Orthopaedic Unit Care

Ovid: Manual of Orthopaedics

Editors: Swiontkowski, Marc F.; Stovitz, Steven D.
Title: Manual of Orthopaedics, 6th Edition
> Table of Contents > 8 – Orthopaedic Unit Care

Orthopaedic Unit Care
The orthopaedic unit must present a warm, friendly, and
quiet atmosphere as an essential part of the treatment program. Most
patients who enter the hospital are frightened and need reassurance
from everyone on the unit. To have an effective team, it is necessary
for each individual to understand the goals of the treatment program
for each patient. Therefore, careful communication is required, as is
recognition that the best run orthopaedic services are those that
involve all of the personnel in the decision-making process. To
maintain the best possible environment for most patients and to ease
the problems of communication, it is helpful to schedule and
standardize activities and procedures. This principle is even more
important with the current emphasis on shortened length of hospital
II. Rounds
Rounds are important in that they constitute an
evaluation for the benefit of the patient and an educational experience
for all of the participants. Be certain that the best interests of the
patient are not sacrificed for education. The knowledge that any word, or non-verbal cue,
uttered in the presence of the patient can stimulate a reaction in him
or her is fundamental to the art of healing. The focus of the language
must center on the treatment of the patient and the disease process.
Fascination, preoccupation, or engagement of the disease (or language
to that effect) must be avoided. The patient must be regarded and
respected, and all allusions to the disease or the treatment must be
framed as a focus on the patient. The patient must be made to feel that
he or she is receiving sympathetic attention as a living human being
rather than being scrutinized like a specimen. This does not
necessarily mean that scientific discussion is inappropriate at the
bedside. However, in general, highly technical debate or lengthy
discussion should be conducted away from the bedside and out of the
patient’s hearing range.
  • The approach to the patient
    must also be direct and personal. Properly conducted, it can be an
    excellent teaching experience for those in attendance and help the
    patient understand his or her problems more completely. If the leader
    of the rounds addresses the patient with friendly words of inquiry or
    explanation, and with permission enters into the discussion, the
    patient tolerates or welcomes clinical discussions. Indeed, when
    managed along these lines, most patients, instead of resenting
    visitations from large groups, may relish the attention they are
    attracting and enjoy participating in the process.
  • Present case histories at bedside only with the patient’s permission.
    Devote attention to examining the patient, giving advice, or obtaining
    further history. The medical student, resident, and nurse who are to
    report on or present the case should take a position opposite that of
    the attending physician at the bedside. Refer to patients by name.
    References to age, sex, or race are out of place unless essential to
    the discussion and cannot be perceived by those in attendance.
  • Sensitive humor
    can be beneficial if the patient shares it. This is an art, carefully
    administered. Laughter can be cruel when the patient thinks it is
    directed toward him or her.
  • The head nurse should be an integral part
    of rounds. The nurse prepares for rounds as well as participates in
    them. When the patient is examined, the nurse should take a station at
    the head of the bed to promote the comfort of the patient during the
    examination. The doctors and students have much to learn from the


    in charge. Personal privacy is very important, and is becoming more so;
    before starting rounds, the nurse or the assistant should ask visitors
    (except close adult members of the family) to leave the patient’s
    bedside. The radio or television set is lowered in volume or turned
    off. Each member of the team performs his or her role with dispatch so
    that the whole activity runs smoothly and gives an impression of
    efficiency and dignity to patients and visitors.

  • Consultations
    are an important part of patient care and usually are ordered by the
    attending physician with a statement as to the current care, opinions,
    and so on. Make every effort to assist the consultant. Frame the
    question, anticipate the need, and provide the data. When the
    consultant enters the patient’s room, the resident or nurse assigned to
    the case should introduce the patient and explain the purpose of the
    visit. The resident should know the relevant findings, plan, and
    appropriate controversies. Discuss the plan with resident or staff
    before rounds.
III. Workup Routines
  • Either before or as soon as possible after admission, the house officer should conduct a complete history and physical examination
    of the patient. This workup should be reviewed, corrected, amended, and
    signed by the chief resident and attending physician within 24 hours.
    The authors prefer problem-oriented medical records. An example of the
    initial record follows:
    • Database
    • Chief complaint
    • History of present
      illness, including relevant aspects of the injury mechanism, which can
      explain and anticipate elements of the soft tissue and bony injuries
    • Patient profile
      • Past medical history
      • Medications
      • Allergies
      • Family history
      • Social history (include smoking, alcohol and drug use history) (1,2)
      • Relevant vocations and avocations
      • Hand dominance, as appropriate
    • Review of systems
    • Physical examination
    • Laboratory reports
    • Imaging findings, remaining imaging (pending), or imaging plan
    • Inpatient problem list, which should be maintained in the outpatient care record
    • An initial plan keyed by number to the inpatient problem list
      • Diagnostic plan
      • Therapeutic plan
        • Lesion-specific (splinting, protections, weight-bearing status)
        • General orthopaedic (infection considerations, anticoagulation, rehabilitation and discharge contingencies)
      • Patient education
  • Anticipate any side effects or complications
    from either the primary problems or the treatment plans and make
    appropriate provisions for prophylactic medications or other measures. Plan ahead, to keep the patient as comfortable as possible. Use every moment of hospitalization optimally.
  • Write progress notes
    as often as there is any change in the patient’s condition or when a
    consultation is obtained. The patient should be seen daily and an entry
    made in the medical record after each visit. The authors prefer the
    problem-oriented style of progress notes. The note should be
    accompanied by a date and time of the entry. After initial impressions
    have been advanced, if there are later complex considerations,
    trade-offs and major evolutions in the plan will be better understood
    if dictated as an “Interim Summary,” which may look very much like a
    history with physical, or be reduced to a summary of thoughts,
    trade-offs, discussions, and explanations on progress.


