Extract
After more than a decade of conflicting publications as well as changes in institutional resources, surgeons rightly question the ideal timing of surgical intervention for various extremity injuries. Is this fracture a true emergency? Can it wait until tomorrow morning? Is definitive management best delayed to minimize further trauma to the patient’s physiology or soft tissues? And how does the availability of protected, daytime operating-room time influence these decisions? To address these questions, we evaluated the evidence regarding the optimal or critical time for surgical intervention in treating various extremity injuries and the influence of a designated orthopaedic trauma room on management strategies.
After more than a decade of conflicting publications as well as changes in institutional resources, surgeons rightly question the ideal timing of surgical intervention for various extremity injuries. Is this fracture a true emergency? Can it wait until tomorrow morning? Is definitive management best delayed to minimize further trauma to the patient’s physiology or soft tissues? And how does the availability of protected, daytime operating-room time influence these decisions? To address these questions, we evaluated the evidence regarding the optimal or critical time for surgical intervention in treating various extremity injuries and the influence of a designated orthopaedic trauma room on management strategies.
Compartment Syndrome
Compartment syndrome of the extremities remains a true orthopaedic surgical emergency. While innovative treatments continue to be developed, little has changed in the diagnosis and management. Once the diagnosis is made, fasciotomy and evaluation of muscle viability is emergent; there are few indications for treatment delay except for a patient in extremis.
Diagnosis
Diagnosis of compartment syndrome remains clinically challenging, and despite technological developments in pressure detection instruments, physical examination and clinical history remain the mainstays of diagnosis. One of the challenges of diagnosis is physical examination in patients who cannot reliably communicate, such as those who are intubated or those with altered sensorium. In these patients, examination can be unreliable1. Additionally, the so-called classic clinical findings, such as changes on vascular examination or paralysis, occur late and are less helpful in preventing morbidity.
Pain out of proportion with passive stretch of an involved muscle group is one of the earliest and most sensitive clinical signs1. Paresthesias are an early sign and likely related to nerve ischemia2. Patients can develop compartment syndromes acutely after injury, after fracture fixation, or in a delayed fashion1,3. Although a specific measured value may be controversial, a delta P (Δp) value is supported for diagnosis when invasive monitoring is selected4. McQueen and Court-Brown defined the differential pressure between the measured compartment pressure and the systemic diastolic pressure4. Their prospective evaluation of tibial fractures revealed that no compartment syndromes were missed when the Δp value was ≥30 mm Hg.
Treatment
Clinical treatment of compartment syndromes is based primarily on our understanding of the natural history and management protocols of compartment syndrome of the leg. Treatment of other extremities is by extrapolation from studies of the leg5,6. Research has defined thresholds for irreversible injury to nerves and muscle with pressure-related ischemia, and worse outcomes have been reported with delay in diagnosis and treatment7. Complete fasciotomies should be performed emergently once the diagnosis of compartment syndrome is determined. In a study of acute compartment syndrome in the leg8, complete pressure release was not obtained until the length of the fasciotomy was ≥16 cm.
Legal Issues
While there is considerable concern with regard to legal liability, malpractice claims for compartment syndrome are uncommon, with an estimated 0.002 claim per year of practice per surgeon9. A recent review evaluated the twenty-year history of a single large malpractice insurer9. The most prominent risk factor for an indemnity payment was a delay before fasciotomy. In fact, the number of hours from the alleged presentation of the compartment syndrome until fasciotomy was linearly associated with the dollar amount of the indemnity payment. Most plaintiffs were employed, insured, and white. The average indemnity payment from this insurer was $426,000.
Authors’ Practice Trends
Compartment syndrome is a true orthopaedic emergency. We proceed with emergency fasciotomies once the diagnosis is made.
Vascular Injuries Associated with Orthopaedic Trauma
Vascular injuries associated with fractures and dislocations are unusual and mostly associated with high-energy trauma. Limb-threatening ischemia requires an organized multiservice approach for limb salvage. One of the most important controversies in management involves the order of repair when combined vascular and osseous injuries and/or dislocations occur. With a pulseless limb, the vascular repair is typically done first and orthopaedic stabilization follows. This can be a problem when the repair is performed with the fracture and/or dislocation in unreduced position because subsequent reduction, including length restoration and angular correction, can disrupt the vascular repair. Treatment acuity for occult injuries—intimal disruptions—is more controversial. In these settings, fixation sequence may affect outcome less and the justification for primary stabilization of the fracture or dislocation is more logical.
