Avinash Ortho & Trauma Care

Orthopaedic Trauma Association
From the OTA Committee on Health Policy and Planning

Orthopaedic Trauma Service Organization


More than half of patients admitted to most trauma centers have musculoskeletal injuries. Providing optimal care for these patients is an essential task for all trauma centers and trauma systems.

In North America, the definitive musculoskeletal care provider is an orthopaedic surgeon. Training in this specialty provides the necessary knowledge and skills for treating patients with fractures, dislocations, and injuries of ligaments, muscles, tendons, and cartilage.

All orthopaedic surgeons are not equally prepared to care for patients with serious injuries. Subspecialization within orthopaedics has led to significant advances in treatment of musculoskeletal conditions of all kinds, but with the inevitable result that distribution of expertise and skills is not uniform. The care of serious injuries, and of severely injured patients with (frequently multiple) musculoskeletal injuries has become an orthopaedic subspecialty area. While orthopaedic surgery residency training and board certification offer a general level of knowledge about the evaluation and treatment of skeletal trauma, they do not provide the orthopaedic generalist, or subspecialist in another field, with all the skills required for care of the seriously injured.

Fellowship training in orthopaedic traumatology is one way an orthopaedic surgeon can prepare for a career that focuses on definitive care of serious injuries. The necessary skills can also be obtained through residency training, self-study, collaboration with others who are practicing in the field, and appropriately chosen continuing medical education programs. All of these, in addition to frequent practice through direct care of seriously injured patients, are required for the surgeon to maintain his / her orthopaedic trauma skills. Most important is the orthopaedic surgeon's commitment to the care of injured patients, which means that he / she must demonstrate willingness to interrupt other activities, often at inconvenient times. This inevitably interferes with elective care of other patients, and with personal pursuits.

The goal of a well-organized trauma system is to ensure that each injured patient is promptly and safely delivered to a hospital that provides optimal, timely care for all injuries. This care does not conclude until the process of rehabilitation has been completed.

It is inappropriate for a hospital holding itself out as a trauma center to rely on a general orthopaedic call roster to provide optimal care of musculoskeletally injured patients. At the very least, every orthopaedic surgeon who will be involved with the care of trauma patients must explicitly demonstrate willingness to participate, and continuing evidence of personal commitment to the care of trauma patients.

It should not be expected that every trauma center will have continuous call coverage by fellowship-trained orthopaedic traumatologists. There are not enough of these individuals available, and many other orthopaedic surgeons are doing an excellent job of providing this care. However, orthopaedic trauma call coverage by uncommitted, perhaps less-than-totally willing, members of the hospital's orthopaedic staff is not appropriate if uniformly optimal care is the goal.

Each trauma center must develop its own solution for delivering optimal orthopaedic care for injured patients. This will require at least a small number of surgeons with expertise and commitment to orthopaedic traumatology. If the number of trauma subspecialists is small, provisions must be made to ensure that they are not overwhelmed by their duties. For example, some of the call coverage might be by other orthopaedic surgeons, who consult with and/or transfer patients to an orthopaedic trauma subspecialist when appropriate. Other institutions might choose to limit orthopaedic trauma coverage to a group of surgeons who have made a specific commitment to treat trauma patients. Typically, collaboration will be required to ensure that care is optimal for those patients whose injuries go beyond the area of concentration of one orthopaedic specialist. Spine, hand, sports, foot / ankle, pediatric and total joint specialists may each offer a valuable contribution to the care of specific injuries.

A trauma center will usually be served best by one surgeon's being designated as the Chief of Orthopaedic Trauma, in charge of administrative issues and quality assurance for orthopaedic trauma care. This individual may or may not be the hospital's Chief of Orthopaedic Surgery. He/She must be one of the on-call orthopaedic trauma surgeons. It is essential that the Chief of Orthopaedic Trauma work closely and effectively with the Trauma Medical Director (The surgeon in charge of the General Surgery Trauma Service).

The orthopaedic Performance Improvement (PI) program must be a part of that of the Trauma Service as a whole, since so many issues of orthopaedic trauma care interface directly with all other aspects of the injured person's care. While reports from the orthopaedic PI program must be submitted to the overall trauma PI program. However, the Trauma Medical Director needs support from the Chief of Orthopaedic Trauma, because, being a general surgeon, he/she does not have expert qualifications in the field of orthopaedic traumatology.

It is appropriate for a trauma center to establish its own policies for orthopaedic trauma care, consistent with its institutional resources and needs. Continuing reassessment of these resources, needs, and how well the needs are being met is the joint responsibility of the Chief of Orthopaedic Surgery, and the Trauma Medical Director.

The current edition of Resources for the Optimal Care of the Injured Patient, published by the American College of Surgeons, should be consulted as a guide to the organization of a hospital's trauma program. This text includes specific recommendations regarding orthopaedic trauma surgery (Chapter 9), and many other important features of trauma systems and trauma centers.

The surgeons participating in the orthopaedic trauma on-call roster should be a recognized group, communicating among themselves, and meeting as appropriate, under the direction of the "Chief of Orthopaedic Trauma". This group might be called the "Orthopaedic Trauma Service."

