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8/20/2019 AO Dialog 2006_02
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The magazine for the AO community 2 | 06
Community zone
Expert zone
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2 | 062
Table of contents
community zone
4 Letters to the editor
news
5 AO helps earthquake victims in Pakistan
AO in depth
6 Message from the Board
7 AO in Poland: growing strong
10 The spirit—and pride—of Davos
people
11 Siegfried Weller: a friend in Asia
events
12 First triple courses in Italian
13 New hand videos
14 Brazil takes a risk—and wins
expert zone
17 Cover story: Injury prevention: our responsibility?
20 Cover story: A health priority for children
24 Most frequent fractures of the carpus and tarsus in racing greyhounds
27 VEPTR
Treating three-dimensional thoracic deformit y of early onset scoliosis
32 Hemiarthroplast y in the treatment of distal humeral fractures
35 ORP news: Preparation of instrument tables
39 The Debate : How to treat sacral fractures with nerve injuries?
AO Dialogue June 2006
Editor-in-Chief: Marvin Tile
Managing Editor: Sylvia Day
Editorial Advisory Board:
Jorge E A lonso
James Hun ter
James F Ke llam
Frankie Leung Joachim Pre in
Jaime Quintero
Pol M Rommens
Publisher: AO Foundation
Design and typesetting: nougat.ch
Printed by Kürzi Druck AG, Switzerland
Editorial contact address:
AO Foundation
Stettbachstrasse 10
CH-8600 Dübendorf
Phone: +41(0)44 200 24 80
Fax: +41(0)44 20 0 24 60
E-mail: [email protected]
Copyright © 2006
AO Foundation, Switzerland
All righ ts res erv ed. Any repr oduc tio n, who le or in par t,
wit hou t the publ ishe r’s wri tte n con sent is pro hibi ted .
Great care has been taken to maintain the accuracy of
the info rma tio n cont aine d in this publ ica tio n. How ever,
the publ ishe r, a nd/ or the dis tri buto r a nd /or the edi tor s,
and/or the authors cannot be held responsible for errors
or any consequences arising from the use of the infor-
mation contained in this publication. Some of the prod-
ucts, names, instruments, treatments, logos, designs,
etc. referred to in this publication are also protected by
patents and trademarks or by other intellectual property
protection laws (eg, “AO”, “TRIANGLE/GLOBE Logo” are
registered trademarks) even though specific reference to
this fac t is not alw ays made in the tex t. The ref ore, the
appearance of a name, instrument, etc. without designa-
tio n as pr opri eta ry i s not t o be co nst rued as a re pres ent a-
tio n by t he pu bli sher tha t it i s in t he pu blic doma in.
Injury prevention in children
Read more about it on page 17
P i c t u r e c o v e r : g e t t y i m a g e s
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3editorial
ing 180,000 graves is in disrepair after
the Second World War. I was also able
to find the small towns of my families,
but sadly, no personal mementos. Visits
to the Nazi camps at Auschwitz, from
which four cousins survived and came
to Toronto post WWII, and Majdanek,
where three of my uncles, aunts andtheir famil ies all perished, added to the
emotional personal roller coaster. Po-
land has a rich history in central Europe
in the past millennium, including parti-
tion from the mid-18th century to 1918;
the new emerging Poland is impressive,
the countryside beautiful, and the cit-
ies being carefully restored. I thank
the people; doctors and some brilliant
guides, who made this trip so memo-
rable for us.
Injury prevention in children “As or-
thopedic surgeons who receive many of
the injured children, I believe we have a
responsibility to be active in supporting,
developing and studying injury preven-
tion,” writes Keith Willett; and “ortho-
pedic surgeons are the natural advocates
for the injured,” writes Andrew How-
ard. Can there be any doubt that injury
prevention is part of our mandate as or-
thopedic surgeons, especial ly for young
children, who are most vulnerable? To
Marvin TileEditor-in-Chief
treat by expert means to be sure, an AO
first principle, but to help in prevention
of injury, is a duty as a doctor, and as
a responsible citizen. At Sunnybrook
in Toronto, the largest trauma unit in
Canada, we have initiated the PARTY
program, which brings teenagers to the
unit to study the lethal effects of alco-hol, drugs and automobiles first hand.
We have an injury prevention program
for the elderly, with the cooperation
of our police. Other units are involved
with automobile companies, to improve
the safety of cars, by studying accident
patterns-one of our deputy editors,
Jorge Alonso has such a program at the
University of Alabama at Birmingham,
Alabama, USA.
More such examples exist, but more areneeded. Please respond to the challenge
by our two authors, Willett and Howard
to make this an important part of your
professional life, you owe it to you pa-
tients and your society.
Welcome to AO Dialogue
In this issue, the second in our new format,
two subjects are very personal to me, and
merit further comment: “AO in Poland” and
“Injury prevention in children”.
AO in Poland In May of this year, I had
the privilege of visiting Poland for the
first time, a visit both professional and
personal. I was invited to be a faculty
member of the AO Advanced Course in
Katowice, organized by the AOAA in Po-
land, chaired by Jarek Brudnicki , and by
course chairmen Tadeusz Gazdzik andJoseph Schatzker. I had the opportunity
to witness the new enthusiasm for the
principles of fracture fixation outlined
in the excellent article by Jarek Brud-
nicki. That Poland is emerging as a full
partner in the European Union, there
can be no doubt. The AO influence on
trauma care will, I am certain, continue
to grow as the new Poland emerges.
On a personal note, although I was born
in Canada, both of my parents were born in Poland and in 1927 immigrat-
ed separately as teenagers to Canada,
where they met and wed. I was able to
extend my time in Poland to explore my
family roots, and I am indebted for the
help I received from Jarek Brudnicki
and his wife Yola, for the success of this
venture. Highlights included finding
the tomb of my grandmother, who died
in 1936, and whom I never knew, in the
Lodz cemetery; it was an emotional mo-
ment, as much of the cemetery contain-
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2 | 064
Dear Sir/Madam,
I wrote to the Editor in June 2005 la-
menting the threatened loss, through
the introduction of the picture archiving
and communications system (PACS), of
an important technique taught at the
AO Principles Courses. The widespread
introduction of filmless systems means
that the technique, whereby tracing
paper is used to reconstruct fracture
fragments and plan preoperatively, has
largely been lost.
Technology has progressed rapidly in
the space of one year. My hospital has
recently converted to PACS technology,
but with that change they have also ac-
quired a software package specifically
targeted at digital preoperative plan-
ning. TraumaCad is the brainchild of an
Israeli software designer who spent sig-
nificant time in an orthopedic depart-
ment after a climbing accident. It was
designed to assist orthopedic surgeonswith trauma and arthroplasty templat-
ing and pediatric deformity correction.
The main competitor in the UK is Or-
thoView which has been around lon-
ger, but was primarily designed for the
purpose of arthoplasty templating. Only
recently have OrthoView extended their
capabilities to trauma templating. Other
providers include Sectra and Hectec.
A comprehensive description of these
various packages is beyond the scope of
this letter, however important points toconsider are DICOM functionality, flex-
ibility of deployment, templating modes
(trauma/arthroplasty/deformity) and of
course, cost.
The extended benefits of these software
packages are easy to foresee. I believe
that in the future they will play an im-
portant role in teaching. The trainee
surgeon will now be able to not only ver-
bali ze his operative management plan at
the daily trauma meeting, but also show
his senior colleagues the plan, through
a templated image of the fracture. Re-
gional and national meetings and dedi-
cated trauma courses will be able to
send out cases in advance; delegates can
then bring their own templated plans to
stimulate further discussion.
For the on-call junior surgeon who is yet
to reach a stage whereby he/she is not
fully confident acting alone in manag-ing specif ic trauma cases, it allows them
to send a detailed operative plan to their
seniors out-of-hours, who will then be
better informed as to whether their help
wil l be needed. For complex cases where
a second or more experienced opinion is
sought, the fracture images can be sent
anywhere around the globe, and then be
templated to give a visible operative plan.
Sending images electronically raises is-
sues relating to patient confidentiality,
however the TraumaCad software al-lows all patient identifying information
to be removed from the image before it
is sent.
What of my own experience? The pro-
gram is user-friendly and easy to navi-
gate, but there is undoubtedly a learning
curve, and I would advise anyone who
is considering these software packages
to ensure that there is ongoing support
available after the initial set-up. I have
no doubt that these software advanceswill play a major role in the way that
the Orthopedic surgeon works in the fu-
ture. The saying “You can never plan the
future by the past” seems to have been
disproved.
