DOI: 10.1308/147363514X14042954770238
Trainees' Forum
In an effort to improve standards and safeguard against
mishaps, strategies used in commercial or military settings
are increasingly being explored. In this article by Wood et
al the application of a modified military combat estimate to
plan orthopaedic trauma fracture care is described. Although
the article highlights its use in orthopaedics, the adoption of
strategic planning can be applied to any surgical discipline
using the framework described.
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the Trainees’ Forum. Authors wishing
to submit an unsolicited study, review
or editorial should email a short
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David Sanders Series Editor
Ann R Coll Surg Engl (Suppl) 2014; 96: 363–365
The seven questions: a novel surgical
planning strategy based on military doctrine
Ryan J Wood Specialty Registrar in Trauma and Orthopaedics1
Major Jeremy Granville-Chapman Specialty Registrar in Trauma and Orthopaedics2
Colonel John C Clasper Consultant in Trauma and Orthopaedics Surgery2
1
Ipswich Hospital NHS Trust
2
Frimley Park Hospital Foundation NHS Trust
Surgical planning is the first step in
operative fracture management. The
degree of planning that is required is
determined by a number of factors,
including the nature of the injury
mechanism and its concomitant
physiological insult, complexity
of the fracture and region,
expertise of the surgical team and
equipment limitations.
The Arbeitsgemeinschaft für
Osteosynthesefragen (AO) foundation
believe planning encourages the surgeon
to focus on the fracture pattern, fixation
technique and surgical approach. This
aids identification of problems that may
be encountered, which when anticipated
may be avoided or more easily overcome.
It has benefits on a number of additional
levels for the surgeon, trainees, theatre
staff and patients alike.
AO suggests four sequential stages in
surgical planning. The first three are
reconstruction, decision making and
fixation. These then lead to the fourth
stage: the surgical tactic, or a series of steps
to be undertaken in the operating theatre.1
Beyond this guidance, formal planning
prior to procedures is rarely practised
and of varying quality, depending on the
experience and character of the operating
surgeon as well as the centre at which the
patient is treated.
It is a topic that is touched upon in
the wider literature by experienced
orthopaedic surgeons offering their
advice and tips.2,3 For many low-volume
trauma surgeons, the process of fracture
fixation can seem like a battle. A number
of factors can conspire to work against
the surgeon and it sometimes seems as
though the surgical team is overmatched
by the problems thrown at it. Adopting
a military level of planning and execution
may therefore optimise the chances of a
successful outcome. With this in mind,
this paper explores a novel method of
surgical planning that draws inspiration
from British military doctrine and the
estimate process. It benefits from a more
global approach that encompasses logistic
as well as surgical constraints.
Combat estimate – the ‘seven
questions’
The estimate process is used by the
British military to allow the formulation
of considered plans. It is a logical process
by which a commander, faced with a
problem, may arrive at a decision as to
how that problem can be solved and the
steps required to achieve the desired
outcome. The estimate occurs at three
levels: the operational, tactical and
combat estimates, with the latter being
ideal for generating tempo at a local
level. It can be described as the process
by which ‘an adequate and flexible plan is
developed in a reasonable amount of time’.4
In real terms, the combat estimate is
used by commanders of smaller units
on the ground to develop plans in a
timely fashion to overcome specific
military situations or adversaries. This
combat estimate is often referred to as
the ‘seven questions’. By going through
each of the questions, problems and
additional requirements will be identified.
These may be in terms of information
that is required or a piece of specialist
equipment that will be needed. This
then generates specific requests for
information or equipment that will need
to be acted upon.
The process offers a very succinct
problem-solving paradigm that, when
adapted, lends itself to the field of
surgical planning, particularly in trauma
surgery. In this case the military
commander is the surgeon, and the foe is
the fracture. The military approach can
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THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETIN
be easily adapted to lend structure to the
thought processes involved in planning an
operation for orthopaedic trauma. The
seven questions of the combat estimate
and our proposed surgical corollary are
shown in Figure 1.
FIGURE 1
SURGICAL ESTIMATE – THE ‘SEVEN QUESTIONS’
Broadly, questions 1 to 3 are concerned
with the development of situational
awareness and understanding of the
mission and the battlespace. These
then feed into questions 4 to 7 to allow
development of a course of action. In
surgical terms, questions 1 to 3 are
similarly focused on understanding the
fracture and 4 to 7 on designing and
documenting a surgical plan.
Question 1: what is the fracture
pattern/location?
This requires identification of the nature
of the injury. What pattern/configuration
is the fracture? Where in the bone is it
located – is it intra- or extra-articular?
The fracture will usually have been
identified on plain radiographs, but in
order to answer question 1 fully, requests
for further information (RFIs) such as
cross-sectional imaging may be required
to delineate the anatomy of the injury.
Question 2: what mode of fixation
do I want to employ?
