02 Sep 2020

Volume 8 Issue 3

From the Executive Editor

Behind every fragility fracture is a bigger picture. Behind the hip fracture on the cover of this JTO the bigger picture is that of my Mum and Dad on their 60th wedding anniversary standing in the steam of the Orient Express. In their late eighties they bowled, argued, had a various ailments and a pushy son; in fact they were ‘people’. However, should one of them have fallen over they may well have become a ‘NOF’. The labels, generalisations and preconceptions of our daily practice may be a route to an efficient pathway but are often a veneer that conceals or even promotes prejudice. Curiously, there was a time when being labelled a ‘NOF’ was a disadvantage as it led to delayed treatment delivered by juniors at the wrong time of day. Then there was a time when the ‘hip fracture’ label got you better treatment than your contemporaries with less lucrative fractures; you would be seen by a physician and put first on the list. We long for a utopia where the bigger picture is sought and recognised and the injured frail are treated on the basis of their individual needs. This issue explores various aspects of this large component of our trauma work.

The Fragility Fracture Network (FFN) UK is introduced by Matt Costa page 52. He describes it as being not a new Society but rather a network of activists to collate and share best practice. The articles that follow explore the problems and potential solutions of the injured frail. Hip fractures are readily accepted as being squarely in the province of the T&O surgeon but rib fractures are more of a Cinderella condition, with the potential to be admitted under the care of any of a number of specialities; always a risky situation for the patient. A constructive approach is to co-operate as is described in ‘Rib fracture management in the older adult; an opportunity for multidisciplinary working’, page 58. Once you have read the articles relating to the care of the injured frail you will likely be fully convinced of the need for constructive co-operative care. Now read ‘Workforce challenges in orthogeriatrics’. The demand far outstrips the supply of orthogeriatricians. Whilst this shortfall continues we must use the skills of those orthogeriatricians that we do have to their best effect. I suspect this will be by way of specialist nurse support and collaborative use of junior staff. We then need to play our part in making orthogeriatrics an attractive career choice. Ironically it ticks many of the boxes that we all considered before and then spouted out in our medical student interview ‘caring, diverse, holistic etc’ but does not have the kudos it deserves and has the significant barrier of years as the RMO.

If we are to change perceptions and adverse labels then we must consider what we can and cannot influence; idle pontification may be therapeutic for the speaker but is otherwise unproductive. ‘A networking event can reduce negative perceptions that deter female medical graduates from pursuing orthopaedic surgery’, page 34 describes how we may help repaint the landscape. The implication is that the white older male should accept that whilst they can support diversity it really does help to have role models. What an ideal time to hand the baton of the JTO Editorship to such a role model and wish Deborah Eastwood well.

Bob Handley, Vice President Elect


Subspecialty Section


A networking event can reduce negative perceptions that deter female medical graduates from pursuing orthopaedic surgery