For more information, visit
ww w.ortho-cad. com
ww w.orthov iew.com
ww w.sec tra.com
ww w.hectec .de
Letters to the editor
are welcome and should be sent to
The edi tors of AO Di alog ue
have the right to edit letters for brevity.
Letters to the editor
Robin ElliotOrthopaedic SHO
Charing Cross Hospital
London, UK
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5community zone news
October 8, 2005 was a day when mountains
shook and the earth gaped, engulfing entire
towns and communities in Pakistan. Our wholecivic infrastructure simply disappeared at a time
when it was most needed. What took a lifetime to
build was destroyed in minutes.
The bird’s-eye view captured by satellite imagery
does not show the destruction beneath the bro-
ken roof tops. The scale of destruction is colos-
sal. It is estimated that 14,000 schools were de-
stroyed. The human cost is even larger with over
100,000 estimated deaths. The suffering of survi-
vors is enormous. In fact, psychological trauma is
far more severe than physical injury.
On October 8, 2005 a major earthquake struck Pakistan, recording
a minimum magnitude of 7.6 on the moment magnitude scale
—similar in intensity to the 1935 Quetta, 2001 Gujarat and 1906
San Francisco earthquakes. An estimated 3.3 million people were
left homeless, and damages were estimated at well over USD
5 billions. AO responded almost immediately with care and supplies.
Muhammad WajidAssistant Professor and
Consultant Orthopaedic
Surgeon
Aga Khan University
Karachi, Pakistan
AO helps earthquake victims in Pakistan
At this t ime of great difficulty, we were pleasant-
ly surprised by the immediate response of the AO
Foundation. Just one day after the earthquake I
received an email from Gregor Strasser, AO CEO,
as well as other members of senior management
within the AO Foundation. The very generous
assistance, provided by both AO and Synthes,
touched the hearts of many. AO provided instru-ment sets as well as implants (ie dispofix, etc).
These were very helpful in treating the earth-
quake victims, as most of the survivors sustained
skeletal injuries.
The local AO Alumni were actively involved in
the medical relief of the injured. We also appre-
ciated the messages of support from our AO col-
leagues around the world.
Muhammad Wajid in Karachi describes his own experience.
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Members, regions, partners
Two years ago I began my term as Pres-
ident of the AO Foundation. At that
time, I had numerous concerns andworries as to what was needed and what
were important aspects to assure that
AO would continue to be successful. I
soon came to realize that our greatest
plus and potentially our greatest down-
fall is cooperation among members, re-
gions and partners. The AO Foundation
is a group of individuals put together
for the common purpose of improving
patient care. These individuals are usu-
ally enthusiastic, aggressive and intel-
ligent surgeons, scientists and operat-ing personnel. Each of us has our own
agendas and needs, but for the Founda-
tion to succeed, it requires cooperation
from all.
Regional and specialty development
The most important area for cooperation
is the regional development program.
As AO expands into new regions and
allows more decentralization, the re-
gional groups must cooperate amongst
themselves and with the Foundation.
A message from the Board James F KellamPresident of the AO Foundation
james.kellam@ aofoundation.org
Foundation cooperation:
a basis for success
We look upon ourselves as a support
service organization providing the re-
gions with the necessary tools to carryout their role. However,
each region unto itself
will not strengthen AO
nor enhance our abil-
ity to meet our mission
unless that cooperation
is there. In fact, that interregional coop-
eration will become mandatory in order
for us to grow. Cooperation between
specialties as well as within each sub-
specialty will also make us stronger.
Cooperation in the classroom
Education requires cooperation in order
for it to be a success. Cooperation must
exist between the individual teachers at
each course to assure that the correct
content of the course is delivered prop-
erly. The cooperation between teachers
and students is imperative. AO educa-
tion works best on a one-to-one rela-
tionship at a practical table or in a dis-
cussion group as the teacher and student
work together as colleagues cooperatingto enhance each other’s skills.
Expert groups
Most important is the cooperation that
must exist between AO’s expert group
system, and the surgeons and scientists
that are developing new techniques and
implants to solve clinical problems. As
surgeons and scientists, we are very in-
terested in improving patient care by
improving our implants and our tech-
niques. However, this is difficult to do
effectively. The system that exists in
the expert group program allows these
individuals to work cooperatively witha group of surgeons
who are recognized in
their field as experts.
This cooperative pro-
gram enhances the
development process.
It also allows the inventor or devel-
oper to avoid conflicts of interest with
industry by being able to assign their
intellectual property to the AO Foun-
dation. This step rewards the developer
by having the best possible implant ortechnique promulgated about the world
by an excellent educational system. In
order for this to work best, a cooperat ive
relationship must exist between the AO
Foundation and its industrial partners.
This cooperative relationship enhances
the strength of the Foundation and the
surgeon.
Staying true to our mission
Should we fail to achieve cooperation
among ourselves in these many areas,our ability to achieve our mission to im-
prove patient care through education,
development and research will not be
forthcoming. If this cannot occur, then
the Foundation will have little purpose
for its existence. At the present time, I
believe that cooperation amongst all our
members and regions is excellent. We
need to continually make sure that co-
operation remains a solid pillar to sup-
port us in achieving our goals.
“For the Foundation
to succeed, it requires
cooperation from all.”
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7community zone cover story AO in depth
Jarek BrudnickiChairman, AOAA Poland
In the 1960s and 1970s, the implants used by
trauma surgeons in Poland were mainly those
manufactured by a rival company—copies of
AO implants and inferior in quality. That com-
pany concentrated only on sales and provided notraining for surgeons in the use of the implants.
The result was that without an understanding
of the principles and methods of plate osteosyn-
thesis that had been evolved by the AO school
and taught to surgeons at the many AO courses,
there was a high rate of complications such as
nonunions, refractures and infect ions. The com-
plication rate was estimated at 25%.
Because those implants were copies of the AO
system, the fai lures and complication rate were
attributed to the AO theories of treatment, not on
the lack of training and the inferior quality of the
implants. As a result, the reputation of the AOin Poland was not at all favorable and the opera-
tive treatment of fractures, part icularly so cal led
“compression plating“, was widely condemned.
In the 1970s, a group of Polish trauma surgeons
introduced Zespol, a Polish system for fixation
of bone fragments. The inventors of the Zespol
system understood the necessity of the surgical
teaching technique. For many years, courses in
osteosynthesis with the Zespol system were the
only opportunities for training Polish trauma
surgeons.
AO in Poland:growing strong
The lat ter half of the 20th century was a period of stagnation for Polish orthopedic
surgery. During that time, access to new developments and current knowledge
was limited, since contact with Western medical centers was discouraged.
The Iron Curtain effectively restricted the flow of information and literature; the
repression of political thought extended to scientific and medical knowledge and
contributed to much suffering.
P i c t u r e : D a n i e l U r s p r u n g
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The leading centers in Poland for the propaga-
tion of the AO philosophy in fracture care are
Krakow, Szczecin and Warsaw. The heads of
these centers, Tadeusz Niedzwiedzki, Andrzej
Gusta, and Andrzej Gorecki have been diligently
engaged in preparing consecutive courses in Po-
land. Foreign and local faculty members have
given lectures together and provided close super-
vision for all the practical, hands-on workshops.
Young doctors just starting out and experienced
surgeons have participated in al l the AO courses
with great enthusiasm.
In 2002, besides the principles course, an addi-
tional AO seminar on joint fractures of the lower
extremities was organized in Szczecin.
2003 proved to be a pivotal year for AO in Po-
land. Since 2003, a regular schedule has been
established for AO educational activities there.
There are two annual courses: the principles
course held in Warsaw in October and the ad-
vanced course held in May in different centers,
in order to enable surgeons from all over the
country to come into contact with AO ideas, and
hear leading surgeons who are members of fac-
ulty. Since 2003, the ORP courses, now carried
on by Susanne Bäuerle, have become an annual
event. Both foreign and local members of facultyhave willingly helped Susanne in her efforts.
In 2003, because the number of surgeons at-
tending local or Davos courses has been grow-
ing steadily since 1997, there has been a cor-
responding increase in interest in AO, in the
centers treating patients with AO techniques,
and in the amount of AO implants used. There
has also been a steady increase in the number
of Polish surgeons reaching faculty status and
teaching AO courses. By 2003, there was a suf-
ficient number of surgeons who had reached thestatus of “alumnus” to create a Polish AO Alumni
Group. To inaugurate the creation of this group,
Antonio Pace, President of the AO Alumni As-
sociation (AOAA) came to Warsaw to present the
structure and aims of the AOAA, and the ben-
Over the years, a small number of Polish sur-
geons had managed to attend the AO courses in
Davos but upon returning home to an environ-
ment hostile to AO, they were unable to influ-
ence the opinions of their colleagues. Thus, the
decision in 1997 to organize the first Principles
Course of AO Fracture Treatment in Poland was
crucial for Polish trauma surgery.