Diagnosis
Rapid detection of vascular injury and localization of the lesion is key to successful management. Classic so-called hard signs that require emergency management include pulsatile hemorrhage, expanding hematoma, palpable thrill, audible bruit, and a frankly pulseless limb that persists after closed reduction and/or limb realignment. The ankle brachial index is an effective noninvasive screening tool for diagnosing vascular injury. Mills et al. prospectively demonstrated excellent sensitivity, specificity, and positive predictive value with an ankle brachial index of <0.9 in patients with knee dislocations10. Doppler (ultrasound) screening can have excellent sensitivity and specificity, but is operator-dependent11. Multidetector computed tomography (CT) angiography may be used and has good sensitivity and specificity12.
Treatment
Detection of vascular dissection is more difficult, but delays in repair are associated with high rates of amputation13. There is a lack of fracture-specific outcome data to counsel patients with both vascular injuries and fractures. High-energy fractures of the tibial plateau with vascular injuries have been demonstrated to be especially problematic. A single-institution study demonstrated that the presence of a dysvascular limb requiring vascular reconstruction was significantly associated with a deep wound infection14. Knee dislocations must be emergently reduced to allow for evaluation of the popliteal artery because there is a high rate of popliteal arterial injury15. Poor outcomes have been reported with the delayed diagnosis in this setting.
Authors’ Practice Trends
In the setting of a vascular injury associated with fracture or dislocation, we prefer to have temporary shunting done for arterial injuries that require repair, with definitive vascular repair performed after reduction and stabilization of the fracture or joint, usually with temporary external fixation.
Open Fractures
The treatment of open fractures has evolved over the past decade with the emergence of the orthopaedic trauma room and its ensured daily availability of operating-room time for urgent cases. In general, there is a trend toward more delayed treatment for open fractures. However, delayed treatment of open fractures is not well supported in the literature.
The etiology of the six-hour rule for open fracture debridement remains somewhat elusive. Although it is commonly practiced and taught to surgeons-in-training, the evidence for this dogma is questionable. Friedrich performed an obscure set of experiments looking at the kinetics of infection using garden mold and dust in a guinea pig surgical wound model16. In these rudimentary experiments, “simple” debridement cleared infection within six hours. By screening for bacteria in contaminated wounds, Robson et al. determined 105 organisms per gram of tissue as the threshold for infection and it was reached at 5.17 hours after injury17. Therefore, the quality of data supporting a six-hour threshold for open fracture debridement is quite limited.
The lack of data for early debridement, however, cannot be solely interpreted as support for cavalierly delayed treatment approaches. In fact, the basic science of bacterial colonization suggests that time is an important variable in the establishment of infection. One description of the establishment of infection has suggested that the fundamental first step in bacterial colonization is the process of adhesion or permanent attachment18. Many common musculoskeletal pathogens utilize biofilm formation during colonization to deter host defenses and promote adhesion. Adhesion is based on a time-dependent protein receptor interaction, polymer synthesis, ionic charge, and physical forces. Biofilms participate in cell-cell aggregation and consolidate adhesion. Devitalized bone stripped of periosteum, as with open fractures, presents a collagen protein matrix and acellular crystal surfaces to which bacteria may optimally bind19. A number of in vitro studies evaluating debris and bacterial removal from biologic tissues have suggested a time-dependent efficacy. Comparing low and high-pressure pulsatile lavage, Bhandari et al. demonstrated the best clearance of Staphylococcus aureus in a human and canine bone model was within three hours of inoculation20. Adherence of Staphylococcus aureus has also been shown to increase after six hours in a rabbit contamination model21.