    • Narrative notes are numbered and titled according to the inpatient problem list and are organized as follows:
      • Subjective data
      • Objective data
      • Assessment
      • Plan
        • Diagnostic
        • Therapeutic
        • Patient education
    • Flow sheets are used when data and time relationships are complex
    • Discharge summary
      • Identifying data
      • Dates of admission and discharge
      • Master problem list with the appropriate dates
        • Use two columns, one headed active problems and one inactive problems.
        • Give each problem a
          number. Once a problem is assigned a number, whether on an inpatient
          list or on a master list, do not use the number again
      • List of operations and procedures, including the dates
      • Description of the inpatient problems
      • Physical examination
      • Laboratory data
      • Hospital course for each problem, including laboratory data, treatment, and plans when appropriate
      • Discharge medications and disposition
IV. Routine Orders and Management of Inpatients
  • The initial orders should state
    • The condition of the patient
    • The type of activity desired
  • Diet, an important part of the overall treatment program (3,4,5).
  • Wise use of consultants. Contemporary
    teaching hospitals are staffed with professionals of many kinds,
    including pharmacists, dieticians, discharge planners, and social
    workers. Use them; anticipate their needs and communicate freely. Help
    them help you care for the patients.
  • If preoperative preparation is necessary:
    • The injury, the patient’s general health,
      and the specific needs of the surgical and anesthesia team must be met.
      Know and understand the local preferences on preoperative protocols
      when writing for skin preps, specific labs, and tests
      [electrocardiogram (ECG), coagulation examinations, etc.]. Anticipate
      the need for the surgical consent and help to obtain it, if appropriate.
    • The surgical prep sometimes includes a 10-minute chlorhexidine (Hibiclens) or povidone-iodine (Betadine) scrub before surgery (6).
      If the patient is ambulatory, then the scrub is most easily
      accomplished by a shower with chlorhexidine or hexachlorophene soap at
      home the night before surgery. The authors advise that shaving of any
      hair from the operative field be done in the operating room with
      mechanical shavers. Small nicks or lacerations often occur with
      standard razors and can become colonized and increase the risk of a
      postoperative infection (6). Fracture blisters should be kept intact and dressed sterilely preoperatively (7,8,9).
    • Laboratory data.
      Patients undergoing a surgical procedure usually have a hemoglobin test
      within 30 days of surgery. The erythrocyte sedimentation rate (ESR) and
      C-reactive protein (CRP) should be determined for all patients with a
      history of infection. If the age of the patient (generally older than
      50 years of age) or the history indicates, then a chest roentgenogram
      and ECG are appropriate. Whenever blood transfusion is deemed likely,
      autologous blood donation should be considered (10). This can be set up through the local blood bank. Up to three units of blood can be drawn and stored over a


      3-week period. Generally, a fourth week before the scheduled procedure
      is allowed for recovery. Because this is not possible for acute trauma
      cases, the use of intraoperative
      suction-collection-filtering-retransfusion (Cell-Saver) should be
      considered. Help your team anticipate these needs.

      Many lab values and imaging reports are within hospital
      computer systems. Learn these systems (if you do not know them
      already). Be prepared to retrieve critical reports and results,
      anticipating for your team what will be necessary for the smooth
      running of the ward, preop preparation, and diagnostic problems. Help
      your team to refocus and address the changing needs of the patients.
  • Antibiotics are used for open fractures and should be used prophylactically for many types of orthopaedic procedures (11).
    For the most part, cephazolin is used, approximately 1 to 2 g before
    the skin incision, and continuing 1 g every 8 hours for 24 hours
    postoperatively. For those adults who are allergic to penicillin or
    cephalosporins, clindamycin [600–900 mg intravenously (IV) every 8
    hours] or vancomycin (750–1000 mg every 12 hours) is appropriate.
    Vancomycin can be associated with hypotension, tachycardia, or
    flushing, so give it slowly. Also, renal toxicity is a major concern,
    and drug levels must be monitored if given for more than a few days.
    Know well the characteristics of the antibiotics used, and obtain a
    careful history to ascertain possible allergies to antibiotics before
    administration. The use of surgical drains does not appear to decrease
    the risk of deep infection. Careful attention to skin preparation at
    the initiation of the procedure can limit the risk to the patient.
  • Analgesics, sedatives, and hypnotics.
    Virtually all orthopaedic patients admitted for acute problems have
    pain and anxiety. It is important to make the patient comfortable
    through adequate medication as quickly as possible. Take into
    consideration the size of the patient, the amount of medication
    received previously, and the type of orthopaedic problem or operation
    causing the pain.
    • Ideally, the analgesic and sedation regimen should keep the patients on a diurnal schedule
      so that they stay awake during the daytime and sleep at night.
      Sleeplessness is itself debilitating. Patients can tolerate
      considerably more pain or discomfort during the daytime (when there are
      distractions) than at night. For this reason, it is frequently helpful
      to use lighter analgesics during the daytime hours. Allow the nurses
      latitude in administration of such medications. Give ranges and seek
      input for the problems and questions which inevitably occur. Consider
      augmenting narcotics with nonopiate analgesics or nonsteroidal
      anti-inflammatory drugs (NSAIDs) to decrease narcotic use, remembering
      that the NSAIDs can interfere with the metabolic pathways of bone
      healing. Remember that many interfere with platelet activity as well,
      which is important in the posttraumatic and postoperative situations.
    • Analgesics.
      It is best if the physician can anticipate a patient’s pain and its
      severity because standing orders may then be written on a time-related
      basis to provide adequate patient comfort. However, these guidelines
      must be written conservatively, with enough provision for oversight and
      management to avoid overdosage. Most helpful in this regard has been
      the development of patient-controlled, parenteral, opiate
      administration systems. Consider monitoring the patient with
      respiratory monitors or pulse oximetry. When patients are allowed to
      titrate small doses of analgesia, they avoid toxicity yet keep their
      blood levels above the minimum effective analgesic concentration.
      Morphine, meperidine, (Demerol), and hyromorphone (Dilaudid) are the
      most widely used drugs with these systems (12).
      Since the effect and risk of these drugs is higher (though
      theoretically more precise) with “patient-controlled analgesia,” know
      the doses and ranges. Be conservative and ask about changing
      recommendations. Many narcotics have similar adverse side effects and
      produce addiction after approximately 4 weeks. The beneficial effects
      (analgesia and hypnosis) as well as the adverse side effects vary among
      patients (13).
    • Chronic pain. Narcotics are invaluable in the control of pain but should be used by experts only for chronic pain problems (14). Consider pain clinic


      consultation for complex problems, conflicting needs, atypical use
      problems, or demanding patients. Sharing the responsibility for such
      decisions in highly charged environments is often wise. Anticipate the
      undesirable side effects (such as reducing the cough reflex and level
      of respiration, depressing bladder tone, lowering bowel motility,
      producing nausea and, occasionally, vomiting) and initiate measures to
      counteract them. Counsel the patient to relieve apprehension regarding
      these side effects. The patient will then require lower doses. The
      reduced dose, in turn, decreases the undesirable effects of the
      analgesics. Patients with chronic pain need the help of an anesthesia
      or pain consultant.

