ACS COVID-19 Guidelines for Triage of Orthopedic Patients

On March 24, 2020, the American College of Surgeons (ACS) published COVID-19 guidelines for triage of orthopedic patients. The general recommendations for all surgical cases include the following^[90]:

Provide appropriate and timely surgical care based on sound surgical judgment and availability of resources
Consider nonoperative management whenever it is clinically appropriate for the patient
Consider waiting on results of COVID-19 testing in patients who may be infected
If possible, avoid emergency surgical procedures at night when staff may be more limited
Aerosol generating procedures (AGPs) increase risk to the health care worker; for patients who are or may be infected, AGPs should only be performed while wearing full PPE including an N95 mask or powered, air-purifying respirator (PAPR) that has been designed for the operating room

During phase II, hospitals have many COVID-19 patients, intensive care unit (ICU) and ventilator capacity are limited, or supplies are limited or the COVID-19 trajectory within the hospital is in a rapidly escalating phase. For trauma patients during this phase, the guidelines recommend restricting orthopedic procedures to new fractures, acute traumatic injury, nonunions, malunions and infections.

During phase III, hospital resources are all routed to COVID-19 patients, there is no ventilator or ICU capacity, or supplies have been exhausted. For trauma patients during this phase, the guidelines recommend restricting orthopedic procedures to new fractures, quad tendon rupture, patellear tendon rupture and acute changes of a chronic injury with inability to function.

AAOS Guidelines for Pediatric Diaphyseal Femur Fractures

American Academy of Orthopaedic Surgeons (AAOS) guidelines for treatment of diaphyseal femur fractures in children include the following^[91]:

Strong evidence supports that children younger than 36 months with a diaphyseal femur fracture be evaluated for child abuse
Moderate evidence supports early spica casting or traction with delayed spica casting for children age 6 months to 5 years with a diaphyseal femur fracture with less than 2 cm of shortening
Limited evidence supports treatment with a Pavlik harness or a spica cast for infants 6 months and younger with a diaphyseal femur fracture, because their outcomes are similar
Limited evidence supports the option for physicians to use flexible intramedullary nailing to treat children age 5-11 years diagnosed with diaphyseal femur fractures
Limited evidence supports rigid trochanteric entry nailing, submuscular plating, and flexible intramedullary nailing as treatment options for children age 11 years to skeletal maturity diagnosed with diaphyseal femur fractures, but piriformis or near piriformis entry rigid nailing are not treatment options
Limited evidence supports regional pain management for patient comfort perioperatively
Limited evidence supports waterproof cast liners for spica casts are an option for use in children diagnosed with pediatric diaphyseal femur fractures

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Media Gallery

Anteroposterior radiograph of a femur fracture in a 45-year-old man.
Lateral radiograph of a femur shaft fracture in a 45-year-old man.
Anteroposterior radiograph of the hip in a 45-year-old man. Distal portion shows the femur fracture.
Anteroposterior radiograph of the hip and proximal femur after antegrade intramedullary (IM) nail placement.
Cross-table radiograph of the hip and proximal femur after antegrade intramedullary (IM) nail placement.
Lateral radiograph of the distal femur after antegrade intramedullary (IM) nail placement.
Anteroposterior radiograph of the distal femur after antegrade intramedullary (IM) nail placement.
Anteroposterior radiograph of a femoral-shaft fracture in a 19-year-old man.
Anteroposterior radiograph of the hip and femur in a 19-year-old man shows a fracture of the femoral shaft.
Lateral radiograph shows flexible nailing in a 19-year-old man.
Anteroposterior radiograph shows flexible nailing in a 19-year-old man.
Anteroposterior and lateral radiographs show flexible nailing in a 19-year-old man.
Example of retrograde nail on distal anteroposterior and lateral radiographs.
Example of retrograde nail on proximal anteroposterior and lateral radiographs.
Patient positioned on a fracture table.
Incision for rod and proximal screw removal.
Example of secondary fracture healing evident on radiography.
Example of an open segmental femur fracture in a 16-year-old, multitrauma patient who sustained this and pelvic, pilon, and Lisfranc injuries on the ipsilateral extremity. Also sustained major chest and head injuries.
As the above patient was extremely unstable, emergent external fixation of the open femur fracture was completed
After delayed antegrade nailing and repeat incision and drainage, note antibiotic beads placed in wound, removed at last incision and drainage.

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Author

Bart Eastwood, DO Orthopedic Surgeon and Sports Medicine Specialist, Sideline Orthopedics and Sports Medicine

Bart Eastwood, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Orthopedics, American Osteopathic Association, Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Knutson, DO Consulting Surgeon, Department of Orthopedic Surgery, Center for Orthopedic Excellence

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

B Sonny Bal, MD, JD, PhD, MBA CEO and President, SINTX Technologies, Salt Lake City, UT

B Sonny Bal, MD, JD, PhD, MBA is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: SINTX Technologies.

Chief Editor

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American College of Surgeons, Eastern Orthopaedic Association, New York Academy of Medicine

Disclosure: Received consulting fee from Stryker Orthopaedics for speaking and teaching.

Additional Contributors

Steven I Rabin, MD Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Musculoskeletal Services, Dreyer Medical Clinic

Steven I Rabin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Forensic Examiners Institute, American College of Surgeons, American Fracture Association, American Orthopaedic Association, AO Foundation, Chicago Metropolitan Trauma Society, Illinois Association of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society, Mid-America Orthopaedic Association, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author coauthor Dr H Kurtis Biggs to the development and writing of this article.

Group	Average Shortening Before Casting, cm	Average Shortening After Casting, cm	Average Time of Casting Needed, wk	Average AP Varus/Valgus Before	Average AP Varus/Valgus After
1 (10-49 lb)	1.7	0.7	6	10.4/8.6	7.6/4.3
2 (50-80 lb)	1.5	1	7.1	9.4/5.4	5.6/2.6
3 (81-100 lb)	2.1	0.9	8	12/14	6.8/2.6

Diaphyseal Femur Fractures Guidelines

ACS COVID-19 Guidelines for Triage of Orthopedic Patients

AAOS Guidelines for Pediatric Diaphyseal Femur Fractures

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