In studies focusing on biomaterial-based infections, a number of interesting findings were postulated22. Within three hours of exposure to a surface such as bone, Staphylococcus aureus attaches to bone with weak van der Waals forces and hydrophobic interactions. After three hours, bone-surface receptor interactions and chemical interactions strengthen the bonds between bacteria and bone. As time continued, the bacteria were able to establish a protective micro zone that inhibited clearance—i.e., biofilm. Thus, early debridement might prevent adherence and colonization. Extrapolation of this sequence to open fracture-related infection might support early debridement. In addition to theoretical risks of time-dependent adhesion, there are practical concerns with delay to open fracture debridement. Clinical experience suggests that it is common to discover higher than expected levels of contamination and nonviable tissue in many open fracture wounds—even simple-appearing wounds. This is a problem since any foreign material may promote bacterial colonization23. Thus, extensive contamination and tissue injury are possible with benign-appearing soft-tissue wounds. Evaluation of the literature with regard to the timing of surgical debridement is varied, primarily retrospective, and minimally helpful in decision-making. There are a minimum of nine retrospective studies that failed to identify increased risk of infection with delayed surgical debridement between six and twenty-four hours24. Two small prospective studies showed no increased risk of infection with delayed treatment of up to twenty-four hours. In one of them, a study of seventy patients with open fractures, Merritt25 took culture samples preoperatively, intraoperatively, and postoperatively, but failed to identify an increased risk of infection with delayed surgical debridement between six and twenty-four hours. Likewise, one Level-I study with a variety of open fractures (forty-one tibiae) and most commonly Gustilo and Anderson type-I open fractures (thirty-nine of 115) failed to identify an increased risk of infection with a delay of greater than six hours26. On the other hand, three small retrospective series demonstrated an increased risk of infection with surgical delay27-29. Overall, the literature does not have high-quality evidence that provides guidance in the timing of treatment for open fractures.
Authors’ Practice Trends
As bacterial adhesion and colonization appears to be time-dependent, our practice is to irrigate and debride open fractures urgently—meaning that the patient goes to the operating room when his or her physiological status and the operating-room resource allow.
Femoral neck fractures in young patients and fractures of the talus have been labeled “surgical emergencies.” The most common justification for emergency care of these patients has been to rapidly reestablish the blood supply to the femoral head and talus, and thus decrease the risk of osteonecrosis and nonunion. Controversy exists in the literature regarding the importance of surgical timing in these patients. With the increasing availability of orthopaedic trauma rooms, surgeons can often take these injuries to the operating room as a guaranteed first case of the day after injury. Conflicting evidence and changes in institutional resource allocation have made surgeons question the ideal timing of surgical intervention. Should these injuries be treated as orthopaedic emergencies or are they better treated as relative “urgencies”?
Should Femoral Neck Fractures in Young Patients Be Treated as Emergencies?
Femoral neck fractures in physiologically young patients are approached differently than those afflicting the elderly, with the primary goal being preservation of the native femoral head30. Complications including nonunion and osteonecrosis are common—the historical rates of osteonecrosis and nonunion have been reported to be as high as 86% and 59%, respectively30-34. Anatomic investigations have demonstrated the importance of the intracapsular retinacular branches of the medial femoral circumflex artery on the perfusion of the femoral head. Simulating complete disruption of the femoral neck and these vessels leads to a complete lack of perfusion of the femoral head in cadaver hips35.
Timing of management has been debated in the literature. Swiontkowski et al. reported low rates of osteonecrosis (20%) and no symptomatic nonunions in twenty-seven patients between fifteen and fifty years old, and attributed this success to the application of an institutional protocol of so-called immediate reduction (within eight hours of diagnosis) and internal fixation with compression30. This pivotal publication labeled these injuries “surgical emergencies” in young patients. Since the publication of that study, several authors have reported small series supporting an association between time to surgery and the outcomes of nonunion and osteonecrosis33,36,37 (Table I).
More recent studies have demonstrated no difference in outcomes between cohorts of patients treated emergently or after a delay32,38. The time considered as a delay varies (eight hours was used by Swiontkowski et al. and twenty-four hours, by Haidukewych et al.32, for example). However, despite different time intervals used to define a delay, the cohorts identified as having surgery late in these publications had outcomes comparable with the early cohorts in the studies promoting emergency fixation. Furthermore, three case series have described cohorts of patients treated after “inadvertent” delays of six days to two years, with rates of osteonecrosis and nonunion similar to those in series in which patients were treated emergently (0% to 25%)39-41 (Table II).
A meta-analysis reviewing eighteen retrospective cohort studies of femoral neck fractures in patients between fifteen and fifty years old (547 fractures) found an overall osteonecrosis rate of 22.5%42. Seven of those studies described comparative data on 110 patients treated within twelve hours and sixty treated more than twelve hours after fracture. No significant differences were noted in the rates of either osteonecrosis or nonunion, despite an incidence of nonunion that was more than twice as great in the group treated within twelve hours.
While the evidence is controversial with regard to the role of surgical timing, other factors have been consistently and more robustly associated with poor outcomes30-33,38,43-46. Injury variables, such as initial displacement and posterior comminution, are strongly correlated with the development of osteonecrosis, nonunion, and loss of fixation. Furthermore, the quality of the obtained surgical reduction is strongly correlated with the rate of reported nonunion, and is the most consistently predictive variable of poor outcome.