    • Sedatives and hypnotics
      • For patients with severe anxiety, it is frequently helpful to combine the analgesics with a sedative or tranquilizing drug.
        If a patient is to undergo physical therapy, then avoid muscle
        relaxants during the day. Hydroxyzine (Vistaril), 50 mg by mouth (PO)
        or intramuscularly (IM), is useful in conjunction with analgesics, such
        as the major narcotics or one of the codeine derivatives (e.g., Tylenol
        No. 3), to control the anxiety and decrease the need for large doses of
      • Generally provide a hospitalized patient with a hypnotic
        for sleep. The need for sleep and the need for pain relief are separate
        but interrelated. Confer with the nurses about specific needs to avoid
        overmedication. These drugs need to be used with caution in the elderly.
  • Prevention of thromboembolism
    • The risk of thrombophlebitis and
      thromboembolism attends every patient at rest and is compounded by
      physical (venous flow) and hematologic changes of inactivity (15,16,17). Elderly patients and those undergoing bed rest for longer than a day should be put on a prophylactic program (18). This program may
      include slight elevation of the foot of the bed, application of elastic
      bandages or stockings, application of sequential compression devices,
      and initiating an active muscle exercise program (foot pumps) to
      stimulate circulation through the lower extremities (19,20). High-risk patients
      include those with a history of previous thromboembolic disease,
      previous surgery to the lower extremities, or chronic venous disease;
      patients on oral contraceptives; patients with a history of cancer or
      significant fractures (of the pelvis or femur); patients who smoke; or
      patients undergoing a lower extremity replacement arthroplasty (18).
      These high-risk patients should have prophylactic therapy. Spinal or
      epidural anesthesia may decrease the incidence of deep vein thrombosis
      (DVT) (21,22). Duplex ultrasound is an accurate method for DVT screening (23).
    • There are many
      options for the prevention and treatment of the patient at risk for
      thromboembolic phenomena. Warfarin, aspirin, dextran, heparin,
      low-molecular-weight heparin and sequential compression devices have
      been used in prophylactic treatment
      . Coumadin acts against the
      vitamin K-dependent clotting factors. Heparin and dextran-related
      (fragmented heparin) drugs are based on the polysaccharides which
      anticoagulate via heparin-based mechanisms (24).
      A third alternative, a pentasaccharide (Arixtra), works by similar
      mechanisms. Generally, the more effective anticoagulation, the greater
      the risk of bleeding-related complications, and treating physicians are
      constantly evaluating this fundamental trade-off. Even after many years
      (even decades), there is no consensus on optimal treatment.
      Furthermore, otherwise effective treatments are complicated by
      administration and technical problems. Coumadin, though easily
      administered, is difficult (and expensive) to monitor, whereas the low
      molecular weight dextrans (enoxiparin) require less monitoring but
      require needle-based injections. Any of these problems may be
      complicating (or disqualifying) in a given treatment situation. For the
      most part, a plan based on the contingencies of the local realities and
      preferences will exist when the student’s service rotation starts. The
      actual treatment selected is largely up to the surgeon because current


      not provide conclusive evidence to support or discredit any particular
      therapeutic regimen. Evidence has supported the prophylactic use of
      warfarin, low-molecular-weight heparin, or aspirin. The relative risks
      of embolic disease versus the complications of anticoagulants
      (hemorrhage, subsequent infection) must be weighed for each patient
      undergoing treatment.

      • If warfarin
        is chosen for DVT prophylaxis for elective surgery, it may be started
        before or after the procedure. The dose will depend on the situation,
        the patient’s underlying comorbidities such as renal or hepatic
        disease, or preoperative need (such as atrial fibrillation, valvular
        disease, or coagulation disorder). The starting dose may be 2.5 to 10.0
        mg (depending on the patient). Thereafter, alter the dose to maintain
        the prothrombin time, as determined by International Normalized Ratio
        at roughly 1.5 to 2 times the normal control. Although this time is
        difficult to regulate, when properly managed it gives a very
        satisfactory method in the prevention of fatal pulmonary embolism.
      • If aspirin is
        chosen, it is started at the surgeon’s discretion based on technical
        consideration of perioperative considerations and risk. The student
        must ask about proper timing. Generally, if aspirin is used for chronic
        anticoagulation, a pediatric-sized aspirin (81 mg) daily is enough.
        Keep in mind the mechanism of aspirin-related platelet effects is
        different and may complicate the use of other methods of
        anticoagulation, either vitamin-K based or heparin based.
      • If low-molecular-weight dextran is selected, check with the pharmacist or hospitalist for proper dosing.
      • If heparin is
        selected, then the usual dosage is 5,000 IU SQ q8h. It has also been
        given in combination with dihydroergotamine, 0.5 mg IM. The treatment
        is often started at operation. For patients who have pelvic or femoral
        fractures, use subcutaneous heparin preoperatively and warfarin to
        maintain the prothrombin time at 1.5 times control level
        postoperatively (25).
      • If low-molecular-weight heparin is chosen, the usual starting dose is 30 mg SQ q12h (24,26,27).
        The advantage of this therapy is that no monitoring of hematologic
        parameters is usually necessary. If this is to be continued after
        discharge, then ask the nursing staff to teach the patient family home
        administration techniques.
    • Check with the orthopaedic team, the
      hospitalists, or pharmacists regarding recommendations on monitoring
      methods, follow-up, and guidelines for cessation (28).
  • Posttraumatic and postoperative urinary retention is not uncommon.
    Indications for bladder catheterization include prolonged anesthesia.
    Prolonged would be easily defined as a case longer than 3 hours, but
    many surgeons will want a catheter for cases much shorter than this.
    The decision for a catheter is a joint decision between the surgeon and
    the anesthesia team. This decision is more easily made if there is good
    communication between the surgeon and anesthesia about case length,
    comorbidities, expected blood loss, fluid parameters, trauma status,
    postoperative nursing needs, and so on. If the bladder has been
    overdistended, it takes several days to regain normal tone. For this
    reason, if the patient requires catheterization, it should be done with
    a small catheter that has a 5-mL balloon. Leave the catheter in the
    bladder and attached to closed gravity drainage. Some state that the
    catheter should be left in place until the patient is ambulatory or is
    off narcotics during the daytime; others argue that the catheter should
    be removed as soon as the patient is alert enough to urinate in order
    to limit possible urinary tract infections (29). As common as catheter usage is, literature-based guidance on catheter usage is lacking.
  • Bowel. Bowel
    problems are best addressed if anticipated. A mix of bulking agents,
    stool softeners, lubricants, and laxatives may make the patient’s
    course more comfortable if given before there is a problem. This is
    particularly true of at-rest patients on narcotics. Docusate sodium
    (Colace), 100 mg b.i.d, usually


    satisfactory, but it may be necessary to supplement this with 30 to 60
    mL of milk of magnesia at bedtime. Mineral oil is a useful stool
    softener/lubricant, but it should be administered with caution because
    it may interfere with vitamin absorption.

