Ortho-Preferred

Workup for Femoral Shaft Frx


Trauma Workup
       -
assessment of perfusion: damage control orthopaedics
       -
timing of surgery in orthopaedic patients with brain injury
       - surgical timing and prevention of pulmonary complications in patients with femur frx

 - PreOp Planning for IM Nailing: (IM Nailing Technique)
          - Fracture Classification 
          - Open Femur Frx
          - Comminuted Frx
          - Proximal Frx 
          - Distal Frx 
 - Associated Injuries/Conditions:
          - Frx - Menu
          - Hip Dislocation
          - Femoral Neck Frx 
                 - need to proactively determine whether a femoral neck fracture is present;
                 - some recommend reconstruction nails for all femur fractures, inorder to prophylactically fix the potentially missed fracture;
                 - references:
                        - Accuracy of reduction of ipsilateral femoral neck and shaft fractures--an analysis of various internal fixation strategies.
                        - Diagnosis of femoral neck fractures in patients with a femoral shaft fracture. Improvement with a standard protocol
                        - Fracture of the ipsilateral neck of the femur in shaft nailing. The role of CT in diagnosis
                        - A retrospective review of high-energy femoral neck-shaft fractures.
                        - Iatrogenic fractures of the femoral neck during closed nailing of the femoral shaft
                        - A cascade of preventable complications following a missed femoral neck fracture after antegrade femoral nailing.
                        - Is reconstruction nailing of all femoral shaft fractures cost effective? A decision analysis.
                        - The sensitivity of ct scans in diagnosing occult femoral neck fractures.
          - Bilateral Femur Frx:
                 - references:
                        - Mortality after reamed intramedullary nailing of bilateral femur fractures.
                        - Invited commentary related to: "Are Bilateral Femur Fractures No Longer a Marker for Death?
                        - Morbidity and Mortality of Bilateral Femur Fractures
          - Knee Ligament Injury 
                        - Ipsilateral diaphyseal femur fractures and knee ligament injuries.
                        - Injuries to the knee ligaments with fractures of the femur.
                        - Ipsilateral knee injury with femoral fracture. Examination under anesthesia and arthroscopic evaluation
                        - Delayed detection of clinically significant posterior cruciate ligament injury after peri-articular fracture around the knee of 448 patients.
          - Pathologic Fracture
          - C-spine
          - Spine
          - Pelvis / Abdomen:
                 - Delayed Internal Fixation of Femoral Shaft Fracture Reduces Mortality Among Patients with Multisystem Trauma
                 - Femoral Shaft Fractures Associated With Unstable Pelvic Fractures
          - Pulmonary: (assessment of perfusion: damage control orthopaedics)
                 - 
fat embolism syndrome
                 - prevention of pulmonary complications in patients with femur frx
          - Vascular Injury 
                 - references
                           - Blunt Vascular Injury Associated With Closed Mid-Shaft Femur Fracture: A Plea for Concern
               Timing of Surgery in Orthopaedic Patients with Brain Injury 

 - Systems:
          - Neuro (see Glasgow)
          - Cranio-Maxillo-Facial
          - Spine
          - Cardiac
          - Renal
          - Compartments
          - Hepatic / GI 
          - Coag
  - Checklist:
          - Consent: Open vs Closed Reduction
          - Posting
                  - Blood & Cell Saver
                  - Implant Selection (Synthes)
                  - Positioning
                  - Table type and Flouro (specify locations of each in the room)
          - Skeletal Traction
                  - skeletal traction w/ 25 lbs (or more) will bring frx out to length;
                  - generally skeletal traction is necessary w/ delayed treatment;
                  - following insertion of skeletal traction, it is necesary to document that frx is out to length w/ portable lateral radiograph; 
                  - ref: Preoperative Skeletal Versus Cutaneous Traction for Femoral Shaft Fractures Treated Within 24 Hours.
          - Blood: 2 units
          - Prophylactic ATB
          - DVT prophylaxis
          - X-rays and Template
          - Planned Incision
          - Anesthesia & Cardiology Consults
          - Misc: antibiotic beads for open frx;

- Initial Orders:
       - NPO p Midnight x Meds
       - IVF D5W LR at 100 ml/hr (in stable patients use D5W 1/2 NS w/ 20 KCl)
       - 2 large bore IV
       - Foley
       - Monitoring;
                - EKG and/or Continuous Cardiac Monitoring;
                - Continuous Pulse Ox monitoring;
       - PreOp Labs:
                - Type & Cross 2-4 units pRBC and/or FFP
                - Musculoskeletal Labs:
                - Urinalysis
       - Meds (Trade Names)
               - Prophylactic ATB
               - DVT prophylaxis
               - Steroids:
                     - for neurological deficits
                     - for FES prophylaxis
               - Heparin 5000 units SQ q8 hrs
               - Insulin (1/2 NPH dose) + S.S. - Accu Check in AM and on call
               - Zantac
               - Morphine
               - Tetanus or Pneumovax if appropriate;
       - Traction: (Buck's vs. Skeletal)
       - Decubiti Prophylaxis:  Egg Crate / Pillow and turn 20 deg q2hr
       - Hiboclens Shower and Bactroban to nares q12 hrs until OR
       - Cleocin solution 300 mg per 100 ml NS q6hr as mouth wash

- Misc:
    - Mechanism: high energy injuries from MVA or GSW, or Pathologic frx;
         - fails in tensile strain;
         - common mech is bending Transverse frx;
         - pathologic frx are more commonly spiral after torsion strain



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, November 22, 2016 4:28 pm