During the four-day course, held in the new Or-
thopedic and Trauma Department of Regional
Rydygier Hospital in Krakow, headed by Tadeusz
Niedzwiedzki, 48 participants were able to learn
and practice modern techniques of operative
fracture treatment. Two eminent trauma sur-
geons, Joseph Schatzker and Emanuel Trojan,
were the chairmen of this first, highly successfulinstructional course.
Since 1997, AO courses have
become regular, educational
events in Poland. From 1998 to
2000, only “Principles” courses
were organized. In 2000, Anne
Murphy organized the first ORP
course in Krakow. In the same
year, the first Polish AO Com-
prehensive Spine Course took place in Poznan.
Advanced courses also began in Poland in 2000.
Joseph Schatzker’s contribution in organizing all
the AO events in Poland has been invaluable. His
work, and that of a number of famous AO teach-
ers whom he invited, as well as the participation
of an enthusiastic, highly motivated group of Pol-
ish surgeons have ensured that these educational
events have been of the highest quality.
“There has been a
corresponding increase
in interest in AO,
AO techniques, and
implants used.”
From left to right:Karol Zyto, Joseph Schatzker, Jarek Brudnicki.
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9
Beside regularly organized Pr inciples, Advanced
and ORP courses each year, there are other AO
events in Poland. In 2004, at the Congress of the
Polish Orthopedic and Trauma Society, Joseph
Schatzker presented a lecture titled “The Evo-
lution of AO Philosophy and Principles of Frac-
ture Care”. That same year, he conducted severalworkshops in various centers of the country on
the principles application of LCP.
There has been great progress in Polish trauma-
tology since 1997. The number of surgeons edu-
cated in the AO philosophy is growing steadily.
Nearly 300 surgeons and 80 scrub nurses have
participated in local AO courses; more than 40
surgeons have attended regional and Davos cour-
ses. A Polish AO faculty group has coalesced from
those who have been involved in AO educational
activity, and since 2003 the number of PolishAOAA members has grown to the point that an
AOAA Chapter in Poland was organized. As the
number of surgeons familiar with AO principles
grows, Poland’s reputation in the medical world
will also grow. The decision to hold the AOSpine
Central European Comprehensive Spine Course
in Krakow in September 2006 i llustrates Poland’s
increasing international prestige.
efits and obligations resulting from membership.
A group of 16 of those most closely involved in
AO activity formed the Polish AOAA and at their
first official meeting, elected Jarek Brudnicki as
chairman. As chairman, I fulfilled the demand-
ing task of coordinating the goals of the Polish
group with Polish legal regulations to achieveofficial status and registration which finally oc-
curred in 2005.
Since 2003, the Polish AO Alumni Group has
become more active in international AO activi-
ties. In 2004, two Polish surgeons participated
for the first time in the Tips for Trainers course in
Stratford upon Avon, England. That same year,
Marius Bonczar became the first Polish surgeon
to be a member of faculty during the principles
course in Davos.
Polish surgeons have also started to participate
in AO Regional Courses outside Poland. In 2005,
Marius Bonczar, Dariusz Larysz and Jarek Brud-
nicki were members of the international faculty
during the regional course in Portoroz, Slove-
nia, where their contributions were given a high
evaluation. In 2005, the Polish AO Alumni were
also present in Sardinia at the AOAA Triennial
Meeting. They presented their plans and expec-
tations regarding Polish membership in AOAA to
the General Assembly.
community zone cover story AO in depth
Joseph Schat zkerat principles coursein Warsaw.
Marius Bonczar and
Susanne Bäuerle at theORP course in Warsaw.
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2 | 0610 AO in depth
In Andrea Meisser’s opinion, the AO Davos
Courses are the most important event in Davos.
That’s quite a statement, considering Davos hosts
the World Economic Forum every year!
Albert Einstein inaugurated the first University
Course at Davos in 1928. In h is opening address
to 45 university professors and more than 350
students from all over Europe he emphasized the
importance of intellectual training. These same
university courses, followed by the “Summer
School of European Studies” and “JuniorCom”,led to a fantastic development of Davos as “Sci-
ence City” and are the background to the AO
Davos Courses.
Thomas Mann, fellow Nobel Prize winner and
who died the same year as Einstein (coinciden-
tal ly, exactly 50 years before the 82nd/83rd Davos
Courses) , published the famous novel “The Magic
Mountain” in 1924 based on his observations in
a Davos sanatorium. He used almost the same
words as Einstein to describe the special situa-
tion of the importance of intellectual thought.
Like the observations by these famous men, the
AO Davos Courses also reflect the spirit of Davos
– cultivating science and intellectual thought. No
longer just a health resort, Davos is also a center
for knowledge, as the World Economic Forum
shows, where hundreds of important world lead-
ers are attracted to the economic incentive ofnetworking and learning every year, and who
quickly infect themselves with the local spirit of
discourse and generosity.
And how do the locals define the “spirit of
Davos”? In Meisser ’s words, “Is it the atmosphere
of this little village, dominated by the spirit of so
many strong, interesting and act ive people? Is it
the fact that dynamic “Downtown Davos” pres-
ents itself dif ferently from year to year, while our
remote valleys remain the same over centuries?
Or is there another mysterious or even esotericexplanation?”
Davos residents are proud of their roots, their
language, and their cultural identity. But what
makes the community so unique is the local an-
choring of identity together with the openness
for a continual widening of horizons that truly
makes up the spirit of Davos.
Davos is a fixed part of AO’s history and identity. But we’re not the only ones
who identify with the spirit of this alpine town. At the opening ceremony of the 82nd
and 83rd Davos Courses in 2005, Andrea Meisser of the Davos City Council gavea presentation titled “The Spirit of Davos”, and which the editors felt captured
so many things AO stands for. AO Dialogue has extracted part of that speech and
shared it with you here.
The spirit
—and pride—of Davos
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11community zone people
Any orthopedic trauma surgeon involved with
AO in Asia from the early 1970s until now will
know Siegfried “Sigi” Weller. Having organized
numerous courses and participated as a faculty
member for 30 years, he was the pioneer in AO
teaching activity in almost every country in Asia.
His devotion to AO education in Asia is enor-mous and has inspired many of his students in
Tübingen, Germany to follow him to the region
and continue to build the AO bridge between
Asia and Europe.
In my second year of ortho-
pedic training at Pramong-
kutklao Hospital in 1977, I
attended a lecture by Hans
Willenegger, then President
of AO International, who had come to Thai land
with Siegfr ied Weller. A group of orthopedic sur-geons attended that seminar, and it was the fi rst
time we had ever heard the name “AO”. Despite a
presentation showing the various cases with su-
perior results compared to our treatment meth-
ods, the reaction from participants was mixed.
I remember questioning myself as to whether
the AO technique could be a new solution that
would improve the current fracture treatment
methods. I was very impressed with both speak-
ers who demonstrated such confidence and en-
thusiasm in the AO method. I had the chance to
meet both of them the following year in Davos,where we got to know each other better outside
the lecture environment.
Siegfried Weller gave me advice and many sug-
gestions on how to implement AO education in
Thailand. I returned home with a lot of enthusi-
asm after attending the course and realized the
importance of teaching surgeons who didn’t have
the same opportunity I had. So, I contacted Hans
Willenegger, and told him that I was interested
in introducing teaching activities in Thailand.
Hans Willenegger designated Siegfried Weller
to visit Bangkok in 1983 on his lecturing trip in
Asia. He was to discuss my request for a dona-
tion of AO instruments to start the education ac-
tivities for Thai orthopedic residents. Six months
later I received word from AO that we would be
supplied sets of instruments for teaching activi-
ties. I believed that AO agreed to this request onthe recommendation of Siegfried Weller, who
put his trust in me. This was a milestone for AO
courses in Thailand. In June 1985, the first AO
Basic Course was held at Pramongkutklao Royal
Thai Army Hospital, followed by another one in
August of the same year.
The Basic Course continues
annually to th is day.
