Acetabular Fxs.

[macdaddy23]

Just wanted to see if this was a problem limited to my area or not.

Any time you mention the word acetabular and fracture in the same sentence to any of our orth guys they say transfer. The problem is there are only 2 guys in about a 200mile area who do acetabular fxs. and if they are not on call that night whoever is will not accept because they don't do them either.

Our ortho group at the hospital will not operate on acetabulums that need to be fixed. They will only admit those who do not require surgery.

Does anyone else have this problem and how do you handle it?

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[Apollyon]

Our ortho group at the hospital will not operate on acetabulums that need to be fixed. They will only admit those who do not require surgery.

Does anyone else have this problem and how do you handle it?

That's completely opposite to what I know. What do they do with the patients they admit? Talk to them?

The ortho groups I know will only admit patients that they WILL operate on.

We were talking about these things this morning, like the proximal humeral fractures in the old ladies - the ortho guys let the arm just dangle, and say "It will heal!" This will continue until someone develops a percutaneous pinning that can be done quickly (and is therefore lucrative), and we figure that in the near future.

 

[dawg44]

Usually only trauma fellowship trained orthopedic surgeons will usually fix an acetabulum. If you ever get a chance to scrub into a case you will see why. They are incredibly challenging cases and really need the team approach that a Level 1 center can provide.
As far as proximal humerus, people do percutaneous pinning of the proximal humerus all of the time. So thats not the case it's that operative intervention historically hasn't been much better than "letting it dangle". The ortho guy was right though they will heal and they definitely can follow up outpatient. Old ladies don't walk on their arms last time I checked.

 

[Apollyon]

Old ladies don't walk on their arms last time I checked.

Umm...even if you don't walk on your arms (which is a kind of a stupid thing to say), until it heals, that arm is out of commission until it heals, and ask any soldier that has lost an arm how effective you are with one arm. Even if perc pinning is done, it can't be lucrative, and that's why it isn't done widely. (Or, if it IS done widely and frequently, it would be very curious and not statistically probable that these people would come to OrthoSx attention without passing through the ED, and, if they heal, then who is getting pinned?)

And, what is it, 40% angulation in the humerus is acceptable?

 

[dawg44]

Umm...even if you don't walk on your arms (which is a kind of a stupid thing to say), until it heals, that arm is out of commission until it heals, and ask any soldier that has lost an arm how effective you are with one arm. Even if perc pinning is done, it can't be lucrative, and that's why it isn't done widely. (Or, if it IS done widely and frequently, it would be very curious and not statistically probable that these people would come to OrthoSx attention without passing through the ED, and, if they heal, then who is getting pinned?)

And, what is it, 40% angulation in the humerus is acceptable?

The point I was trying to make is this thread was talking about an admissions. So no that is not a stupid statement. Assuming you are talking closed fractures here, a humerus fracture is not a "fracture of mobility" like an acetabulum or a hip fracture. Hips are not pinned because they are financially lucrative, I could do one shoulder arthroscopy and make similar money. They are pinned because patients will have a higher mortality rate if a hip is not fixed within 4 days. All again because they are a "fracture of mobility".

I'm sure a one armed soldier is pretty ineffective, but you were talking about little old ladies not the green berets in your previous post. Contrary to popular belief everything done in ortho is not about how "lucrative" it is. Alot of things go into if someone was going to have their shoulder pinned. Like the familiarity of the surgeon with the technique, how aggressive the surgeon is in proximal humerus fractures, how high of a demand patient they are treating. There are alot of surgeons that believe the only way to make a humerus NOT heal is to operate on it.

I guess a better question would be have you seen a proximal humerus that hasn't healed in the E.R.. It is easy to guess initially what to do when you don't follow a patient and know how they actually do in the long term operative vs nonoperative.

40% depends on the patient and location and components of the fracture. A 10 year old absolutely acceptable. A 24 year old pitcher probably not. A 55 year old accountant- I'd judge it by the CT scan. A 75 year old- I'd probably tell them to put their cans on a lower shelf.

I do absolutely agree with one statement from your previous post. I only admit patients that I will operate on. If you are doing something else, why are you admitting them? You are a surgeon not a social worker.

 

[macdaddy23]

We have all admitted some fxs that are not operated on.

An acetabular fx which does not require surgery but which one cannot ambulate I have never sent home. They can't even get into a wheelchair sometimes. Also, lumbar compression fxs are very rarely touched but they sometimes get admitted if they live by themselves and can't get around.