Examples of requirements that should be considered for membership on an institution's Orthopaedic Trauma Service are the following:

1) Certification and recertification by the ABOS (or, for new members of the staff, eligibility to take the ABOS oral examination).

2) Medical Staff membership

3) A requirement that trauma service members personally cover a significant percentage of their on-call days. (Goal is participation in sufficient numbers of resuscitations to maintain trauma skills.)

4) A requirement that the on-call orthopaedic surgeons maintain a certain maximal response time, interfacing appropriately with general surgery trauma, neurosurgeons, and ED physicians.

5) Attendance at an out-of-area trauma-related CME program annually, with willingness to discuss specifics at the monthly "trauma panel" meeting.

6) Attendance at a specified percentage of Orthopaedic Trauma Service Meetings.

7) Participation in the Quality Assurance Program, attending morbidity and mortality conferences, with willingness to discuss individual cases openly, as judged by the Director of Orthopaedic Trauma at the Medical Center.

8) Support of all trauma-related meetings at the medical center, by attending a specified percentage, and/or as a designated representative of the orthopaedic trauma service, i.e. General Trauma Surgery M&M, quality assurance, and any other related meetings.

9) Support of, and participation in Trauma Center Verification and other site visits as required by the institution to obtain / maintain its appropriate status.

10) A periodic review of all qualifications. Specification of a probationary period for members failing to meet criteria (example = 6 months), to enable an attempt at qualifying successfully. If not successful, the surgeon will be disqualified from the Trauma Service for a specified time period. (Certain issues such as excessive response time or failure to achieve Board Certification might be dealt with immediately, without a probation period.)

11) Sufficient advance notice is required before a member of the on-call Trauma Service voluntarily resigns (to minimize impact on the call schedule for the other members).

It is essential that a trauma center consider the impact that it has on the practices and lives of its orthopaedic trauma surgeons. Their recruitment, development, and retention are essential for ensuring quality care. Hospitals typically require participation in on-call lists as a requirement for continuing Medical Staff membership. The burdens assumed by on-call surgeons are not necessarily equally divided. The on-call orthopaedic trauma surgeon may find that his/her duties are adequately reimbursed by payments for care of trauma patients. In some trauma centers, institutional support may be required to provide adequate compensation for call duties, including the continuing care of uninsured patients which may in large part be carried out in the surgeon's private office, after the patient is discharged from the trauma center. Policies for reimbursement of orthopaedic traumatologists must be developed with awareness of the impact that commitment to orthopaedic traumatology has on an elective orthopaedic practice.

To ensure that quality care is provided for patients with musculoskeletal injuries, it is appropriate that a trauma center provide the essential resources.

The Orthopaedic Trauma Association believes essential supporting resources for optimal care of patients with musculoskeletal injuries include the following categories:

A) Staff : 1. Orthopaedic surgeons with a commitment to the care of injured patients. 2. Supporting staff in operating rooms, wards, and clinics, and 3. Administrative staff, for record keeping, quality assurance, research, and business purposes. (Supporting medical staff include anesthesia / pain management, trauma surgery, neurosurgery, critical care, plastic surgery, nutrition, rehabilitation, neurology, infectious disease, internal medicine, etc.)

B) Staff Development Resources include time and funding for onsite and offsite educational programs.

C) Space : An accessible operating room, 24 hours a day, 7 days a week, with anesthesia, nurses and technologists familiar with orthopaedic trauma care procedures. A well-equipped and staffed ED orthopaedic area. A cast-room or equivalent area on or adjacent to inpatient wards.

D) Services : (24/7 Radiology, in ED, OR (including C-arm fluoroscopy), and Hospital wards, with adequate staff and facilities for timely standard (department and portable) radiographs, CT, MRI, ultrasound, and special procedures.

E) Equipment : Modern orthopaedic beds with frames for mobility aids, support / suspension and traction; modern instrumentation for wound care (debridement, lavage, and temporary or definitive closure), and fracture fixation (plates & screws, intramedullary nails, and external fixators.) Adequate resources for information management are essential - computers and support, medical records systems and staff, etc. Provision for an orthopaedically relevant Trauma Registry is essential for performance improvement and clinical knowledge development.

F) Supplies : To be determined in consultation with the Orthopaedic Trauma Service: For example, fracture-fixation implants, joint replacement prostheses, appropriate hand and power instruments, and disposable equipment (drill bits, reamers, etc.), bone cement, bone graft substitutes, splinting and casting equipment, prefabricated braces, etc.

Reasonable Performance Goals : might include the following: Timely operation for open fractures, and for hip fractures (consistent with medically fitness). Patients with multiple trauma should have timely stabilization of long bone and pelvis fractures, unless medically inappropriate. Patients with fractures and associated limb-threatening vascular injuries will be in the OR promptly after arrival, unless medically contraindicated, 100% of X-rays will be available wherever and whenever needed, 100% of in-patient medical records will be available whenever needed for outpatient care, etc.