Siegfried Weller has re-
turned to Bangkok on several occasions with
his head of department Ulrich Holz, followed byother department staff members such as Ulrich
Pfister, Honke Hermichen, Heiner Winker, and
Dankward Hoentzsch, who took part in d ifferent
courses in Bangkok at the Royal Thai Army Hos-
pital. They all became and remain good friends
to many surgeons in Asia.
Siegfried Weller nominated me as an AO Trustee
in 1988, and asked me to join him as an AO in-
ternational faculty member when the AO course
was held in Asia. Despite my anxiety at this,
Siegfried supported me throughout and mademe believe in myself. He wanted to show that if
we follow the AO principles correctly, the Asian
surgeons could also get good results and be able
to set an example for the others. And he did this
tirelessly for 30 years.
The AO community has grown tremendously
with the increase of teaching activity worldwide,
and recognized the importance of regionaliza-
tion. Siegfried Weller is one of the founders of
AO East Asia (AOEA) and was elected as its Hon-
orary President. When AOEA was founded in
Siegfried Weller (left) is
Honorary President of AOEA.
“This was a milestone for
AO courses in Thailand.”
Siegfried Weller:
A friend in AsiaSuthornBavonratanavechBumrungrad Hospital
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1994, the most significant change was the for-
mation of Permanent Workshops (PWs) for the
AOEA group. These allow flexibility for each
country to set the timing of courses, resulting in
more convenience and advantages.
The theory session is designed to guarantee the
teaching is up to a worldwide standard. Our pride
is in confronting and overcoming the problems
and obstacles to a point where the AO principles
and knowledge of operation for fracture treat-
ment can be widely spread among instructors as
well as surgeons—resulting in direct benefits to
the patients.
In many Asian countries AO has strong roots
and is flourishing. In 2004, AOEA celebratedits 10-year anniversary by organizing the first
Asian AAOA Chapter Symposium in Chiang
Mai, Thailand, which was attended by 300 par-
ticipants from 18 different countries. One of the
highlights at that event was the opportunity to
honor Siegfried Weller for his lifetime dedica-
tion to AO education in Asia. Without him, AO
in Asia would not have reached the standard it
holds today.
I’m happy to have this opportunity to recognize
the work of Siegfried Weller, who has contrib-
uted so much to the history of AO education in
Asia since its beginnings until today, and making
the younger generation aware of the d ifficulties
and obstacles encountered by the former genera-
tion. I would also like to express my gratitude to
a man who so kindly guided and educated me.
Through Siegfried Weller’s work in Asia, he not
only shared the AO principles and latest tech-niques, but also the ethics and philosophy of
how to be a good surgeon.
For the first time, three AO Courses held in Ital-
ian took place in Davos from February 19-24.
More than 200 participants attended these Basic,Advanced, and Comprehensive courses which
included a Basic Course, organized by Dario
Capitani (President AOAA, Local Chapter Chair-
man Italy) and Francesco Maggi, an Advanced
Course, organized by Francesco Franchin (Ital-
ian AO Trustee) and Frederico Santolini, and a
Comprehensive Course, organized by Antonio
Pace (President AOAA) and Pietro Regazzoni.
First triple
courses in Italian
The Comprehensive Course, a first in this format,
focused on the shoulder and elbow, combining
all aspects of surgical intervention in theory andpractice including preoperative imaging and
planning, the study of approaches on anatomical
management, practicals on Synbone models, and
endoscopy and prosthetic joint replacement.
The three courses were a great success, as were
the ensuing social events including plenty of ski-
ing! The participants also got a tour of the AO
Center and the laboratories, giving them a good
insight into AO.
Esther StoopAOAA
Thomas RüediFounding Member of
AO Foundation
Siegfried Weller:
A friend in Asia
events
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1313community zone events
From February 2–7, after a long period of prepa-
ration, the “hand videos” from 1999/2000 wererevised and updated in the AO Center.
The medical team comprised of Regula Steiger,
Director of Hand Surgery at the Kantonsspital
Liestal, Switzerland, Klaus Lowka assisted by
medical student Sammy Dowlatshahi and OP
nurse, Monika Öhler, all from the Center for Di-
agnostic and Outpatient Surgery (Zentrum für
ambulante Diagnostik und Chirurgie), Freiburg
im Breisgau, Germany. Our valued colleague,
Jürgen Koebke, Head of the Institute of Anatomy
of the University of Cologne provided us withfresh specimens of excellent quality (frozen, not
formalin fixed!).
The video team recorded all the individual ana-
tomical steps by video camera; photos and close-ups were taken by Jürgen Staiger with his digital
camera.
We structured the procedures in such a way that
Jürgen Steiger and myself took turns: one of us
“operated“, while the other one assisted and gave
critical advice.
In the postproduction phase we went into the
labs where the recorded material was ordered
and assigned preliminary captions. All togeth-
er we visualized 42 different approaches to thehand, wrist, and forearm.
New hand videos:
behindthe scenes
Klaus Lowka
Center for OutpatientHand Surgery
Freiburg, Germany
One of 42 new approaches for the hand videos.
The video teamhard at work.
Getting the right shotrequires patience.
As ever, the AO Center offered the best work-ing conditions. In one of the operating rooms we
could perform the approaches we had planned
on the defrosted specimens. During preparation
the high quality of the anatomical material was
confirmed.
The AO video/multimedia and publishing teams,
represented by Felix Kräft, Jürgen Staiger, Ran-
dolph Stadelhofer and Matteo Attanasio had
built up their equipment around the table. Mar-
tina Caflisch took good care of organizational
matters and support.
On February 7, our last day in Davos, we startedto cut the huge amount of film material and got
ourselves set up with work to take home with us.
To sum up, we are sure that a worthwhile result
will come out of the collaboration of these few
days.
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“A key factor in the course
success was the local faculty.”
José Sérg io FrancoAO Trustee
Rio de Janeiro, Brazil
jsf ranc [email protected] om
Cléber PaccolaSão Paulo, Brazil
The AO Advanced Courses have been imple-
mented in Brazil successfully for several years.
The opportunity of having the Tips for Trainers
in Brazil for the faculty with the educators LisaHadfield-Law and Patricia R Pinto a few weeks
before the course gave us the capability to use
the principles and techniques to improve our
teaching skills.
As co-chairmen of the 2005 AO Advanced Course
in Brazil , we share the same ideas regarding the
changes presented at the Brazilian course. The
focus of our actions must be the quality and the
way we give the information to the participants.
The course took place at JP Hotel in RibeirãoPreto, São Paulo, where it has been held since
1999. Practical exercises and discussion groups
were held in different areas.
The course was sponsored
by AO International, AO
Latin America, LATOC
and the AO Foundation
with support from Synthes Brazil. Special thanks
go to Micheline Bertolani and staff, whose expe-
rience and dedication provided smooth logistics
and running of a long program.
A key factor in the course success was the local
faculty. They were 100% in tune with the AO
philosophy, sending consistent messages and
allowing greater interaction between table in-structors and participants – something that has
become the AO Course trademark. A spirit of ca-
maraderie never hurts, either!
A team of nations
The four international faculty members included
Fernando Garcia from Mexico, Suthorn Bavon-
ratanavech from Thailand, Peter Trafton from
the USA and Robert Sanhueza from Chile.
The interaction among the Brazilians and other
nationalities was recognized by everyone andconsidered one of the highlights. The Spanish
language made communication easier but the
interpreting between English and Portuguese al-
lowed both instructors
and participants to
interact normally. Af-
terwards, there were
suggestions on how to
improve the course and feedback to the impor-
tant changes presented to them.
The latest AO Advanced Course in São Paulo, Brazil was
a huge success. Several changes were made to improve the
goal of giving participants the best of the AO philosophy.
The event co-chairmen provide their report to AO Dialogue.
Brazil takes a risk
—and winsFirst Advanced Course in Portuguese
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community zone events
Learning pays off
Thanks to the Tips for Trainers course, we re-
ceived these four points as the basis of our work
during the Advanced Course:
• Taking a risk
• Learning by teaching
• Decision-making process in fracture manage-
ment with technical aspects
• Basing the decision on solid AO principles.
The four-day course began with a pre-course
which was very useful. This was split into four
parts including introduction, practical exercises,
ARS and Tips for Trainers, and a social event.
Faculty members on the subcommittees were
presented and the chairman gave a brief expla-
nation on what was expected from the group.
Hot topics were also discussed with questions
from the floor.
Improvements to the course
The four-day course ran smoothly. High-level
presentations and good discussions along with
practical exercises fulfilled the expectations of
“A spirit of camaraderienever hurts.”