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  3. Rao RD, Khatib ON, Agarwal A. Factors Motivating Medical Students in Selecting a Career Specialty: Relevance for a Robust Orthopaedic Pipeline. J Am Acad Orthop Surg. 2017;25(7):527-35.
  4. Bucknall V, Pynsent PB. Sex and the orthopaedic surgeon: a survey of patient, medical student and male orthopaedic surgeon attitudes towards female orthopaedic surgeons. Surgeon. 2009;7(2):89-95.
  5. Peters K, Ryan M, Haslam SA, Fernandes H. To belong or not to belong: Evidence that women’s occupational disidentification is promoted by lack of fit with masculine occupational prototypes. Hogrefe Publishing; 2012. p. 148-58.
  6. Subramanian P, Kantharuban S, Subramanian V, Willis-Owen SAG, Willis-Owen CA. Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study. BMJ. 2011;343:d7506-d.
  7. Barnes KL, McGuire L, Dunivan G, Sussman AL, McKee R. Gender Bias Experiences of Female Surgical Trainees. J Surg Educ. 2019;76(6):e1-e14.
  8. Peters K, Ryan MK, Haslam SA. Marines, medics, and machismo: Lack of fit with masculine occupational stereotypes discourages men's participation. Br J Psychol. 2015;106(4):635-55.
  9. Hill E, Vaughan S. The only girl in the room: how paradigmatic trajectories deter female students from surgical careers. Med Educ. 2013;47(6):547-56.
  10. Farooq S, Kang S-N, Ramachandran M. Sex, power and orthopaedics. J R Soc Med. 2009;102(4):124-5.
  11. Lewis VO, Scherl SA, O’Connor MI. Women in Orthopaedics—Way Behind the Number Curve. JBJS. 2012;94(5):e30.
  12. Ek EW, Ek ET, Mackay SD. Undergraduate experience of surgical teaching and its influence and its influence on career choice. ANZ J Surg. 2005 Aug;75(8):713-8.
  13. Okike K, Phillips DP, Swart E, O'Connor MI. Orthopaedic Faculty and Resident Sex Diversity Are Associated with the Orthopaedic Residency Application Rate of Female Medical Students. J Bone Joint Surg Am. 2019;101(12):e56.
  14. Childs S, Krook ML. Critical Mass Theory and Women's Political Representation. Political Studies. 2008;56(3):725-36.
  15. Harrington MA, Rankin EA, Ladd AL, Mason BS. The Orthopaedic Workforce Is Not as Diverse as the Population It Serves: Where Are the Minorities and the Women?: AOA Critical Issues Symposium. J Bone Joint Surg Am. 2019;101(8):e31.
  16. Bellini MI, Graham Y, Hayes C, Zakeri R, Parks R, Papalois V. A woman's place is in theatre: women's perceptions and experiences of working in surgery from the Association of Surgeons of Great Britain and Ireland women in surgery working group. BMJ Open. 2019;9(1):e024349.
  17. Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Quality of life during orthopaedic training and academic practice. Part 1: orthopaedic surgery residents and faculty. J Bone Joint Surg Am. 2009;91(10):2395-405.
  18. Lambert TW, Smith F, Goldacre MJ. The impact of the European Working Time Directive 10 years on: views of the UK medical graduates of 2002 surveyed in 2013-2014. JRSM Open. 2016;7(3):2054270416632703.
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100 years of BOA nerve repair

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2. A Dissertation on the Treatment of Morbid Local Affections of Nerves. Edinb Med Surg J. 1821(68):424-41.

3. Guillery RW. Relating the neuron doctrine to the cell theory. Should contemporary knowledge change our view of the neuron doctrine? Brain Res Rev. 2007;55(2):411-21.


5. Hernaman-Johnson F. The Use of Condensers in the Diagnosis, Prognosis, and Treatment of Nerve Lesions. Proc R Soc Med. 1916;9(Surg Sect):1-22.




9. Tinel J. Le signe du fourmillement dans les lésions des nerfs périphériques. Presse Med. 1915;23:388.

10. Jacobson WH. The Healing of Nerves." Ann Surg. 1902;36(4):627-38.


Hanigan W. The development of military medical care for peripheral nerve injuries during World War I. Neurosurg Focus 2010;28(5):E24.

13. Jones R. The problem of the disabled. JBJS. 1918;2(5):273-90.

14. Jones R. Orthopaedic surgery of injuries. H. Frowde, 1921.

15. Mostofi SB. (editor). Who’s Who in Orthopedics. London, Springer London, 2005.

16. Hagy M. "Keeping up with the Joneses"-the story of Sir Robert Jones and Sir Reginald Watson-Jones. Iowa Orthop J. 2004;24:133-7.

Nursing standards and fragility fracture outcomes

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  2. MacDonald V, Butler-Maher A, Mainz H, Meehan A, Brent L, Hommel A, et al. Developing and testing an international audit of nursing quality indicators for older adults with fragility hip fracture. Orthop Nurs. 2018;37(2):115-121.
  3. Meehan A, Butler Maher A, Brent L, Copanitsanou G, Cross J, Kimber C, et al. The International Collaboration of Orthopaedic Nursing (ICON): Best practice nursing care standards for older adults with fragility hip fracture. Int J Orthop Trauma Nurs. 2019;32:3-26.
  4. Hertz K, Santy-Tomlinson J. (2017) The nursing role. In: Falaschi P, Marsh D (eds) Orthogeriatrics. Springer, Cham, pp 131–144.
  5. Drennan V, Ross F. Global nurse shortages—the facts, the impact and action for change.

    Br Med Bull. 2019;130(1):25-37.

  6. Aiken L, Sloane D, Bryneel L, Van den Heede K, Griffiths P, Busse R, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014;383(9931):1824-30.

  7. Brent L, Hommel A, Butler Maher A, Hertz K, Meehan A, Santy-Tomlinson J. Nursing care of fragility fracture patients. Injury. 2018;49(8):1409-12.

