This audit, conducted between September 2023 and April 2025, evaluates the patterns, frequency, and management outcomes of orthopedic emergencies seen at Kanuni Sultan Suleyman Training and Research Hospital, a major tertiary trauma referral center in Istanbul. The objective is to assess performance in key domains of emergency orthopedic care and identify areas for improvement in clinical response, training, and resource allocation
Emergency Type |
No. of Cases |
Avg. Time to Intervention |
Complication Rate |
Notes |
Open Fractures (Gustilo I - III) |
108 |
6.5 hours |
12% (SSI, debridement) |
Prompt debridement was key |
Fracture-Dislocations with NV Risk |
47 |
2.8 hours |
6% (delayed recovery) |
Mostly elbow/knee; some missed pulses |
Acute Compartment Syndrome |
19 |
3.2 hours |
21% (foot drop, fibrosis) |
Early signs sometimes missed by juniors |
Septic Arthritis/Osteomyelitis |
32 |
5.5 hours (aspiration) |
9% (reoperation) |
Mostly hip and knee; some delayed IV antibiotics |
Pediatric Ortho Emergencies |
100 |
4.1 hours |
2% (mild deformity) |
Supracondylar fractures were most common |
Polytrauma with Ortho Involvement |
55 |
3 hours (to OR) |
15% (infection, mortality) |
Team communication was critical |
1) Standardize early neurovascular documentation
2) Implement compartment syndrome simulation training and structured teaching modules to improve resident recognition of subtle vascular injuries, particularly in high-risk cases such as pediatric supracondylar fractures
3) Improve access to urgent imaging
4) Establish fast-track infection protocol
5) Strengthen liaison with EMS and regional hospitals
6) Mandate and standardize frequent (e.g., hourly for the first 6 hours) serial neurovascular examinations in suspected compartment syndrome, with structured documentation using the standardized audit tool
This audit underscores both the breadth and complexity of orthopedic emergencies managed at Kanuni Sultan Suleyman Training and Research Hospital. While trauma care is generally prompt and well-coordinated, delays in infection management and diagnostic ambiguity in early vascular/compartment syndromes remain key areas for improvement. Delays in infection management were evident, with an average of 5.5 hours to joint aspiration in septic arthritis/osteomyelitis cases, exceeding the institutional goal of intervention within 2 - 3 hours. These delays, along with instances of postponed intravenous antibiotic initiation, contributed to a 9% reoperation rate. Addressing such gaps through a fast-track infection protocol and closer coordination with microbiology and emergency services is essential. Through targeted education and process optimization, orthopedic teams can continue improving outcomes in this high-stakes domain
This standardized form is intended for initial and serial assessment of neurovascular status in patients with extremity trauma, especially fractures and dislocations. Accurate documentation aids early diagnosis of vascular compromise and compartment syndrome, and ensures medico-legal safety.
Patient Information
Name: _________________________Hospital ID/MRN: ______________
Date & Time: ___________________Examiner (Name & Title): _________________________
Injury Side: ☐ Left ☐ Right Limb: ☐ Upper Extremity ☐ Lower Extremity
1) Vascular Examination
Vessel/Pulse |
Present |
Absent |
Doppler Sound |
Comments |
Radial (if upper limb) |
☐ |
☐ |
☐ Yes ☐ No |
____________________ |
Ulnar (if upper limb) |
☐ |
☐ |
☐ Yes ☐ No |
____________________ |
Dorsalis Pedis (lower limb) |
☐ |
☐ |
☐ Yes ☐ No |
____________________ |
Posterior Tibial |
☐ |
☐ |
☐ Yes ☐ No |
____________________ |
Capillary Refill Time |
☐ |
☐ |
☐ Yes ☐ No |
____________________ |
2) Motor Examination
Movement |
Nerve |
Intact |
Weak |
Absent |
Wrist/Finger Extension |
Radial |
☐ |
☐ |
☐ |
Thumb Opposition |
Median |
☐ |
☐ |
☐ |
Finger Abduction |
Ulnar |
☐ |
☐ |
☐ |
Ankle Dorsiflexion |
Peroneal |
☐ |
☐ |
☐ |
Toe Flexion / Plantar Flexion |
Tibial |
☐ |
☐ |
☐ |
3) Sensory Examination
Technique: Assess light touch and pinprick sensation in corresponding dermatomes of injured limb.
Findings:
- _________________________________
- _________________________________
4) Compartment Assessment (If Fracture or Crush Injury Present)
Pain out of proportion: ☐ Yes ☐ No
Pain on passive stretch: ☐ Yes ☐ No
Tense swelling: ☐ Yes ☐ No
Paresthesia: ☐ Yes ☐ No
Motor weakness: ☐ Yes ☐ No
Repeat exam in: ________ minutes
Signature: ____________________
Designation: __________________
Time Completed: _______________
This sample entry reflects appropriate documentation of compartment syndrome by a resident in a trauma setting. It demonstrates serial neurovascular assessment, decision-making rationale, and timely intervention.
Date/Time: 2024-10-05, 14:20
Patient: Male, 26 years old, motor vehicle collision – closed tibial shaft fracture
Initial Exam:
Serial Monitoring:
Decision:
Clinical diagnosis of acute compartment syndrome confirmed based on pain, paresthesia, and tense compartments.
Action Taken:
Fasciotomy performed at 16:00 by orthopedic senior resident and attending surgeon.
Outcome:
Anterior and lateral compartments decompressed. Muscle bulks preserved. No evidence of muscle necrosis. Foot drop ruled out at 48-hour follow-up.
Resident: Ahmed Dervis (PGY-2)
Consultant: Dr.
Step 1: Initial Assessment
Assess airway, breathing, circulation (ABCs)
Check level of consciousness
Obtain history of injury (mechanism, time, symptoms)
Step 2: Evaluate for Emergency Signs
Open fracture? (Bone protruding through skin)
Neurovascular compromise? (Absent pulse, numbness, paralysis)
Severe deformity or angulation?
Compartment syndrome signs? (Pain out of proportion, tense swelling)
Associated head, chest, or abdominal injury?
If YES to any emergency signs → Immediate orthopedic and trauma team consult → Urgent management
If NO → Proceed to Step 3
Step 3: Clinical Examination of Limb
Inspect for swelling, bruising, deformity
Palpate for tenderness, crepitus
Assess active/passive range of motion
Check distal pulses and sensation
Step 4: Imaging
Obtain appropriate X-rays (include joint above and below injury site)
If suspected complex injury or growth plate involvement, consider advanced imaging (CT/MRI)
Step 5: Fracture Classification & Stability Assessment
Stable fracture (e.g., buckle/torus fractures)
Unstable fracture (displaced, comminuted, involving growth plate)
Step 6: Management Decision
Stable fractures → Immobilization with cast or splint → Discharge with follow-up
Unstable fractures → Orthopedic consult for possible reduction, fixation, or admission
Step 7: Pain Control & Instructions
Administer analgesics as needed
Educate caregivers on limb elevation, signs of complications
Arrange timely orthopedic outpatient follow-up