Then, we performed modifications on previous
year’s programs. The idea was to introduce new
concepts to improve learning. We decreased lec-
ture time for all faculty members. We increased
time for case discussions, introduced the ARS
(audience response system) for case
discussion in the lectures hall atthe end of each lecture session, and
increased the amount and time of
practical exercises.
A changing, committed process
The first step was how to present and change the
plans, and how to perform to improve learning,
support our decisions in the team, and logistics.
The homogeneity, union and spirit of working
in a group such as the Brazilian AO faculty and
international faculty provided an ideal envi-ronment for innovations and modifications in
the course routine. Keeping in mind that 100%
commitment of instructors was the key to suc-
cess, we focused on creating subcommittees for
all the faculty members, so that each one of them
would have a specific task besides presentations
or practical exercises. Each become responsible
for one activity, and the distribution was based
on the individual personality and abilities in the
different areas. Activities and sessions were dis-
cussed and evaluated at the end of the day.
both faculty and part icipants. The international
faculty members were outstanding teachers, and
the introduction of the ARS gave us the instant
feedback on several topics that we wanted to
analyze.
There were a total of 45 lectures with first-timeinterpreting from Portuguese to English and vice-
versa. Nine practical exercises were conducted
with three to four table instructors, creating a
closer relationship between the participants and
instructors. The ARS showed that this new for-
mat of exercises was very positive – 87% said it
was an “evolution” from the principles course.
Case discussion groups were also held afterwards,
proving to be another highl ight of the course.
Keeping the spirit aliveThe courses in Brazil were clearly a success in
the eyes of participants and faculty. The process
of education improved in all aspects and will cre-
ate a positive impact on the learning process for
future courses. The commitment of faculty and
staff exercising the AO spirit is one of the key el-
ements to keeping AO even more united toward
achieving better patient care.
15
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17expert zone cover theme polytrauma management
Injury prevention: our responsi ility?A focus t roug a c il ’s e ucation
Keith Willett
My family has never lost a child to injury, but in the last twen-
ty years as a trauma surgeon I have shared in that tragedymany times. The death of your chi ld or witnessing their severe
injuries is probably the greatest trauma one can suffer. That
despair i s heightened by the knowledge that most injuries are
preventable, compounding the parents’ guilt that they fai led
to protect their child.
Injury is now the leading cause of chi ld death in economically
developed countries; for every death there are hundreds of
hospital admissions and thousands of Emergency Department
attendances. In Europe it is estimated that one in four chil-
dren attend an Emergency Department each year, 75% as a
result of injury. Our special ity is Trauma and Orthopedics and
for most, more than 50% of our workload is injury-related.
Despite this, there has been limited interest in the prevention
of injury. Over the last forty years there has been a gradual
decline in unintentional deaths but the injury fatality rates for
children have not fallen as much as those for cancer and infec-
tion. The costs of injury we know are enormous, encompass-
ing both the medical costs and subsequent societal support
costs. Then there are the unquantifiable and huge psychologi-
cal costs to families. So how do we reduce this burden?
Injury reduction may be effected with changes to the three
E’s: Environment, Enforcement of Law and Education.
The latter has been in most part ineffective in adults, their at-
titudes to risk and safe behavior having already been estab-lished. In general the role of education in adult injury preven-
tion is confined to persuading sufficient of the receptive
population to accept a legally enforceable change in the envi-
ronment such as seat belts, speed restriction, motorcycle hel-
mets and blood alcohol limits for driving. These can then be
applied to all, thus impacting on those at highest risk who are
often the least receptive to safety advice. Non-consensual envi-
ronmental changes such as segregation of different road uses,
street lighting, traffic calming measures and changes to road
furniture and layout have all been proven highly effective.
To identify effective options [1] for reducing injury in chil-
dren, we must first understand that the environments in
which their injuries occur are age-specific and secondly that
there are strong socio-economic factors determining vulner-
ability. In children, unlike in adults, there is the opportunity
to influence long-term perceptions of risk awareness. In a
child’s formative years, it is logical to assume, and it has been
demonstrated, that knowledge can be imparted and attitudes
influenced to reduce risk and promote life-long safe behavior.
The very young pre-school child is typified by their physical
vulnerability and developmental immaturity. They are at the
pre-logical phase of thinking; this means they cannot assess
safeness and are often unresponsive to cautioning messages.
expert zone cover story injury prevention
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They do not link potential threat to actions and have little ap-
preciation of time beyond the present moment. This also fre-
quently creates unreal istic expectations in adults! For this agegroup the risks are predominantly in their home environment
and very dependent on the level of supervision. Socio-eco-
nomic factors are at their highest with a five-fold increase in
risk for those in deprived homes. This differential risk has not
improved in recent decades. Particular risks are from fires,
choking, drowning and poisoning. The prevention focus
should therefore be on educating parents on f ire prevention,
smoke detection, water safety, and medicine and domestic
chemical safety measures.
A further demonstration that the nature of the injuries relates
to where and how children spend their time is their incidenceof involvement in road traffic colli sions as either pedestrians
or cyclists. This increases dramatically when children attend
school and particularly into teenage years when they need to
travel independently and over longer distances to access sec-
ondary education. More than half the deaths in this age group
are a result of road traff ic impacts. Adolescence is typified by
testing out their environment and their parents! Investigation
of child pedestrian accident scenes show that by far the great-
est factor is unpredictable high-risk behaviour. Boys are twice
as likely as girls to be fatal ly injured. Initiatives to encourage
conforming patterns of behavior and to use protective devices
such as cycle helmets are frequently unacceptable to this in-dependence-seeking age group. Risk taking is part of this de-
velopment phase and varies between individuals; that indi-
vidual trait probably cannot be changed but the knowledge
base on which they determine the level of risk can. Taught
didactic educational programs such as the US-based Tufty
Club for pedestrians or bicycle proficiency instruction have
not been shown to have a protective effect. However, there are
now programs using a broad range of interventions integrated
into the school curriculum that are more encouraging. Health
promotion needs to draw on the expertise of both the health
and education professional communities. Adolescents natu-
rally respond to experiential-learning, interacting with their
community and seeking adult skills. If this can be incorpo-
rated into health education programs effective learning will
occur.
UNICEF in 2001 published international comparisons using
World Health Organization mortality data [2]. Sweden, the
UK, Italy and the Netherlands had the lowest child injury
death rates, with the USA and Portugal having levels twice as
high, and Mexico and South Korea approaching levels four
times greater. Cultural differences in the countries were re-
flected in the relative incidence of the different types of inju-
ries suffered. That analysis was not entirely straightforward
with the UK’s overall road safety record, for example, being
very good despite high child pedestrian exposure and high
population density. The annual death rate per 100,000 chil-
dren varied from the lowest in Sweden at five per year, with
Canada, Switzerland and Australia at almost ten per year. TheUSA, Portugal, Mexico and Korea had fourteen or more fa-
talities per year.
Most developed countries are now setting targets or establish-
ing health policy initiatives through transportation, fire ser-
vices, consumer organizations, education and health. In the
UK and other countries there have been statutory or nonstat-
utory guidance built into the nation’s school curr iculum pro-
moting awareness, first aid principles and basic life support
responses appropriate for the age, ability and knowledge of
the child. Given the limited success historically with educa-
tion interventions there was a signif icant potential to pursueineffective methods despite the good intent. Programs should
ideally be evidenced based or at least evaluated.
It was in response to this that in Oxford in 1994, after multi-
agency advice and international consultation, the Injury
Minimization Program for Schools (IMPS) [3] was established
to respond to the need to teach injury prevention and life sup-
port. The core IMPS program targets pupils at the age of 10
and was developed by a combination of health and education
professionals. The program integrates the key r isk knowledge
elements into the taught National Curr iculum lessons for the
most common injuries of wounding, electrocution, drown-
ing, choking and burns. The IMPS project developed lesson
plans and resources that were delivered by schoolteachers si-
multaneously achieving the key stage curriculum educational
targets without further burden. For example, in the science
lesson on electricity when they learn about current, volts,
conductors and non-conductors, they are taught what elec-
tricity would to the body; so rather than “don’t play with elec-
tricity”, they understand the effects of electrocution and can
therefore judge the risk of their actions. Those taught lessons
are then given credibility through experiential learning with
the children attending a local hospital where dedicated IMPS
trainers (health professionals) consolidate the risk and life sci-
ence lessons by demonstrating the consequences of injury and
teaching the appropriate response first aid and life support
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19expert zone cover theme polytrauma management
techniques, so completing the r isk-injury-response-outcome
loop. The IMPS program has now taught over 60,000 children
across the UK in fourteen centers and has been the focus of a
prospective non-randomized matched control study demon-
strating its effectiveness [4]. Recognizing the absolute need to
reach across the breadth of society, in addition to the school
curriculum integration, IMPS is also available in modified
forms for children excluded from schools, those with special
needs, children educated at home and those with different
ethnic needs.
