Orthopaedic In Low Resource Settings

Question 1

What is the need to tackle the global burden of disease and risk factors?

Answer 1

• 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

Question 2

What is the need for surgery in Motor Vehicle Accidents?

Answer 2

• 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

Question 3

What is the ICRC wound management doctrine?

Answer 3

• Standardised approach
• No high-tech resources
• No surgical specialities
• No onward referral
• Differs from military doctrine
• Extensive database

Question 4

What are the initial measures after an incident has occurred?

Answer 4

• Dressings
• Intravenous fluids
• Antibiotics
• Analgesia
• Anti-tetanus serum & tetanus toxoid
• X-rays

Question 5

Describe how primary surgery is carried out

Answer 5

• Amputate under tourniquet
• Wound excision
• No primary repair of nerve or tendon
• Removal of de-vitalised bone
• Leave wound open
• Dry, sterile dressing
• Immobilise

Question 6

What happens after delayed primary closure? (PART 1)

Answer 6

• 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

Question 7

What happens after delayed primary closure? (PART 2)

Answer 7

• 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

Question 8

What measures do you need to put in place before carrying out an amputative technique?

Answer 8

• Determine necessity of amputation
• Scoring systems rarely helpful
• Consensus with colleagues
• Consent

Question 9

Describe the amputative technique (PART 1)

Answer 9

• 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

Question 10

Describe the amputative technique (PART 2)

Answer 10

• Dry, bulky sterile dressing
• Monitor T, P, BP
• All open wounds Smell!
• “good bad smell”
• “bad bad smell”
• Do not change dressing on ward!

Question 11

Describe the amputative technique (PART 3)

Answer 11

• Remove dressings in theatre under anaesthesia at 5/7
• Should reveal granulating, slightly bleeding tissue
• Skin retracts
• Muscle flaps swell

Question 12

Describe the amputative technique (PART 3)

Answer 12

• Close myoplasty over bony stump (?myodesis)
• Drain
• Avoid tension
• If infected, or contaminated, re-debride & repeat process

Question 13

List some key notes on ICRC wound management

Answer 13

• 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

Question 14

Describe surgery on open wounds

Answer 14

• Great burden of open wounds in developing world hospitals
• Often septic
• Malodorous

Question 15

Describe skin grafting used in surgery

Answer 15

• Split skin grafting
• Dermatome knife
• Involves Blades
• Surgical skill
• Meshing
• Application to wound

Question 16

Describe skin grafting/closure in further detail

Answer 16

• Split skin grafting takes time ++
• Can be safely delayed
• No dermatome? – carving knife
• Hand meshing
• Or Gorachon method….morsellised fullthickness graft
• Priority areas first

Question 17

Describe the features of split skin grafting - donor site morbidity

Answer 17

• Painful
• Sepsis
• Dressing changes
• Scarring, esp keloid

Question 18

Describe morsellised full thickness graft: harvesting

Answer 18

• Elliptical full thickness graft
• LA or GA
• Fat removed in harvesting
• Primary closure of donor site

Question 19

When do infected wounds occur?

Answer 19

• 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

Question 20

How is wound care carried out during war?

Answer 20

• Sugar dressing: Sugar, vaseline, glycerine. Antiseptic. Malodorous wounds
• Vacuum dressing: KCI system £5K, Small electrical fish tank pump, tubing, foam

Question 21

How is trans-femoral carried out during war surgery

Answer 21

• 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

Question 22

How can trans femoral occur through the knee?

Answer 22

• 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

Question 23

How are trans-tibial amputations carried out?

Answer 23

• 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

Question 24

When is a Syme’s amputation used?

Answer 24

• 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!

Question 25

When is an upper limb amputation used?

Answer 25

• 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

Question 26

How are fractures treated during surgery?

Answer 26

• Mostly contaminated, compound
• Debridement
• Conservative treatment: Plaster of Paris, Traction
• External fixation
• Internal fixation rarely ( ever?) indicated

Question 27

What is an internal fixation - upper limb fractures?

Answer 27

• Distal radial fractures
• Both bone forearm fractures
• High union rate, minimal handicap from malunion in African context

Question 28

How are ankle fractures treated in war surgery?

Answer 28

• Common presentation
• Difficult to treat conservatively if unstable
• Poor outcomes
• Salvage (arthrodesis) is complex
• A priority in the “fixation hierarchy”

Question 29

What are the signs of an intramedullary nail?

Answer 29

• 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)

Question 30

How are burns dealt with during war surgery?

Answer 30

• Resuscitation
• Debridement
• Open vs. occlusive treatment
• Treated using Antibiotics
• Transfusion
• Split skin graft: Priority Areas, Pinch grafts

Question 31

Conclusion

Answer 31

• 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.