Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Fractures in Rural North-East of Democratic Republic of Congo
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Falls, in general, constitute the primary cause of fractures in our area (a total of
39.38% of our cases). Traffic accidents came in second position with 29.02% of
cases. It is important to stress that in rural area such as ours, the poor state of the
roads, the age vehicles, and the drivers recklessnes and drunkenness at the wheel are
all factors in motor vehicle accidents.
In 12.44% of cases, patients presented with open fractures. In more than half of
these cases, the tibia and fibula was the site of the fracture. This can cause very
serious complications in developing countries due to the potential for infection.
More than 90% of our patients were treated conservatively. The choice of therapeutic
modality is one of the most crucial points in the care of patients with fractures
in underdeveloped countries. We believe that the advice given by Anderson 7 is
very relevant in our area, for the choice of fracture depends upon the experience and
judgement of the surgeon, and surgical treatment must be reserved for difficult and
unstable fractures. Due to the shortage of orthopedic surgeons, and of necessary
materials for open reductions, Duraiswami 8 has noted that in fracture luxations of
the ankle, every effort should therefore be made to aim at perfect reduction by
manipulation, followed by immobilisation of the injured part in plaster.
Even in developed countries, open reductions are not done without complications.
Failure of the bones to heal after setting of the plates, 10 weakness of the affected
bones 11 and refractures occur. 12 Moreover, it is possible in our work
environnment to obtain a satisfactory treatment of fractures with simple and elementary
material, as Bewes 13 and Ebong 14 have shown.
This study can help us to draw practical lessons for people who work in rural
areas where most of the time the physician finds himself abandoned, alone and
overworked. (1) Paramedical personnel can render tremendous services in the making
of plaster and the setting of traction if well supervised. (2) Most fractures can be
treated conservatively, and the required training for young physicians and paramedical
personnel must be oriented towards providing experience in this area. This will help
to diminish numerous physical handicaps encountered in the bush and also help to
avoid many amputations. 15
This study of the epidemiology and treatment of fractures has shown that they
are frequent in distant rural areas. Men are stricken more often than women, and
both sexes are affected during the productive periods of life. Children under the age
of 16 years are most affected, and they can suffer serious consequences on their
development, or they may become handicapped. Falls and traffic accidents represent
the most frequent causes of fractures; and they can be improved only with
widescale community effort, improvement in living conditions, and also amelioration
of transportation and roads.
From the therapeutic standpoint, we are convinced that many fractures can be
reduced orthopedically with satisfactory results, and surgery should never be
recommanded unless its benefits outweight those offered by conservative treatment.
Open reductions require sophisticated equipment and qualified personnel having
an extensive knowledge of anatomy and physiology which in rural tropical areas
such as ours is an extremely remote possibility.
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