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Guidelines
Hip & Pelvis

BOAST: The Management of Patients with Pelvis Fractures

Assessment

  • Pelvic binders should be applied pre-hospital

  • Patients should be managed at an MTC

    • If transferred to trauma unit - resuscitation, then transfer to MTC for definitive treatment

  • Assessment of associated injuries:

    • Urological injuries - should be suspected, diagnosed and managed as per BOAST – The management of Urological Trauma Associated with Pelvic Fractures (see below)

    • Open Injuries (Vaginal / Rectal) - inspect for open injuries including vaginal, rectal and perineal

 

Investigations

  • All patients with suspected pelvic fractures should have a trauma CT scan on admission

 

Management

  • IV Tranexamic acid should be given within 1 hour of injury

  • Haemodynamically unstable patients

    • Resuscitate with blood products as per major haemorrhage protocol

    • Non-responders and active bleeding - consideration of surgical packing / embolization

 

Operative intervention

  • External fixation should be considered when early definitive surgery cannot be performed

  • Vertical Shear Fractures - traction should be considered if early definitive surgery cannot be performed

  • Definitive fixation should occur within 72 hours once patient is physiologically stable

 

Post-operative Care

  • Local VTE protocols

  • Publish results to TARN

  • Specialists follow up with management of physical, psychological and urological disabilities

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Reference

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[1] BOA. BOAST – The Management of Patients with Pelvis Fractures. Available at https://www.boa.ac.uk/resources/boast-3-pdf.html

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BOAST: The Management of Urological Trauma Associated with Pelvis Fractures

Assessment

  • High energy trauma - Examination

    • Perineum

    • Urethral meatus

    • PR examination

  • Attempt Single catheter passage

    • 16 French soft silicone catheter

    • Blood-stained urine = perform retrograde cystogram via catheter

    • Unable to pass catheter = withdraw (DO NOT INFLATE) - perform retrograde urethrogram

 

Management

  • Urological injury - Contact Urology Registrar urgently

  • Suprapubic catheter

    • If unable to catheterise will need suprapubic catheter

    • Seldinger technique using USS

  • Urine leak from bladder / urethra - Treat as open fracture

 

Operative management

  • Intra-peritoneal rupture - laparotomy + repair

  • Extra-peritoneal rupture - may be treated by catheter drainage alone

  • Urethral injuries - usually delayed repair 3 months post injury

 

Post-op

  • High incidence of urinary + sexual dysfunction

  • Specialists follow up

  • TARN data upload 

 

Reference

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[1] BOA. BOAST – The Management of Urological Trauma Associated with Pelvic Fractures. Available at: https://www.boa.ac.uk/resources/boast-14-pdf.html 

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BOAST: The Care of the Older or Frail Orthopaedic Trauma Patient

Aims

  • To allow full weight bearing after surgery

  • Managed on frailty pathway including orthogeriatric assessment within 72 hrs

  • Ceilings of care should be discussed

    • (With patients + family)

  • Pain management strategy in place

  • Protocols for reversal of anti-coagulation agents

 

Management

  • Falls and bone health assessment should be performed

  • Nutritional assessment

  • Delirium Assessment during inpatient stay

  • Seen by Physiotherapy post-operative day one

 

Post-operative care

  • Discharge planning pathway - rehab + co-ordination with community services

  • TARN database upload

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Reference

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[1] BOA. BOAST – The Care of the Older or Frail Orthopaedic Trauma Patient. Available at: https://www.boa.ac.uk/resources/boast-frailty.html 

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NICE: Hip Fracture Management

Aims

  • Operative on patients with the aim to allow them to fully weight bear in the immediate post-operative period

  • Operate on patients within 48 hours (Note: BPT is <36hours)

  • Orthogeriatrics review within 72 hours

 

Investigations

  • Order MRI if NOF suspected but XR’s -ve

    • (CT if MRI not available)

 

Management

  • Displaced intracapsular fractures - perform replacement arthroplasty

  • Offer THR to patients:

    • Able to walk independently out of doors with no more than the use of a stick

    • Do not have a condition or comorbidity that makes the procedure unsuitable for them

    • Are expected to be able to carry out activities of daily living independently beyond 2 years.

  • DHS for intertrochanteric fractures

  • IM Nail for subtrochanteric

 

Operative (Arthroplasty)

  • Use a proven femoral stem

    • (Rather than Austin Moore or Thompsons stem)

  • Use cemented implants for arthroplasty

  • Consider an anterolateral approach in favour of posterior approach when inserting hemi-arthroplasty

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Reference

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[1] NICE. Hip Fractures: Management. Available at: https://www.nice.org.uk/guidance/cg124 

BOAST Management of Metastatic Bone Disease (MBD)

Pathways

  • Units must have clear policies for MDT management and referral pathways for MBD

  • Specialist centres should ensure quick access to opinions, advice, and transfers

 

Assessment

  • Prodromal pain, history of malignancy, or night pain should raise suspicion of MBD

  • Multidisciplinary decisions on adjuvant therapy must be recorded before surgery

  • Orthopaedic assessment should be prompt for suspected MBD

 

Investigations

  • Initial tests:

    • FBC, U+E, LFT, calcium & bone profile

    • PSA (men)

    • Myeloma screen.

  • Imaging:

    • Orthogonal radiographs

    • CT-TAP within 24 hours

 

Referral

  • Primary bone tumour features require referral to a bone sarcoma centre within 72 hours

  • Solitary bone metastasis requires referral to a tertiary centre

  • MBD without an obvious primary site should be discussed with acute oncology services

 

Management

  • Surgery should be consultant-led, aim for long-term durability, and allow immediate weight-bearing

  • Thromboprophylaxis is required, with contraindications documented.

  • Adjuvant therapy, rehabilitation, and palliation should involve the patient and family.

 

Follow-up

  • Ongoing pain requires continued orthopaedic surveillance for disease progression or reconstruction failure.

  • Failed surgical interventions must be discussed with a tertiary centre

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Reference

[1] BOA. BOAST - Management of Metastatic Bone Disease. Available at: https://www.boa.ac.uk/resource/boast-management-of-metastatic-bone-disease.html

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