  • Skin. Pressure sores are often prevented by good nursing care (30).
    Pressure problems are common over the sacrum and the heels. Patients
    who are unable to change position frequently following surgery or
    trauma must be turned frequently by the staff. Dressings which cover
    these common areas must be applied anticipating the inability to move
    or protect. When exposed, skin checks for redness are critical,
    especially on newly injured patients, unconscious patients, patients
    with dementia, patients with spinal cord injury or spina bifida,
    splinted extremities, and extremities in traction. The problem is especially acute
    in paraplegic and quadriplegic patients or in patients with concomitant
    head injury. If the orthopaedic condition does not allow frequent
    change in position, consider using special flotation mattresses or
    rotating beds (31). Check the skin during
    rounds. Consider the pressure areas at the same time that the other
    areas at risk in surgery are considered (calf tenderness, wound
    complications, etc.).
  • Activities and physical therapy.
    The postoperative activity/physical therapy plan should be recorded in
    the written operative note. Weight-bearing status and allowable use of
    the hand below a dressing or splint (whether long arm or short arm) are
    technical decisions related to many specific orthopaedic considerations
    (injury, prosthesis, surgical confidence), so ask. Also ask for the
    rationale so that the student will learn. Each morning on rounds the
    staff decides what activity or therapy the patient should have that
    day. Activities may take diverse forms from minor diversions to a
    full-scale physical therapy program. Dumbbells and pulleys can be used
    to toughen the hands and strengthen triceps and shoulder muscles in
    preparation for crutch ambulation. Dumbbells are also useful in
    increasing chest muscle activity and improving cardiopulmonary exchange
    (32). All muscles, except those immediate to
    the injured or operative area, should be exercised in a set daily
    program. This exercise provides excellent distraction as well as a
    general sense of improved well-being. In addition, it may help prevent
    a thromboembolic episode. Regularly scheduled turning, the use of an
    incentive spirometer, coughing, deep breathing, and leg exercises are
    integral to any early physical therapy program. It is essential to turn
    all patients and inspect any areas of potential pressure at least once
    every 4 hours.
  • Common preoperative orders for a general orthopaedic procedure
    • Diagnosis
    • Condition
    • Diet nothing by mouth before surgery, usually 12 hours before, or after midnight for a case the following day
    • Activity
    • Vital signs
    • Enema (optional for hip and back surgeries)
    • Laboratory data and other testing. Check with specialists and anesthesia
      • Hematocrit/hemoglobin, as appropriate
      • Urinalysis
      • Chest roentgenogram if patient is older than 50 years
      • ECG if patient is older than 50 years and no recent ECG results are available
      • ESR (and/or CRP) if there is history of infection
      • Roentgenogram of operative area, if indicated
      • Blood typed and
        cross matched if significant loss is anticipated. The use of an
        intraoperative suction, collection, and transfusion system such as the
        “cell saver” should be anticipated and used when blood loss is
        anticipated to be more than 500 to 600 mL. Similarly, the efficient use
        of a tourniquet can limit blood loss and should be planned
      • Culture, of wounds which will require treatment
    • P.126

    • Antibiotics if indicated
    • Analgesics if indicated
    • Hypnotic
    • Instruction in physical therapy that may be required postoperatively
  • Postoperative orders for a general orthopaedic procedure
    • Operation performed
    • Patient condition
    • Diet or IV orders
    • Activity or position
    • Vital signs record intake and output if indicated
    • Patient turned, coughing, incentive spirometry, and deep breathing encouraged q1–4h
    • Small urinary catheter inserted if no urine is produced within 8 hours postoperatively
    • Analgesic (as appropriate) prescribed on a time-related basis or patient-controlled system
    • Hypnotic
    • Multivitamin and supplements IV or PO
    • Postoperative hematocrit/hemoglobin (if indicated, preferably at least 8 hours postoperatively)
    • Postoperative roentgenogram if indicated
    • Physical therapy orders
    • Physician notified
      typical guidelines include: if blood pressure is less than 90/60, pulse
      is greater than 100, or temperature is greater than 38°C
    • When a diet is tolerated, appropriate diet, including considerations for diabetes (3)
    • Iron (therapeutic doses) if
      anemic or if anemia is anticipated and transfusion is not necessary.
      Review the contraindications of iron therapy and ask for preferences
    • Anticoagulation therapy if indicated (see above, remember to ask for particular preferences)
    • Postoperative antibiotics, including those for treatment or for general prophylaxis
    • Bowel program including softeners (Docusate sodium) and laxatives (milk of magnesia) as needed
    • Social service consultation if needed for disposition
V. Orthopaedic Tips for Students and Interns
Discuss with your residents and staff at the beginning of the rotation
  • Regarding the involvement of medical students on the orthopaedic team:
    • To what extent should the student be
      actively involved with patient care decisions, patient communications,
      and so on? At what level should the student show initiative?
    • Ensure a balance between exposure to the clinic, hospital rounds, and operating room.
    • Are there office staff who will have
      schedules, knowledge of the other services, and related educational
      opportunities? To whom should the student report or ask questions?
    • Would a presentation to the group be of
      interest? Such presentations, and the interest that they convey, are
      great ways to get a deeper insight into orthopaedic decisions, thought
      processes, and priorities. It makes the cases that present especially
      relevant. What is learned in this exercise will last with the student
      for his or her entire practice career.
    • Ensure exposure to the various areas of
      orthopaedics. Discuss how each of the subspecialists makes decisions
      about what to care for and what to refer.
  • Regarding patient care and ward decisions.
    Remember that orthopaedic patients, though they have many of the same
    general needs as medical surgical patients, have other important needs
    specific to orthopaedics. These include prophylactic antibiotics,
    prophylactic anticoagulation, imaging needs (which are specific and
    evolving as


    case progresses), and physical therapy (including weight-bearing status
    and protective activities). The student helps the care tremendously by
    considering these factors, questioning them, and reevaluating them in
    light of comorbidies, pending surgeries, and interactions with other
    services. Some of these issues include:

