The advances of orthopaedic trauma surgery have resulted from years of overcoming struggles and the knowledge gained through such experiences. These struggles have resulted in a variety of published aids to help orthopaedic surgeons navigate complex cases. Peer-reviewed medical journals, like the Journal of Orthopaedic Trauma, have dedicated specific sections on “Tips and Tricks,” which surgeons can review and learn from their colleagues. In addition, books such as Planning and Reduction Technique in Fracture Surgery authored by Dr Jeffrey Mast et al1 are available. Similar to other specialties, a team approach is most appropriate and beneficial in providing quality trauma care.2–4 Residents and fellows and even medical students are critical members of the team making significant contributions to orthopaedic workflow. However, outside of academic or teaching facilities, orthopaedic services typically do not have postgraduate training programs to help alleviate workload demands. Therefore, orthopaedic trauma surgeons must be creative in meeting these demands not only in the operating room but also in negotiating with hospital administration. The purpose of this article is to provide some tips and tricks that have been helpful in my practice as an orthopaedic trauma surgeon without help from residents. We are an 886 bed, level 1 hospital currently averaging 32,000 discharges annually.
TIP 1: MIDLEVEL PROVIDERS
Physician assistants and nurse practitioners are vital to help fill the void created by the lack of a residency program. This is particularly true in the care required for trauma patients. The utilization of midlevel providers to the orthopaedic service is favorable for both the hospital and the patient.5 Research indicates that midlevel providers enhance the quality of care by improving patient safety, access, satisfaction, and continuity of care. In addition, service revenue increases as a result of increasing patient flow provided by the midlevel provider.6 As an extension of the physician, midlevel providers are crucial in supporting the service in 3 major areas, including the operating room, emergency department, and in the clinic. Beyond providing assistance in the OR, midlevel providers can remedy problems, round on patients, and cover call in the absence of the attending physicians. In turn, this increases patient safety while keeping interruptions to patient flow minimal. In addition, using midlevel providers in the OR significantly decreases theater time, allowing the surgeon to start another case provided a flip room is available.
TIP 2: MULTIPLE MIDLEVEL PROVIDERS
Depending on the volume, multiple midlevel providers may be warranted to provide optimal care. It becomes quickly difficult for one physician and midlevel provider to keep the service running efficiently. In a busy trauma service, there would be a midlevel provider covering each of the 3 areas mentioned above accounting for scheduled vacation time also. However, hiring multiple midlevel providers is costly. Therefore, gaining support from hospital administration is critical for the success of the program. Before proposals are presented to leadership, a business plan aligned with the services' strategic plan should be detailed showing exact cost and benefit for each midlevel provider while addressing improvements to patient safety, quality, and satisfaction.
TIP 3: SURGICAL TECHNICIANS
If you do not have midlevel support, utilization of more than one surgical technician to assist during cases can be significantly beneficial. Surgical technicians directly decrease OR time and risk while improving overall quality and safety. Experienced surgical technicians can be extremely helpful by knowing your instrumentation preferences and case routines. Communicating your plan and expectations allows them to better anticipate your needs and to quickly address issues as they arise. In addition to direct assistance during the surgical procedure, technicians can help with patient positioning and maintaining overall case flow throughout the day. Technicians with specialized advanced training are also able to close wounds. Again, this frees the surgeon to focus on surgical management of the patient.
TIP 4: FEMORAL DISTRACTOR
It has been said that femoral distractor never complains or gets tired and provides continuous distraction. An example is using the distractor for controlled distraction of the femoral head while debriding the hip joint as a result of an acetabular fracture. This technique takes the place of a resident pulling on a T-handle chuck attached to a Schanz pin. After exposure to the acetabulum, Schanz pins are placed in the supra-acetabular region and in the femur just above the lesser trochanter parallel to one another. The femoral distractor is then assembled and attached to the Shanz pins (Figs. 1A, B). Position the arm of the distractor to provide clear access to the joint. Once you start distracting with the “tommy bar,” be cautious of the skin and soft tissue. The soft tissue can become caught in the threads between the rod and the wheel. Once the joint is distracted enough that the debris is identified, remove with a pituitary rongeur and irrigate the joint. When completed, turn the distraction wheel in the opposite direction and reduce the joint.
