Reflections of an octogenarian skeletal trauma surgeon

Christopher Colton

Chris Colton is Professor Emeritus in Orthopaedic and Accident Surgery at the University of Nottingham and was a Consultant Orthopaedic, Trauma and Paediatric Orthopaedic Surgeon at Nottingham University Hospital for more than 20 years. He was an ABC Travelling fellow, BOA President, Founding Trustee and Lifetime Honorary Member of the Board of Trustees of the AO Foundation.

Last year, I was invited to write a letter to myself as a final year medical student exhorting me to consider a career in Trauma and Orthopaedics.

I wrote:

“Dear Chris,

You are nearing the end of your time as a medical student, and I know that you will do well. Remember that it does not mean that you know everything, you simply knew enough!

I warn you that this is not the top of the ladder, just a chance to stand on the bottom of the next one. There will always be another ladder, but that is the essence of medicine – a lifetime of learning and challenge.

Never forget that you have a bounden duty of care to your patients, your colleagues, your profession, and to yourself.

Your journey ahead can take many pathways and only you can choose which. My instinct is that you are more a surgeon than a physician; should you select a surgical route, remember that you are first and foremost a doctor… one who also operates. Surgery is fun, but the hallmark of a good surgeon is to know when not to operate.

Permit me to dangle before you an enticing prospect. The specialty of Trauma and Orthopaedics is initially seductive by virtue of the drama, dare I say glamour, and immediacy of managing the injured. But, T&O is more than that and, whereas the trauma element is the portal of entry for many a young surgeon, there is much to elective orthopaedics.

In the past, orthopaedic surgeons were thought of as front-row forwards with a hammer in hand, but T&O has changed beyond all recognition in the last few decades. You would enjoy a firm scientific basis for musculoskeletal surgery, a massive expansion in our biomechanical understanding, an explosion of investigative techniques and there is now available a huge inventory of relevant instrumentation.

Fifty years ago, an orthopaedic surgeon was expected to cover the whole field. With all the developments mentioned here, there has arisen an imperative to focus down to subspecialties. This academic diversification includes posttrauma reconstruction, hand and upper limb surgery, pelvic and acetabular surgery, foot and ankle, shoulder, spinal surgery, bone tumours – and who knows what in the future, in any of these areas?

There are great opportunities for teaching and research.

Chris, whatever you decide, always remember that surgery is not a science, it is a scientific art: the art is two-fold. The first is the art of handling tissues with biological finesse and delicacy; the second is the art of handling your patients and their near ones with respect, humanity and humility.”

I recall my first biology lesson, during which I was fascinated to see, for the first time, a human skeleton – not a plastic model such as would be used today – and was mesmerised by the thought that it once supported a human being. I went home and told my parents that I wanted to work with human bones. My father suggested osteopathy. Thereafter I was set on osteopathy, until one Christmas at a hotel, in Herne Bay, I got into conversation with a mature gentleman as he sipped his pink gin, and told him that I wanted to be an osteopath. He almost choked on his Gordon’s and told me to become an orthopaedic surgeon, like him. Who he was, I have no idea, but thereafter orthopaedics was my goal.

I have no major regrets and can reflect on a satisfying journey. Trauma always exerted great traction on my interests and after five years as a general T&O consultant, the opportunity presented itself to ditch adult elective work, and I grabbed the chance to focus on trauma and paediatric orthopaedics. The rest of my professional trajectory was set.

Although I had no medico-political aspirations, I got drawn into being active in the BOA and also in the AO Foundation. To my astonishment, I ended up as president of each. Such honours are heady stuff and I confess that I revelled in the limelight and the travelling in style, notching up air miles by the bucketful. These subsidised my passion of warm-water SCUBA diving that I took up in my sixties; I finally became a Master Diver, notching up over 600 dives before having to stop at 80 years of age because of respiratory disease.

With AO, I lived through an exciting period of development of fracture surgery and its scientific basis. I now feel that the future focus in trauma care should not be the invention of ever-sophisticated and increasingly expensive implants and instruments, but to focus on bringing modern osteosynthesis to that 75% of the world who are priced out of the market. Let us bring low-cost fracture-care techniques to the LMICs. As a founder member of the AO Alliance Foundation (https://ao-alliance.org/), I champion its raison d’être.

I developed an interest in clinical research and thoroughly enjoyed contributing to many publications. This inevitably led to teaching activities and a number of Visiting Professorships. The greatest honour, however, was a Special Professorship awarded to me by Nottingham University for contributions to research and education. This was my proudest achievement.

When I was younger, I enjoyed oil-painting (Figure 1), and this translated into a skill with computer graphics in the creation of visual aids for teaching. This became more of a hobby than an educational endeavour.

Figure 1: An early Provençal scene painted using a palette knife.

I was delighted to have been asked by the International Civil Aviation Authority’s cabin safety group to create the graphics of their recent report (Figure 2)

Figure 2: Graphic of escape from smoke-filled cabin.

The challenge of treating fractures comprises a sound knowledge of mechanics and of the biology of bone healing. It is this discipline of biomechanics that lies at the heart of being a fracture surgeon. In December, 1914, Dr Miller E. Preston of Denver addressed Medical Society of the City and County of Denver and stated: “The internal fixation of a fracture is decidedly an engineering problem, as well as a surgical procedure…”[1] .

