Preoperative Evaluation and Questions: Which extremities are involved? Open? Closed? Where is the IV access? If one or both upper extremities are involved IV access could be an issue. Starting Hct? NPO status? Compartment syndrome? Myoglobinuria/HyperKalemia? Open fractures are “urgent” and should be taken to the OR within 1-4hrs of arrival for wash-out/reduction/fixation of Fx. Closed Fx can be done with similar priority as other add-on cases. How sick is the Pt? Many are elderly with multiple co-morbidities. Could this repair be done under Neuraxial or Regional Anesthesia block?

Risk: Humerus Fx: Distal UE Fx: Femur Fx: 12 mo Mortality up to 30% if > 65yo. Morbidity: Fat/Thromboembolism up to 40%. Tibial Plateau Fx: Distal LE Fx: [Jaffe RA: Anesthesiologist’s Manual of Surgical Procedures, 4th ed. LWW: Baltimore, 2009]

Induction/Airway: RSI if trauma. If non-trauma and aspiration risk is low, LMA is reasonable choice.

Lines and Monitors: Standard ASA, If Multiple Trauma may need more monitors.

Mode of anesthesia: General Anesthesia.

Positioning: Supine

Surgical Course: Positioning may vary depending on exact location of injury. Initial x-rays to reduce Fx. Placement of hardware. Closure. Splinting.

Intraoperative Goals and Events: If Trauma, avoid sedating pre-meds. If using Jackson table may be easier to induce on stretcher, intubate, then transfer. RSI w/ cricoid pressure. Surgeons may request NMB to facilitate reduction of Fx. Intra-op x-rays will be necessary, have lead/protection available. Wide fluctuations in stimulation requiring titration of narcotics or deepening anesthesia. Surgeons will likely place splint or cast at end of procedure while patient still under GA.

EBL: 100-500ml

Duration: 3-5hrs

Emergence: Standard.

Pain: 7-9/10

Post-Operative Concerns, Transport, Disposition: Usually PACU. ICU if Multiple trauma. Pain control may be difficult post-op. Poor oxygenation may be sign of Fat Embolism.

Evidence-Based Medicine: Safety of GA vs. Neuraxial Anesthesia