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Jungle Orthopaedics
ORTHOPAEDIC PROBLEMS IN A PRIMITIVE SETTING
Diplomate American Board of Orthopaedic Surgery
Date of production in this revised format: February 15, 2001
Monograph #1, October 11, 1994
Introduction
The idea of writing a book to give orthopaedic instruction to non-orthopaedists came about as a result of the need at Memorial Christian Hospital in Bangladesh. After working in that hospital over a period of seventeen and one-half years as an orthopaedic surgeon, interrupted only by furlough years, it was very evident to me that the demand for orthopaedic care was not going to stop when I left the scene. However, the doctors who were taking over the medical work at the hospital had not had much orthopaedic training. Many of the short term doctors who came from time to time to assist in the work for several weeks or several months, also had not had much orthopaedic surgery training during their residencies. Orthopaedic problems are very common in mission hospitals, especially at Memorial Christian Hospital in Bangladesh, and, like-it-or-not, the doctors are pressed into handling orthopaedic emergencies. Clearly, I thought, there is a need for a simplified treatise on how to handle orthopaedic problems in such a setting. That's when I got the concept of writing such a book. However, realizing that considerable time would be required to write this in a book form, and that the need on the field for such information is NOW, I decided to write in a series of short monographs, instead of a book. The missionary doctor “on the front lines” has little time to read. These short monographs could be more “bite-size” and could be read as they arrived. Then, they could be filed in a loose-leaf notebook for future reference. The articles are very basic, assuming no knowledge of orthopedic terms, equipment, procedures, etc. on the part of the reader. To the experienced surgeon they may be oversimplified, but it is hoped that they will be helpful to some doctors.
I do not intend to spend much time on elective orthopaedics-that is, reconstructive surgery, or non-emergency work. The big demand on our field, and I suspect on many mission fields, is for knowledge and expertise in the handling of trauma cases. This will be our major thrust. However, many non-emergency orthopaedic problems are quite simple to care for, and I will discuss some of these.
In my own case, when I arrived in Bangladesh, having had a formal orthopaedic residency training, followed by six years of clinical practice of orthopaedics in California, I had been thoroughly indoctrinated in principles of handling various orthopaedic problems. It did not take long for me to realize that these "principles" could not always be applied in the primitive setting where our hospital was located. Cultural, traditional, and environmental factors all require modifying treatment to fit each individual situation. For example, the standard approach in developed countries for treatment of tuberculosis of the knee joint might be considered to be joint fusion. This is good treatment, and often results in a “cure” of the TB. However, Bangladesh has a squatting culture. Squatting is required to use an Asian toilet in anything resembling a comfortable position. A stiff knee requires one to sit on the bricks on either side of the opening in the floor; and this may be quite messy--not a pleasant situation! Therefore, your patient with a stiff knee may not be very happy with the final result.
Patients arriving at the hospital for treatment have often had treatment elsewhere, resulting in considerable delay, and often in severe complications. It is not possible to describe the great variety of such complicated problems, but they may be more prevalent in your practice than nice, fresh, clean injuries. They will require special consideration and often special handling. This is where the "tricks of the trade" often come in handy.
When the patient arrives and is seen by the national staff of medics, nurses, or even doctors, one must not assume that the patient has been adequately triaged by these persons. The doctor must do his own triage and assessment, taking nothing for granted.
The expectations of the patient need to be considered. The uneducated patient often expects immediate results. He does not understand the need for "staged" treatment. Do not assume that he or she will follow instructions, and that they will return as requested for further treatment. Often they have come a long way, and have no place to stay around for a few days while you get lab work, x-ray work, and special tests. You are pressed into doing as much as you can on that first visit.
The patients often know little or nothing about their anatomy or physiology, so detailed explanations only confuse them. Superstition or fear may cause them to reject recommended treatment, even if it may be lifesaving or lifesaving.
With that as an introduction, let us begin by considering some very basic orthopaedic management procedures and techniques. Let's start with TRACTION, since this is the orthopaedist's great "master tool". No matter how complicated a fracture might appear to be, traction will often times pull the fragments into alignment very nicely, and surgery may be avoided. Traction is a two-edged sword, however. It can cause problems as well as treat problems.
