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A SIGN technique sawbones session provided one of many educational opportunities during the conference.
Courtesy of SIGN Fracture Care International

AAOS Now

Published 4/1/2015
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Lewis G. Zirkle Jr, MD

SIGN Conference Addresses Growing Challenge of Trauma Care

Surgeons from around the world explore treatments for severe injuries

Lewis G. Zirkle Jr, MD

Developing countries around the world, as identified by the United Nations, range from economic giants India and China to impoverished Haiti and Sudan. Despite their differences, these countries have many of the same problems, including high rates of severe orthopaedic injuries and lack of access to adequate care. Every year, 30 million people across the developing world sustain traumatic injuries, such as fractures in motor vehicle accidents. All too often, the lack of proper care results in permanent disability.

As the rate of traumatic injuries around the world continues to grow, SIGN Fracture Care International is working to provide specialized orthopaedic trauma care in 53 developing countries. SIGN assists surgeons through education and donation of implants that can be used in these developing countries.

Last fall, 150 orthopaedic surgeons from 30 developing countries as well as the United States and Canada attended the 2014 SIGN Conference, a 4-day event in Richland, Wash., to discuss providing orthopaedic trauma care for these underserved populations. During the conference, experts explored recent research and techniques for treating traumatic injuries when access to surgical implants, instruments, and imaging equipment is limited. Attendees also participated in SIGN sawbones exercises, bone deformity correction, Ponseti lectures and workshops, and shared their meals together, promoting collegiality among attendees.

Fifty surgeons also participated in the Surgical Management and Reconstructive Training (SMART) course held at San Francisco General Hospital and Trauma Center in conjunction with the SIGN Conference. During the SMART surgical skills course, sponsored by the Institute for Global Orthopaedics, attendees received hands-on training about limb salvage and flap procedures.

Asking “beautiful questions”
Although the 2014 SIGN Conference focused on the treatment of difficult fractures around the world, a common thread running through it was based on the book A More Beautiful Question: The Power of Inquiry to Spark Breakthrough Ideas by Warren Berger. In this work, the author encourages readers to ask thought-provoking, potentially life-changing questions that challenge the status quo and foster action and innovation. For surgeons, asking a “beautiful question” means learning about and challenging a certain subject and then potentially changing the way care is delivered to patients.

One “beautiful question” asked whether new methods could be found for treating high-energy open fractures, common injuries in developing countries. Ross K. Leighton, MD, then the president of the Orthopaedic Trauma Association, provided an overview of the principles of open fracture treatment. SIGN surgeons then presented the protocols and innovations they have developed for treating open fractures and osteomyelitis with scarce resources, including limited operating room time. Antibiotic administration, the use of bleach for irrigation fluid and methyl methacrylate for bone spacers, the need for repetitive débridements, and the timing of intramedullary nail insertion were among the topics discussed.

The larger question attendees explored was “How can SIGN surgeons treat the increasing number of patients who sustain traumatic injuries each year?” New instruments for faster reduction of fractures and more effective bone grafting techniques are also greatly needed.

Because fracture reduction more than 10 days after injury generally doubles the length of surgery, strategies to reduce the time from injury to surgery to less than 1 week are also required. Discussions centered on developing an integrated, collaborative surgery center network as a means of treating more fractures with limited personnel and supplies. Patients would be sent promptly to a trauma center by surrounding hospitals, have timely surgery for their fractures, and return to the referring hospitals for follow-up care.

Participants also noted that new protocols for patient transfer and operating room procedures, as well as new construction of short-stay trauma centers, would help facilitate treatment of trauma patients. Finally, attendees noted that collaboration with governments, local personnel, teaching organizations, and hospitals regarding patient care must be ongoing.

Request for input
SIGN Fracture Care International solicits AAOS members’ comments regarding potential strategies for successfully treating the increasing numbers of severely injured patients in developing countries. Please email me directly at
Lewis.Zirkle@signfracturecare.org or contact me via the website, www.signfracturecare.org

Lewis G. Zirkle Jr., MD, is the founder of SIGN Fracture Care International and was the recipient of the 2007 AAOS Humanitarian Award.