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Competing Interests: Disclosure The authors report no conflicts of interest in this work.

On the occasion of the 10th anniversary of the foundation of the German Society for Orthopedics and Trauma Surgery (DGOU), the current General Secretary of the German Society for Trauma Surgery sees the need for a standpoint on trauma surgery in Germany. This manuscript outlines future options and perspectives for the development of trauma surgery in Germany.

Background: Given that the management of severely injured children requires coordinated care provided by multiple pediatric surgical subspecialties, we sought to describe the frequency and associated costs of surgical intervention among pediatric trauma patients admitted to a level 1 trauma centre in southwestern Ontario., Methods: All pediatric (age < 18 yr) trauma patients treated at the Children's Hospital - London Health Sciences Centre (CH-LHSC) between 2002 and 2013 were included in this study. We compared patients undergoing surgical intervention with a nonsurgical group with respect to demographic characteristics and outcomes. Hospital-associated costs were calculated only for the surgical group., Results: Of 784 injured children, 258 (33%) required surgery, 40% of whom underwent orthopedic interventions. These patients were older and more severely injured, and they had longer lengths of stay than their nonsurgical counterparts. There was no difference in mortality between the groups. Seventy-four surgical patients required intervention within 4 hours of admission; 45% of them required neurosurgical intervention. The median cost of hospitalization was $27 571 for the surgical group., Conclusion: One-third of pediatric trauma patients required surgical intervention, of whom one-third required intervention within 4 hours of arrival. Despite the associated costs, the surgical treatment of children was associated with comparable mortality to nonsurgical treatment of less severely injured patients. This study represents the most recent update to the per patient cost for surgically treated pediatric trauma patients in Ontario, Canada, and helps to highlight the multispecialty care needed for the management of injured children.

Background: The small developing countries in the Pacific are grouped together as Small Island Development States (SIDS) because they face similar problems which they cannot cope with nationally. They are developing countries, so-called low and lower middle income countries (LMIC), are economically weak and the islands of the different nations are widely scattered. Approximately 80% of the 10 million inhabitants live in rural regions., Epidemiology and Surgical Capacity: Over 40% of patients in the surgical departments of hospitals are hospitalized for injuries, and this tendency is increasing. Fractures of the upper extremities are relatively more frequent in the Pacific than in the countries of the North. Long distances, lack of possibilities for treatment and lack of transport often cause complications, such as infected open fractures, pseudarthrosis and posttraumatic malformations. There are too few hospitals with sufficiently competent surgeons, anesthetists and obstetricians (SAO) and appropriate equipment., Pacific Islands Orthopedic Association (pioa): The PIOA was founded in Honiara, Solomon Islands, and offers surgeons of the Pacific SIDS a comprehensive, structured trauma and orthopedic surgery training in their own countries. It lasts 4 years and leads to an M‑Med (orthopaedic surgery) diploma and to a Fellowship of the International College of Surgeons (FICS), which are both recognized by the participating hospitals. It is free for participants., The Ao Alliance Foundation (aoaf): The AOAF is an independent organization with the only aim to enhance trauma surgery capacity in LMICs. The AOAF supports the PIOA program together with the Wyss Medical Foundation. Currently, 18 trainees from 8 Pacific SIDS are participating in the PIOA training program.

Background: Trauma surgery is a discipline in which the training phase for specialization requires a technical and time-intensive learning curve, including the repetitive training of manual skills. This results in prolonged operation times and thus elevated costs., Objectives: The present study retrospectively examines operations in trauma surgery and orthopaedics at a Munich university hospital according to the required curriculum for further specialist training. The duration of procedures at the various training levels and the resulting costs were compared., Material and Methods: Based on digital surgical records, more than 2,000 surgical interventions were analysed and checked that they fulfilled the practical requirements. Patients with multiple injuries and polytrauma, in addition to irregularly complex cases, were removed from the calculation to ensure high comparability of the individual cases. This yielded more than 1,000+ cases for evaluation. The per-minute cost was calculated to allow for the translation of operating time into costs., Results: The study shows a prolonged duration of operating time of 19.75 % when the procedure was conducted by residents. This prolongation can be split into 37 subgroups according to body region and type of procedure. The prolongation of operation time could be quantified as a specific prolongation per cluster, in addition to cumulative prolongation. By including the operating costs, the operation-dependent training costs are shown as an exact sum of Euros., Conclusion: Surgical training of residents costs hospitals the appropriate amounts of time and money and reduces the overall number of procedures performed, justifying special consideration of the financing of training hospitals.

