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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: dialogue@aofoundation.org

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 

aotile@rogers.com

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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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

dialogue@aofoundation.org 

 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

rre72@yahoo.co.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

muhammad.wajid@aku.edu

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

 jarbru@mp.pl

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

suthorn@bumrungrad.com

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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

esther.stoop@aofoundation.org

 Thomas RüediFounding Member of

AO Foundation

thomas.ruedi@aofoundation.org

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

k.u.b.lowka@t-online.de

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 o@globo.c om

Cléber PaccolaSão Paulo, Brazil

cajpacco@fmrp.usp.br

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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18 2 | 06

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, UKkeith.willett@orthopaedic-surgery.oxford.ac.uk

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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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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, OntarioCanadaandrew.howard@sickkids.ca

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

 johnson.2064@osu.edu

Alessandro Piras

Oakland Small AnimalVeterinary ClinicNewry, Northern Ireland, UKalexpvet@btclick.com

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.