This question requires the application
of the principles of basic fracture
management and asks whether primary
(direct) or secondary (indirect) bone
healing is desirable and how that is
best achieved. For intra-articular
fractures, anatomical reduction and
absolute stability with interfragmentary
compression may be required and the
surgical strategy and equipment will need
to be adapted to achieve this. The same
applies for relative stability and question
2 will generate surgical options, but
question 3 needs to be considered before
choosing the most appropriate of the
surgical fixation options.
Question 3: what can I do to
optimise fracture healing?
Having identified the fracture type
and the surgical options available, one
must also consider fracture healing and
how to optimise it. This will depend
on the location of the fracture, patient
comorbidities and the nature of the
surrounding soft-tissue injury. It may
generate the need for further information
in terms of the patient’s medical, drug
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FIGURE 2
SURGICAL ESTIMATE FLOWCHART
and social histories. Additional needs
such as the involvement of other medical
and surgical specialties may also become
apparent at this stage – eg plastic surgery
to aid in management of open fractures or
input from medical teams to mitigate the
risk of comorbidities.
Question 4: where and when will
the operation need to take place?
Having built up a picture of the patient
and the fracture in questions 1 to 3, the
urgency of fixation and the ideal timing
of surgery should be apparent. This
may be on the next available trauma
or emergency theatre list but may
also involve additional planning if the
equipment or personnel requirement
so dictate. It may involve a decision to
proceed with damage-control surgery
and a staged definitive solution.
Question 5: what resources do I need
to accomplish each action/effect?
We now have an understanding of
how the fracture is going to be fixed
THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BULLETIN
and where and when this may happen.
This allows consideration of the surgical
equipment, supporting personnel
(eg anaesthetists, radiographer) and
implants that will be required. Specific
limitations at this point may feed back
and alter the considerations made in
the previous question – in some cases
changing either the timing of surgery or
the mode of fixation to be adopted (in the
developing world, image intensification
is not always available. Closed reduction
techniques and minimally invasive
techniques may not therefore be feasible).
Question 6: in what order do I
need to perform the steps of the
operation?
This represents the formulation of a
step-by-step surgical plan, based on
the considerations above. This reflects
the AO principles and will inform not
only the operating surgeon and his or
her assistant(s) but also the rest of
the theatre team. The generation of
a surgical planning diagram is already
taught on AO courses, both basic
and advanced. It can be done either
on TraumaCad ® systems or on paper
and includes: patient positioning and
preparation; surgical approach and
hazards therein; fracture reduction
techniques and contingency measures;
implants to be used and their sequence
of application; and wound management
and closure. This plan can be displayed
in theatre for reference for all before
and during surgery.
Question 7: what postoperative
measures do I need to impose?
Prior to surgery, thought can be given
to the postoperative control measures
that can be put into place to ensure
that rehabilitation of the patient begins
at the earliest possible moment. This
would include further antibiotics,
venous thromboembolism prophylaxis,
weight-bearing status of the patient and
range of movement of adjacent joints.
Some aspects of this may be altered
postoperatively to reflect intra-operative
findings and events (eg quality of bone
for screw purchase). By considering
these factors preoperatively, one can
undertake a more informed consenting
process in terms of likely inpatient stay,
rehabilitation constraints and patient
expectations of final outcome.
Summary
All surgeons would attest to the
importance of considered planning in
trauma surgery. This seven-question
surgical estimate, derived from a
combat planning tool, provides a concise
structure by which many aspects of
planning can be considered. It should help
surgeons in their approach to complex
trauma. For surgeons who regularly
tackle complex fractures in a high-volume
trauma centre, this may be a formalised
version of an analysis that already occurs
on a daily basis. Its strengths may well be
in improving planning in smaller centres
where logistical support for trauma is not
so robust.
From a training perspective, it has
many added advantages. Trainees
might be encouraged to undertake and
present their surgical estimates to their
supervising consultants. This would
form the framework for a case-based
discussion and lead naturally onto a
procedure-based assessment as the
trainee executes their plan. Above
and beyond the surgical plan, this
planning tool develops an awareness
and understanding of the logistical
constraints to surgery that can alter
decision making.
In terms of feedback, the structured
estimate can be interrogated to see if it
‘survived contact’ with the patient. The
old military adage that ‘no plan survives
first contact’ probably runs true in
surgery but with adequate planning and
subsequent critical analysis, the ability
to remain flexible and adapt can be
increased. Any areas where unexpected
problems arose, or contingency measures
were required, can be highlighted and
inform future planning and personal
development. We commend this
approach to all surgeons operating on
trauma patients.
References
Porteous MJ. Pre-operative planning. In: Ruedi TP,
Buckley RE, Moran CG, eds. AO Principles of
Fracture Management. Stuttgart: Thieme; 2007.
2. Graves ML. The value of preoperative planning.
J Orthop Trauma 2013; 27: S30–34.
3. Martin CR. Preoperative planning for fracture
management. Am J Orthop 2012; 41: E128–129.
4. Estimates. Army Doctrine Publication: Operations:
Ministry of Defense; 2010.
1.
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