Uganda, like many low-income countries, has a tremendous volume of orthopaedic trauma injuries. The Uganda Sustainable Trauma Orthopaedic Program (USTOP) is a partnership between the University of British Columbia and Makerere University that was initiated in 2007 to reduce the consequences of neglected orthopaedic trauma in Uganda. USTOP works with local collaborators to build orthopaedic trauma capacity through clinical training, skills workshops, system support, technology development, and research. USTOP has maintained a multidisciplinary approach to training, involving colleagues in anaesthesia, nursing, rehabilitation, and sterile reprocessing. Since the program's inception, the number of trained orthopaedic surgeons practicing in Uganda has more than doubled. Many of these newly trained surgeons provide clinical care in the previously underserved regional hospitals. The program has also worked with collaborators to develop several technologies aimed at reducing the cost of providing orthopaedic care without compromising quality. As orthopaedic trauma capacity in Uganda advances, USTOP strives to continually evolve and provide relevant support to colleagues in Uganda.

The dire challenges faced in Haiti, both preearthquake and postearthquake, highlight the need for developing surgical infrastructure to care for traumatic musculoskeletal injuries. The proposed Orthopaedic Trauma Care Specialist (OTCS) residency program aims to close the critical human resource gap that limits the appropriate care of musculoskeletal trauma in Haiti. The OTCS program is a proposal for a 2-year residency program that will focus primarily on the management of orthopaedic trauma. The proposed program will be a comprehensive approach for implementing affordable and sustainable strategies to improve orthopaedic trauma care. Its curriculum will be tailored to the injuries seen in Haiti, and the treatments that can be delivered within their health care system. Its long-term sustainability will be based on a "train-the-trainers" approach for developing local faculty to continue the program. This proposal outlines the OTCS framework specifically for Haiti; however, this concept is likely applicable to other low- and middle-income environments in a similar need for improved trauma and fracture care.

Background and Purpose: The AO Foundation Operative Fracture Management course is the gold standard in training courses currently available for trainees at ST3 level. We have devised a low cost operative skills course comprising instructional lectures, demonstrations and practical dry bone workshops. To assess the quality of teaching, candidates' feedback was analysed in two cohorts for the running of the course over two consecutive years: 2008 and 2009., Methods: Trainees were given short instructional lectures by consultant surgeons followed by workshops, with a trainer to candidate ratio of 1:4. A trauma inventory was provided by Stryker Trauma UK, ensuring a nominal fee for each candidate (£50). Feedback was anonymously collected according to a Likert scale and analysed using non-parametric methods appropriate for ranked data., Main Findings: Twenty one of 22 (95%) candidates gave feedback in 2008 and 18 out of 18 candidates (100%) in 2009. The teaching provided was highly rated consistently for both years, apart from an informal session on theatre tips and tricks in 2008. This was not repeated in 2009 to allow more practical time. Only one session, an intramedullary nailing lecture, had a significant difference in scores between the 2 years (p = 0.044) because of improved scores in 2009., Conclusions: Due to changes in training, trainees have reduced exposure in theatre and this has implications for the early stages of acquiring practical operative skills. As an adjunct to the AO course, practical skills teaching by consultants in the format of a low cost skills workshop outside of a theatre environment can be achieved with support from a trauma implant supplier., (Copyright © 2011 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.)

Today universities can offer a variety of educational resources to their students through the internet. These may include lecture notes, PowerPoint presentations, or even an entire recording of a lecture in video format. At the Hannover Medical School (Hannover, Germany), the Trauma Surgery Department in collaboration with the Institute of Medical Informatics has developed an alternative method of "E-learning". We created a web-based multimedia resource center for Trauma Surgery using the Content-Management-System (CMS) Schoolbook application, which was initially developed by the Institute of Medical Informatics. The so called "Trauma Surgery Schoolbook" was first adopted in October of 2005 and has since been used and evaluated by medical students at our institution. The evaluation results for the academic year 2005/06 are reported in this paper. The majority of students enrolled in the Trauma Surgery rotation utilized the Schoolbook, which they regarded as a helpful and effective study tool. Our students embraced the possibility of being able to prepare for lectures and use the Schoolbook for independent home studying purposes. Over time, there was a steady increase in the utilization of the Schoolbook by the students from 67% in the first trimester to 93% in the third trimester. The majority of the surveyed students (79.6%) found the Schoolbook to be constructive and helpful. 8.1% did not have any opinion, and only 12.3% found it to not be helpful. The instructors also found this web-based training program to be both constructive and practical, and were able to utilize its multimedia components to complement their lectures. Overall, our experience with this computer-aided learning program demonstrated that web-based technologies can improve the quality of medical education, benefiting both the students and the instructors.