  8. UK Parliament, Commons Select Committee: Health (2018). The Nursing Workforce. Available at:  https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/353/35304.htm.

FFN UK - Orthogeriatric medicine

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  2. Irvine RE, Devas MB. The geriatric orthopaedic unit. J Bone Jt Surg. 1963;49:186-7.
  3. British Orthopaedic Association and British Geriatric Society. The Care of Patients with Fragility Fracture (Blue Book). British Orthopaedic Association; East Sussex, UK: 2007.
  4. The National Institute for Health and Care Excellence (NICE) (2017). Hip fracture: management - Clinical guideline [CG124]. Available at: https://www.nice.org.uk/guidance/cg124.
  5. The National Institute for Health and Care Excellence (NICE) (2017). Hip fracture in adults [QS16]. Available at: https://www.nice.org.uk/guidance/qs16.
  6. The Royal College of Surgeons (2019). The National Hip Fracture Database - NHFD 2019 annual report. Available at: https://www.nhfd.co.uk.
  7. Patel NK, Sarraf KM, Joseph S, Lee C, Middleton FR. Implementing the National Hip Fracture Database: an audit of care. Injury. 2013;44:1934-9.
  8. Lisk R, Yeong K. Reducing mortality from hip fractures: a systematic quality improvement programme. BMJ Qual Improv Rep. 2014;3(1):u205006.w2103.
  9. NHS England (2019). 2019/20 National Tariff Payment System – A consultation notice: Annex DtD Guidance on best practice tariffs. Available at: https://improvement.nhs.uk/documents/484/Annex_DtD_Best_practice_tariffs.pdf.
  10. Neuburger J, Currie C, Wakeman R, Johansen A, Tsang C, Plant F, et al. Increased orthogeriatrician involvement in hip fracture care and its impact on mortality in England. Age Ageing. 2017;46:187-92.
  11. The National Institute for Health and Care Excellence (NICE) (2013). Falls in older people: assessing risk and prevention [CG161]. Available at: https://www.nice.org.uk/guidance/cg161.

Rib fracture management in the older adult; an opportunity for multidisciplinary working

  1. Kehoe A, Smith JE, Edwards A, Yates D, Lecky, F. The changing face of major trauma in the UK. Emerg Med J. 2015;32(12):911-5.
  2. Ziegler DW, Agarwal NN. The morbidity and mortality of RIB fractures. J Trauma. 1994;37(6):975-9.
  3. National Office of Clinical Audit (NOCA). Major Trauma Audit National Report 2016 Key Findings. Available at: https://www.noca.ie/audits/major-trauma-audit-national-report-2016-key-findings.
  4. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma. 2000;48(6):1040-6; discussion 1046-7.
  5. Bergeron E, Lavoie A, Clas D, Moore L, Ratte S, Tetreault S, et al. Elderly trauma patients with rib fractures are at greater risk of death and pneumonia. J Trauma. 2003;54(3):478-85.
  6. Barry R, Thompson E. Outcomes after rib fractures in geriatric blunt trauma patients. Am J Surg​​​​. 2018;215(6):1020-3.
  7. Todd SR, McNally MM, Holcomb JB, Kozar RA, Kao LS, Gonzalez EA, et al. A multidisciplinary clinical pathway decreases rib fracture-associated infectious morbidity and mortality in high-risk trauma patients. Am J Surg. 2006;192(6):806-11.
  8. Livingston DH, Shogan B, John P, Lavery RF. CT diagnosis of rib fractures and the prediction of acute respiratory failure. J Trauma. 2008;64(4):905-11.
  9. National Institute for Health and Care Excellence (NICE) (2016). Major trauma: assessment and initial management [NG39]. Available at: https://www.nice.org.uk/guidance/ng39.
  10. Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. 

    Eur J Cardiothorac Surg. 2003;23(3):374-8.

  11. Battle CE, Hutchings H, Lovett S, Bouamra O, Jones S, Sen A, et al. Predicting outcomes after blunt chest wall trauma: Development and external validation of a new prognostic model. Crit Care. 2014;18(3):R98.

  12. Fokin A, Wycech J, Crawford M, Puente I. Quantification of rib fractures by different scoring systems. J Surg Res. 2018;229:1-8.

  13. Pressley CM, Fry WR, Philp AS, Berry SD, Smith RS. Predicting outcome of patients with chest wall injury. Am J Surg. 2012;204(6):910-3; discussion 913-4.

