Improving outcomes for fracture clinic patients

By Crystal Mackay, MA'05

The fracture clinic in London, Ontario is a bustling place, with surgeons and trainees often seeing more than 70 patients each day. The array of injuries is vast – from hip and shoulder fractures to broken femurs – and the patients are diverse, representing every facet of the local community.

The busy clinic presents a range of challenges for health care workers, creating opportunities for academic surgeons like Dr. Emil Schemitsch to ask important research questions and hunt for answers.

An under-recognized problem

For every 100 female patients presenting to fracture clinics across the country, two of them are seeking medical attention for an injury related to intimate partner violence, and a third have had a lifetime prevalence of abuse, either physical, emotional or financial.

“We’ve identified that this is an under-recognized problem, that it is highly prevalent, and that orthopaedic surgeons at busy fracture clinics are having a challenge managing it,” said Dr. Schemitsch, Chair/Chief of the Department of Surgery.

Determined to do something to improve screening and supports for these patients, Dr. Schemitsch along with researchers across the country set out to design and test an education program for fracture clinic health care providers and staff.

“Unless you are asking the right questions and know what to look for, you are going to miss an opportunity to identify patients, and then potentially miss an opportunity to present resources that can help,” he said.

The team, led by McMaster researcher Dr. Sheila Sprague, developed an educational program called EDUCATE that empowered orthopaedic surgeons, health care staff and trainees to better identify patients experiencing intimate partner violence and provide appropriate support.

The program consisted of an introductory video, three online modules and an in-person training session.

They tested the educational program across seven fracture clinics in North America, and determined that the program led to significant improvements in health care providers’ readiness to manage intimate partner violence. Their research was recently published in CMAJ.

Next, Dr. Schemitsch would like to see fracture clinics employ social workers who are trained to help patients with intimate partner violence. “This will allow patients to be looked after in a less hurried, more private and holistic type of environment,” he said.

Black hole in orthopedics

And while Dr. Schemitsch continues to explore this line of research, he is also embarking on a new CIHR-funded study which will help surgeons better understand outcomes for a complicated fracture of the shoulder. 

The DECIPHER study will enlist close to 800 patients across 17 sites to examine what factors predict whether or not surgical interventions are effective for a proximal humerus fracture. The researchers will be looking at factors such as age, gender, comorbidity and fracture pattern.

“Right now, proximal humerus fractures are a black hole in orthopedics. We don’t know who benefits from surgery, we don’t know how to classify fractures and we don’t know what the best surgical treatment is,” he said.

Proximal humerus fractures are complex because the injury involves more than just bone, it also integrates critical soft tissue attachments like the rotator cuff. When the fracture occurs, those attachments can completely break off. It is also hard to visualize through medical imaging, resulting in disagreement about what the fracture patterns are.

Dr. Schemitsch has recently started recruiting patients at London Health Sciences Centre to take part in the study, it is expected to take three years to complete. “Right now this is extremely important because we currently have no real understanding of what determines outcomes,” he said.