Douglas W. Lundy

Two open forearm fractures after airbag deployment during low speed accidents

Automotive airbags effectively mitigate the impact of vehicular collision by absorbing and distributing a force that otherwise would be sustained by the occupants. To be effective, inflation must be instantaneous and sufficient to provide restraint to a moving body. Deployment of automotive airbags is a violent event that may cause injury to the occupants of the vehicle. This report describes two patients with severe, open radius and ulna fractures that were caused by airbag inflation during low velocity motor vehicle accidents. The degree of soft tissue injury and bone comminution in these patients was not fully appreciated until surgery. Orthopaedic surgeons should be aware of the explosive nature of airbag deployment and realize that the injury may be far greater than expected from a low energy motor vehicle accident.

A Day at the Office: Smooth Transitions—Setting Up the Next Phase of a Professional Life

F or better or worse, my career as a private practice orthopaedic surgeon defines me. But as I enter the latter half of my professional career, I am starting to consider my life beyond my practice. When will I retire? How will I walk away? Physicians inevitably retire from medicine, but just a rare few do so at the right time—that sweet spot in a surgeon’s career when the skills remain, but perhaps the willingness to dedicate oneself to the work fades. Indeed, I find that most private practicing orthopaedic surgeons are reluctant to give up their practices, unwilling to leave behind the legacy and reputation they have built for themselves. I certainly empathize with physicians who tenaciously hold on to their final years, even as they dip a toe into the retirement pool. In the world of business, one would characterize our profession as having tremendous ‘‘entry barriers.’’ After training, we must successfully pass board certification and maintain that certification over a period of decades. Private practicing orthopaedic surgeons are not guaranteed patient referrals; good will and an outstanding reputation must be developed through years of availability and selfless service. Walking away from all of this ‘‘sweat equity’’ after years of labor must be incredibly difficult. Still, how we cross that threshold is vitally important. From a business perspective, our private practices need effective and efficient succession planning to smoothly recruit and effectively retain new talent. Behind every retiring physician who decides to stick around a little longer is a disappointed surgeon eager to make his or her own mark on the practice. It certainly can be awkward. What if that surgeon feels marginalized and decides to leave? Instead of a smooth transition, the practice has two surgeons out the door and no replacements lined up. After watching many physicians waffle about their decisions to stop practicing and waver on their future plans, I am struck by the ones who did it with class and grace. I recall one prominent orthopaedic surgeon who walked out on his last day and vowed never to roam the halls of the hospital again. He left exactly when he said he was going to and never became the ‘‘former chief’’ that continued to live out the glory years in conferences and A note from the Editor in Chief: We are pleased to present the next installment of A Day at the Office. In this column, private practice orthopaedic surgeon Douglas W. Lundy MD, MBA, provides perspective on the pressures that orthopaedic surgeons face on a typical ‘‘day at the office,’’ as well as a broader viewpoint about trends in nonacademic clinical-care settings. The author certifies that neither he, nor any members of his immediate family, has have any no commercial associations (eg, such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. D. W. Lundy MD, MBA Resurgens Orthopaedics, Atlanta, GA, USA

A Day at the Office: In the Arena - Becoming More Involved in Organizational Leadership

Ina previous column [4], I described four domains that all orthopaedic surgeons should consider before retirement: Charity, research, teaching, and leadership. Orthopaedic surgery is an amazing vocation, but without purposeful action, the private practicing orthopaedic surgeon can get lulled into the daily grind of maintaining a career in medicine. But some are left wondering: “Is that all there is?” By stopping to consider these four domains, private practitioners can focus on activities that give back to others, which I believe offers both personal and professional satisfaction. By taking part in any of the four domains, private practicing orthopaedic surgeons can: (1) Expand their world (Charity). Our talents can help the poor and underprivileged anywhere and everywhere. Seek out opportunities abroad to help those in need now while you still can. (2) Expand their knowledge (Research). Interested in an orthopaedic subspecialty? Partner with colleagues in academia on a research project you are interested in. Volunteer with residents at a nearby academic institution, or by conduct clinical studies through your own practice. (3) Expand their reach (Teaching). There are often many opportunities for those of us in private practice to impart our experience on future generations as teachers or mentors. Physicians at my practice often teach nursing students and physician assistants in our offices. (4) Expand their voice (Leadership). Given that we are busy private practitioners with personal hobbies, family commitments, and heavy clinical burdens, carving out time for a leadership role simply feels like extraneous work. But if we don’t fill organizational leadership positions, others will, and our voices will not be heard. In thinking about this column, I kept returning to the leadership domain and the question: Why should we expect those in academia to champion private practitioners when we don’t champion ourselves? A quick review of the chairpersons who lead our national organizations (American Academy of Orthopaedic Surgeons [AAOS], American OrthopaedicAssociation [AOA], and our specialty societies) suggests that academic surgeons are the predominant leaders of our specialty even though 72% of the workforce comes from outside academia [2]. Are private-practicing orthopaedic surgeons being well-represented? And while I believe rank and file privatepracticing orthopaedic surgeons should get more involved in leadership roles, we first need to discover: (1) Why we haven’t gotten more involved in the first place and (2) the ways we can get more involved.

A Day at the Office: What if “Later” Never Comes? Four Tips for Volunteering Abroad Now

I n my previous column, I highlighted one concern that may be common among private-practicing orthopaedic surgeons: Retiring without experiencing all of the opportunities that orthopaedic surgery offers [1]. I bundled these opportunities into four categories: Charity, research, teaching, and leadership. Although all four of these endeavors are vital, to me, charitable work is the most fulfilling. It is easy to forget that large portions of the globe are in such desperate need, and that our time, skill, and compassion are ours to share. In 2003, I volunteered abroad for the first time in Ulaan Baatar, Mongolia to teach Mongolian trauma surgeons some of our approaches to patients with musculoskeletal injuries. The decision to volunteer abroad changed my purpose as an orthopaedic trauma surgeon. Since that time, I have been on 15 other foreign medical mission trips in Asia, Africa, Eastern Europe, and Haiti. At the time of that first trip, I had only been in private practice for 3 years, and I was planning to go on a medical mission when I was more financially stable and my children were older. In private practice, everything depends on our productivity. The stress of developing your practice while trying to be a worthy spouse, parent, and friend can be overwhelming, and I suspected that the ‘‘moreexperienced me’’ would volunteer abroad once I had fewer family and professional demands. But plans change. I received a message from an organization I belonged to that needed an orthopaedic trauma surgeon to teach in Mongolia. It struck me that I didn’t have to wait until later in my career to volunteer abroad. Why wait? What if later never comes? Although there are clear-cut healthcare delivery disparities in the United States, this inequity is far more dramatic in other parts of the world. There is a little-known concept described as the 10/40 window. Approximately 82% of the poorest people in the world live between 10 N and 40 N parallels, and there is tremendous need for quality orthopaedic care in these countries [2]. Indeed, there are several good reasons why we should participate in charity work at all phases of our work life, but volunteering abroad deserves careful consideration. Here are some tips the private practice surgeon should consider before volunteering his or her time. A Day at the Office Published online: 31 August 2017 The Association of Bone and Joint Surgeons1 2017

A method to locate the radial digital nerve of the index finger.

The radial digital nerve of the index finger is susceptible to injury during penetrating trauma or elective release of the Al pulley. The intersection of a line drawn down the midline of the index finger and the proximal palmar crease identifies the location of the radial digital nerve. This method of identifying the topography of the nerve should assist the surgeon in determining the likelihood of injury after penetrating trauma, and preventing injury during elective procedures.