Malawi has a population of about 13 million people, 85% of whom live in rural areas. The gross national income per capita is US$620, with 42% of the people living on less than US$1 per day. The government per capita expenditure on health is US$5. Malawi has 266 doctors, of whom only nine are orthopaedic surgeons. To address the severe shortage of doctors, Malawi relies heavily on paramedical officers to provide the bulk of healthcare. Specialized orthopaedic clinical officers have been trained since 1985 and are deployed primarily in rural district hospitals to manage 80% to 90% of the orthopaedic workload in Malawi. They are trained in conservative management of most common traumatic and nontraumatic musculoskeletal conditions. Since the program began, 117 orthopaedic clinical officers have been trained, of whom 82 are in clinical practice. In 2002, Malawi began a local orthopaedic postgraduate program with an intake of one to two candidates per year. However, orthopaedic clinical officers will continue to be needed for the foreseeable future. Orthopaedic clinical officer training is a cost-effective way of providing trained healthcare workers to meet the orthopaedic needs of a country with very few doctors and even fewer orthopaedic surgeons.

Orthopaedic surgical training in Nepal began in 1998, and four major centers now produce between 15 and 20 graduates annually. The duration of the training is four years in one center and three years in the remaining centers. Trainees have adequate trauma exposure. The major challenges include: tailoring training to suit local needs, avoiding the dangers of market driven orthopaedic surgery, adequately emphasizing and implementing time honored methods of closed fracture treatment, and ensuring uniformity of exposure to the various musculoskeletal problems. Training in research methods needs to be implemented more effectively. The evaluation process needs to be more uniform and all training programs need to complement one another and avoid unhealthy competition. Training for nonorthopaedists providing musculoskeletal care is virtually nonexistent in Nepal. Medical graduates have scant exposure to trauma and musculoskeletal diseases during their training. General surgeons provide the majority of trauma care and in the rural areas, health assistants, auxiliary health workers and physiotherapy assistants provide much needed basic services, but all lack formal training. Traditional "bone setters" in Nepal often cater to certain faithful clientele with sprains, minor fractures etc. A large vacuum exists in Nepal for trained nonorthopaedists leading to deficiencies in prehospital care, safe transport and basic, primary emergency care. The great challenges are yet to be addressed.

No diploma for orthopaedic surgery is available in the current medical education and licensing system in China. The orthopaedist generally receives on-the-job training in a clinical practice after getting a license to practice surgery. There are multiple training pathways to and opportunities in orthopaedic surgery, and these vary from hospital to hospital and from region to region. These include on-the-job training, academic visits, rotation through different departments based on local medical needs, fellowship training in large general or teaching hospitals (locally, regionally, nationally, or internationally), English language training, postgraduate diploma training, and Internet CME. Due to the current training system, orthopaedic techniques and skill levels vary greatly from hospital to hospital.

There is currently an escalating epidemic of trauma-related injuries due to road traffic accidents and armed conflicts. This trauma occurs predominantly in rural areas where most of the population lives. Major ways to combat this epidemic include prevention programs, improved healthcare facilities, and training of competent providers. Mozambique and Sri Lanka have many common features including size, economic system, and healthcare structure but have significant differences in their medical education systems. With six medical schools, Sri Lanka graduates 1000 new physicians per year while Mozambique graduates less than 50 from their singular school. To supplement the low number of physicians, a training course for surgical technicians has been implemented. Examination of district hospital staffing and the medical education in these two countries might provide for improving trauma care competence in other developing countries. Musculoskeletal education is underrepresented in most medical school curricula around the world. District hospitals in developing countries are commonly staffed by recently graduated general medical officers, whose last formal education was in medical school. There is an opportunity to improve the quality of trauma care at the district hospital level by addressing the musculoskeletal curriculum content in medical schools.

Serbia, a middle-income country, is located in southeastern Europe, with territory of 88,361 km(2) and 9,400,000 inhabitants. Average month salary is US$542 and the registered unemployment rate is 22%. The country is administratively divided into 30 districts (193 municipalities). The healthcare system is territorially organized. In the state capital there are five clinical hospitals with musculoskeletal traumatology departments, as well as one in each of the four university centers. In addition, there are orthopaedic departments in 40 smaller hospitals throughout the country and in three military hospitals, along with several pediatric surgical departments involved in managing musculoskeletal trauma. There are 524 orthopaedic trauma surgeons (1:18,000 people), with a minor number of additionally trained general and pediatric surgeons who care for musculoskeletal problems. Bonesetters are neither recognized nor included in the healthcare system. Orthopaedic traumatology services are well organized, with variable accessibility depending on the distance between injury site and nearest medical facility. Preventive strategies are well developed and mainly consider agricultural, industrial, and traffic injuries. Distribution of medical institutions is satisfactory. Future activities should include continuing medical education of specialists, exclusion of inappropriate specialists, improvement of preventive strategies and medical transport facilities, as well as standardization of medical equipment, diagnostics, and treatment protocols.