In recent years the program has further evolved to include a
cross-age peer-delivered education program for 15-year-olds.
This citizenship program has been developed as part of thecurriculum’s Personal Social and Health Education. It pro-
vides teaching and citizenship skil ls to students who then, in
pairs, take responsibility for composing, planning and deliv-
ering an injury prevention lesson to children aged 6 in a pri-
mary school. They select a topic relevant to that age group and
choose the appropriate lesson resources and teaching tech-
nique. That project has also been positively evaluated with
pupils recording a strong effect on their safety attitude, child
development knowledge and self-esteem.
As orthopedic surgeons who receive many of the injured chil-
dren, I believe we have a responsibil ity to be active in support-
ing, developing and studying injury prevention initiatives. Iam aware of numerous community health and education
based programs across the world. Perhaps within the interna-
tional AO faculty we have an opportunity to share and de-
velop our experiences.
The death or crippling of a child from injury remains a pre-
ventable tragedy.
Bibliography
1 Towner E, et al (1996) Preventing unintentional injury in ch ildrenand young adolescence. Effective Health Care; June Volume II (5)ISSM: 0965–0288.
2 UNICEF (2001) A League Table of Child Death by Injury in RichNations. Florence, Italy; UNICEF Innocentir Research Centre: 1–28.
3 Injury Minimization Programmes for Schools: www.impsweb.co.uk
4 Frederick K, et al (2000) A n Evaluation of the Effectivenessof the Injury Minimization Programme for Schools (IMPS):Injury Prevention; 6(2): 92–95.
5 Frederick K, Barlow J (2006 and 2005) The Citizenship SafetyProject: a pi lot study. Health Educ Res, Feb; 21(1):87–96. Epub Jul 15.
expert zone cover story injury prevention
Keith Willett
Professor of Orthopaedic Trauma Surgery
University of OxfordJohn Radcliffe HospitalOxford, England, [email protected]
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A health priority for children
Andrew Howard
Injury is the leading cause of death for children in all devel-
oped countries, and a leading cause of hospitalization and dis-
ability. 90% of chi ldhood injuries are preventable, yet injury
prevention does not receive the systematic attention it de-
serves. Preventing injuries requires input from multiple sec-
tors—health, transport, sports and recreation, justice, city
planning, public health—and everyone’s responsibility un-fortunately often becomes nobody’s responsibility.
Orthopedic surgeons think carefully and systematically about
the treatment of injuries, day or night. Treating fractures care-
fully is part of the spectrum of injury control. We are less
commonly engaged in a systematic approach to preventing in-
juries in the first place. Many of the injuries we treat are emi-
nently preventable, and our skills in analyzing the biome-
chanics of injury, and our credibility as advocates for our
patients, can make us effective partners in injury prevention
and control.
For children aged 1 to 15 in OECD (Organization for Econom-
ic Cooperation and Development) countries, the number of
deaths due to injury (6000 per year) exceeds the sum total of
death for the second through tenth leading causes combined.
Injury is the last great threat to the health and integrity of the
children of the developed world economies.
This paper focuses on the prevention of unintentional injuries
sustained by children. I wil l begin by discussing a framework
for injury prevention, and show how it applies to major cate-
gories of injury (traffic, sports and leisure) in countries in the
developed world. Examples will be drawn from the injury
prevention research I carry out in my orthopedic practice at
the University of Toronto, Canada.
Injury is preventable Injury is damage to the body caused
by excess energy transfer. Mechanical, thermal, and chemical
energy are included. Pre-event strategies stop the injury event
from happening. For example, road design, traffic laws, and
vehicle features together can prevent a motor vehicle crash.
Event time strategies reduce the injury consequences of a
crash, for example using seat belts and airbags to reduce oc-cupant injury. Post-event prevention includes systems to min-
imize the effect of injuries received—mainly emergency re-
sponse systems involved in communication following injury,
scene control, and rapid transfer of injured people to appropri-
ate medical facilities. Treatment and rehabilitation do not
need defining for orthopedic surgeons, but exemplify our cur-
rent role in injury control.
Public health injury researchers also speak about the person,
vehicle, and environment being potentially modifiable to pre-
vent a particular injury. Again using the example of a car
crash, the person (driver) can be protected from injury by ap-
propriate acquisition of skills and experience (for example
graduated driver licensing programs). The person may be
made more likely to be injured by alcohol or drug intoxica-
tion, or distraction during the driving task. The vehicle can be
modified by improving the structure, seatbelts, and airbags.
The environment can be improved by separation of traffic
flow, well-designed and well-lit roads, and appropriate traffic
regulations.
Thinking about person, vehicle, and environment factors at
the pre-event, event, and post-event times leads to the matrix
shown in Fig 1 and named Haddon’s matrix for a surgeon who
was a pioneer in automotive injury control. For many types of
injury it is possible to think of modifiable risk factors and in-
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21expert zone cover theme polytrauma management
jury countermeasures in most if not all of the boxes in the
matrix. Multiple strategies work synergistical ly to prevent in-
jury. Safer cars on safer roads crash less often, better occupant
protection reduces the injury consequences of a crash, and a
well functioning trauma system reduces the death and dis-
ability per injury. This synergy has resulted in a remarkable
decline in the r isk of traffic death over several decades in mostdeveloped countries.
Although person, vehicle, and environment factors can all be
considered in preventing childhood injury, I believe that en-
vironmental modifications are key to success. We live in a
man-made environment most of the time, and we can design
it to reflect what we value—including optimizing the safety of
our children—rather than designing for the efficiency and
convenience of the powerful and their motorized l ifestyle.
Traffic injury in children
Motor Vehicle Occupants Kinetic energy is the injurious force
in motor vehicle collisions. The formula for kinetic energy is K
= _ mv2 with m being mass and v velocity. The importance of
mass and velocity is highlighted by the fact that curb weight
(mass) and horsepower (related to velocity) explain 55% of
the variability in dr iver death rates across vehicle types in theUnited States. This association is stronger than that between
cigarette smoking and lung cancer. Control of kinetic energy
is achieved by all of the primary and secondary prevention
strategies listed in Fig 1.
Seatbelts are one of the most effective public health measures
ever, with a 70% reduction in the risk of dying from a crash.
Children have not benefited from seatbelts as much as they
should because children do not fit into seatbelts designed for
expert zone cover story injury prevention
Fig 2
Motor vehicle collision investigation
to prevent child occupant injury.
Fig 1
Haddon’s Matrix—this conceptual framework allows a sys tematic approach to interventions which prevent injury, and can be appliedto any category or mechanism of injury.
Haddon’s Matrix for Injury Control (Example—Motor Vehicle Crash)
Person Equipment Environment
Pre-Event
primary prevention
Alcohol, driver training Steering , brakes , headlights ,
electronics—ABS brakes,
stability control
Road design, speed limits,
traffic, lights
Event
secondary prevention
Body composition—mass,
strength, osteoporosis
Seatbelts, air bags,
safety cage, crumple zones
Roadside barriers
Post-Event
tertiary prevention
First aid, training Communication, cell phone Emergency medical services
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22 2 | 06
adults. While any restraint is generally better than no re-
straint, the well-described seatbelt syndrome (transverse ab-
dominal bruise, abdominal organ injury, lumbar spinal inju-ry) is a particular risk for preschool and young school-aged
children using poorly fitting belts. The solution is to use boost-
er seats until the child is ta ll enough and large enough for an
adult seatbelt (generally not before age 9). Booster seats pre-
vent lap belt injuries, head injuries, and ejections. Unfortu-
nately, most children who should be in a booster seat do not
currently use one in many jurisdictions. Recent booster seat
laws may change this.
Infant and child car seats are complex devices for parents to
instal l in the car and buckle chi ldren into properly. Misuse of
these important devices is so common that ongoing design ef-forts must improve both performance and usability. Subopti-
mal use puts children at additional injury risk including ejec-
tion from the vehicle.
