compartment syndrome). Proximal humerus, supracondylar, etc. are usually sent out.
 
Here's what I have found working in the community:

"You do it all, I'll see them in the clinic

Call if questions

Thanks
-Ortho "
 
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Here's what I have found working in the community:

"You do it all, I'll see them in the clinic

Call if questions

Thanks
-Ortho "

you forgot the "Admit to medicine..." part...if they really need to be admitted. ('Cause that hip fx ain't going home, and ortho sure as hell ain't admitting it.)
 
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Here's what I have found working in the community:

"You do it all, I'll see them in the clinic

Call if questions

Thanks
-Ortho "

This is my experience too but I think it's worthwhile to document a phone call with "our on call Orthopedic specialist ... whose expert opinion I respected."
 
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Just call until you get a feel for it. If nothing else, it's a reminder of who is buttering their bread. Except the hand/plastics guys, they hate you because you send them a bunch of uninsured and Medicaid patients. Not sure what it is about the inverse correlation between payor status and need for a hand surgeon.

My experience is that a ****load of hand injuries are workers comp. Also not known for high reimbursement rates!
 
Just call until you get a feel for it. If nothing else, it's a reminder of who is buttering their bread. Except the hand/plastics guys, they hate you because you send them a bunch of uninsured and Medicaid patients. Not sure what it is about the inverse correlation between payor status and need for a hand surgeon.


This is perfect...we have a hand guy in our area. He loves to trash talk the ED. The ED doesn't do this right blah blah blah.

According to him, there are a whole bunch of things that "really should go to a hand surgeon".

One of the other residents asks him one day, "what if they have medicaid?".

Hand surgeon " well then they can probably just follow up with their PCP"

What a load of bull.
 
Which fractures need ortho consult in the ED? Which ones can be discharged to see ortho later (referral)?

I'm doing a "deep-dive" of this topic, since I feel that my residency program didn't really prepare us well for ortho fx topics. I thought this was pretty straightforward to learn, as I just started being an attending. However... Anyone out there feel that learning ED dispositions of ortho fractures can sometimes be more difficult than it should be?? I say this because different sources sometimes have different recommendations.

Some examples... (given that fx are not open, and without neurovasc compromise):

DISPLACED OLECRANON:
1) First Aid for EM Boards: consult ortho in ED
2) Tintinalli's: ortho referral
3) Uptodate: consult ortho in ED

DISPLACED PROXIMAL HUMERUS FX:
1) First Aid for EM Boards: ortho referral
2) Tintinalli's: consult ortho in ED
3) Uptodate: ortho referral

DISPLACED SUPRACONDYLAR:
1) First Aid for EM Boards: ortho referral
2) Tintinalli's: consult ortho in ED
3) Uptodate: consult ortho in ED

GALEAZZI FX:
1) First Aid for EM Boards: ortho referral
2) Tintinalli's: consult ortho in ED
3) Uptodate: "likely" consult ortho in ED

I was hoping Orthobullets would clarify, unfortunately many times it only answers which are "Operative" and "Nonoperative" but doesn't usually answer the questions above. I realize that some practice differences may be due to local ED agreements with local orthopods.

Anyone would like to offer suggestions?


Olecrenon: usually reduces easily, needs posterior mold. Talk to ortho on the phone, do what they say
Proximal Humerus: Shoulder sling, outpatient follow up. Sometimes needs coaptation splint. Talk to ortho on phone, do what they say
Displaced Supracondylar: Nightmare fracture, especially in children. Poor healing, lots of complication. Most ortho's won't touch it. Expect to transfer. If it's grossly displaced, document at least TWO pulse checks, splint in position of comfort. Will need to be admitted for neurovascular checks, most get surgery pretty quick.
Galeazzi Fx: 1st rule, stop using this term, it means almost nothing. 2nd, these need surgery in adults, but children often do ok without operation. Reduction very important in kids, but they are just plain hard. Talk to ortho on phone. This is the type of fracture that it is reasonable to request they come in for reduction in children, because it can mean not going to surgery. In adults, they need surgery, so reduction is mainly for comfort. Splint in sugar tong with posterior mold to immobilize wrist brachioradialis (wrist supinator).

I applaud you trying to learn your ortho early. In residency, most places have an ortho resident who comes down and does all the broken bones stuff, so if you are not careful, you can graduate and know very little about managing orthopedic injuries. This is a mistake.

When you get into practice, especially if you are in a community ED, you have to know your ortho. You are going to see a ton of it.

Advice during residency:
1. Always do your own splints. Always. Who cares if you don't move patients as fast....that's why your in residency. Once you have done 100 splints of all the major variety....you will be very fast at them! The techs are better at splinting during intern year, but you will outgrow them fast

2. When the ortho resident comes down for a reduction, try to do as many as possible. You will need to know how to reduce stuff when it's only you at 2am. Wrists are hard. Ankles are easy. Shoulders can be tricky, Hips are critical.
 
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