What is the standard format for writing an orthopedic (ortho) sheet when a patient presents to the casualty department with an orthopedic issue?

Orthopedic Casualty Sheet Format

When documenting an orthopedic trauma patient in casualty, use a structured format that captures clinical status grading, mechanism of injury, anatomical assessment, and immediate management decisions to guide treatment pathways and predict perioperative risk. 1

Patient Demographics and Presentation

• Date and time of arrival 1
• Age, sex, and relevant comorbidities (cardiac failure, respiratory failure, coagulopathy) 1
• Mechanism of injury (fall height >6m, motor vehicle collision with ejection, penetrating trauma, crush injury) 1
• Pre-injury functional status (independent living, ability to perform activities of daily living) 1

Initial Assessment - Vittel Criteria Documentation

Document if ANY single criterion is met (defines severe trauma): 1

• Vital signs: Glasgow Coma Scale <13, oxygen saturation <90% on room air, systolic blood pressure <90 mmHg 1
• Mechanism: ejection from vehicle, death in same compartment, fall >6m, explosion/blast 1
• Prehospital resuscitation: mechanical ventilation required, fluid expansion >1000mL, catecholamine infusion 1
• Anatomical injuries: penetrating trauma, amputation proximal to wrist/ankle, flail chest, acute limb ischemia, pelvic fracture 1

Clinical Status Grading (Predicting Perioperative Risk)

Classify patient as stable, intermediate, or unstable based on: 1

Hemodynamic Status and Transfusion Requirements

• Stable: No vasopressors, no transfusion, lactate <2.5 mmol/L 1
• Intermediate: Norepinephrine 2-4 mg/h, 1-4 units packed red blood cells, lactate 2.5-4 mmol/L 1
• Unstable: Norepinephrine >4 mg/h, ≥5 units packed red blood cells, lactate >4 mmol/L 1

Hemostasis

• Prothrombin time ratio: <1.2 (stable), 1.2-1.5 (intermediate), >1.5 (unstable) 1
• Fibrinogen: >1.5 g/L (stable), 1-1.5 g/L (intermediate), <1 g/L (unstable) 1
• Platelets: >100,000/mm³ (stable), 50-100,000/mm³ (intermediate), <50,000/mm³ (unstable) 1

Temperature and Respiratory Function

• Core temperature: >35°C (mild), 32-35°C (moderate), <32°C (severe hypothermia) 1
• PaO₂/FiO₂ ratio: >300 (stable), 150-300 (moderate ARDS), <150 (severe ARDS) 1

Muscle Involvement

• Myoglobin levels: <10,000 IU/L (no rhabdomyolysis), 10,000-20,000 IU/L (severe), >20,000 IU/L (massive) 1

Associated Injuries

• Injury Severity Score (ISS): <25 (mild), >25 or AIS=4 (intermediate), >40 or AIS≥5 (high-risk) 1
• Traumatic brain injury: GCS 13-15 (mild), 9-12 (moderate), <9 (severe) 1
• Thoracic/abdominal injuries: Document organ injury scale grades 1

Anatomical Documentation of Limb Injury

• Location: Specify exact anatomical site (femur, tibia, humerus, pelvis, etc.) 1
• Type: Open vs closed, fracture pattern, dislocation, neurovascular compromise 1
• AIS classification: Document if ≥2 for severe limb trauma 1
• Neurovascular status: Pulses (present/absent/diminished), capillary refill, sensation, motor function 1
• Soft tissue injury: Degree of contamination, muscle viability, skin loss 1
• Limb ischemia: Transitory/subclinical vs critical 1

Pain Assessment

• Pain score (0-10 scale) at rest and with movement 1
• Location and character of pain 1
• Current analgesic use (prescribed and over-the-counter) 1

Immediate Management Documented

• Prehospital interventions: Splinting devices applied (femoral traction splint, pelvic circumferential compression device), hemorrhage control measures 1
• Weight-bearing status: Non-weight bearing, partial weight bearing, weight bearing as tolerated 2
• Tetanus status and antibiotic administration (for open fractures) 1
• Analgesia administered: Specific medications, doses, routes, and timing 1

Therapeutic Proposal Based on Risk Stratification

Document planned pathway: 1

• Low-risk patient: Early safe definitive orthopedic surgery 1
• Intermediate-risk patient: Initial resuscitation, temporary stabilization, prompt individualized safe management (PRISM) 1
• High-risk patient: Damage-control orthopedics (mid-term stabilization) followed by safe delayed definitive surgery 1

Imaging and Investigations Ordered

• Plain radiographs: Two views of affected area 1
• CT imaging: If indicated for complex fractures, vascular injury assessment 1
• Laboratory studies: Complete blood count, coagulation profile, lactate, myoglobin (if crush injury suspected), renal function 1

Disposition and Follow-up Plan

• Admission location: Operating theater, intensive care, orthopedic ward 1
• Surgical timing: Emergent (<2 hours), urgent (<24 hours), delayed 1
• Consultant notification: Document time operating team notified 2
• Outpatient follow-up: Specify timing and which team member (operating surgeon vs other) 2