Some types of crashes remain very dangerous even to appro-
priately restrained children. Side impact crashes result in a
severe triad of head injury, trunk injury, and limb injury (sim-
ilar to a pedestrian triad) in a child who is seated next to a
struck vehicle door. Current restraints do little to change this
pattern of injury. Moving children further away from the
doors and toward the center of the car is an obvious design
modification not yet fully implemented. Novel means of inter-posing impact absorbing material between the child and the
struck side of the vehicle are being investigated by my group
and others.
Pedestrians Unlike motor vehicle occupants, pedestrians are
not armored. They are ‘vulnerable road users’. Worldwide, far
more vulnerable road users die on the road than do motor
vehicle occupants. The main reason that this is not so in North
America is because nobody really walks anywhere any more—
not an altogether healthy circumstance.
Children are much more likely to be injured as pedestrians
than are adults, both because they do more walking and be-
cause they lack the skil ls, experience, and judgment to be safe
in traffic.
Education of children to improve road crossing behavior works
in principle (children’s behavior changes) but has not made
convincing differences to injury rates. I do not like this ap-
proach (as a sole approach) because it blames the victim, and
because attempts to change human nature or behavior are
generally less successful than attempts to make the environ-
ment safer for children. Making the road environment safer
for children includes multiple interventions. Speed limits in
built-up areas and around schools are of paramount impor-
tance. A chi ld struck at 35 km/hour has double the chances of
dying as one struck at 30 km/hour (The v squared in kinetic
energy!). Separating traffic from children, having sidewalks,
raised pedestrian crossings properly placed, crossing signals,
crossing guards, appropriate visibility can all allow cars andchildren an easier coexistence. Presence of outdoor parks and
playgrounds in a neighborhood reduces children’s pedestrian
risk by literally keeping them off the street.
Cyclists Cycling should be a healthy and safe activity, and yet
many child cyclists die in traffic each year. Motor vehicles are
almost always involved in fatal cycling crashes. Separation of
cycling from vehicles is an important environmental counter-
measure. Children should have bike paths completely free of
vehicular traffic for recreational cycling. It is more challeng-
ing to separate motor vehicles entirely from bicycles used for
transportation, but the excellent urban cycle paths in Amster-dam or Stockholm set an example of just how much this is
possible. Helmets are 85% effective at preventing head inju-
ries in cycle crashes, even when motor vehicles are involved.
Helmet use should be mandatory for children, the experience
with helmet legislation in Ontario showed a substantial de-
crease in cycle-related head injuries in children.
Sports and leisure injury in children While road traffic is
the most common context for injury death among children,
sports and leisure activities are the most common context for
injuries requiring hospital admission or emergency depart-
ment treatment. This group of injuries is also eminently ame-nable to prevention. Again, I favor environmental modifica-
tion as a strategy for injury control.
Playgrounds allow healthy and necessary physical play. Most
major injuries on playgrounds result from fal ls off play equip-
ment. Falling heights greater than 1.5 meters and inappropri-
ate falling surfaces are risk factors for injury. Standards for
playground construction exist in most countries. In 2000, the
Toronto Distr ict School Board abruptly removed playground
equipment from 136 schools because it was dangerously non-
compliant with standards. Safer equipment at 225 other
schools was left in place. We studied the injury rates at both
groups of schools. Before correction, the noncompliant play-
grounds had almost twice the injury rate per child than the
compliant ones. After the equipment was removed and re-
placed with safer equipment, the injury rates dropped by 50%.
The same sort of children did the same amount of playing, but
in a safer environment the injury risk was substantially re-
duced. It is gratifying for a pediatric orthopedic surgeon to
find out how to prevent supracondylar fractures!
Studying ice hockey has al lowed us to investigate the regula-
tory environment for sports. The province of Quebec does not
allow children to body check until the age of 14, whereas in
Ontario the age at which body checking is introduced was
lowered from 12 to 10 in 1998. Analysis of hockey injuries in
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Bibliography
1 A League Table of Child Deaths by Injury in Rich Nations.
UNICEF 2001 February.2 Beveridge M, Howard A (2004) The burden of orthopaedic
disease in developing countries. J Bone Joint Surg Am; Aug, 86-A(8):1819–1822.
3 Howard A, McKeag AM, Rothman L, et a l (2003)Ejections of young children in motor vehicle crashes. J Trauma; Jul; 55(1):126–129.
4 Howard A, McKeag AM, Rothman L, et a l (2005) Cervical spineinjuries in children restrained in forward-facing child restraints:a report of two cases. J Trauma; Dec; 59(6):1504–1506.
Andrew Howard Associate Professor,Divisions of Orthopaedic Surgery and PopulationHealth Sciences
University of Toronto, Hospital for Sick ChildrenToronto, [email protected]
the two provinces showed a greater than twofold increase in
the odds of injury where checking was al lowed, with a higher
proportion of head injuries and fractures resulting from body
checking. A simple change in regulations could prevent a lot
of injuries (and lost ice time) among children playing hockey
in Ontario. Without body checking the game would also im-
prove, with increased focus on skating, stick handling, and
puck skills.
The examples of playgrounds and ice hockey are not exhaus-tive for informal and organized sports and leisure activities.
Decreasing the amount of activity children undertake, or the
amount of fun they have, is not a necessary or desirable com-
ponent of injury control. Children need to be active; in fact
they need to be encouraged to live more actively than they do
today, but it is possible to do this in a safe environment. Im-
Fig 3
A dangerous playground.
Fig 4
A safer playground.
Falling height >2m here
Can fall onto concrete here
Surfacing in poor condition
proving the safety of sports and leisure activities, and of walk-
ing and cycling, makes it more likely that children will in-
crease their participation in healthy activities.
Summary Injury poses the greatest threat to life for children
in high income countries. Systematic efforts to reduce the in-
cidence, severity, and consequences of injury events can sub-
stantially reduce this death and disability burden. Orthopedic
surgeons are natural advocates for the injured. We can make
a big difference in our own communities by efforts to put in- jury control knowledge into practice. Think about the daily
lives of children you are involved with as a parent, coach, or
leader. What can make them safer: walking, cycling, or travel-
ing in cars? How can their recreational activities be made
safer? Thinking systematically through each area reveals
many potential improvements to be made.
5 Howard A, Rothman L, McKeag AM, et a l (2004) Children
in side-impact motor vehicle crashes: seating positions and injurymechanisms. J Trauma; Jun; 56(6):1276–1285.
6 Howard AW (2002) Automobile restraints for chi ldren:a review for clinicians. CMAJ; Oct 1; 167(7):769–773.
7 Howard AW, MacArthur C, Willan A , et al (2005) The effectof safer play equipment on playground injury rates among schoolchildren. CMAJ; May 24 ; 172(11):1443–1446.
8 Macpherson A, Rothman L, Howard A (2006) Body-checkingrules and childhood injuries in ice hockey. Pediatrics; Feb;117(2):e143–147.
expert zone cover story injury prevention
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Most frequent fractures of the carpusand tarsus in racing greyhoundsPart II
Alessandro Piras and Kenneth A Johnson
Central Tarsal Bone (CTB) Fractures The highest incidence
of CTB fractures (96%) occurs in the right leg and some of
these can be so devastating that they terminate the patient’s
racing career. There are several factors to consider for a thor-
ough understanding of how these fractures occur. During the
anti-clockwise racing in the bends, the right hind leg is pro-
curing propulsion but is also counteracting the centrifugal
forces (Fig 1). In this situation the central tarsal bone is acting
as the buttress for the medial aspect of the tarsus where all the
greatest compressive forces are applied as the dog is negotiat-
ing the curves. It has also been theorized by Kenneth Johnson
et al that adaptative remodeling due to cycling loading can
produce changes of the bone mineral density with micro-
cracks, predisposing to catastrophic fracture [2-3].
According to the shape and severity, fractures of the CTB have
been classified into five types [4]:
Type I dorsal slab fragment with no displacement
Type II dorsal slab fragment displaced
Type III medial fragment displaced
Type IV combination of dorsal slab fragment and medial slab
fragment more or less displaced
Type V comminuted fracture with several fragments
Types I – II and IV are the most common.
Clinical findings vary according to the severity of the fracture;
the tarsus can present a mild swelling on its dorsal aspect in
Types I and II; severe swelling with crepitation and evident
varus deformity are common findings in Types IV and V.
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Fig 2a–c
A Type II fracture of the central tarsal bone
treated with a 2.7 mm lag screw inserted in
a dorsoplantar direction.
a b c a b c d
Fig 1 A racing greyhound engaging a bend
at full speed. In this case the lef t tarsal region is
withs tanding the full weight and cent ripetal acce l-
eration.
