On-calls, nights and weekends can be swapped between individuals given that all other commitments remain covered by the swap. These must be approved by the Rota Coordinator, Debbie Loker. Debbie will ensure the swap is fair and, if so, amend the rota.

There should be 4/5 doctors available to cover the ward and on call, so annual leave should only be taken when there is a minimum of 5 doctors. Study leave should be negotiated depending on cover. Annual leave is not fixed; you need to arrange it amongst yourselves. It should be booked 6 weeks in advance. Any ward commitments must also be covered and a signature of the person agreeing to cover them should also be sought.

If you are unable to work due to sickness or require carers leave, please contact the Rota Co-ordinator on OrthopaedicRotaEnquiries@wsh.nhs.uk. Please also inform the Registrar on call and your colleagues via WhatsApp (T&O Group Chat) so that we can arrange cover as quickly as possible if needed.

• Is the pt MOFD? If not, what is the reason to reside?
• What do we need to do to make them MOFD?
• Is the patient PT and OT optimised?
• Have all referrals been sent e.g. clinical or CAB?
• Are the TTO's completed?

Do a ward round for every patient every weekday. Document in the notes using ward round note (change the note type to Trauma & Orthopaedics and please complete the subject e.g. trauma WR). For ortho-geri WR please change the type to Ortho-Geriatric ward round and the subject to have either Dr Suresh wr/ortho-geri SPR WR. Please document the reason to reside or if the patient is MOFD in every ward round note.

Major post-op patients need check bloods (FBC and U&Es) on the first post-operative day and a check.

X-ray if appropriate (for fracture fixation image intensifier is used during the procedure and images are saved). If in doubt check the post op instruction in the operative notes. Please document which consultant or SPR has reviewed the post op x-ray.

Make sure wounds are healing well, there is no catheter in situ unnecessarily, pain relief and laxatives are written.

On a Monday, Wednesday and Friday, Dr Suresh is available to do an Orthogeriatric ward round for the femur fracture patients, and patients over 75 with a fracture in the morning around 10:00. Dr Suresh also has an SPR who will review the orthogeriatric patients Monday – Friday after the red to green meeting unless they are the med reg on call. Please know your patients to help the ward rounds run smoothly. Update the clinical summary after ward rounds to help other members of the team know what is happening with your patients.

If patients are well post-op, then write they are medically fit in the notes so social arrangements can be made if indicated.

If patients are likely to go home, then do their discharge summary and discharge medications early in the day to speed up their discharge and free up vital beds. Pharmacy closes at 17:00.

Please complete the green audit form in the patients' notes on discharge.

You may not be able to complete a ward round on every patient over the weekend, therefore an out of hours T&O list and sick patient list (orthopaedics) have been made available; on a Friday you will add patients to these lists for review.

• The F4 patients on the out of hours T&O list will need a face-to-face WR day 1 post op.
• The sick list patients will have a consultant review; they are the clinically unwell, unstable patients that need senior reviews.
• The T&O out of hours list is for patients who need jobs completing over the weekend like post op bloods and x-rays.

Please complete ward rounds on the patients if time allows.

• A&E (including A&E)
• Other specialities from the hospital
• Local walk-in centres
• GPs
• Patients from fracture clinic (it is not a referral)

When presenting, give:

• A brief history of the event
• PMHx
• Functional status (mobility, walking aids, careers, mental state score if appropriate)
• Social history
• Examination findings
• What the radiographs show
• What your working diagnosis is
• What you have done
• What your plan for that patient is

You must be familiar with the PACS system and be able to present x-rays, CT scans, MRI scans (recognise T1, T2 images).

Face to Face every Tuesday lunchtime in the trauma discussion room from 12:30. Please help to present at this teaching; you will be allocated SpR support so work closely with them to help deliver this training.

Discuss audits with your supervising consultants and they will be able to give you ideas of what to do. All the resident doctors should be involved in an audit during the rotation; it is suggested the wards are staffed with weekend cover for you to attend.

There is a clinical governance meeting every month. You are expected to attend this, which is currently online. During this meeting there are useful presentations and a resident doctor forum which can help highlight any issues you are having.

Benefits: Fracture stabilisation, reduce pain, improve mobility, symptomatic relief.

Risks (almost everyone): Bleeding, infection, DVT/PE, blood vessel/nerve damage, ongoing pain, swelling, stiffness.

Risks (fractures): Malunion, non-union and failure of fixation.

Risks (hip replacements): Leg length discrepancy, aseptic loosening, dislocation.

Head-injured adults who need neuro-observations are admitted under the on-call orthopaedic team.

Have a low index of suspicion and a low threshold for CT.

NICE (Overview | Head injury: assessment and early management | Guidance | NICE) have very clear CT Head indications. All scans must be discussed with the duty radiologist on-call. If you feel that someone who does not fit into the guideline needs a CT scan, request a scan. Our department believes that if someone needs observation on the wards, then they need a CT head as well.