Skin Traction
In a hot climate, skin traction is oftentimes poorly tolerated. Adhesive tape traction strips may cause traction blisters at the edges of the tape. Efforts to wrap the extremity securely enough to prevent the tape from slipping may embarrass the circulation. I have found that the most effective way to apply skin traction is by means of orthopaedic tubular stockinette applied over some sort of "skin glue", such as tincture of benzoin or Ace Adherent. This gives circumferential traction to the skin, avoiding problems at the edges of tape strips. Some sort of spreader must be applied at the end of the limb, to avoid squeezing the tubular stockinette tightly over pressure points, such as the malleoli. This can be a wood block with a hole in it for the rope, or can be a wire spreader.
If tubular stockinette is not available, one might improvise by applying the "skin glue", and then wrapping the limb snugly but not tightly with cloth strips or bias-cut stockinette, in a circumferential fashion. Then, strips of adhesive tape can be applied in a longitudinal fashion over the cloth layer, and traction applied to the tape strips. This will give circumferential traction, without the "shear force" at the edges of the tape strips.
Skin will only tolerate about 8-10 pounds of pull without blistering. If more pull than this is required, you need to go to skeletal traction.
If an elastic bandage is used to wrap around the tubular stockinette to hold it next to the skin, great caution must be used to see that the elastic bandage is not too tight. I think it is better to wrap the extremity with a nonelastic wrap, such as a bandage roll, to avoid excessive tightness. This wrapping should be rewrapped DAILY, or more often if it gets wrinkled into a series of rope-like constrictions.
Each day, as the physician makes rounds on patients in traction, he must thoroughly inspect the traction to see that it is staying in place and not causing skin problems. Skin problems can complicate surgery or casting.
Types of Skin Traction
Buck's traction: This is straight traction to one leg, and is often used in cases of hip fractures, or knee injuries. Trac-tion is applied by applying the tubular stockinette to the leg from just below the knee to the ankle, securing it in place with circumferential wrapping, and then applying a spreader block or wire distally, connected to a rope. Sometimes longitudinal strips of tape are applied to the stockinette and traction is applied to the tape strips. The rope is ideally passed through a pulley at the end of the bed, and connected to a 5-8 pound weight. If no pulley is available, one can simply use the foot of the bed, or a smooth round rod between two chairs, over which to pass the rope. Caution is necessary to see that the traction does not pull the heel down against the bed, as this will result in a bedsore behind the heel. These are very difficult to treat! Be certain to assess the circulation after application of the traction, and check it daily.
Bryant's traction: This is sometimes used in small children with femur fractures, applying Buck's-type traction to both legs in an upward direction. This pulls the legs straight up, with the hips flexed 90 degrees. Great caution must be exercised in using this form of traction on other than very small children, weighing less than 30 pounds. The circumferential wrapping, together with the elevated position, may cause ischemia to the leg or foot, which can be disastrous! Enough traction is applied to just lift the buttocks off the bed.
Russell's traction: This is an extremely useful form of traction, utilizing a system of pulleys to result in a strong traction force without over-tracting the skin. The resultant or vector force between the upward traction and the longitudinal traction is about double the weight applied. Here it is absolutely necessary to use a spreader bar on the sling above the knee, to avoid a constrictive force around the distal thigh.
Side-arm traction: This Is useful in fractures of the humerus, and may also be useful in some cases of forearm fractures. Again, great caution is necessary to ensure the circulation is not compromised.
Cervical traction
5-6 pounds of continuous cervical traction can be tolerated via a traction sling beneath the occiput and beneath the chin. This sling should be padded well. In cases of cervical fracture the traction must be in line with the trunk (axial). In cases of suspected herniated cervical discs, the traction should be in about 20-30 degrees upward angulation.
Pelvic traction
Pelvic traction may be used for herniated lumbar discs. In this case the traction should be applied in about 30 to 45 degrees upward direction.
This reverses the lumbar lordotic curve, opening the posterior part of the intervertebral disc space. Pelvic traction may also be used in some cases of spinal fractures. This will be discussed in detail under that category.