Progression to osteonecrosis, nonunion, and poor functional outcome is multifactorial in these patients. Current best evidence suggests a lack of association between time to reduction (less than twenty-four hours) and osteonecrosis or nonunion, but is composed of underpowered observational cohorts (Levels III and IV) and is far from conclusive.
Authors’ Practice Trends
We strive for an urgent anatomic reduction. We consider delaying late or overnight surgery to the first case the next morning if we expect that operating-room conditions will influence the quality of our achieved reduction, and if there is guaranteed operating-room time available for a first-case start.
Should Talar Neck Fractures Be Treated as Emergencies?
The historically high rates of osteonecrosis (50% among Hawkins type-II fractures and 84% among Hawkins type-III fractures) associated with talar fractures have been attributed to fracture displacement injuring the fragile retrograde blood supply, preventing vascularization to the talar body47,48. Several small observational studies have demonstrated decreased rates of osteonecrosis (<35% in displaced fractures) with early or immediate surgical stabilization49-51. Those authors advocated emergency treatment of talar neck fractures, stating that early reduction promotes revascularization and helps to preserve any remaining blood supply to the posterior aspect of the talus.
Publications from multiple experts in foot and ankle trauma have subsequently found no correlation between surgical timing and outcomes. Vallier et al. reported an overall rate of 36% for osteonecrosis and 5% for nonunion, with no correlation between outcomes and surgical time interval52. Osteonecrosis was associated with Hawkins type (39% of Hawkins type-II fractures versus 64% of Hawkins type-III fractures), talar neck comminution, and open fractures. Similarly, Lindvall et al. evaluated twenty-six patients, twelve of whom were treated early (within six hours) and fourteen of whom were treated more than six hours after the injury53. The rate of osteonecrosis in the open fractures was 85%. No significant difference was seen between the six closed fractures fixed within six hours and the thirteen closed fractures treated more than six hours after injury. Collectively, these authors agreed that injury severity and associated soft-tissue injury were strongly associated with patient outcomes, and recommended that consideration be given to delayed definitive fixation of the talar neck fracture until the soft tissues were favorable for surgery.
These series are all limited by small sample size, study design, and confounding variables. The current best evidence is Level IV and inconclusive, but it does not seem to demonstrate a relationship between surgical timing and outcomes.
Authors’ Practice Trends
Open talar neck fractures are urgently debrided and are spanned with external fixation when appropriate to allow soft-tissue stabilization and wound management. Fracture-dislocations are treated as emergencies when associated with neurovascular compromise. Definitive management is delayed until the soft-tissue swelling has abated, to avoid problems of skin necrosis and wound complications.
History of Damage Control Surgery
Timing of definitive fracture fixation in trauma patients has evolved over the past several decades. As implant options broadened and improved in the 1980s, a more aggressive initial approach to fracture management was undertaken. A subsequent alteration in treatment paradigms, with a shift toward decreasing acute surgical burden in critically injured patients, evolved in the 1990s on the basis of the general surgery concepts of the so-called triad of death—coagulopathy, hypothermia, and hypotension—and the importance of minimization of acute surgical burden in patients with major trauma54,55. The goals of damage control surgery were to lessen complications arising from a result of the so-called second hit of increased acute surgical burden. Orthopaedic surgeons began to adopt this concept, and Pape et al.56 added soft-tissue injuries as a fourth consideration in bluntly injured trauma patients. Within the orthopaedic trauma field, the staged approach to surgical intervention and a greater respect for the patient’s physiologic status have developed, with increased consideration given to the timing and nature of operative interventions.
Inflammatory and Resuscitation Considerations
Traumatic injury and surgical procedures are known to induce a systemic inflammatory response and a counter-inflammatory response57,58. In a prospectively randomized trial, the acute inflammatory marker interleukin (IL)-6 increased more in stable patients with a femoral fracture undergoing immediate definitive fixation with an intramedullary nail than in patients undergoing a staged treatment protocol with initial external fixation59. The potential for the exacerbation of the trauma inflammatory response by subjecting a patient to longer and more invasive surgery is sustained for several days following the acute traumatic event and is associated with organ dysfunction. Pape et al., in a prospectively randomized group of trauma patients, found those who were converted to intramedullary stabilization of a femoral fracture between days 2 and 4 after the injury had higher postoperative levels of IL-6 compared with those who underwent delayed conversion on day 5 or later after the injury60. Additionally, patients with higher initial IL-6 levels in the day-2 to 4 conversion group had significantly higher rates of organ dysfunction compared with the delayed conversation group. While a host of immunomodulators are released during the acute trauma phase and surgical interventions, IL-6 levels can be predictive of clinical outcomes with higher levels correlated to increased morbidity57,61,62. Therefore, not only should the inflammatory effect of the trauma be considered, but also the inflammatory burden of early and prolonged surgery.