If signs of bleed, discuss with Addenbrookes Neurosurgical Registrar on-call via switchboard, and complete the ORION referral form online/ORION.

Low index of suspicion. If clinically C-spine is not cleared:

• Immobilise C spine (collar and blocks)
• Plain radiographs to investigate (AP/Lateral/Peg view), if inadequate (C1–T1 not visualised, unclear images, OA) then arrange urgent CT C-Spine scan.
• If fracture detected, discussion with Ipswich spinal surgeons on call and online referral via referapatient.org.

• Ask the patient if he/she was able to walk following injury.
• Think about malignancy, do Myeloma screen if not adequate trauma.
• Full neuro examination.
• CT scan / MRI scan.
• Most of these fractures are discussed with Ipswich spinal team for advice.

Record timings of onset and duration of symptoms. Use ##CES in eCare when clerking as it is the Ipswich proforma for documenting Cauda equine syndrome.

If daytime urgent MRI, discuss with on-call radiologist, review scans and check written report to make sure they match. If cauda equina, discuss with Ipswich spinal surgeon on-call. Make sure the images have been sent through the Image Exchange Portal prior to call.

If out of hours discuss with Ipswich or Addenbrookes if clinical examination is suspicious, as patient may warrant urgent transfer for overnight MRI (it does not happen frequently, most of the times an MRI scan is enough the next day).

These should be admitted under the medical team according to WSH protocol.

If develops in a patient on the ward and it does not require urgent surgery, call the acute oncology team so they can consider radiotherapy.

If the skin is not at risk, discharge in sling, arrange a virtual fracture clinic follow up and discuss at the trauma meeting.

If closed injury, discharge in sling, arrange a virtual fracture clinic follow up and discuss at trauma meeting.

By nature, a high energy injury! Therefore, look for other serious injuries, e.g. chest, spine etc.

Always rule out posterior dislocation (light bulb sign). Axillary view of the shoulder is the most reliable way.

Rule out fracture dislocation. Check axillary nerve function (regimental patch).

Treated in a collar and cuff to allow the weight of the arm to provide traction to the fracture, NOT a poly sling.

Assess radial nerve function (1st web space sensation, wrist drop).

Functional brace / collar and cuff / hanging cast.

Check neurovascular status.

Adults: Back slab

Children: If displaced, might need urgent surgery. Check pulse, and median/radial/ulnar nerve function, as you always do!! Discuss with registrar.

Try to take sample if there is collection of fluid and start ABX.

(If clinically clearly not septic arthritis.)

Above elbow back slab, vascular and nerve function, consider compartment syndrome if not settling with analgesia. Some children may have their fractures reduced in A&E (paediatric forearm fracture protocol) by the on call orthopaedic SpR.

Reduce fracture (should be done by A&E); if in acceptable position, book a virtual fracture clinic appointment, or if needs surgery obtain contact phone number for ORIF.

If flexor tendon-, nerve-, blood vessel injury then should be referred to the plastic surgeons at Addenbrookes. If isolated vascular injury, contact on-call vascular surgeons (based at Addenbrookes). Extensor tendon and nailbed injury can be treated locally.

5th MC fractures — ulnar gutter splint, # clinic.

• Discuss with SpR
• Cardinal signs
• Admit, take sample for culture if appropriate, start iv ABX according to guideline

• If unstable pelvic fracture, trauma call should be initiated and patient to be transferred to Addenbrookes. Pelvic compression should be applied.
• Isolated pubic rami fracture under medical team if needs admission.
• Acetabular or stable pelvic fractures can be discussed with Addenbrookes in working hours if necessary.
• There is an on-line pelvis referral form that the SpR fills out.

• Establish cause of fall (consider MI, stroke)
• Involve medics acutely if not mechanical cause
• Key things in the history include AMTS, mobility and social status (carers/ uses stairs etc)
• If past history of cancer, order full length views of femur before they leave A+E
• A+E should have undertaken all appropriate pre-operative investigations (ECG/CXR/Bloods/G+S/Clotting+/-INR)
• IV fluids, DVT prophylaxis
• Analgesia, regular medication to prescribe
• Mark & Consent
• AMTS MUST be documented in the notes.

Confirmed Femur fractures can be “fast-tracked” to the ward by A+E.

• A+E should have undertaken all appropriate pre-operative investigations (ECG/CXR/Bloods/G+S/Clotting+/-INR).
• Trauma nurse specialist will be informed during daytime hours.
• A bed will be allocated.
• You can then clerk them on the ward if the Trauma nurse has not clerked them for you.

Dr Suresh is the main ortho-geriatric consultant. He does a ward round 3 times a week, on a Monday, Wednesday and Friday. Primarily he will see the trauma patients over 75, and all femur fractures. However, he may be able to advise on other patients.

