Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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180 Surgery and Healing in the Developing World
of the usual complications associated with traction at bedrest can be avoided by this
mobility. When the patient reclines, boards hold up the bottom of the mattress. By
6 to 8 weeks fracture healing has usually progressed sufficiently to allow application
of a brace cast, and the patient can leave the hospital using crutches. Perkin’s traction
also works well for elderly patients with intertrochanteric hip fractures. The
fracture can be well controlled and the mobility permitted helps to prevent the
complications associated with bed rest in this age group. As fracture healing progresses,
many patients are able to stand up in the space between the mattress and the end of
the bed allowing them to regain muscle strength and balance.
Tibial Fractures
Plaster cast application remains the basic treatment for tibial fractures. Functional
treatment regimes with immediate weight bearing are appropriate when satisfactory
plaster is available. Delayed unions can be managed by osteotomy of the
fibula and continued plaster treatment. External fixation works very well for unstable
tibial fractures. It is particularly useful with open fractures as it allows access
to the wound for dressing changes and skin grafting. The pin and plaster technique
can substitute for external fixation if necessary.
Calcaneal traction on a Böhler frame is used for complex tibial fractures, but it is
more difficult to manage than external fixation. Open treatment using plates or rods
is rarely indicated because of the danger of infection and the lack of equipment.
Joint Injuries
For comminuted intra-articular fractures secondary to gunshot wounds or other
high energy trauma are common (Fig. 3), surgical reconstruction in the best of circumstances
often does not yield a satisfactory result. When resources are limited, treatment
with immediate active range of motion can result in a satisfactory functional
Figure 3. Severe intra-articular fracture
which was treated with removable splints
and early range of motion.