Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Orthopedic Surgery
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outcome. Dana first proposed this concept and outlined the principles underlying the
method of continuous passive range of motion. Injuries such as those in Figure 3 can
be treated using a removable splint initially with range of motion exercises beginning
within a few days of injury. When necessary, functional traction which will allow
active motion can be used in place of the splint. Olecranon traction works well in
certain elbow injuries involving the distal humerus. Our experience indicates that
joints regain stability and remain sufficiently free of pain to allow functional activities.
Surgical Techniques
Open fractures require early wound debridement and lavage to prevent secondary
infection. It is a significant challenge to teach the proper technique in all cultures.
Principles include removing all devitalized tissue, copious lavage, allowing the
wound to remain open, redebridement of the wound as necessary and closure by
suture or skin graft only when all tissues remain viable and clean. The temptation to
close wounds early is universal and must lie somewhere deep in our intuitive self.
The technology for accomplishing proper wound debridement is simple but does
consume some resources including operating room supplies and personnel time.
Studies done in Africa comparing irrigation fluids indicate that boiled water is just
as effective as other more expensive processed solutions for wound lavage. Internal
fixation of open fractures in this environment should be avoided.
Certain fractures do better when treated with internal fixation if a “safe operating
room” is available. These include tension type fractures involving the olecranon
and patella. The tension band technique requires simple and inexpensive implants,
can be accomplished through small incisions, and does not require intraoperative
X-ray. Kirschner or other smooth pins and 18 gauge stainless steel wire are all of the
implants necessary. The resulting fixation is stable enough to allow early range of
motion in most cases (Fig. 4). The technique is applicable for fractures of the oleranon,
patella, proximal humerus, and medial malleolus.
The Rush rod is another simple but effective device which has a variety of uses in
orthopedic care. They are available in variety of diameters and lengths with a hook
Lateral View AP View
Figure 4. AP and lateral view of the tension band technique in use for an olecranon
fracture.
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