Trauma and orthopaedic surgeons

Abstract

The relationship between elective orthopaedic surgery and the acute management of musculoskeletal trauma has never been comfortable: for many reasons, these two aspects of care of the same system are not easy to combine. In some countries these are distinct specialties, which creates other problems. In the United Kingdom an experiment in which the Birmingham Accident Hospital provided all-system care for trauma did not become generally accepted. It can be argued that injury to one region or organ should be managed by experts in that field, despite the problems created by conflicting priorities and loss of overall control. In most specialties, elective and acute care can be relatively easily combined, but in orthopaedics the sheer number of trauma patients and the recent rapid division into subspecialties has created new difficulties. The two main concerns are the care of critically ill patients with multiple injuries, and the treatment of increasing numbers of cases of isolated trauma to bones, joints and soft tissues. These are closely related problems, but are rarely considered together. There can be no clear general answer which will be applicable throughout the world: local conditions vary too much in terms of the pattern of trauma, population density, transport facilities and the level of available expertise. In developed countries, the patient-related factors now include an ageing population, a boom in athletic leisure pursuits, and high expectations of complete recovery, while financial and political factors also have an influence. Countries with comprehensive health services are finding it increasingly difficult and expensive to provide the treatments made possible by technical advances in surgery. Patients (and some surgeons) will often opt for the ‘latest’ method, even if it has been devised for expert use only, and for a particular type of problem. Fashions come and go; methods which have been devised for limited indications become widely adopted. An isolated displaced tibial fracture provides one example: there have been successive waves of popularity for plate and screw fixation, for external fixation, and for intramedullary nails, first reamed and now unreamed. These methods all need special skills; but all produce their own set of complications, especially during successive learning curves. In the past, manipulation and plaster provided many satisfactory results and this may still be a viable option. It is unfortunate that the experience needed to select this simple treatment and the skill to perform it well are being lost in favour of high technology. Because of the wide variation in practice in countries with differing traditions, population density and patient expectation it is impossible to provide an overall view for our world-wide readership. To allow a constructive debate, it seemed best to have contributions from a number of surgeons with experience in trauma management. In this issue, Charles Court-Brown and Margaret McQueen give their forthright views on the state of the primary care of musculoskeletal injuries in the United Kingdom. Future editorials are being invited from a number of other countries.