  14. Abbey J, Piller N, De Bellis A, Esterman A, Parker D, Giles L, Lowcay B. The Abbey pain scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliat Nurs. 2004;10(1):6-13.

  15. O’Connell KM, Quistberg DA, Tessler R, Robinson BRH, Cuschieri J, Maier RV, et al. Decreased risk of delirium with use of regional analgesia in geriatric trauma patients with multiple rib fractures. Ann Surg. 2018;268(3):534-40.

  16. Harrop-Griffiths W, Cook TGill HHill DIngram MMakris M, et al. Regional anaesthesia and patients with abnormalities of coagulation: The Association of Anaesthetists of Great Britain & Ireland the Obstetric Anaesthetists’ Association Regional Anaesthesia UK. Anaesthesia. 2013;68(9):966-72.

  17. Thiruvenkatarajan V, Cruz Eng H, Adhikary SD. An update on regional analgesia for rib fractures. Curr Opin Anaesthesiol. 2018;31(5):601-7.

  18. Simon JB, Wickham AJ. Blunt chest wall trauma: An overview. Br J Hosp Med (Lond). 2019;80(12):711-5.

  19. May, L, Hillermann C, Patil S. Rib fracture management. BJA Educ. 2016;16:26-32.

  20. Granetzny A, Abd El-Aal M, Emam E, Shalaby A, Boseila A. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. 2005;4(6):583-7.

  21. Tanaka H, Yukioka T, Yamaguti Y, Shimizu S, Goto H, Matsuda H, Shimazaki S. Surgical stabilization of internal pneumatic stabilization? a prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52(4):727-32; discussion 732.

  22. Marasco SF, Davies AR, Cooper J, Varma D, Bennett V, Nevill R, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg. 2013;216(5):924-32.

  23. Pieracci FM, Leasia K, Bauman Z, Eriksson EA, Lottenberg L, Majercik S, et al. A multicenter, prospective, controlled clinical trial of surgical stabilization of rib fractures in patients with severe, nonflail fracture patterns (Chest Wall Injury Society NONFLAIL). J Trauma Acute Care Surg. 2020;88(2):249-57. 

Fragility Fractures, Frailty and Fragmented Care

  1. Kehoe A, Smith JE, Edwards A, Yates D, Lecky, F. The changing face of major trauma in the UK. Emerg Med J. 2015;32(12):911-5.
  2. The Trauma Audit and Research Network (TARN) (2017). Major Trauma in Older People – 2017 Report. Available at: https://www.tarn.ac.uk/Content.aspx?c=3793.
  3. Campbell AJ, Buchner DM. Unstable disability and the fluctuations of frailty. 

    Age Ageing. 1997;26(4):315-8.

  4. Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013;381(9868):752-62.

  5. Vetrano DL, Palmer K, Marengoni A, Marzetti E, Lattanzio F, Roller-Wirnsberger R, et al. Frailty and multimorbidity: A systematic review and meta-analysis. J Gerontol A Biol Sci Med Sci. 2019;74(5):659-66.

  6. Van De Ree CLP,  Landers MJF, Kruithof N, de Munter L, Slaets JPJ, Gosens T, de Jongh MAC et al. Effect of frailty on quality of life in elderly patients after hip fracture: A longitudinal study. BMJ Open. 2019;9(7):e025941.

  7. Partridge JSL, Harari D, Martin FC, Peacock JL, Bell R, Mohammed A, Dhesi JK. Randomized clinical trial of comprehensive geriatric assessment and optimization in vascular surgery. Br J Surg. 2017;104(6):679-87.

  8. Eamer G, Taheri A, Chen SS, Daviduck Q, Chambers T, Shi X, Khadaroo RG. Comprehensive geriatric assessment for older people admitted to a surgical service. Cochrane Database Syst Rev. 2018;1(1):CD012485.

  9. Ellis G, Whitehead MA, O’Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital: Meta-analysis of randomised controlled trials. Cochrane Database Syst Rev. 2011;(7):CD006211.

  10. Ellis G, Gardner M, Tsiachristas A, Langhorne P, Burke O, Harwood RH, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. 2017;9(9):CD006211.

  11. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, Mitnitski A. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489-95.

  12. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526-9.

  13. Hewitt J, Carter B, Vilches-Moraga A, Quinn TJ, Braude P, Verduri A, et al. The effect of frailty on survival in patients with COVID-19 (COPE): a multicentre, European, observational cohort study. Lancet Public Health. 2020;5(8):e444-e451.