The distractor is useful for most, if not all, periarticular fractures. It should be one of your “go to” tools when operating without residents.
TIP 5: BUMPS
Although seemingly puerile, bumps are one of the simplest items that can be used to significantly ease your case when used appropriately. This can range from just 1 to 2 towels folded or using a stack of towels cobanded together. Bumps of varying sizes can be used to create a “step ladder” for a reduction aid. One of the most common procedures this technique benefits is treating distal femur fractures because of the deforming forces. A bump positioned at the apex of the posterior sag at just the right height can aid in reduction. This significantly decreases the amount of help needed to hold the reduction (Fig. 2).
TIP 6: FRACTURE TABLE FOR PELVIC FRACTURES
The fracture table can be used to facilitate vertically unstable pelvic fracture reductions. The Traction Arc attachment is secured onto the flat table of the Mizuho OSI table (Mizuho OSI, Union City, CA) (Fig. 3). The leg on the side of the vertical displacement has a femoral skeletal traction pin placed in it. This is then attached to a traction bow and attached to the reduction crank. A triangle is placed under the knee to pull along the appropriate force vector to produce an accurate reduction. The contralateral leg is attached to a leg holder that is used to pull traction during a hip fracture repair. There will, however, be no traction pulled through this leg. This side will act to hold the pelvis in place to provide a counter force to pull against. Care should be taken to prevent the knee on this side from flexing. Once the pelvis and legs are positioned, the standard views are taken off the pelvis Anterior/Posterior view, inlet and outlet. The crank on the side of the displacement is dialed in until reduction is complete. At this time, an iliosacral screw can be passed to further reduce and hold reduction in place.
TIP 7: PERIOPERATIVE POSITIONERS
These devices are positioning aids that make exposure and using C-arm easier. There are many different shapes and sizes available for a number of procedures. The traditional ramp (Bone Foam; Bone Foam Inc, Plymouth, MN) probably has the most utilization because of its use during lower extremity fracture repairs (Fig. 4). The leg with the injury is elevated above the contralateral side, which aids with lateral imaging. Using positioners can significantly decrease the number of staff needed to hold and position extremities during surgery. In addition to leg fractures, using positioners can also be beneficial during the repair of calcaneal and elbow fractures.
TIP 8: FRACTURE TABLE LEG HOLDER
Use the leg holder (PROfx; Mizuho OSI) for prone positioning of elbow and humerus fractures. Because of the variation of arm length between patients, having an adjustable platform such as this device makes repair easier. This device is extremely useful when you lack additional assistance during positioning and holding. I have found that using the leg holder vertically for long arms and horizontally for short arms provides the best benefit (Fig. 5).
TIP 9: FRACTURE EXPOSURE
Do not be afraid to expose the fracture. When you do not have residents or other skilled personnel available to assist, quality reduction can be difficult. You should avoid being afraid of getting the exposure you need for quality reduction. This does not mean you have to devascularize the periosteum. However, you should obtain adequate exposure of the fracture so that appropriate clamps can be positioned and reduction achieved.
TIP 10: REMEMBER YOUR TRAINING
Although you may not have residents available for assistance or collaboration, maintaining your confidence during a complex case is critical. We have all completed at least 5 years of postgraduate training, and many of us received advanced education with a trauma fellowship. Even though you have not seen every variety of case possible, you have been exposed to 100s of different scenarios. We have acquired the knowledge and skills during our training to take on most cases, including the complex trauma patient. Just remember to go back to the basics and build from there.
Orthopaedic trauma surgery is a dynamic specialty. Every case has different nuances and requires the surgeon to constantly seek innovative ways to solve problems. By sharing these innovative approaches between colleagues, quality of patient care continuously advances within our field. Through the great leaders in orthopaedic trauma, the specialty has become what it is today.
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