Orthopedic Injuries: Clinical Considerations for the Trauma Surgeon

In this interview of the Behind the Knife Podcast, Lynette Scherer MD, FACS, Chief Medical Officer (CMO) of Surgical Affiliates, provides her take on important considerations for trauma surgeons, including early intervention, medication management, and communication among the surgical team. This podcast interview was conducted following Dr. Scherer’s talk, titled “Broken Bones – What the Trauma Surgeon Needs to Know,” presented at the 2018 Trauma, Critical Care & Acute Care Surgery (TCCACS) event held April 9-11, in Las Vegas, NV. Listen to the full interview at Behind the Knife.

“I love making a difference.” These 5 simple words are what Lynette Scherer MD, FACS, uses when asked about what makes her excited when it comes to trauma and acute care surgery.

Patients presenting the emergency room with traumatic injuries are often extremely sick and have a high mortality risk. Surgeons possessing many years of experience in trauma and general surgery substantially improve the chance of survival. This experience and skill set has driven the success of Dr. Scherer’s own practice as well as her contribution as Chief Medical Officer of Surgical Affiliates. “I think the breadth of what we do is great,” Dr. Scherer added, “and I feel like I make a difference when I go to work every day.”

Orthopedic Injury Management: Key Considerations from Dr. Scherer

Orthopedic injuries require a management approach that focuses on early intervention while maintaining quality care. Medication management is an important consideration in this setting, particularly among those with open fractures. According to Dr. Scherer, trauma surgeons need to pay close attention to delivering antibiotic treatment to patients with open fractures within a 60-minute window of hospital admission. “I realize that in some rural settings, the patient might not get to the hospital within 60 minutes, but the focus is on delivering antibiotics as soon as possible,” said Dr. Scherer. “In fact, doing this is just as important as your secondary survey.” Additionally, Dr. Scherer recommends having a goal of early termination of antibiotic therapy to ensure a positive outcome. “The other thing we have in our control is how long the patient is receiving antibiotics,” added Dr. Scherer. “The focus should be on getting these antibiotics turned off within 24-72 hours.”

The Importance of Early Intervention

Similar to most emergency surgeries, early intervention is key for improving prognosis in trauma patients, regardless of injury type. For femur fractures, however, certain challenges exist in many hospital settings that prevent timely surgical management. “I think it’s pretty well accepted on getting femur fractures fixed early,” Dr. Scherer explained, “but as we see fewer and fewer orthopedic surgeons who are willing or able to cover trauma surgeries, we’re starting to see a little bit of a push back on how quickly those femur fractures can be stabilized.” Early stabilization, according to Dr. Scherer, is key for favorable outcomes in these patients. Hospitals with a specialized 24-hour surgery team may be in a better position to ensure early intervention in these patients.

Timely Delivery to the OR

For individuals presenting to the hospital with an orthopedic injury, conventional wisdom states that these patients must be delivered to the operating room (OR) early, or at least within 6 hours of arrival. However, this isn’t always the case, particularly for low-risk injuries. “We now have pretty solid evidence, especially for the lower grade injuries, that these surgeries can be performed within 24 hours,” Dr. Scherer commented, “except for patients with grossly contaminated wounds. In that case, these wounds should be washed out as soon as possible.” Most often, a washout for contaminated wounds that count for the trauma registry “is the one that happens in the OR where devitalized tissue is debrided and the wound is completely washed out.”

Other Considerations for the Trauma Surgeon

In cases where a trauma patient has a head injury and has also developed venous thromboembolism (VTE), Dr. Scherer again advocates for early management, specifically in regard to VTE prophylaxis. “We like to start [VTE prophylaxis] within 24-48 hours after stable CT,” commented Dr. Scherer, “depending upon what kind of bleeding they had.” Communication within a neurosurgery team is also critical for appropriate management of these and other trauma patients. “I think communication with the neurosurgeons is critical, and sometimes it has to be over and over and over to get a group consensus,” Dr. Scherer explained, “and invariably there’s a discussion about patients with more complicated wounds.”

The emphasis on early presentation and treatment highlights the importance of having a robust, fully capable team of experienced and specialized trauma surgeons available to take on cases, regardless of the time of day. Surgical Affiliates works with existing hospital systems to support current surgical teams and improve standards of care by offering a 24-hour trauma and acute care service, facilitating earlier intervention and reduced transfers. To learn more about the program read through our real-world case studies here.