 |
Home | Sitemap | Contact |
Jungle Orthopaedics
ORTHOPAEDIC PROBLEMS IN A PRIMITIVE SETTING
Diplomate American Board of Orthopaedic Surgery
Date of production in this revised format: February 15, 2001
“Jungle Orthopaedics” 1 No. 4.
Recommended Books
Since the last monograph was written, I have become aware of four books, that are written for doctors who have not had much, if any, orthopaedic trauma. There is certainly no need to “reinvent the wheel,” so I have recommended that any doctors seriously interested in developing familiarity with orthopaedic principles purchase these four books. I will be referring to these books as I go along. These books are:
"Practical Orthopaedics" by Lonnie R. Mercier, published by Mosby, ISBN 0-8151-5903-X (soft cover), Fourth Edition.
"Emergency Orthopaedics, The Extremities" by Simon and Koenigsknecht, published by Appleton & Lange, ISBN 0-8385-2208-4, Third Edition.
"Emergency Orthopaedics, The Spine" by Galli, Spaite, and Simon, published by Appleton & Lange, ISBN 0-8385-2203-3, First Edition.
"Current Diagnosis & Treatment in Orthopaedics" by Skinner, published by Appleton & Lange, ISBN 0-8385-1-009-4, First Edition.
Since these books do not go into surgical techniques in any detail, I will also be referring to Campbell’s Operative Orthopedics and other texts.
Another extremely useful manual has been prepared by Dr. Ronald Garst, entitled, "A guide to management of common problems in orthopaedics and related subjects in developing countries, especially applicable to mission hospitals."
Contact Dr. Garst at 2749 Tuckaleechee Pike, Maryville, TN 37803, phone 865-982-1472.
Compartment Syndromes
COMPARTMENT SYNDROMES result from increased pressure within a closed compartment, due to hemorrhage or edema. They are frequently seen in the lower leg and in the forearm. Untreated, this increased pressure may result in necrosis of muscles within the compartment. Volkmann’s ischemic contracture of the forearm is one example of this. Compartment syndrome should be suspected in all cases of fracture of the leg and forearm, and frequent examinations done to rule out its presence.
There is a good discussion of this topic in “Current Therapy,” pages 485 & 486.
The outstanding symptom is PAIN OUT OF PROPORTION TO THE INJURY. This pain may be accentuated by passive stretching of the muscles involved. There may also be paralysis of the muscles involved. There is also marked tenderness to pressure over the involved compartment. The pulse may not be involved early. In the leg a very useful sign is the patient’s inability to dorsiflex the great toe. In the forearm, the patient is unable to extend the fingers.
Increased compartment pressure can be determined by an improvised instrument, consisting of a blood pressure manometer, a 20 ml. syringe, two IV extension tubes, a four-way stopcock, an 18 gauge needle, and some sterile normal saline. See diagram:
Saline is aspirated into the first extension tubing, for approximately one-half its length. The needle is then inserted into the compartment being tested. The apparatus is kept at the level of this needle. The stop cock is then opened such that it is open to the syringe, and the IV tubing on either side. The syringe should be filled with air at this point. Slowly compress the piston of the syringe. Watch the end of the fluid in the first tube. When it begins to move, the compartment pressure is measured on the manometer.
Normal compartment pressue is zero to 10 mL. of mercury. Compartment pressures between 15 and 20 mL require careful observation. Pressures over 30 to 40 mL. demand immediate fasiotomy. Prolongation of this osrt of pressure for more than a few hours will result in tissue necrosis.
If the compartment pressure is moderately eleveated, it is treated by elevation and ice packs, without any constricting dressings. If this does not promptly relieve the situation, fasciotomy must be done.
Fasciotomy
Prophylactic fasciotomy should be done in cases where there has been ischemia for four hours or more.
In the forearm the volar compartment is the one most often requiring fasciotomy. The incision should extend into the arm and into the carpal tunnel:
An epimysiotomy of the involved muscle bellies should also be performed. The serpentine incision is used to minimize contracture by scar as the wounds heal. Sometimes the incision can be closed secondarily after the sweeling goes down, but most often a split thickness skin graft is used.
The dorsum of the forearm can be opened with a simple longitudinal incision:
In the hand each compartment must be opened individually. Two longitudinal incisions over the dorsum will provide access to the interosseous muscles. Other compartments will require separate incisions. Fasciotomy of the fingers may be necessary in the case of snake bite or burns, and is performed if the swelling appears to be causing ischemia.
In the leg there is an ANTERIOR compartment between the tibia and fibula, a PERONEAL compartment lateral to the fibula, and a SUPERFICIAL AND DEEP POSTERIOR compartment. All four of these must be released. This can be accomplished as illustrated. in the following diagrams:
