In this Q&A article, editors of Rockwood and Green's Fractures in Adults, 10th Edition and Rockwood and Wilkins' Fractures in Children, 10th Edition, talk about the current advances, challenges, and changes in the field of fracture management.
In the ever-evolving field of orthopaedics, few areas are as dynamic and impactful as fracture treatment. This article brings together some of the most respected voices in the industry, each bringing decades of experience and a wealth of knowledge. Dr. Tornetta, Dr. Ollivere, Dr. Waters, and Dr. Skaggs are leaders in orthopaedic innovation, known for their work and dedication to enhancing fracture patient care. Their experience with trauma in different populations offers valuable insights into the latest advancements in fracture management, providing actionable advice and cutting-edge strategies.
1. What are the recent advances in fracture treatment for adults and children that you are the most excited about?
Dr. Tornetta: We are steadily improving our techniques, becoming iteratively better in our implant design, surgical techniques, and use of technology. Despite this, the advances I am most excited about are cognitive. As we develop larger data sets and research cooperatives, we will finally be in a position to improve our collective decision making. This is where we can make the greatest improvements for our patients in complex and even simple injury treatment. Specifically, evidence-based indications for surgery, the types of surgeries that will yield the highest benefit/risk ratio, and how to best rehabilitate our patients after injury are all areas we will make progress.
I am also excited about the ability to use patient-derived outcomes to better understand interval interventions when things do not go as planned.
Dr. Ollivere: There have been so many changes in the treatment of patients, not necessarily in the hardware used but in the understanding of how best to use what we have to greatest effect in our treatment populations. For me, the emphasis is on the older frail population, understanding how best to utilize plates to the greatest effect in frail bone either as plate-nail combination or just understanding how to optimize outcomes (such as the superb description of managing osteopenic shoulder fractures).
2. What are the major limitations of adopting the new advances in fractures globally?
Dr. Waters: Issues that are limiting for children are: (1) access to timely care; and (2) availability of diagnostic technology and advanced equipment for highly specialized care. The surgeons and healthcare professionals are skilled, smart, caring and can learn if provided the educational support and equipment availability.
3. What are the biggest challenges for orthopaedic specialists dealing with fractures?
Dr. Tornetta: There are challenges at every level of fracture care. This begins with an accurate diagnosis and the knowledge needed to not miss associated problems. Most errors in medicine are cognitive rather than technical and a full understanding of current best practices helps to avoid complications. However, even with a strong knowledge base, the care of the injured patient requires difficult decisions and keen judgement. When is the skin capable of healing after an incision? What can be done percutaneously? What can be done to avoid infection? When can rehabilitation be aggressive and when must the patient have restrictions? How can we best manage pain safely? All these issues are challenging and patient-specific. A full understanding of all possible treatments is needed for us, as Physician-Surgeons, to treat patients in the way that best suits their individual needs and goals. For instance, elderly patients often require the use of all four extremities for ambulation while a younger athlete may require immediate return to exercise and a middle-aged adult may have neither of these requirements. Treatment is based on the patient and the challenge we face is how to meet their individual needs.
Dr. Waters: Ensuring an accurate diagnosis is crucial for effective treatment of pediatric fractures of the elbow where vagaries in the secondary centers of ossification and unappreciated fractures through the unossified distal humerus and proximal forearm can lead to misdiagnosis and complications. Maintaining a high index of suspicion and using advanced imaging with ultrasound, CT scans, and MRI scans can facilitate correct identification of the type and extent of the fracture.
Dr. Ollivere: Improving outcomes for patients with fractures has become so much more than the operative decision making. Bringing a single system to bear to provide optimal outcomes for everything from frailty hip and ankle fractures, through the highest energy open fractures and managing the patient's pain and rehabilitation, are the most complex of tasks. In the modern healthcare environment, it is incumbent on the attending/consultant surgeon to not only perform great surgery and be an advocate for their patients but to ensure the complex systems continually evolve to provide great care for every patient.
4. What is the future of fracture management?
Dr. Ollivere: We are still awaiting the magic bullet of injectable biologics that will heal the fracture. The future certainly isn’t more metalwork. I think the future is more personalization with implants able to offer surgeons more control surrounding stability independent of the fixation they offer.
5. How does residency now differ from when you were specializing?
Dr. Ollivere: It would be easiest to ask how it is similar. With the advent of freely available non-curated information, we have both information overload, real attention, and retention problems (I understand around 30 seconds is the average time an individual spends on a website or TikTok etc) coupled with restrictions on working time and massively reduced clinical and operative exposure. It is harder to be an excellent surgeon than it ever was despite the apparent improvements in information accessibility.
6. What would be your piece of advice to medical students and residents wanting to specialize in orthopaedics, particularly in trauma and fractures?
Dr. Skaggs: To anyone considering a career in orthopaedics, I could not recommend it more highly. You will be part of an elite team of professionals working together facing new challenges each day and, more importantly, helping improve the lives of those in need.
While the field of surgery may diminish over time as there are more medical and biological solutions, orthopaedic surgeons specializing in trauma will always be needed and highly respected.