Fig 3a–e
a–b Preoperative x-rays of a Type IV fracture of
the central tarsal bone.
c–d postoperative x-rays of the same fracture
repaired with a mediolateral 4.0 mm partiallytreated cancellous sc rew and a 2.7 mm
cortex screw inserted in dorsoplantar
direction in a lag fashion.
e intraoperative picture: two pointed reduction
forceps are holding the reduction during the repair.
e
Flexion of the tarsus elicits pain and slow return to weight
bearing.
Radiographic examination is mandatory to establish the se-
verity and type of fracture. Plantarodorsal to mediolateral and
lateromedial views are usual ly diagnostic; in Type I fractures
it is useful to apply stress in extension in the lateromedial
view to evaluate the degree of dislodgement of the slab; in
Types IV and IV it is useful to take oblique views to better
determine the amount of comminution and shape of the frag-
ments. With very few exceptions, CTB fractures require open
reduction and internal f ixation to achieve anatomical recon-
struction and real ignment of the tarsus to improve postinjury
prognosis [5].
The CTB is approached by a dorsomedial incision; surgical
fixation consists of repair using lag or positional screws. Sin-
gle dorsal slabs as in Types I and II are repaired with the inser-
tion of a dorsoplantar lag screw, usually of 2.7 mm or 2.0 mm
diameter (Fig 2).
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The rare Type III fractures are repaired with a single medio
lateral screw, although nonvisible at x-ray examination, a
nondisplaced dorsal slab is often detected at time of surgeryand should be repaired with an appropriate size lag screw in-
serted in dorsoplantar direction. In hundreds of fractures of
the CTB, the authors can only recall one genuine Type III.
Type IV fractures are traditionally repaired with a mediolat-
eral 4.0 mm partially treaded cancellous screw and a dorso
plantar 2.7 mm or 2.0 mm lag screw. The mediolateral screw
is inserted, ensuring that the treaded portion is sunk deep in
the fourth tarsal bone.
Type V fractures can be repaired with insertion of multiple lag
screws, small washers or a single-hole piece of veterinary cut-
table plate could be used to contain very small unfixable frag-ments. With the surgeon’s increased expertise and the flatten-
ing of the learning curve, together with the use of appropriate
instrumentation and mini implants, the number of Type V
fractures considered nonreparable is decreasing.
Although these fractures tend to be quite similar as reported
in the classif ication by Dee et al in 1976 [4], the variability of
the shape and position of the fragments can complicate thesurgery leading to unpleasant surprises. Recent preliminary
data indicate that the degree of comminution detectable with
CT scan is greater than could be appreciated, radiographically
suggesting that it will probably be necessary to review the
classif ication and the prognosis of these fractures.
Prognosis is usually very good for Types I, II and III, good to
fair for Type IV and fai r to poor for Type V, nonassociated to
other tarsal bone fractures. Although the authors’ preference
is always surgical repair, there are some reports that casting of
some CTB fractures has been successful, with some dogs re-
turning to their full performance.
After surgery, the dog is confined and the tarsus is supported
with a cast or a splint for a period variable from 3 to 4 weeks.
The cast should be removed as soon as the radiographic con-
trol shows signs of healing, starting a physiotherapy protocol
to reduce the recovery time.
Kenneth A Johnson
Ohio State University
Department of VeterinaryClinical SciencesColumbus, Ohio, USA
Alessandro Piras
Oakland Small AnimalVeterinary ClinicNewry, Northern Ireland, [email protected]
Bibliography
1 Boudrieau RJ, Dee JF, Dee LG (1984) Central tarsal bonefractures in the racing greyhound: a review of 114 cases. JAVMA; 184:1486–1491.
2 Johnson KA, Muir P, Nicoll RG, et al (2000) Asymmetric adaptivemodelling of central tarsal bones in racing greyhounds. Bone; 27:257–263.
3 Muir P, Johnson KA, Ruaux-Mason CP (1999) In vivo matrixmicrodamage in a naturally occurring canine fatigue fracture. Bone; 25_571–576.
4 Dee JF, Dee L , Piermattei DL (1976) Classification, managementand repair of central tarsal fractures in the racing greyhound.JAAHA; 12:398–403.
5 Boudrieau RJ, Dee JF, Dee LG (1984) Treatment of central tarsal bone frac tures in the raci ng greyhound. JAVMA; 184:1492–1500.
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VEPTR Treating three-dimensional thoraciceformity of early onset scoliosis
The Synthes Spine Vertical Expandable Prosthetic Titanium
Rib (VEPTR) allows new growth sparing surgical proceduresfor treatment of spine deformity in early childhood. The prime
FDA indication for its use is the presence of thoracic insuffi-
ciency syndrome [1], which is the inability of the thorax to
support normal respiration or lung growth. This syndrome is
most often due to three-dimensional thorax deformity. A
major shift in paradigm has occurred: spine deformity can no
longer be considered an isolated deformity, but rather should
be considered a component of the total thoracic deformity that
adversely impacts thoracic volume, function, and growth.
VEPTR is not a new “growing rod”; it is an instrumentation
that stabilizes volume enhancing thoracic reconstructions.
Specific VEPTR expansion thoracoplasties can address the
different anatomic volume depletion deformities of the thorax
[2] (Table I), indirectly correcting scoliosis without fusion, al-
lowing the thoracic spine to grow and contribute to thoracic
volume with probable benefit to the growth of the underlying
lungs. Early spine fusion, a growth inhibition procedure, does
not seem to address thoracic insufficiency syndrome (TIS)
with recent reports [3, 4, 5] emphasizing that early spine fu-
sion is associated with decreased vital capacity by maturity.
VEPTR is a “buy time” procedure, correcting the thoracic de-
formity early in life, so rib cage and spinal growth can nurture
lung development with definitive spine fusion postponed
until adolescence when thoracic volume is optimal. At this
time, unfortunately little is known about the normal inter-
relationship between spine, rib cage and lung growth, or how
spine deformity distorts the rib cage with loss of thoracic vol-
ume for lung growth, or how biomechanically the spine de-formity disables the thoracic ability to expand the lungs
through rib cage motion. While much remains to be learned,
some basic knowledge exists.
Lung growth is dependent on thoracic growth. The relation-
ship between chest and lung growth was emphasized as early
as 1947 by Eng [6]. In 1977, Roaf [7] emphasized that in sco-
liosis, movements of the chest wall did not increase the vol-
ume of the thorax with failure of development of the lungs. In
1979, Chopin [8], through CT scan study, first analyzed the
distortion of the rib cage in scoliosis. Two natural history
models of thoracic insufficiency syndrome (TIS), Jarco-Levin
Syndrome and Juene’s Asphyxiating Thoracic Dystrophy,
have a high mortality rate from restrictive lung disease sec-
ondary to severe congenital constriction of the chest. Volume
of the normal thorax depends on the rib cage providing width
and depth and thoracic spine providing height, and the vol-
ume is a function of age. Demiglio and Bonnel [9] reported
that the thorax is 6.7% adult volume at birth, enlarges to 30%
adult size by age 5, becomes only 50% adult size by age 10, but
doubles in size to adult volume by skeletal maturity. Lung
growth paral lels thoracic growth and the increase in lung size
depends on two mechanisms: alveolar cell multiplication that
is most rapid in the first two years of life and probably contin-
ues until at least age 8, then lung alveolar cell hypertrophy, an
important but poorly understood aspect of lung growth, en-
expert zone
Robert M Campbell, Jr
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larges the lung to adult size [10]. The normal
thorax has two important characterist ics: it must
have a normal volume, and the ability to changethat volume (thoracic function) through both
the primary breathing of the diaphragm and the
secondary breathing of rib cage expansion [1].
The thorax should be of optimal volume and
function by skeletal maturity, because aging ad-
versely affects pulmonary function. Normal vital
capacity decreases with time [11]. Children with
an abnormal thorax due to spine deformity and
associated chest wal l abnormality probably have
additional losses of vital capacity with aging,
with possible pulmonary morbidity and an ad-
verse effect on long-term survival.
The first prototype VEPTR operation was done in 1987 at our
institution, Christus Santa Rosa Children’s Hospital in San
Antonio, Texas, USA. Vertical Steinmann pins were used to
treat a potentially lethal congenital chest wall deficiency.
Postoperatively the chi ld was successfully weaned off his ven-
tilator within f ive days of surgery and his scol iosis improved.