Dr Suresh will want to know the following for each patient on his ward round:

• Reason for admission
• ? cause for the fall
• PMH, medications

He will review chest x-rays and ECGs on his 1st review, so make sure they are ready. He will want to know how much the patient is eating and drinking and when they last had their bowels opened (please make sure laxatives are prescribed and taken by the patient or he will want enemas giving). He will review bloods and medications.

All Femur fractures should be operated on within 36hrs of admission, so it is essential to prepare them for theatre ASAP.

If any concerns with the femur fracture patients or any elderly trauma patients, please discuss with the medical SpR or Dr Suresh (Dr Suresh is happy to be contacted most times of the day. His number is on the whiteboard in the F3/4 resident doctor's office).

We have purchased our own 24-hour tape machine. If one of our orthopaedic patients needs one please include in you reason for investigation; TRAUMA HOLTER then your reason. Cardiology will then apply our recorder and not put our patient on the 24-hour tape inpatient wait list. This allows us to get this investigation quicker reducing length of stay.

Ideally reduced by A&E. If several dislocations and the patient comfortable, can be discharged, but needs follow up. If first dislocation, admit.

If not relocated by A&E, inform SPR.

The questions you must ask the patient:

• Who has done the procedure?
• When and where was it done?
• Previous dislocations?
• If yes, what was the plan?

Admit, skin traction + yellow booklet if elderly patient.

Always think about NOF if elderly!

Tibia, femur, hip if child.

• Look for effusion
• Straight leg raise (quadriceps rupture)

• Obvious fracture dislocation should be relocated prior to x-ray (A&E SpR will be able to do this, usually it should be done before you get called).
• Check x-ray following casting!! Check the check x-ray!! If not satisfactory, re-manipulate or seek for senior review.
• Tinzaparin for duration of cast.
• Elevation, ICE on the ward!!

• If crush injury, admit for observation and check NV status regularly.
• Calcaneal fracture usually does not need plaster, just high elevation and ice. Needs to be admitted.

You are going to have several calls enquiring septic arthritis, mainly from medical wards.

• Before you see the patient ask for blood test and x-ray of the involved joints.
• Examination of the joint including documented range of movement.
• Bloods — FBC, CRP, ESR, URATE (consider differential diagnosis), blood cultures
• Joint aspiration (not through bursitis), in theatre if TKR/implant inside.
• Send aspirate to lab immediately for urgent ‘gram stain and crystals’, discuss with on-call microbiology technician. Out of hours please follow the overnight microbiology service guidance in the orange folder.
• Results should be conveyed to you within one hour.

Medics, aspirate if any suspicion of septic arthritis and send for gram stain, MC&S and crystals.

DVT is a medical diagnosis. We are involved if the patient has been treated for limb injuries or had recent elective orthopaedic operation.

• Follow trust protocol.
• Treat as DVT until proven otherwise with therapeutic dose of Tinzaparin.
• Pt can be discharged.
• Urgent DVT clinic appointment.

• Septic arthritis.
• Osteomyelitis (excluding that related to diabetic foot ulcer and sacral pressure sore ulceration).
• Upper limb cellulitis (including hand).
• Most operable fractures (excluding upper limb fractures and fragility ankle/foot fractures that are to be managed non-operatively — these must have a documented orthopaedic plan in the notes before coming to AAU, including follow-up arrangements).
• Pelvic fractures (excluding pubic rami fractures) — ED/T&O to discuss with NCS at MTC. Admit under T&O.
• Head injuries with traumatic intracranial bleeds — ED to refer via Orion or discuss with neurosurgeons at Addenbrooke's (see appendix 1). Admit under T&O.
• Head injuries (excluding over-80-year-olds with acute medical conditions leading to a fall) (see appendix 1).
• Acute traumatic back injury — if surgery is needed, T&O to discuss with Ipswich. Admit under T&O.
• Cauda equina syndrome — T&O to discuss with Ipswich. Admit under T&O.
• Acute back pain is otherwise admitted under medicine (discitis, metastatic cord compression, sciatica, low-energy fragility fractures).
• RTA / trauma cases (excluding thorax/abdominal injuries — admit under general surgery).
• Suspected / confirmed necrotising fasciitis (extremities only; excluding groin/axilla/perianal which are admitted under general surgery).

• Trauma cases with thorax / abdominal injuries.
• Cellulitis with abscess of groin (femoral triangle), axilla, torso, back or perianal.

• Fournier's gangrene (necrotising fasciitis of the perineum/genitalia).

ED / General Surgery to discuss with the Vascular team at CUH. Admit under the on-call General Surgical team to F5/6 if not for intervention and a vascular plan is achievable at WSH.

• Cold white limb.
• Gangrenous limb.
• Ruptured aneurysm not for intervention.

• Cellulitis of the mouth / lip.
• Facial trauma.