Little controversy exists with regard to treating stable patients with early definitive fixation and treating unstable patients, or those in extremis, with staged management. The question of the best treatment plan arises with respect to the patient with borderline status and how to identify those who fall into that category. Since IL-6 values are not available in most U.S. trauma centers, other methods of determining patients at risk must be used. Pape et al. expanded the so-called triad of death to include soft-tissue injuries in blunt trauma patients and provided a reasonable tool to be used to assist in the identification of borderline patients, with reclassification possible as the patient undergoes resuscitation or subsequent deterioration56 (Table III). Pape et al., using their criteria for stable and borderline status, prospectively randomized patients in these categories who had femoral fractures to initial treatment of intramedullary nailing or external fixation with eventual conversion to intramedullary nail63. Borderline patients managed with provisional external fixation had fewer pulmonary complications. Further analysis also revealed longer ventilatory times in stable patients randomized to provisional external fixation rather than definitive fixation. The results underscore the benefits of patient stratification for appropriate initial management. Therefore, if the patient is stable, early definitive care is appropriate. However, borderline patients seem to benefit from provisional external fixation and delayed definitive management.
Included in the previously mentioned guidelines for patient stratification is the idea of resuscitation, as measured by base deficit and lactate level. The general surgery and orthopaedic trauma literature have demonstrated resuscitation to be an important predictor of outcome in the trauma patient population, and clinically available parameters such as serum lactate levels and base deficit can be useful64-66. O’Toole et al.67, using resuscitation as a predictor of readiness for surgical intervention, demonstrated low rates of both acute respiratory distress syndrome and death in patients with multiple traumatic injuries undergoing intramedullary fixation of femoral shaft fractures after adequate resuscitation (lactate levels trending toward 2.5 mmol/L). Predictably higher rates of mortality were noted in the external fixator group, which had significantly higher lactate levels and less stable cardiopulmonary parameters compared with those in the intramedullary fixation group.
Patients with Head Injuries
While clinical signs of hypoperfusion and associated laboratory findings are important predictors of patients who may respond well to a limited initial approach, special consideration must also be given to those persons presenting with or at risk of developing traumatic brain injuries. No prospective randomized trial is available to provide specific criteria indicative of the readiness of a brain-injured patient for definitive operative intervention. Understanding the diagnosis and management of the head injury can direct the care of these patients and guide clinical decision-making. Adequate resuscitation and maintenance of appropriate perfusion of brain tissue is important in the avoidance of further cerebral insult. Cerebral perfusion pressure is quantified by measuring the difference between mean arterial pressure and intracranial pressure. Intracranial pressures of >20 to 25 mm Hg should trigger initiation of therapy to decrease intracranial pressure and thus increase cerebral perfusion pressure68. In orthopaedics, consideration of the effect that operative intervention can have on cerebral perfusion pressure should factor into surgical decision-making. Anglen et al.69 demonstrated an intraoperative decrease in mean arterial pressure and cerebral perfusion pressure in patients undergoing intramedullary femoral fixation. Careful consideration of the specific neurological condition of a patient, his or her resuscitation status, the expected length of procedures, and the effect of surgery on the cerebral perfusion pressure should be discussed with the neurosurgical team to ensure avoidance of further cerebral insult.
Authors’ Practice Trends
Although our general surgery trauma colleagues play a critical role in determining when borderline patients are adequately resuscitated for surgery, we take a proactive role with them in determining what definitive and what staged procedures can be done for the patient when he or she is cleared for operative management. If there is any question, staged management is chosen to avoid major complications.
Two commonly encountered injuries that have been shown to benefit from staged management (damage control orthopaedics), primarily because of the risk of complications secondary to the soft-tissue injuries, are high-energy tibial plateau and pilon fractures. Either injury-related factors (high energy) or patient-related factors (medical comorbidities) place patients at a considerably high risk of complications. Delayed definitive fixation with early temporary joint-spanning external fixation allows improved imaging and evaluation of the fracture and allows the soft-tissue injury to recover prior to a second surgical procedure.
