My center is in the process of updating our cervical spine clearance protocols, and I wanted to share this work with you to help those who may be doing the same. Today, I’ll review our new clearance method for patients with normal mental status. Tomorrow I’ll go over the protocol for patients who are obtunded.
Here are the key points:
- Clinical clearance is acceptable except in patients with a high risk mechanism (see link to YouTube video below for clinical clearance technique)
- If risk factors are present or exam is abnormal, we use our Blunt Trauma Imaging Protocol to order the appropriate imaging study (see link below)
- If clearance efforts fail but radiographs are normal, upright plain images are obtained to evaluate stability
- Flexion/extension xrays are no longer used
- Patients with an abnormal exam but normal radiographs may be discharged with a soft collar and re-evaluated in a week.
Many of you know my opinion on soft collars (see link below). However, they do serve a purpose here. The protocol will demonstrate that if the patient potentially has an injury, it is stable. Unstable injuries will have been identified and referred to a spine specialist. The collar reminds the patient to voluntarily limit their neck motion to reasonable amounts until they are re-evaluated. And it is also inexpensive, does not lead to skin breakdown, and has much better patient compliance.
Yesterday, I wrote about the classic Gustilo and Anderson open fracture classification system. Today, I’ll explain the newer classification system proposed by the Orthopaedic Trauma Association (OTA).
The OTA developed this system using both good and not so good methodology: literature review and panel consensus. It offered an opportunity to refine definitions to try to make the system as useful as possible. It evaluates 5 pathoanatomic factors and provides 3 subgroupings for each factor. Here’s the rundown:
- Can be approximated
- Cannot be approximated
- No appreciable muscle necrosis, or some injury with function intact
- Loss of muscle but remains functional, or localized necrosis in injured area that requires excision
- Dead muscle, loss of function, partial or complete compartment excision, complete disruption of muscle-tendon unit, muscle injury not approximatable
- No injury
- Injury, no ischemia
- Injury with distal ischemia
- None or minimal
- Surface, easily removed and not embedded in deeper tissues
- a. embedded in bone or deep tissues, b. high risk environment (feces, contaminated water, etc.)
- Bone loss, but still some contact between proximal and distal fragments
- Segmental bone loss
The authors recommend using this classification at the end of the surgical debridement for best accuracy. It was also disigned for simplicity to reduce variability between raters.
Bottom line: Although it looks a bit clunky, this new OTA open fracture scoring system looks to be an improvement over the good old G&A. Expect to begin seeing research papers using this system in the near future. But it will take some time to build up the depth of experience with this system to be able to make good predictions on outcomes.
Reference: A new classification scheme for open fractures. J orthop Trauma 24(8):457-465, 2010.
The Orthopaedic Trauma Association (OTA) Open Fracture Study Group has published a proposal for an updated system for classification of open fractures. So far, I don’t know of anyone who is actually using the new system, but I wanted to publicize it for your comments. Today, I’ll discuss the current classification standard in most trauma centers. Tomorrow, I’ll review the newly proposed one.
The most widely used system was developed by Gustilo and Anderson (G&A), with work starting in 1969. A number of modifications have been made over the years. Here’s the current classification system:
- Grade I: Clean wound, <1cm in length
- Grade II: Wound >1cm, but no extensive soft tissue injury, flaps or avulsions
- Grade III: Extensive soft tissue laceration or damage, or open segmental fracture. Three subtypes were later developed:
- Grade IIIa: Adequate periosteal coverage of the fracture
- Grade IIIb: Extensive soft tissue loss, periosteal stripping, bone damage. Usually includes massive contamination.
- Grade IIIc: Vascular injury requiring repair, regardless of degree of soft tissue injury
A few minor modifications have been made by others over the years, but they are not in general use.
So what’s the problem with G&A? Here are a few. Is the injury classified before or after debridement? Preop classification or intraop? Can you use this system for treatment when it is already based on treatment? How reproducible is it? Is there good data on outcomes? Do outcomes rely on other factors, such as the level of trauma hospital treating the fracture? To name a few. In it’s favor, it is in widespread use and nearly all orthopaedic surgeons are well versed in it.
Tomorrow I’ll discuss how the new OTA system addresses some of the shortcomings in the G&A system.
- Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 58:453–8, 1976.
- Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 24:742–6, 1984.
Practice guidelines are everywhere. More and more organizations have developed processes to create high quality ones. But why should we care? Do they improve what we already do?
Here are my reasons for using practice guidelines:
- They provide a consistent way of approaching a clinical issue. Everybody working with the patient knows how things will be done, so they don’t have to remember the nuances that particular doctors or providers like.
- They (hopefully) use the best and most valid scientific data to address the care issue, thus giving trauma professionals the opportunity to provide the best care we know of.
- They decrease errors and complications by narrowing the number of choices available to providers.
- They decrease waste for the same reason. For example, drawing blood every 6 hours vs daily for solid organ injuries can add up to three unneeded tests every day.
- They provide our trainees with one good way to deal with the clinical issue. This is important when they move on to independent practice, and sometimes when taking standardized tests (boards).
Bottom line: If 10 trauma professionals deal with a given clinical problem 10 different ways, then none of them are doing it right! Develop a guideline that all of them can live with, based on current literature (if any). That way they can all be right for once, and our patients will reap the benefits.
The following link illustrates a protocol we developed for chest tube management. There is no literature that details when and how to remove a chest tube, so this one was hammered out by our group of trauma surgeons. We now all do it the same, and our length of stay has decreased since we eliminated much of the arbitrary variability in this process.
The radiologist made me order that (unnecessary) test! I’ve heard this excuse many, many times. Do these phrases look familiar?
- … recommend clinical correlation
- … correlation with CT may be of value
- … recommend delayed CT imaging through the area
- … may represent thymus vs thoracic aortic injury (in a 2 year old who fell down stairs)
Some trauma professionals will read the radiology report and then immediately order more xrays. Others will critically look at the report, the patient’s clinical status and mechanism of injury, and then decide they are not necessary. I am firmly in the latter camp.
But why do some just follow the rad’s suggestions? I believe there are two major camps:
- Those that are afraid of being sued if they don’t do everything suggested, because they’ve done everything and shouldn’t miss the diagnosis
- Those that don’t completely understand what is known about trauma mechanisms and injury and think the radiologist does
Bottom line: The radiologist is your consultant. While they are good at reading images, they do not know the nuances of trauma. Plus, they didn’t get to see the patient so they don’t have the full context for their read. First, talk to the rad so they know what happened to the patient and what you are looking for. Then critically look at their read. If the mechanism doesn’t support the diagnosis, or they are requesting unusual or unneeded studies, don’t get them! Just document your rationale clearly in the record. This provides best patient care, and minimizes the potential complications (and radiation exposure) from unnecessary tests.
Reference: Pitfalls of the vague radiology report. AJR 174(6):1511-1518, 2000.