I came from a program that was big EM but ortho was very strong and the ED used the strong ortho residents as a crutch. Now I'm in community practice and feeling the burn. I feel like I am just miserable at reducing - had a closed NVI trimal that I thought I reduced but looked just about the same on the post -splint. I guess it may have slipped out. No C arm. I thought it looked better after reduction. should I just splint this and BBfx that are closed and NVI and save my patient the complications of anesthesia?
new attending, i suck at ortho
- Thread starter migm
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deleted109597
No. You'll end up with fracture blisters and open conversions.
You should just reduce them. You don't even have to do procedural sedation, you can use a hematoma block. It works great.
You should just reduce them. You don't even have to do procedural sedation, you can use a hematoma block. It works great.
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As stereotypical as it sounds, ortho reductions are about 90% muscle and 10% everything else. Hit the gym!
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"Brutane" works every time!
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A trimal is a very unstable fracture. It's not very hard to reduce, but it won't stay there on its own. My guess is that you got a reduction, but it fell out of place during splinting or while your casting material was hardening. Did you have an assistant maintain traction while splinting and while the material hardened? Try that next time and you'll likely have a better result.
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I have never been unable to reduce a fracture or dislocation (that didn't require surgery because it kept popping out). I did reduce a hip on a 300 pound woman once three times but it kept falling out and she needed a revision. Lifted her off the bed. Probably my favorite reduction(s) ever. Fun times!
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I agree, it's very possible this unstable fx fell out of place during the hardening of the splint. this will need surgery anyway, so you can always call ortho and tell them that you have a bad fracture that is reducing poorly. maybe they'll take it to the OR today? remember, if they're getting paid fee for service, they will like these sorts of referrals unlike in residency where it's just more work.
also, orthobullets.com is a good look into the ortho-world and may help guide your decision making.
if you're single coverage and you weigh 90 lbs, ask the ED tech's/nurses to help pull on it with you // help hold the bones in the right spot if they're falling out of place. also don't feel bad about conscious sedation for a fracture like this. I would venture to say most people would want this.
also, orthobullets.com is a good look into the ortho-world and may help guide your decision making.
if you're single coverage and you weigh 90 lbs, ask the ED tech's/nurses to help pull on it with you // help hold the bones in the right spot if they're falling out of place. also don't feel bad about conscious sedation for a fracture like this. I would venture to say most people would want this.
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Haha! I have to disagree on this one. You don't need that much power. it's really more about technique and relaxation -- especially for dislocations.
i am guessing because the patient extended her knee that it slipped out from the gastroc/soleus pulling on the fx site - I had difficulty getting her completely relaxed and to bend the knee with ketamine
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You can disagree all you want. Doesn't change the fact that reductions are always easier the stronger you are. Not trying to be a dick, I just think that everyone should work out more. 8)
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deleted109597
Precisely. It's leverage, and understanding about what you need to disengage. The bone is always stronger than you, so muscle doesn't make up for poor technique.
Think of it like Judo.
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Yep, reduced somebody's shoulder with a gentle massage yesterday.
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Not familiar with the latter, but for the Cunningham:
1 - Don't try it on someone who is in too much pain/anxiety to cooperate.
2 - Really coach the patient on sitting up straight and pulling the shoulder blades together.
3 - Be patient but consistent - stay actively within each step for a couple of minutes.
4 - The massage is mostly a distraction technique - your muscle activity should be directed towards keeping constant downward traction on the humerus.
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I'm all for physical fitness, but it was a 220lb active duty doc who taught me to "pull smarter, not harder".
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deleted547339
Perfect is the enemy of good.
allow me to rephrase - i'll take 'somewhat resembles anatomic alignment - clinical correlation required'. With all the hemarthrosis my palpation does not allow me to deduce if the malleoli are now somewhere in orbit of the ankle
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deleted245139
FARES method is excellent for the shoulders.
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deleted109597
Reduced joints are able to articulate.
no doubt with a simple dislocation this is true - with an unstable fx/dislocation I'm not sure I've ever seen ortho try to range a fx/disloc
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I've only had cunningham fail once in the last few years since I learned it, and that was in a guy with multiple shoulder surgeries who we couldn't get it in even with propofol and ended up going to the OR. Never need to give any meds with this technique either. The trick is to convince the patient that it's going to work so they relax. That matters way more than the actual technique.
Definitely some good advice being given to you here. Just like with any procedure, your reductions will get better with time and increased exposure.