As you can see from the foregoing discussion, skin traction is quite limited by the amount of weight that can be applied to the skin without causing problems. When more weight is needed, one must go to skeletal traction. Or, when traction will be prolonged beyond just a few days, it is usually better to use skeletal traction than skin traction, to avoid skin problems.
Skeletal traction
This is the orthopaedist's great friend, but must be used carefully. There are two main types of pins used for skeletal traction --Steinmann pins and Kirschner wires. Both of these come in both threaded and smooth, or non-threaded styles. In general, threaded pins or wires should NOT be used for skeletal traction as they may break more easily than the smooth ones. However, in very small children undergoing femoral traction, it may be better to use threaded pins to prevent side-to-side slipping of the pin with subsequent contamination of the pin-sites.
Kirschner wires are usually nine inches long and in three diameters: I/32", 3/64", and I /16" (. 035, . 045, and .062 in. , or 0.9, I.2, and I.6 mm). Because of their small diameter, Kirschner wires are only used for smaller bones. Traction on the ends of the wire will cause it to bow. Therefore, Kirschners wire traction bows are necessary.
When tightened, these change the easily bendable K-wire into a tight-wire, and considerable pull can be applied to the traction bow without bowing the wire very much.
Remember - because K-wires are relatively fine, they will cut through bone rather easily, just like you cut cheese with a tight wire. This is especially true in osteoporotic bone.
Steinmann pins are thicker than K-wires. They, too, usually come in 9 inch lengths (you can get longer ones on special order). They come in a greater variety of diameters: 5/64", 3/32'", 7/64", 1/8", 9/64", 5/32", and 3/16" (2.0, 2.4, 2.8, 3.2, 3.6, 4.0 and 4.8 mm). They come with various kinds of points, and some are pointed on both ends. One very useful modification of a Steinmann pin has suture holes drilled in each end, and can be used for passing suture through bone.
Because of their increased size, Steinmann pins do not require a "wire stretcher" like the K-wire traction bow. Instead, traction can be applied by a simple traction bow.
When drilling skeletal traction pins through bones it is very important to drill SLOWLY, so as to not cause overheating of the bone around the pin with resultant ring-sequestrum. This will also lead to loosening of the pin with prolonged traction, and paves the way for infection. Sites for application of skeletal traction will be discussed under the various uses.
Pins or wires can usually be inserted under local anesthesia. Very careful sterile technique is a MUST. The area should be thoroughly cleansed with soap and water, and then prepped with Betadyne (if available), or other strong germicide. Tincture of iodine can be used, and is usually available. Then, the area is draped with sterile towels. The operator should wear sterile gloves, and all of the equipment must have been suitably sterilized. I % or 2% lidocaine is injected at the site of pin insertion, down to the periosteum. The site of pin exit is also injected. The pin or wire is then drilled slowly through both cortices of the bone with a hand drill.
It is important to take good care of the pin-sites, to avoid infection. They should be dressed with a sterile sponge and antibiotic ointment, or left open and cleansed daily with hydrogen peroxide. Care must be exerted to see that the pin does not move from side to side through the bone, which will pull contaminated wire into the traction hole.
Improvisation: Mission hospitals may not be able to afford the luxury of "store-bought" K-wires and Steinmann pins, and the "missionary drums" may not contain a sufficient supply. It is possible to make your own pins and wires from type 316 stainless steel rods and wires available from various sources. Such rods and wires should be sufficiently stiff to allow insertion in bone. Do not use ordinary stainless steel, as it is not well tolerated in the human body. At the same time ask about getting type 316 nuts and washers to use with the threaded pins. Usually nuts and washers are only used on threaded pins of 1/8" diameter and larger. These are very useful, as will be described later.
You can have the wires and rods cut to three-foot lengths for ease in shipping. When you get them, cleanse the grease off with solvent, cut them to desired lengths, sharpen the ends with a file (using a grinder will cause them to overheat and lose their temper), and then polish them with steel wool.
The easiest way to sharpen the ends so that the wire or pin will act as a drill point is to fashion a "trocar point".