    • How are prophylactic antibiotics used? What are the typical first-line, second-line, and back-up drugs?
    • What will be used for prophylactic anticoagulation? Who will monitor any necessary lab values?
    • Ask about guidelines for preoperative
      workups and indications for ECGs, labs, chest x-ray. Who will obtain
      necessary informed consent?
    • What are the indications for urinary catheters? What are the indications for using them or discontinuing them?
    • How are narcotics to be used? What is the role of respiratory monitors and pulse oximeters?
  • Advice to the student on how to be useful and get the most out of your rotation
    • Be around the ward, clinic, and operating rooms. They are all important.
    • Start early. If possible, round and review before the team.
    • Know the plan. The plan is dynamic and
      will evolve. Know the contingencies which would change the plan. Help
      to anticipate these contingencies.
    • Communicate with all. Ask the nurses, the staff, the residents, and the consultants.
    • Provide for the needs of the patient. Know the necessary steps to get them ready for the next stage of their care.
      • For surgery,
        check on the completion of the preparations. Check and confirm NPO
        status, pending lab values, pending imaging, surgical consents, and
        consultant evaluations.
      • For the postoperative situation,
        ensure adequate pain medication and follow-up on postoperative images
        and lab values (e.g., hemoglobin, electrolytes). Question the need for
        urinary catheters and discontinue as early as possible.
      • For discharge and follow-up, help get them ready. When appropriate, involve the therapists, nurses, and social workers with the orthopaedic team.
    • Contribute energy. Be lighthearted but
      earnest about the priorities and stresses of patient care. Be willing
      to contribute on those small but unavoidable tasks (e.g., fetching
      x-rays, changing dressings, removing sutures).
    • Be careful about what information you give directly to the patient. Err on the side of caution. Never be the first one to give the patient bad news (unless specifically directed otherwise by the staff physician).
    • Read, study, and ask. Reading is best done immediately surrounding the teaching event, whatever it is.
  • Maturing as a student of orthopaedics
    “Becoming is superior to being.”—Socrates
    Orthopaedic deformity is alarming. The pain is deep and
    visceral, and for the uninitiated there is something untouchable about
    it. The patient’s pain is accompanied by a fear of new injury. This
    fear and the deep special quality of the distress touch the patient and
    the caregiver alike.
    However common and understandable, a student’s personal
    sensations may be of hindrance to the proper evaluation of these
    patients. In other specialities the medical evaluation is often not
    painful, but a fracture or sprain cannot be examined or treated without
    pain. The fear, which we see in our patients’ eyes, can push us away
    and may result in the lack of the necessary touch toward the
    consolation, proper examination, necessary positioning, or dressing of
    the limb.
    Intervening takes risk. It takes time to know the
    patterns of injury, the resources (e.g., imaging, referral expertise),
    and to know the patterns of response. Like any refined art, it is
    actually a mix of science and art, which requires a mix of subjective
    and objective proficiencies to physically execute. There is no place
    for a lack of courage, lack of humanitarian concern, or energy.


    The medical student who chooses to rotate through
    orthopaedics has a challenging mix of skills, relationships, and
    resources to develop. What the student takes with him or her will be
    deeply personal based on his or her own investment. Face time with
    staff is important. Reading is critical. Student involvement results in
    a buzz of staff interaction and worthy debate about pathophysiology,
    social expense, and techniques of surgery. As in the rest of medicine,
    everyone benefits, including (and especially) the students and patients.
    If you are interested, there is no substitute for
    actually being there. Unfortunately, these interactions may occur at
    odd hours of the night or very busy periods of the day. They occur in
    the operating room, the ward, and in the conference room. The student
    must invest that time.
    If the student is interested in procedures or the kind
    of in-depth experience that helps him or her in a career decision, he
    or she should say so. Just like other disciplines, the learner will
    need to put in more time, and a greater physical effort will pull
    available learning opportunities to them. This means standing in
    surgery, watching in clinic, running for x-rays, or making the
    necessary phone calls. Closed reductions (and the snap or crepitation
    that go with them) or the insertion of a screw may be routine for
    staff, but it could be life-changing for the right student. Every
    regular in a teaching institution is there because of prior teaching
    experience and wants to reward interest.
    The student should be proud of his or her contribution.
    Students may look or feel lowly but they contribute energy, enthusiasm,
    and concern to each situation in which they are involved. Orthopaedic
    situations require as much of each of those as it can get. Students are
    valuable for their present value and future value for all the patients
    that their staff and residents will never see. We, as teachers and
    physicians, know that. Socrates said “becoming is superior to being,”
    and it is as true now as it was then. The staff respects what the
    student is becoming.
    Having stated the philosophical truth about the value
    and interest of students, some principles are common to all areas of
    medicine and education; some are unique to orthopaedics:
    • Dealing with patients
      • Address their expectations. A patient’s
        satisfaction is, in large part, a function of his or her concept of the
        treatment and reasonable expectations.
      • Communicate, reassure, and assuage. When
        communicating with a patient, strike a balance between the
        self-justifying catharsis and arrogant selfishness with the facts and
        reality. You are there because of all the needs you can provide, not
        just the technical execution of what you know. Even if you are not the
        final authority to do what may be necessary, your contribution can
        become a light post to the patient from which he or she may venture
        from reluctantly.
      • Exert the necessary energy. There is
        physicality to being with orthopaedists. The internist may surmise the
        fluid status of the patient by the strain on the ECG, but the
        orthopaedist will never know the status of the wound without removing
        the dressing or the nature of the fracture pattern without digging up
        and looking at the x-rays ourselves. We will never learn without taking
        a stab at identifying, describing, and classifying the injury or
      • Recognize the helplessness of orthopaedic
        patients. The damaged limb is painful and requires help at several
        levels (pain medication, splinting, judicious surgery) to make it less
        so. Orthopaedic patients will not be able to walk out of a hospital in
        a fire. For the most part, they are truly helpless during the injury
        and perioperative periods. The student is there to develop a
        perspective on sensitivity and knowledgeable contribution. Maximizing
        the function and accelerating the recovery of such patients is a
        demanding process.
  • Principles specific to orthopaedics
    • Handle bone with the care it needs. It
      may look hard and impenetrable, but we know it is living tissue.
      Protect it from inflammation, infection, avascularity, and abnormal
      (either excessive, inadequate, or malaligned) stresses and motions.
    • P.129