Just a quick word of warning, though. You say that you were reducing a trimalleolar fracture that ultimately had the same appearance post-splint. I agree with the other posters.....this is an unstable fracture and very likely did move on you. The other possibility is sometimes you have a bony or cartilaginous fragment that impedes a proper reduction from being done. In any case, though....trimalleolar fractures that need to be reduced are generally done because a tibiotalar dislocation is present. Tread cautiously....if you're actually referring to a trimal fracture/dislocation that still looks about the same, the joint is dislocated. Go ahead and keep the splint on for comfort, but this one needs to be admitted for an urgent repair. (For those in residency....I know you're likely admitting all trimal fractures. This isn't always done in the community.) Be sure you're not discharging a dislocated joint.
Promise I'm not trying to question what you're seeing. Just a good discussion for residents to consider as well.
Just a quick word of warning, though. You say that you were reducing a trimalleolar fracture that ultimately had the same appearance post-splint. I agree with the other posters.....this is an unstable fracture and very likely did move on you. The other possibility is sometimes you have a bony or cartilaginous fragment that impedes a proper reduction from being done. In any case, though....trimalleolar fractures that need to be reduced are generally done because a tibiotalar dislocation is present. Tread cautiously....if you're actually referring to a trimal fracture/dislocation that still looks about the same, the joint is dislocated. Go ahead and keep the splint on for comfort, but this one needs to be admitted for an urgent repair. (For those in residency....I know you're likely admitting all trimal fractures. This isn't always done in the community.) Be sure you're not discharging a dislocated joint.
Promise I'm not trying to question what you're seeing. Just a good discussion for residents to consider as well.
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Good points - the tibotalar joint was subluxed not quite dislocated and she was not an easy sedation. Ortho was okay with NWB and d/c.
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I think of it more like aikido, but I get your point: Medicine is a fight between you and your patients. You must force them into submission.
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I used it intermittently with decent success prior to my current job. These days I mostly just use a slug of propofol and find that success is directly proportional to degree of sedation. Except for prosthetic hips... F%^% those things, especially the "locking" variety.
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With shoulders, since I started doing intra-articular lidocaine 3-4 years ago, I've only had to do one sedation. It works great, especially single coverage. The real key is that you need to aspirate a small amount of blood to know you're in, as it's essentially a hematoma block of the shoulder.
I also combine gentle traction/external rotation with the Park Method and have had complete success.
https://www.aliem.com/2013/trick-of-the-trade-got-a-shoulder-dislocation-park-it/
I also combine gentle traction/external rotation with the Park Method and have had complete success.
https://www.aliem.com/2013/trick-of-the-trade-got-a-shoulder-dislocation-park-it/
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This will probably come off sounding lazy, but I'll put it out there.
Being able to do a perfect reduction on an unstable fracture can take a lot of time and effort.
In a lot of cases I just don't have the time to get this done. I will do the best I can in a reasonable amount of time and call ortho if I need them. They are getting paid to be on call and I have a whole department to run.
I can't be screwing around for an hour while the whole department goes to hell.
In residency overnight we had one attending in a place that was really too busy for single coverage. The overnight attending who ran the department best would never do any reductions or anything similar that required sedation.
Her thought process was that there was no way she could justify being tied up in a room that long with the possibility of really sick patients coming in like they always do.
This may be a little extreme, but she ran the department better than anyone else I've ever seen.
Being able to do a perfect reduction on an unstable fracture can take a lot of time and effort.
In a lot of cases I just don't have the time to get this done. I will do the best I can in a reasonable amount of time and call ortho if I need them. They are getting paid to be on call and I have a whole department to run.
I can't be screwing around for an hour while the whole department goes to hell.
In residency overnight we had one attending in a place that was really too busy for single coverage. The overnight attending who ran the department best would never do any reductions or anything similar that required sedation.
Her thought process was that there was no way she could justify being tied up in a room that long with the possibility of really sick patients coming in like they always do.
This may be a little extreme, but she ran the department better than anyone else I've ever seen.
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That's nice when you have ortho on call. Some places I work it's a two hour ambulance ride to see an orthopedist.
Once you get good at the Cunningham technique you rarely need joint injection or sedation. If it doesn't go in right away I'll ask for IN or IM fentanyl, and most of the time it's in by the time the nurse gets back with the meds.
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I wasn't talking about shoulders and neither was the op.
I use the Cunningham for shoulders first line.
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I realize that. The first line was replying to you and the second line was just about the shoulder talk in this thread in general. Sorry if it was unclear.
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Not lazy at all, perfectly rational.
