Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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178 Surgery and Healing in the Developing World
stigma in certain cultures, and generally, prosthetic availability is limited. It is often
not essential to correct all angular deformity and shortening following long bone
injuries as long as the patient gains sufficient function to provide a livelihood for
himself and his dependents. An extremity with slight angulation and shortening
that heals solidly without infection is preferable to attempting perfection without
the proper equipment ending in a disastrous result.
There are many lessons to be learned from patients and colleagues who live and
work in this environment. The challenges and rewards are endless for those willing
to participate in the improvement of medical care for all on the global scale.
Trauma Care
Musculoskeletal trauma is increasing worldwide due primarily to the increase in
motor vehicles available, and an increasing urban population. The Burden of Disease
Project predicts that motor vehicle injuries will be the third leading cause of
morbidity and mortality worldwide within the next two decades. Many patients
from motor vehicle trauma fit into the polytrauma injury patterns. The protocols
for dealing with these patients in North America and Europe include early and
aggressive stabilization of pelvic and long bone fractures as part of the resuscitation
protocols. A study done comparing trauma outcomes in the developing world with
a U.S. trauma center showed the time to arrival at the hospital in the developing
world was less than 24 hours in 41% of patients, one to seven days in 44%, and
greater than one week in the remaining 15% of patients. It is clear that many of the
most severely injured patients did not survive the trip to the hospital, but in addition,
early stabilization was simply not possible in the majority of patients. If patients
are seen early, very often the ability to perform sophisticated procedures such
as internal pelvic fixation and interlocked intramedullary rods is not available because
of the lack of equipment, X-ray, and a safe operating room environment.
Other methods must clearly be employed.
External fixation has provided one of the great benefits to trauma care throughout
the developing world and can be used for pelvic and long bone fractures. It is a technique
that can be taught to technician level personnel using improvised equipment
and has provided a means of salvaging many otherwise unsalvageable limbs. Figure 1
shows a homemade fixator placed in a patient with an unstable pelvic fracture.
Femoral Fractures
The treatment of femoral fractures provides an example of the innovations necessary
in treating severe injuries when resources are limited. It is possible in the
correct environment to place intramedullary femoral rods using an open retrograde
technique. This can be done without X-ray control and provides an effective treatment
method if a safe operating room environment is available. Use of percutaneous
intramedullary locking rods is usually precluded by the lack of expensive implants
as well as the required X-ray equipment. When any doubt exists as to the safety of
operative stabilization, traction treatment should be considered. There are many
different methods that are being used throughout the world and perhaps the most
common is either skin or skeletal traction in a Böhler frame. Minimally trained
personnel can easily arrange these materials, and the frames are usually available in
most provincial level hospitals. Skin breakdown, fracture malposition and delayed
healing have been a problem, but if these are attended to, the patient can be treated
satisfactorily with little or no X-ray resources needed. Traction weight can be determined
by leg length measurements and alignment judged visually.