Orthopaedic Trauma Resident Handout

1) Pelvic Fracture Hemorrhage Pathway

Immediate suspicion and binder use

• Suspect unstable pelvic injury in high-energy blunt trauma with shock pattern.
• Binder indication: hypotension with suspected unstable/open-book pelvic mechanism.
• Binder placement: centered over greater trochanters (not iliac wings/belt line).

Binder safety limits

• Check pressure areas/skin every 12h.
• Aim to remove within 24h (absolute maximum 48h).
• Convert to definitive stabilization as soon as physiology allows.

Hemodynamic branching

2) Open Fracture Infection-Prevention Priorities

TQIP timing targets

• Antibiotics <=60 minutes from ED arrival.
• Debridement within 24h (emergent if vascular compromise, compartment syndrome, or gross contamination).
• Soft-tissue coverage within 7 days when flap/graft required.

Antibiotic starter table

ED wound management

• Remove gross contamination.
• Apply saline-moistened sterile dressing, then dry sterile wrap.
• No high-pressure ED lavage.
• Photograph wound before final dressing for OR documentation.

3) Polytrauma Fixation Strategy: DCO vs EAC

DCO (temporary stabilization) when physiology is poor

Use DCO if any major instability marker is present:

• pH <7.25.
• Lactate >4 mmol/L.
• Base deficit worse than -6.
• Temperature <35 C.
• INR >1.5.
• Ongoing MTP or persistent hemodynamic instability.
• Severe TBI/pulmonary injury where prolonged definitive fixation adds risk.

EAC (definitive fixation 24-36h) when resuscitation succeeds

• Hemodynamics stabilized.
• Lactate/base deficit improving/normalized.
• No ongoing major transfusion requirement.

Borderline patients: reassess repeatedly; strategy can transition DCO <-> EAC as physiology evolves.

4) Geriatric Hip Fracture: Golden 24

Timing targets

• Target: OR within 24h from ED arrival.
• Acceptable: up to 48h for brief, necessary medical optimization.
• Hard stop: >48h is associated with major mortality increase.

Do not delay surgery for these alone

• Routine echo without management-changing indication.
• Routine cardiology clearance without active ischemia/unstable arrhythmia.
• Antiplatelet washout alone.
• Waiting for full INR normalization after appropriate reversal when operative team is ready.

Co-management and pain strategy

• Early trauma + ortho + anesthesia + medicine/geriatrics alignment.
• Fascia iliaca block early when feasible.
• Delirium prevention and early mobilization planning from day 0.

5) Hard Stops

• No binder placement above greater trochanters.
• No unexplained antibiotic delays beyond 60 min in open fractures.
• No unexplained debridement delay beyond 24h when indication present.
• No prolonged DCO posture after physiologic recovery without explicit rationale.
• No geriatric hip fracture delays >48h without attending-level documentation of unavoidable cause.

6) PIPS Metrics to Track

• Binder at greater trochanters: target 100%.
• Open-fracture antibiotics <=60 min: target >=90%.
• Open-fracture debridement <=24h: target >=90%.
• Geriatric hip fracture to OR <=24h: target >=80%.
• Geriatric hip fracture to OR <=48h: target 100%.
• Binder duration <=24h: target >=95%.

Source Basis

Condensed from active orthopaedic trauma guideline used in trauma workflow.