My main question is what do you do if you can't find anyone that feels comfortable enough operating on a bad acetabular fx.

I had a similar case a few nights ago which no ortho would accept because they "don't do those" and I had to admit to our ortho to try to transfer later in the week when one of the "acetabular/trauma guys" were on.
This was a young guy(only injury was his pelvis-and stable) who was laid up in bed until we could transfer him somewhere that could fix him.

 

[deleted109597]

Hell, we admitted a clavicle fx one time. Because the lady walked with a cane, and thus couldn't use that arm for a cane, or use it to catch her as she was on her way to breaking her hip.

 

[dawg44]

We have all admitted some fxs that are not operated on.

An acetabular fx which does not require surgery but which one cannot ambulate I have never sent home. They can't even get into a wheelchair sometimes. Also, lumbar compression fxs are very rarely touched but they sometimes get admitted if they live by themselves and can't get around.

My main question is what do you do if you can't find anyone that feels comfortable enough operating on a bad acetabular fx.

I had a similar case a few nights ago which no ortho would accept because they "don't do those" and I had to admit to our ortho to try to transfer later in the week when one of the "acetabular/trauma guys" were on.
This was a young guy(only injury was his pelvis-and stable) who was laid up in bed until we could transfer him somewhere that could fix him.

Thats pretty common and no harm is done by admitting and bedding them down putting a traction pin in and waiting to transfer. That's absolutely appropriate. ORIF acetabulums are set up on a semi-elective basis anyway. You have to get the OR time set up and all of the studies, labs, doppler for a DVT and repeat CT if it is a poor study take time anyway.
As far as a nonoperative or operative acetabulum they get admitted to trauma at my institution. If they had a big enough injury to break their acetabulum they need a trauma eval anyway.
Lumbar compression fractures I wouldn't know I don't do backs or windows.
Most of the Level 1s I have been at will take the transfer and let the "acetabulum" guy know in the morning.

 

[ERMudPhud]

Here in Colorado a very large number of the acetabular fractures go to DG where they have an ortho trauma guy who does a lot of them. When I was on the service we took acetabular transfers from everywhere. Most of the rest of the ortho guys in the area don't want them.

I think Dawg's point is that here's lots of ortho stuff WE admit that doesn't go to the OR but in the private world most of it doesn't go to ortho it goes to the hospitalist and from there to the SNF

 

[ERMudPhud]

My only problem with the humerus issue is it seems inevitable that the patient and family look at you in disbelief when you try to explain, "Not only do you not need surgery for you broken arm, you don't even need a cast" I think most of them think I'm lying

 

[dawg44]

Here in Colorado a very large number of the acetabular fractures go to DG where they have an ortho trauma guy who does a lot of them. When I was on the service we took acetabular transfers from everywhere. Most of the rest of the ortho guys in the area don't want them.

I think Dawg's point is that here's lots of ortho stuff WE admit that doesn't go to the OR but in the private world most of it doesn't go to ortho it goes to the hospitalist and from there to the SNF

I agree life is alot different away from the tertiary referral center or teaching hospital to say the least.

 

[dawg44]

My only problem with the humerus issue is it seems inevitable that the patient and family look at you in disbelief when you try to explain, "Not only do you not need surgery for you broken arm, you don't even need a cast" I think most of them think I'm lying

I always especially in older patients lay the groundwork right off the bat. I tell them that this shoulder is never going to be the same as it was before the injury. If you can feed and clean yourself and touch your head I will be happy. Anything else is gravy. There is no guarantee that they will have a better result with surgery and they are free to get a second opinion about it. I think setting the groundwork is extremely important in these cases.

 

[edinOH]

These fractures can be hell from a dispostion standpoint.

Our trauma center is the only game in town for these. If they are on divert or just being as ses that day I can get caught in a bind.

There have been a few times I had to bed them down until a bed became available at the tertiary center. Then we have the battle of who to admit to. Surgery, hospitalist or ortho. They all make convincing arguments why they shouldn't be admitted to their respective services but I can also make convincing arguments why they should. All in all it is a tough deal for everybody.

What should be a pretty simple disposition can become quite a headache.

 

[dawg44]

Those discussions do get old. Thats why ortho is a consult only service at our hospital in the emergency room. That and the rise of the hospitalist has thrown that turf war discussion out the window.