  14. British Orthpaedic Association (2019). BOA Standards for Trauma and Orthopaedics: The care of the older or frail orthopaedic trauma patient. Available at: https://www.boa.ac.uk/resources/boast-frailty.html.

  15. Richardson L, Windsor F, Spence JN, Ralhan S,& HardwickJ. Best Practice Tariffs in Trauma – only half the battle for Geriatricians. [Poster Abstract EL204.1/5]. Presented at EBPOM: Annual London Congress of Perioperative Medicine (2020).

Workforce challenges in orthogeriatrics

  1. The Royal College of Surgeons (2019). The National Hip Fracture Database - NHFD 2019 annual report. Available at: https://www.nhfd.co.uk.
  2. National Institute for Health and Clinical Excellence (NICE) (2020). COVID-19 rapid guideline: critical care in adults. NICE guideline [NG159] [cited 2020 Jul 16]. Available at: https://www.nice.org.uk/guidance/ng159.
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A networking event can reduce negative perceptions that deter female medical graduates from pursuing orthopaedic surgery

Appendix 1: Survey questions before and after event 

Pre-event survey

1. What is your gender?

2. What age range do you belong to?

3. What high school did you go to?

4. What profession do your parents belong to?

5. What stage are you in your medical career?

6. What specialty/specialties in medicine are you aspired to pursue?

Post-event survey

1. What is your gender?

2. On registration, we asked if you had a question that you would like answered during the event. Is that question answered?

3. We also asked if you had a specific objective you would like to achieve out of this event. Has that objective been achieved?

4. After this event, what is your view now about the following perceived barriers to women

pursuing orthopaedics? (answer from both females and males are welcome). Please tick only

one option "A" or "B" for each pair of options

1A. The "old boys club" culture seems to be less prevalent now and unlikely to stop aspired women from pursuing orthopaedics

1B. No change. The surgical culture of orthopaedics is that of an "old boys club" and women do not fit into that culture well

2A. Sexism is no longer so prevalent and tolerated now. A woman surgeon's life in orthopaedics can be good most of the time or at least equivalent to that in other surgical specialties.

2B. No change. Sexist and discriminatory attitude observed in orthopaedics can make life of a woman in this field very hard at times

3A. Women are strong enough to do orthopaedics, plus working conditions are changing (e.g. motorized tools) to make orthopaedic physically possible for women.

3B.Generally speaking, women are not as physically strong as men. Yet orthopaedics is a physically demanding specialty

4A. A work-life balance is not a unicorn and can be obtained by most women in orthopaedics

4B. Orthopaedic surgeons' lifestyle and training does not accommodate a family life very well

5A. Orthopaedics for women is not as isolating as it used to be. Quite a few successful ones are around.

5B. There are not enough women in orthopaedics currently so it can feel lonely, isolated and quite hard being a

woman in this specialty

Other (please specify)

5. Has the event provided you with some valuable ideas/solutions regarding how to break down personal barriers to pursuing a career in Orthopaedic Surgery?

6. Has the event provided you with some encouragement and aspiration towards pursuing orthopaedics as a career?

7. We may hold another event like this next year (similar theme, different content). Would you like to be invited to that one?

7. Is there any question would you like answered during this event?

8. Is there any specific objective you would like to achieve out of this event?

9. What do you think is/are the biggest barrier(s) to women pursuing orthopaedic surgery?

(answer from both females and males are welcome)

  • The surgical culture of orthopaedics is that of an "old boys club" and women do not fit into that culture well
  • Sexist and discriminatory attitude observed in orthopaedics can make life of a woman in this field very hard at times
  • Generally speaking, women are not as physically strong as men. Yet orthopaedics is a physically demanding specialty
  • Orthopaedic surgeons' lifestyle and training does not accommodate a family life very well
  • There are not enough women in orthopaedics currently so it can feel lonely, isolated and quite hard being a woman in this specialty
  • Other (please specify)


10. What are the potential barriers to pursuing a career in Orthopaedic Surgery for you personally?


11. What would be most helpful to encourage you to pursue orthopaedic * surgery?

Culture shift with less sexism so I feel that I belong and encouraged to succeed

A more diverse environment e.g. seeing more females being successful in orthopaedics

Seeing that it is possible to have a good work-life balance in orthopaedics

Career opportunities with a focus in women, to "level the playing field" somewhat

Other (please specify)