Tibial plateau fractures vary substantially with regard to fracture pattern and overlying soft-tissue injury despite the association of more complex fracture patterns with high-energy injuries. In patients with preexisting, poor soft tissue due to age or medical comorbidities, such as diabetes mellitus or peripheral vascular disease, a simple low-level fall can create a relatively simple fracture pattern but a substantial soft-tissue injury. High-energy fractures in any patient can create a severe soft-tissue injury and more complex fracture patterns that require multiple surgical approaches to adequately address the fracture. The use of a temporary knee-spanning external fixator has proven to be safe70 and effective in decreasing the risk of infection from up to 80% to less than approximately 8%, especially when dual surgical approaches are used14,71-73.
The management of tibial pilon fractures has changed notably over the last ten to fifteen years on the basis of a historical complication rate of up to 100% with primary open reduction and internal fixation (ORIF)74 to <10% with staged management75-77. Although a recent article retrospectively evaluating early primary ORIF (median time from injury to surgery was eighteen hours) showed a deep infection rate of 6% in ninety-five patients with AO/OTA (Orthopaedic Trauma Association) type-43C pilon fractures, the condition of the soft-tissue envelope should determine when definitive ORIF is performed to minimize the risk of previously reported major complication rates78 (Figs. 1-A, 1-B, and 1-C).
Authors’ Practice Trends
The soft-tissue injury should determine when definitive ORIF is performed for both tibial plateau and pilon fractures. In high-energy injuries or low-energy injuries in patients with a poor preexisting soft-tissue envelope, a two-staged approach with delayed definitive ORIF with early joint-spanning external fixation, if indicated, is supported by the literature and is what we practice.
The “orthopaedic trauma room” is a new concept over the last decade that provides dedicated time, separate from the general surgery trauma room, during normal daylight hours that is staffed with experienced orthopaedic support personnel. The room is “late release,” meaning that cases can be scheduled in the room typically up until the same morning without being placed as an add-on. Historically, orthopaedic trauma cases that were not emergencies would be placed on the add-on list to be done at the end of the day when all of the electively scheduled surgeries are completed. This historically led to inefficient care for patients who were bedridden or had limited mobility secondary to their injury and would have benefited the most from early care. It also led to longer lengths of stay and a higher burden on the on-call hospital staff and the associated hospital resources. In addition, it contributed to orthopaedic trauma surgeons burning out and not being able to sustain a full-time acute trauma practice for their entire career.
After-hours surgery is associated with a higher rate of complications. Ricci et al. prospectively followed patients who underwent intramedullary nailing of femoral and tibial fractures and found a significantly higher rate of unplanned reoperations and deep implant removal in the patients who had a femoral fracture79.
Several studies have shown that a dedicated orthopaedic trauma room leads to more efficient care with fewer complications. Bhattacharyya et al. retrospectively reviewed the efficacy of the orthopaedic trauma room at a level-I trauma center80. The room was utilized 88% of the available time, which is above the standard acceptable utilization rate for an operating room. Fewer elective orthopaedic cases were moved, and there was a 72% reduction in the number of hip fractures that were treated operatively after 5 p.m. There were also fewer complications and less surgical time for patients undergoing femoral nailing prior to 5 p.m. Wixted et al. also showed that the orthopaedic trauma room led to an improved case flow, with a greater total number of cases being done, fewer after-hours cases, and an increased likelihood of isolated femoral shaft fractures being transferred to the orthopaedic traumatologist81. In comparing two level-I Canadian trauma centers, one with and one without a dedicated orthopaedic trauma room, Elder et al. convincingly showed that the availability of the orthopaedic trauma room significantly decreased the time to surgery and morbidity by almost 50% in elderly patients with subcapital femoral neck fractures82.
Authors’ Practice Trends
All of the authors have the availability of the orthopaedic trauma room and believe it is a critical factor for efficient care of the trauma patient, improved career satisfaction, and sustainability for orthopaedic traumatologists and those who regularly manage orthopaedic trauma patients.
Although technical and resource trends have changed over the last few decades, true orthopaedic emergencies related to extremity injuries continue to occur and include compartment syndrome and fractures or dislocations associated with vascular injury. Open fractures, displaced femoral neck fractures in young adults, and open fractures of the talus or those with potential soft-tissue compromise should be managed as soon as the patient status and resources allow. Definitive fixation of extremity injuries should be done when the patient and the soft-tissue status provide the best opportunity to minimize the risk of complications. Finally, the orthopaedic trauma operating room has allowed for more efficient care of these potentially, critically injured patients and has improved resource utilization, decreased the risk of complications, and improved job satisfaction for orthopaedic surgeons who manage trauma patients.
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