Arguably, he was the father of fracture biomechanics.

The thrill of fracture care is that every fracture is different and every fracture patient is different, expressed by EA Nicoll as the “personality of the fracture”[2]. The individuality of the decision making in every fracture problem, requires the surgeon to understand each patient, and to tailor his/her approach to the patient’s needs, fears and expectations, and with children to understand the family context. Similarly, the injury is not what you see on an X-ray, or scan – that’s just a broken bone – but, as Stanley Boyd said in 1895: ”The most important divisions of fractures – simple, compound and complicated – are based upon the condition of the soft parts; less important varieties rest upon the condition of the bone”[3].

Who most inspired me along the way?

When I was a registrar in Bristol, my wonderful mentor was Keith Lucas (Figure 3). Without his support and encouragement, I would have given up.

Figure 3: Keith Lucas.

I did cross swords with a certain consultant but it was the paternal encouragement of the beloved Keith Lucas, who had faith in me, that carried me through and led me to secure a registrar position at the RNOH in London.

There, I worked for two six-month periods with Lorden Trickey (Figure 4). I came to admire him unreservedly for his clinical acumen and, above all, for his immaculate surgical technique. It was a joy to see him operate and to learn from him.

Figure 4: Lorden Trickey

He never made one move surgically that didn’t advance the procedure, and his reverence for the soft tissues was a true inspiration.

I shall single out another – Nicholas Barton in Nottingham. He supported me hugely in my early consultant days as I fought for modern fracture care whilst facing a certain resistance from more conservative seniors. I believe that my philosophy and use of modern principles earned acceptance and respect.

Finally, I pay tribute to Maurice Müller of Bern, Switzerland. He was the intellectual powerhouse of AO. What inspired me about him? He was a brilliant technical surgeon – to watch him operate was magical: he was an accomplished conjuror and his brilliance at surgery evoked the same admiration as his baffling legerdemain. Additionally, he was the quintessential lateral-thinker and inventor: finally, he was friendly and approachable, with a wicked sense of humour. What a privilege to have spent many hours on many occasions and in many settings in his company. His life has been wonderfully encapsulated by Joseph Schatzker in “Maurice Edmond Müller – In His Own Words”[4].

What would I (or should I) have done differently?

Not a lot. Each step that one takes along the professional path seems the best idea at the time and I seem to have been blessed with a certain intuitive capacity to do the right thing.

What was my best achievement?

This is a difficult question. My gut feeling is that my post-graduate teaching – clinical, didactic and as a mentor, is the vapour-trail that I am proud to have left behind. Bernard de Chartres said, in 1120: “We are as dwarves on the shoulders of giants, so that we can see more than them…” 5 , later plagiarised by Isaac Newton in 1676 in a letter to Robert Hooke. I hope that I have been such a set of shoulders.

I would say to would be T&O educators that you must know your stuff, don’t pretend that you know something that you don’t, and don’t be afraid, when questioned, to admit that you don’t know – “but I shall find out and tell you later.” The art of education requires knowledge, confidence and flair, as well as the ability to connect with your audience.

The establishment, by John Webb and myself, of the Nottingham Fracture Forum, which celebrates its 40th year in 2021, has moulded the attitudes of countless senior registrars to fracture surgery, and has become a template for similar initiatives abroad, notably the New England Fracture Forum.

I believe also that I have been a ‘good doctor’ in the holistic sense, connecting with the essence of my patients: a surgeon is a ‘doctor’ who happens also to operate.

I have, in fact, treated a few high-profile patients, but that is not for what I should wish to be remembered. They were no more important than all my other patients. Just a bit more scary!

What of the future?

This is tricky as I have some health problems, and we currently endure the battle against COVID-19 pestilence. I greatly miss diving (Figure 5). I look forwards to as many days as I have, in the company of my wife, enjoying reading, some editing, photography, walking (on the flat and rather slowly). The light at the end of this tunnel would be an easing of restrictions and reconnecting with my wider family. After a very busy life, my aspirations for the future are modest and realistic.

Figure 5: Doing what I loved best in retirement.

In conclusion, I make no apology for leaving you with a reiteration of my advice to myself as a medical student:

“Chris, whatever you decide, always remember that surgery is not a science, it is a scientific art: the art is two-fold. The first is the art of handling tissues with biological finesse and delicacy; the second is the art of handling your patients and their near ones with respect, humanity and humility.” •

References

1. Preston ME. Conservatism in the operative treatment of fractures. Colo Med 1916;13:83-8.

2. Nicoll EA. Fractures of the tibial shaft. A survey of 705 cases. J Bone Joint Surg Br. 1964;46:373-87.

3. Boyd, S. A System of Surgery by Frederick Treves, Cassell and Co., London, 1895. Page 734

4. AO Foundation (2018). Maurice Edmond Müller—In His Own Words. Available at: https://aotrauma.aofoundation.org/-/media/project/aocmf/aotrauma/documents/news/2018/aof_mem-in-his-own-words.pdf.

5. John of Salisbury 1159, Metalogicon.