Guidelines Summary

COVID-19 pandemic guidelines

On March 24, 2020, the American College of Surgeons published COVID-19 guidelines for triage of orthopedic patients. The general recommendations for all surgical cases include the following^[54]:

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.

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Media Gallery

Supracondylar femur fracture treated in traction. Traction allows nonoperative restoration of length and alignment while the patient is stabilized for surgery, but it is associated with the major complications of prolonged bedrest when used as definitive treatment.
Supracondylar femur fracture treated with a dynamic condylar screw plate. This device allows fixed-angle stabilization of the fracture, which usually prevents late loss of reduction, but it is technically limited because it cannot be used to fix multiple fragments.
Supracondylar femur fracture treated with a blade plate. This device allows fixed-angle stabilization of the fracture, which usually prevents late loss of reduction, but it is technically limited because it cannot be used to fix multiple fragments.
Supracondylar femur fracture treated with a supracondylar buttress plate. This device provides multiple holes for screw fixation of multiple fragments, but it is not a fixed-angle implant so it may allow late deformity.
Supracondylar femur fracture treated by retrograde intramedullary nail. Intramedullary devices are mechanically stronger than plates but have limited ability to control multiple fragments and require exposure through the knee joint.
Supracondylar femur fracture treated with Zickel flexible intramedullary rods. These devices act as an internal splint and can be placed rapidly with minimal blood loss and surgical exposure but do not control length and alignment.
Supracondylar femur fracture treated with external fixation and minimal internal fixation. This technique allows immediate restoration of length and alignment with minimal surgical exposure, but it often cannot hold the alignment in the long term and has associated problems with pin care.
Supracondylar femur fracture treated with a cobra plate. This device is strong and can achieve fixation in multiple fragments but is not fixed angle.
Supracondylar femur fracture treated with a tibial buttress plate. This type of plate is rarely used for these fractures but can allow low-profile fixation of stable fracture patterns. New periarticular plates are replacing this implant in this area.

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Author

Steven I Rabin, MD, FAAOS 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, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, 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.

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.

Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey D Thomson, MD Professor of Orthopedic Surgery, University of Connecticut School of Medicine; Orthopedic Surgeon, Connecticut Children’s Medical Center

Jeffrey D Thomson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Pediatric Orthopaedic Society of North America, Scoliosis Research Society

Disclosure: Nothing to disclose.

Additional Contributors

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) Professor, Department of Orthopedic Surgery, University of Texas Medical School at Houston

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Supracondylar Femur Fractures Guidelines

Guidelines Summary

COVID-19 pandemic guidelines

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