    • Handle joints with the care they require.
      Restore alignment, anatomy, and soft tissue. Support structure, and
      consider cartilage stresses. Restoration of anatomy and physiology
      (stresses and motion) to the joint, its blood supply, its motor
      control, and its cognitive control are all vital to the function of the
      joint. Remember that the implications for bone injury, whether
      diaphyseal, metaphyseal, or periarticular, have specific implications
      for each of the joints of the limb.
    • Be precise in your understanding of pain.
      The high incidence of pain as a presenting complaint makes orthopaedics
      unique. There are many types of pain including classic orthopaedic
      pain, acute and chronic depression, muscle spasm, and neuralgia.
      Patients may have more than one, and treatments for one of these may
      not be good treatments or substitutes for another. The pattern of pain,
      the physical exam, and the imaging are the methods by which the lesions
      are mostly separated out. Attack it at every level: the painful lesion,
      the transmission, and the central pathways. Minimize its effect by
      addressing the dysfunction and the depression.
    • Remember the soft tissues. Anticipate
      what the soft tissues will do. Know the difference between disease and
      disuse. Understand weakness, adhesion, incoordination, and soft-tissue
      blocks to function.
    • Have a plan of attack and know what you
      are attacking. Know what is primary (often fracture deformity) and what
      is secondary (usually inflammation and pain). Know the difference
      between primary interventions (fracture repair for pain relief) and
      palliative ones (control of inflammation, control of pain).
    • Appreciate anatomy. Usually the return of
      function parallels the restoration of anatomy. It makes some sense,
      intuitively, that this would be true, but sometimes the anatomic
      relationships are not easily restored. Closed reductions require a
      level of abstract consideration because they are out of site, but such
      considerations are also common of open reductions, joint replacement
      surgery, and balancing operations.
    • Appreciate balance. Much of fracture
      orthopaedics occurs within the acute situation, but the
      responsibilities of the orthopaedic intervention are related to the
      acceleration of the restoration of normalcy. This cannot be considered
      complete without a consideration for the social situation as well.
      Balancing these considerations is at the essence of orthopaedics and is
      dependent on a number of individual factors including those particular
      to the patient (personal fear of surgery, age), the medical environment
      (facilities and surgical interest), and those of society (funding
      priorities, long-term care).
    • Restore the physiologic milieu. Set in
      place the timeline and processes for that physiologic milieu. With a
      fracture, reduction of the fracture may be the method. In rheumatoid
      arthritis, control of inflammation may be the method. Surgery may look
      like a technical exercise in the restoration of anatomy, but it is at
      least that and, more fundamentally, a manipulation of physiology. We
      see and easily relate to the visible deformity, but no technical
      situation will respond to an ignorant assault on that alone. Anatomy
      relies on biochemistry, and the successful surgeon thinks of, respects,
      and protects the physiology of the entire process.
    • Anticipate future problems. For the most
      part, those deformities that are known to be associated with late
      problems are understood by the orthopaedist.
    • Know pathophysiology and physiology of
      each of the processes, including the different forms of pain,
      inflammation, soft-tissue repair, scar, and regeneration. This includes
      the fracture healing and patient-human response of anxiety and
      depression. The treating doctor will be a better physician and the best
      practitioner if he or she anticipates and attacks pathophysiology at
      every opportunity. Every patient wants his or her surgeon to be a true
      physician in every sense of the word.
    • Look for and treat an underlying
      pathophysiology. Social impairment or lack of access to resources may
      be at the root of the patient’s inability to thrive, which may be the
      real reason for the bone disease that leads to the fracture.
    • P.130

    • Understand the unique demands of
      orthopaedic tissues, physiologic loading (valgus/varus, longitudinal,
      and rotational alignment), stress-strain relationships, cyclic loading,
      vascular support, and bony congruity. Know the difference between the
      biologic needs of orthopaedic tissues (respiration, vascular supply)
      and the mechanical ones (strain rates, cyclic loading and catastrophic
      failure, and incremental failure).
    • Recognize the interrelationship of the
      biologic/biophysical and the mechanical. The mechanical and biologic
      needs of orthopaedic tissues are linked, affecting both the onset of
      lesions (like stress fractures and tennis elbow) and also the healing
      rates (incorporation of bone graft, etc). It is fundamental and unique
      to orthopaedics to consider these interactions and protect the patient
      from adverse effects of whatever may affect this interaction, such as
      smoking or premature weight bearing.
    • Have a plan B. Have a way out. Save tissue. Create options.
    • Study what is visible on the x-ray. Know the normal alignments and landmarks.
    • Protect the patient who is distracted by pain elsewhere, is unconscious, or unable to express or describe the symptoms.
    • Minimize the secondary injury. Stiffness,
      weakness, and autonomic dysfunction all follow the orthopaedic injury
      and may be as related to treatment (unnecessary immobilization, poor
      patient support) as the original injury.
    • Learn and execute excellent dressing
      techniques. Covering a wound or an injured limb is not the same as
      caring for it or protecting it. The dressing usually has a series of
      responsibilities, including alignment, immobilization, and compression
      (to minimize venous stasis and swelling). Apply the dressing
      knowledgeably and thoughtfully, cognizant of how much patient comfort
      and care depends on your dressing. Your goal is to ease the patient’s
      transition to the next stage.
    • Recognize that children are different,
      their problems are different, and their needs are different. Things
      happen in kids that do not happen in adults, and the injuries and their
      responses are age and site dependent.
      • The anatomy is different. The
        supracondylar area of the elbow goes through a narrow remodeling phase
        between ages 4 and 8, hence all the fractures in this age group. There
        are other classic patterns (tri-plane fractures and Tillaux fractures
        of the ankle). There is no substitute for simply knowing the patterns
        which occur, watching for them, and treating their idiosyncrasies.
      • The physiology is different. The blood
        supply to certain areas (femoral head, epiphyseal fragments) passes
        through a period of vulnerability. Their ability to heal is different,
        but the implications of maltreatment, malalignment, or corollary damage
        (i.e., avascularity, growth plate injury) may be magnified over time.
        The dynamism of growth is directly related to motor use and function.
  • Principles of the mature care giver
    • Be a clinician. Suppress and delay the inclination to define the problem with an x-ray. Take a history, know the patient, and examine the patient.
    • Remember that you must confirm the significance of imaging changes and the absence of other changes not reflected by the images.
    • Act but recognize an economy of motion,
      resources, and time. As a student, you may just have to ask. Know where
      your opportunity is in the timeline of the pathophysiology. Timing in
      orthopaedics is everything.
    • Know what you are treating. Know the
      difference between the valid goals of palliation, temporizing, buying
      time, using time, allowing healing, mental relief, and cure.
    • Remember the simple things like ice, heat, rest, elevation, and reassurance.
    • Understand inflammation. Understand what
      it is and is not in orthopaedics. Know when it is primarily part of the
      pathology (rheumatoid arthritis, bursitis) and when it is part of the
      healing (fractures, sprains). Know how its treatment may assist the
      treatment of the orthopaedic problem (reduce pain, augment narcotics)
      and how that treatment may interfere with the desired outcome


      fracture healing). When inflammation is the component of the disease
      process that you want to manage, manage it, but remember that in other
      situations it is an initial component in the normal processes and
      pathophysiology including fractures, infection, neoplasia, soft tissue
      trauma, and pain.

