Springer Nature is making Coronavirus research free. View research | View latest news | Sign up for updates

The role of a trauma review system and development of intra-operative checklists in improving the quality of fracture fixations in a high volume tertiary centre

  • 4 Accesses



In high volume centres, audits are essential to ensure good surgical techniques and fracture fixations to avoid complications, revision surgeries and poor outcomes. A method to assess fixations for fractures of different regions employing different implants and surgical demands is a challenge. We present here a simple method of review and follow-up work flow of more than 6000 fixations every year that helped in improving outcomes and also provide training for residents and junior staff.

Materials and methods

The results of 6348 fracture fixations in 2014, led to a trauma review system in January 2015 to classify all fracture fixations by senior consultants into three categories: category A (good fixations); category B (acceptable fixations; need further follow-up); category C (poor/unacceptable fixations needing revision) combined with a teaching program. A strategy was evolved that included the following practices: (1) identifying ‘red flag’ fractures that led to frequent failures, (2) routine senior surgeons’ involvement in such fractures, (3) evolving ‘intra-operative checklists’, (4) requirement of senior surgeons’ intervention if there was a ‘fiddle time’ of more than 20 min, and (5) approval of post-fixation c-arm image by a senior person before closure. The impact of these rules on the fixations for 2015, 2016 and 2017 were prospectively analysed.


In the years 2015, 2016 and 2017 the number of fracture fixations performed were 6579, 6978 and 7012, respectively. There was a significant increase (p < 0.001) in the number of category A fixations (87.7%, 94.6% and 96.3% in 2015, 2016 and 2017, respectively) and also a decrease in the number of category C fixations (2.23%, 0.7% and 0.2% in 2015, 2016 and 2017, respectively). The quality of fixations of the ‘red flag’ fractures also improved.


We present here a very effective, tested, simple and easily reproducible method of audit and follow-up work flow that can be used in all high turnover trauma centres to improve outcomes and can also serve as a teaching resource for junior staff.

Study design

Prospective study.

Level of evidence

Level II.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2



Arbeitsgemeinschaft für Osteosynthesefragen


Getting it right first time


  1. 1.

    Drosos GI, Bishay M, Karnezis IA, Alegakis AK. Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures. J Bone Jt Surg Br. 2006;88(2):227–31.

  2. 2.

    Yeranosian M, Horneff JG, Baldwin K, Hosalkar HS. Factors affecting the outcome of fractures of the femoral neck in children and adolescents: a systematic review. Bone Jt J. 2013;95-B(1):135–42.

  3. 3.

    Lachiewicz PF, Funcik T. Factors influencing the results of open reduction and internal fixation of tibial plateau fractures. Clin Orthop Relat Res. 1990;259:210–5.

  4. 4.

    Sochart DH. Poor results following internal fixation of displaced subcapital femoral fractures: complacency in fracture reduction. Arch Orthop Trauma Surg. 1998;117(6–7):379–82.

  5. 5.

    Parker MJ, Kendrew J, Gurusamy K. Radiological predictive factors in the healing of displaced intracapsular hip fractures. A clinical study of 404 cases. Hip Int. 2011;21(4):393–8.

  6. 6.

    Briggs T. GIRFT, that's the main thing. BMJ. 2018;360:k1188.

  7. 7.

    Dijkink S, Nederpelt CJ, Krijnen P, Velmahos GC, Schipper IB. Trauma systems around the world: a systematic overview. J Trauma Acute Care Surg. 2017;83(5):917–25.

  8. 8.

    McDermott FT. Trauma audit and quality improvement. Aust N Z J Surg. 1994;64(3):147–54.

  9. 9.

    Davis JW, Hoyt DB, McArdle MS, Mackersie RC, Eastman AB, Virgilio RW, Cooper G, Hammill F, Lynch FP. An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement. J Trauma. 1992;32(5):660–5 (discussion 665–6).

  10. 10.

    Helfen T, Siebenbürger G, Fleischhacker E, Biermann N, Böcker W, Ockert B. Open reduction and internal fixation of displaced proximal humeral fractures. Does the surgeon's experience have an impact on outcomes? PLoS ONE. 2018;13(11):e0207044.

  11. 11.

    Patra SK, Shetty AP, Jayaramaraju D, Rajasekaran S. Radiation exposure to the surgeon, surgical assistant, and scrub nurse during closed intramedullary nailing of long bones-does it vary depending on the experience of the surgeon? J Orthop Trauma. 2019;33(2):e52–e5757.

  12. 12.

    Cahill PJ, Pahys JM, Asghar J, Yaszay B, Marks MC, Bastrom TP, Lonner BS, Shah SA, Shufflebarger HL, Newton PO, Betz RR, Samdani AF. The effect of surgeon experience on outcomes of surgery for adolescent idiopathic scoliosis. J Bone Jt Surg Am. 2014;96(16):1333–9.

  13. 13.

    Cevasco M, Ashley SW. Quality measurement and improvement in general surgery. Perm J. 2011;15(4):48–53.

  14. 14.

    Rui M, Lee JE, Vauthey JN, Conrad C. Enhancing surgical performance by adopting expert musicians' practice and performance strategies. Surgery. 2018;163(4):894–900.

  15. 15.

    So JP, Wright JG. The use of three strategies to improve quality of care at a national level. Clin Orthop Relat Res. 2012;470(4):1006–16.

Download references


This study was funded by Ganga Orthopaedic Research and Education Foundation (GOREF).

Author information

Correspondence to Raja Bhaskara Rajasekaran.

Ethics declarations

Conflict of interest

The authors declare no conflict of interest.

Ethical approval

The study was performed in accordance with the ethical standards in the 1964 Declaration of Helsinki.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Rajasekaran, R.B., Jayaramaraju, D., Agraharam, D. et al. The role of a trauma review system and development of intra-operative checklists in improving the quality of fracture fixations in a high volume tertiary centre. Eur J Trauma Emerg Surg (2020).

Download citation


  • Audit
  • Fracture fixation
  • Trauma review
  • Outcomes