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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

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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.

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Getting it right first time


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

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Correspondence to Raja Bhaskara Rajasekaran.

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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.

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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). https://doi.org/10.1007/s00068-020-01317-0

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  • Audit
  • Fracture fixation
  • Trauma review
  • Outcomes