    • Study the problem from all angles,
      perspectives and depths, mechanisms, and pathophysiologies. Look for
      referred pain. Look for missed injuries. Know the classic associations.
  • Work well with others
    • Be an effective part of a team. Know the
      roles of the professionals around you. As expectations have improved,
      the precise management of the patient in the hospital is scrutinized
      and overseen by many specialists. They will help us to anticipate the
      needs of the patients, communicate, and administer cost-efficient care.
      The same goes for nurses, physician assistants, pharmacists, and a host
      of experts who can teach and guide through the host of problems our
      patients will face. The same admonitions about humor, principles, and
      wisdom that govern our actions in conference are appropriate for our
      relationships with these other professionals.
    • Follow the trends of the rest of
      medicine. Right now, these are precision, biologic management, patient
      involvement, natural (common sense) nutrition, health, etc. The
      practice and the expectations are not created in a vacuum. Fit yourself
      within the context of society and its direction; cling to the
      principles that have formed your education and those things that you
      know to be true.
    • Do what is necessary to facilitate
      orderly transfer of care. This is by direct communication with those
      assuming the care. It is not by hospital note or by the assumption of
      the role of others. Most specifically, it is not by voice mail or
      email. Nothing substitutes for direct knowledge that the care and
      decision making is really transferred, questions are asked, and
      responsibility is accepted.
    • Do not expect to be the judge of your
      contribution. Know that, however trivial or ungratifying something such
      as a follow-up or phone call may seem to you, you may be the only
      person in the world with the knowledge, insight, or time to make it. It
      may be your major contribution toward relieving patient suffering that
      day, however, it may not seem that dramatic. As Emerson said, “The
      grandeur of character acts in the dark.” Much of what you do will be
      silent and unrecognized. That is the nature of the healing arts. No one
      will ever be able to appreciate the depth of your preparation or the
      depth of your considerations. Your rewards will often need to be
  • Presenting at rounds.
    It is one of the great exercises in the study of medicine to learn by
    presenting a case. The exercise puts the patient out there and gives
    the student presenters a focus to bring principles and practice
    together, which they will do innumerably during their careers. It gives
    the expert an opportunity to illustrate specifics and generalities. It
    gives everyone an opportunity to interact. There should be a hint of
    reverence to the ideas, a deference to the history and leadership, an
    excuse to ask questions, and a chance to become friends and better
    There is a natural strain in
    the room. There is pride, anticipation, and excitement. There is
    conscious and subconscious activity. The best rounds become a mix of
    energies, humanitarian concern, and academics, dripping with pearls of
    experience and humor. Obviously, if the student is interested in
    orthopaedics, it is important to present one’s self professionally. The
    staff wants to see grace and poise, real knowledge, humility, and
    compassion in someone that they like to work with. This presumes a
    certain competence, but it is much more than that. The personality of
    the student must fit the group, and there is a cadence, humanity,
    confidence, and character aspects to all of this. There is little room
    for showing off, name-dropping, esoteric article references, or
    deliberate sandbagging.
    • Be organized. Know the case. Know the
      radiographs. Be sure to have reviewed them before the case because you
      can be sure that as soon as they are presented, a roomful of very
      smart, conscientious, very experienced people will


      begin to critique them for orderliness, quality, relevance, subtle cues, and missed lesions.

    • Know the point of the case. You can be
      sure that if someone wants you to show the case, there is a point. If
      it is a controversial point or some unexpected outcome, the person
      should be willing to step in when things get interesting. That does not
      keep the student presenter from knowing or appreciating the interest of
      those who want to see it, but if the questions get too pointed, show
      your interest and stay deferential.
    • Keep control of the case. It makes a room
      of orthopaedists very anxious and unpleasant if the critical elements
      of the case are missing and are not available to help them toward a
      reasonable decision. Know the local feeling about certain classic
      controversies (if appropriate) including closed versus open methods,
      approaches, borderline circumstances, etc. Know what is necessary. Ask
      your fellow residents and mentors for the issues likely to come up.
    • Listen for the pearls to drop. The best
      conferences are a mix of academics and practical considerations playing
      off of one another. There will be insights about diagnosis, technique,
      decision making, and people. The subjective reward for presenting is an
      incremental professional growth in thinking, problem solving, and
      interpersonal skills. The objective benefit is that the student will
      learn something specific about the problem at hand.
    • Know the controversies. The average
      medical student (and some early residents) will not really know how to
      interpret all the data. The inability to anticipate questions makes for
      a very uncomfortable presentation, especially if someone in the room
      might be waiting for you to speculate your way onto the attending’s hot
      button. On the contrary, presenting the case in a context of what is
      known so that the attending (for example) can teach some hard-won
      lesson is appropriate and may be the exact reason for the presentation.
      If the information is to be meted out for the purposes of some teaching
      exercise, know this and do it appropriately.
    • Keep it positive. Do not “sandbag.”
      Purposely leading the conference astray may have a point in very
      specific circumstances, but it is a job for experts. Never upstage the
      staff, and make the points reachable with insight and experience.
      Misleading the staff with mismarked films, coincidental shadows, and
      technical obstructions can make things fun, but it cannot be done at
      anyone’s expense.
    • Watch for the pace of the conference.
      Some participants will want it to move along, and it will certainly be
      a different conference if it attempts to instruct residents and not
      staff. Know which it is.
    • Speak the language. There is a language
      of fractures. Valgus, varus, proximal, distal, fracture type and
      classification, and soft tissue injury class are within the point of
      the presentation exercise. If you use a name (“Colles,” “Barton’s,”
      “Bennetts”), expect to be asked the derivation of the name. If a
      fracture class (Schatzker) or injury class (Gustilo, Tscherne, etc.) is
      used, it is imperative that the student can describe why it is that
      class and what the definition of the other classifications are. This is
      basic: expect to be asked. Almost all
      classification systems have inadequacies or shortcomings; be prepared
      to discuss these. Be prepared to show additional studies that define,
      if the plain films cannot, why they represent the case. Remember that
      the best classification systems also include mechanism,
      pathophysiology, and treatment considerations.
    • Use humor if appropriate, or if someone else does, laugh along with everyone else.
    • Show courage. If you are in trouble, do
      not expect to be rescued too early. Orthopaedists love what they do and
      they love people who love what orthopaedists do. This means that they
      will enjoy watching a competent student struggle with forming a concept
      or discovering a truth, but it will never be sadistic. Do not bail or
      defer to the staff or teachers too early. Though it is the first time
      for you (perhaps), you are probably one of hundreds of students that


      members of the conference have seen in this circumstance, and they will
      want you to succeed, overcome, and grow. This will take some sweat on
      your part, but it is the way medicine and the fraternity/sorority of
      caregivers has been handled for centuries. Remember, if someone asks
      you to present, it is a compliment of sorts; live up to it.

