Orthopaedic In Low Resource Settings Flashcards
What is the need to tackle the global burden of disease and risk factors?
- HIV is the major cause of disease in sub-Saharan Africa
- Malaria
- Injury : 16% of the adult burden of disease
- Affects young males
- Socioeconomic aspects
What is the need for surgery in Motor Vehicle Accidents?
- Each year 1.2 million killed, 50 million injured
- By 2020 3rd in global burden of disease
- Prevention
- Treatment of injured
- Roads of Malawi are 200x more dangerous per vehicle than UK
What is the ICRC wound management doctrine?
- Standardised approach
- No high-tech resources
- No surgical specialities
- No onward referral
- Differs from military doctrine
- Extensive database
What are the initial measures after an incident has occurred?
- Dressings
- Intravenous fluids
- Antibiotics
- Analgesia
- Anti-tetanus serum & tetanus toxoid
- X-rays
Describe how primary surgery is carried out
- Amputate under tourniquet
- Wound excision
- No primary repair of nerve or tendon
- Removal of de-vitalised bone
- Leave wound open
- Dry, sterile dressing
- Immobilise
What happens after delayed primary closure? (PART 1)
- Leave dressings in place
- Antibiotics
- Monitor vital signs
- Blood transfusion only if Hb< 8.0 g/dl
- Take down dressings in theatre at 5/7
- Only return to theatre before this if evidence of infection & patient unwell
What happens after delayed primary closure? (PART 2)
- If clean, close without tension or split skin graft
- (suction) drainage
- If infected / necrotic further wound excision & leave open
- Elevate 48 hrs
- Physiotherapy
- Amputees: prosthesis at 6-8 weeks if available
What measures do you need to put in place before carrying out an amputative technique?
- Determine necessity of amputation
- Scoring systems rarely helpful
- Consensus with colleagues
- Consent
Describe the amputative technique (PART 1)
- Doctrine is to fashion flaps at primary surgery (cf guillotine)
- Skin is relatively resistant to blast & ballistic injury
- Use myoplastic technique
- Leave wound open, dry, bulky sterile dressing
Describe the amputative technique (PART 2)
- Dry, bulky sterile dressing
- Monitor T, P, BP
- All open wounds Smell!
- “good bad smell”
- “bad bad smell”
- Do not change dressing on ward!
Describe the amputative technique (PART 3)
- Remove dressings in theatre under anaesthesia at 5/7
- Should reveal granulating, slightly bleeding tissue
- Skin retracts
- Muscle flaps swell
Describe the amputative technique (PART 3)
- Close myoplasty over bony stump (?myodesis)
- Drain
- Avoid tension
- If infected, or contaminated, re-debride & repeat process
List some key notes on ICRC wound management
- Avoid too high of an expectation of wound closure at first, re-look, especially in amputations
- Primary closure acceptable in wounds of head & neck, dura, pleura and peritoneum
- Small fragment wounds, minimal culture medium..? Non-operative management
Describe surgery on open wounds
- Great burden of open wounds in developing world hospitals
- Often septic
- Malodorous
Describe skin grafting used in surgery
- Split skin grafting
- Dermatome knife
- Involves Blades
- Surgical skill
- Meshing
- Application to wound
Describe skin grafting/closure in further detail
- Split skin grafting takes time ++
- Can be safely delayed
- No dermatome? – carving knife
- Hand meshing
- Or Gorachon method….morsellised fullthickness graft
- Priority areas first
Describe the features of split skin grafting - donor site morbidity
- Painful
- Sepsis
- Dressing changes
- Scarring, esp keloid
Describe morsellised full thickness graft: harvesting
- Elliptical full thickness graft
- LA or GA
- Fat removed in harvesting
- Primary closure of donor site
When do infected wounds occur?
- Often due to late presentation and / or inadequate wound excision
- Excise dead & contaminated tissue
- Treated with Antibiotics
- Large volume of exudate – try daily sugar dressings
- Could also be treated with Antiseptic solutions? – only if above fail
How is wound care carried out during war?
- Sugar dressing: Sugar, vaseline, glycerine. Antiseptic. Malodorous wounds
- Vacuum dressing: KCI system £5K, Small electrical fish tank pump, tubing, foam
How is trans-femoral carried out during war surgery
- Often begins as trans-tibial then revised to trans-femoral when proximal extent of tissue damage appreciated
- Elective level : 15-25cm below trochanter
- Excise contamination along track of sciatic nerve
- Vastus lateralis / adductor magnus myoplasty
How can trans femoral occur through the knee?
- Rarely utilised in war surgery
- Not suited to delayed closure due to exposed cartilage
- Occasionally indicated as rapid amputation in critical patient - Later revision to trans-femoral
- Prosthetic difficulties
- Useful in children
How are trans-tibial amputations carried out?
- The commonest war surgical amputation
- Elective level : thickest point of calf
- Improvise skin flaps
- Section fibula 2-3 cm proximal to tibia
- Medial gastroc / hemi-soleus / soleus myoplasty
When is a Syme’s amputation used?
- Only rarely possible for war wounds
- Rarely done in developed world due to sophistication of BK prosthetic technology & poor cosmesis
- But good for third world: End bearing stump, Simple, “elephant boot” prosthesis
- Cannot fashion flap at initial surgery as postioning is critical!
When is an upper limb amputation used?
- Much easier than lower limb
- Less muscle bulk
- Excise dead & contaminated tissue
- Delayed closure
- Very little access to UL prostheses
- Krukenberg procedure in thru-wrist or trans radio-ulnar amputation
How are fractures treated during surgery?
- Mostly contaminated, compound
- Debridement
- Conservative treatment: Plaster of Paris, Traction
- External fixation
- Internal fixation rarely ( ever?) indicated
What is an internal fixation - upper limb fractures?
- Distal radial fractures
- Both bone forearm fractures
- High union rate, minimal handicap from malunion in African context
How are ankle fractures treated in war surgery?
- Common presentation
- Difficult to treat conservatively if unstable
- Poor outcomes
- Salvage (arthrodesis) is complex
- A priority in the “fixation hierarchy”
What are the signs of an intramedullary nail?
- Surgical Implant Generation Network”
- Solid, unreamed intramedullary nail
- Designed specifically for developing world use, provided free
- One or two locking screws both proximally & distally
- No need fluoroscopy for scew insertion
- Originally designed for tibial fractures, open or closed
- Can also be use in distal femoral fractures (retrograde insertion)
How are burns dealt with during war surgery?
- Resuscitation
- Debridement
- Open vs. occlusive treatment
- Treated using Antibiotics
- Transfusion
- Split skin graft: Priority Areas, Pinch grafts
Conclusion
- The treatment of the war injured patient poses unique surgical challenges
- Adherence to set protocols , with emphasis on delayed primary closure, can give good results even with limited resources.