Trauma is becoming a leading cause of death in most of the low-income and middle-income countries worldwide. The growing number of motor vehicles far surpasses the development and upkeep of the road and highway networks, traffic laws, and driver training and licensing. In Thailand, road traffic injuries have become the second leading cause of death and morbidity overall since 1990. The lack of improvement to existing roadways, implementation of traffic safety and ridership laws including seatbelt regulations, and poor emergency medical assistance support systems all contribute to these statistics. An insufficient number and inequitable distribution of healthcare professionals is also a national problem, especially at the district level. Prehospital care of trauma patients remains insufficient and improvements at the national level are suggested.

Increasingly, nonspecialist Ghanaian doctors in district hospitals are called upon to perform a variety of surgical procedures for which they have little or no training. They are also required to provide initial stabilization for the injured and, in some cases, provide definitive management where referral is not possible. Elsewhere continuing medical education courses in trauma have improved the delivery of trauma care. Development of such courses must meet the realities of a low-income country. The Department of Surgery, Kwame Nkrumah University of Science and Technology developed a week-long trauma continuing medical education course for doctors in rural districts. The course was introduced in 1997, and has been run annually since. The trauma course specifically addresses the critical issues of trauma care in Ghana. It has improved the knowledge base of doctors, as well as their self-reported process of trauma care. Through the process we have learned lessons that could help in the efforts to improve trauma training and trauma care in other low-income countries.

In India, health policies, services, health indices, and medical education are improving despite the country's enormous population and limited resources. Orthopaedic training in India should be geared to serve the predominantly rural population (72% of total population) living in some 550,000 villages, but unless the basic amenities improve in villages and towns, orthopaedists will remain averse to serving in these areas. Traditional practitioners play an important role in musculoskeletal trauma care in villages and even some town and city areas, and hence cannot be ignored. We suggest a stratified system of orthopaedic training for medical graduates, postgraduates, and paramedics with a well-defined need-based curriculum, and a clear cut division of labor, terms, and conditions to suit the stratified social and demographic structure of India. This stratified system is intended to provide appropriate musculoskeletal trauma care services to the rural population, reduce neglected and mismanaged trauma, consequently avoiding subsequent orthopaedic disability, and reduce the financial burden of managing these cases. This system also intends to prevent overloading of teaching hospitals and apex institutes and ensure availability of subspecialized orthopaedic services in the country at designated centers. Traditional practitioners shall be periodically educated regarding safe orthopaedic practices, which are anticipated to yield improved trauma care services.

The trauma pandemic disproportionately kills and maims citizens of low-income countries although the immediate cause of the trauma is often an industrial export of a high income country, such as a motor vehicle. Addressing the trauma pandemic in low-income countries requires access to relevant research information regarding prevention and treatment of injuries. Such information is also generally produced in high income countries. We explored various means of making scientific information available to low-income country surgeons using the internet. If orthopaedic surgeons want to maximize their global impact, they should focus on writing about trauma questions relevant to their colleagues in low-income countries and ensuring these same colleagues have access to the literature.

China is a developing country with a population over 1.3 billion with the second largest group of people in poverty next to India. There are about 159 million motor vehicles, with 163,887,372 drivers. From 2001 to 2004 over 100,000 people died each year in traffic accidents. With law enforcement and public education, traffic accidents have decreased, and the death rate is now less than 100,000 each year.

Approximately 2000 lives are lost in Uganda annually through road traffic accidents. In Kampala, they account for 39% of all injuries, primarily in males aged 16-44 years. They are a result of rapid motorization and urbanization in a country with a poor economy. Uganda's population is an estimated 28 million with a growth rate of 3.4% per year. Motorcycles and omnibuses, the main taxi vehicles, are the primary contributors to the accidents. Poor roads and drivers compound the situation. Twenty-three orthopaedic surgeons (one for every 1,300,000 people) provide specialist services that are available only at three regional hospitals and the National Referral Hospital in Kampala. The majority of musculoskeletal injuries are managed nonoperatively by 200 orthopaedic officers distributed at the district, regional and national referral hospitals. Because of the poor economy, 9% of the national budget is allocated to the health sector. Patients with musculoskeletal injuries in Uganda frequently fail to receive immediate care due to inadequate resources and most are treated by traditional bonesetters. Neglected injuries typically result in poor outcomes. Possible solutions include a public health approach for prevention of road traffic injuries, training of adequate human resources, and infrastructure development.