    • Recognize “roundsmanship.” Know where the power is. Know which of the staff really
      knows. The senior staff may lead or save the last word for good
      reasons. The interaction of the junior staff may be fun to watch. The
      last comment, particularly if it is poignant or insightful, may be
      where the wisdom comes from. Be ready to discern technical input from
      true wisdom.
    • Never lie or
      fudge. If you are presenting a case that you have never seen, say so
      early. If there is missing data, say that too. This can be very
      embarrassing at times. Orthopaedists get fussy if their opportunity to
      lead to a logical conclusion is robbed from them. If there is no point
      to the presentation, or they cannot be brought logically to that point,
      they get fussy about that too.
    • Ask what was learned, what was decided,
      and whether the goals were achieved. Know if there is a relationship of
      the case you are presenting to the other cases that are being
      presented. It will come off better if there is an underlying theme,
      principle, or deeper insight. Learners at all levels appreciate the
      observation, the obscure lesson, and the surgical trick. However, they
      will really appreciate the principle,
      wisdom, or a depth of understanding. These higher level lessons leave a
      mark. The useful is what they come for; the profound is what they
      hunger for. Enable this, if you can, by priming the staff. Know it when
      you see it. Associate with those who can do it; learn their methods and
      insights. Probe the depths a little.
    • Be ready to apply what is learned. If
      nothing is learned, at least put a note in the chart that documents
      that it was presented. How much of the controversies go into the chart
      is decided by the staff and residents on the case.
  • Working with orthopaedists.
    On the ward and in the clinics, medical and professional principles
    apply to your behavior. Orthopaedists love what they do, especially the
    creative and inventive aspects of it. The orthopaedic story behind each
    injury makes the cases interesting. Know it.
  • Final Thoughts
    • Primum non nocere. For a student on orthopaedics, this means be there, be sensitive, ask questions, and follow through.
    • Know your limitations. This is closely related to primum non nocere.
      One of the great hazards in medicine is the practitioner who rises to a
      level of incompetence and does not pull back from it. Periods of growth
      (including being a medical student) carry risks of failure for both
      patient and doctor. The practitioner takes his or her patient from the
      realm of the unknown with him or her to the known. Seek and ye shall
      find. If asking for help is uncomfortable, use that as an opportunity
      for growth too.
    • Take good medical care of your patients.
      There is no substitute for seeing (actually seeing) your patients.
      Remember that they need touching and interaction.
    • Respect patients as humans. Communicate
      respectfully and honestly. If you do not know, “I don’t know, but I’ll
      check” is a useful thing to say. Apologize when late and give a
      reasonable explanation when it is appropriate. Make eye contact. Touch
      the patient lightly in a neutral-safe area; shake hands often; and give
      consolation, sympathy, empathy, and sensitivity to what they may be
      feeling emotionally and physically. These subjective elements are
      inestimable in our society, especially today and especially for the
      less fortunate.
    • Have reverence for the history and
      process that put you in this remarkable circumstance. The principles
      you apply were discovered at great cost over centuries. When the exam
      room door closes, it will be you, the patient, and those principles.
    • Be supportive of your colleagues. It may
      be your feeling that the patient has been poorly or inadequately served
      somehow, but it may only add to their suffering to give them misgivings
      or guilt about how they may have or should


      done things differently. Conversely, if you like or have confidence in,
      or appreciate certain consultants, assistants or referral primaries,
      say so. Patients like to be part of a team that works.

    • Do not let anything about your personal
      limitations or emotions detract from your accomplishments (or those of
      the profession or department). Remember that you are there to learn
      professionalism in addition to orthopaedics.
    • Remember, most fundamentally, you are there to relieve suffering of any kind.
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32. Reilly DE, McNeely MJ, Doerner D, et al. Self reported exercise tolerance and the risk of serious perioperative complications. Arch Intern Med 1999;159:2185–2192.
33. Bono JV, Carl AL, Schneider JM. Exsanguination: gravity vs. esmarch. Contemp Orthop 1995;30:117–119.
Selected Historical Readings
WH, Athanasoulis CA, Waltron AC, et al. Prophylaxis of deep-vein
thrombosis after total hip replacement, dextran and external pneumatic
compression compared with 1.2 or 1.3 grams of aspirin daily. J Bone Joint Surg (Am) 1985;67:57–62.
Henny CP, Odoom JA, Ten Cate H, et al. Effects of extradural bupivacaine on the haemostatic system. Br J Anaesth 1986;58:301–305.
Jensen JE, Jensen TG, Smith TK, et al. Nutrition in orthopaedic surgery. J Bone Joint Surg (Am) 1982;64:1263–1272.
Kay SP, Moreland JR, Schmitter E. Nutritional status and wound healing in lower extremity amputations. Clin Orthop 1987;217:253–256.
PJ, Wishart HY, Smith G. Long-term outcome after repair of fractured
neck of femur: comparison of subarachnoid and general anaesthesia. Br J Anaesth 1984;56: 581–585.
Means JH. The amenities of ward rounds and related matters. Boston, MA: Massachusetts General Hospital Print Shop, 1942.
Michelson JD, Lotke PA, Steinberg ME. Urinary bladder management after total joint replacement surgery. N Engl J Med 1988;319:321–326.
Schaeffer AJ. Catheter-associated bacteriuria. Urol Clin North Am 1986;13:735–747.
Thorburn J, Louden JR, Vallance R. Spinal and general anaesthesia in total hip replacement: frequency of deep vein thrombosis. Br J Anaesth 1980;52:1117–1121.
Weed LL. Medical records, medical education, and patient care, 2nd ed. Chicago, IL: Year Book, 1970.

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