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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 No. 8 - Potporri
Care of Wounds
This is mainly for non-surgeons who might be reading this monograph, but surgeons may also find some benefit from it, as it pertains to "non-clean" conditions in particular.
The important thing to remember in primitive settings is that wounds sustained in such a setting are usually very dirty. The environment is dirty. Sanitation and personal cleanliness may be poor. The article causing the wound is usually very dirty. Initial wound care at the site of the incident causing the wound may have introduced even more contamination into the wound-such as manure, leaves, urine, caustic chemicals, and various unknowns.
A good policy is to consider practically all wounds dirty and debride them carefully. "Debridement" really means "excision" of the wound, as much as is possible without harming important structures. This must be done under good lighting and must be meticulous, with copious irrigation with normal saline. Gentle scrubbing with a surgical brush may help dislodge sand and small bits of rock. Soap can be used (mild soap), but must be rinsed out thoroughly. When all contaminated or devitalized tissue possible has been excised, the decision must be made whether to close the wound, or to leave it open. If there is ANY doubt as to the cleanliness of the wound, or of the viability of the remaining tissues, the best course is to pack the wound open with saline-soaked gauze, and bring the patient back to the operating room in a few days for secondary debridement. This may have to be done several times before the wound can be considered clean enough to close.
One must also remember that there will be swelling of the tissues around the wound. Any closure will become tighter, due to this swelling, and circulation to the skin may be further compromised. This is particularly true in the lower leg. Closure may be possible after this swelling has run its course, with salvage of much more skin than if primary closure had been attempted.
Wounds that are left open and allowed to heal by secondary intention do surprisingly well. We saw this well illustrated in patients who came in with multiple machette cuts, some of which went very deep into muscles. After debriding these as much as possible, they were left open and allowed to heal by secondary intention, avoiding any risk that might accompany attempts to close them. In most cases these healed with no greater scarring than might have been expected if they had been closed primarily.
Wounds over joints deserve special mention and discussion. A wound that penetrates a joint is a special situation, because the wound may have introduced foreign matter or infected material into the joint. Untreated, this may result in septic arthritis and possible loss of the joint cartilage. If there is any doubt as to whether or not the joint has been penetrated, it is better to open it through a separate incision, and do a thorough inspection and lavage. If there has been penetration, after the lavage it is best to close the joint wound with a small Penrose drain that should remain for several days. Do not instill antibiotics directly into the joint, as they are very irritating to the synovial tissues.
In the case of a wound that exposes a joint, every effort should be made to close the synovium and not leave the joint open. Again, leave a small drain for a few days. You may have to transpose a bit of muscle or other soft tissue to provide closure of the joint. This same principle is true in regard to major vessels, nerves and tendons--if left open they will dry out and become necrotic. Try to cover them with something.
Many years ago, while in general practice, I used to use a poultice paste called "Osmopak". It was magnesium sulfate paste, with brilliant green dye. This was a powerful poultice. In Bangladesh we decided to use a saturated solution of magnesium sulfate for our wet dressings, to provide a "poultice-like" effect, as well as stimulating granulation tissue formation. The main drawback is that it stings a lot when applied, but it has been very effective in helping soupy wounds to clean up. In my hands it works much better than normal saline. We changed the wet dressings every eight hours (once per shift), and put them on "sloppy wet".
Gentian violet has been a good friend in wound care. It is bacteriostatic, is a good stimulant of granulation tissue growth, and also is an epithelial cell growth stimulant. It also provides some psychological benefit, in that the patient can definitely see that you have applied some medicine (much better than a colorless solution).
Granulation tissue formation can also be stimulated by application of granulated sugar in the wound. This is very effective in bed sores. It was my routine practice to apply a triple antibiotic ointment to the suture line whenever I closed an incision, even in clean cases. This may be "empirical", but I very seldom saw any suture abscesses. Hydrogen peroxide can be used at the time of dressing changes, or at pin sites, but should not be applied to open wounds as it is too harsh for the tissues.
SOME BASIC PRINCIPLES REGARDING X-RAYS
Any x-ray of a long bone for a suspected fracture should show two joints, one above and the one below the fracture, if at all possible. Many people have missed a fracture of the proximal fibula, for example, in the presence of an ankle fracture--or, a fracture of the proximal ulna in a distal radial fracture. Fractures or dislocations of the hip are not uncommon along with a knee fracture.
Always strive to get two views of any area, preferably a true AP and a true lateral. It is also wise to get a comparison view of the normal extremity, especially in children and infants.
Be aware of the "Mach" effect--a linear shadow on the x-ray caused by tissue overlap, that may be mistaken for a linear fracture. The shadow of the Mach effect, upon close inspection, can be seen to extend beyond the bony margins.
Be aware that non-displaced fractures may not be visible on x-rays taken within a few hours or a few days of the injury. Roentgenograms are basically shadows. If there is no separation of the fragments, no line will be visible in the shadow. If you suspect a non-displaced fracture, it is wise to splint the extremity and repeat the x-ray after ten to fourteen days. At that time there will have been enough bony resorption at the fracture site to make the fracture line visible:
Epiphyseal injuries need to be discussed a bit. A separation can occur through an epiphyseal line, and then spontaneous reduction occur, such that no defect is visible on x-ray. Usually, however, a small fleck of metaphysis at one side or the other of the epiphyseal line will have been displaced along with the epiphysis. When seen, this indicates that there has been an epiphyseal separation, and it should be immobilized. Sometimes such an injury becomes evident during the course of stress x-rays for suspected ligamentous injury of the knee.
Whenever a fracture line crosses an epiphysis there is cause for concern. The healing may cause a bony bridge across the epiphyseal line, with subsequent growth arrest. Even when anatomically reduced, it is well to advise the parents (preferably in writing) that growth problems may occur in spite of any treatment that has been rendered, and that the patient must be followed for several years.
ABOUT TOURNIQUETS
It has been said that trying to debride a wound or do surgery deep in a wound without a tourniquet is like trying to fix a watch that is immersed in an ink well. This is very true. Proper use of a tourniquet can turn a trying ordeal into an orderly, systematic and efficient surgical exercise. Tourniquets can be abused, however, with resulting harm to the tissues.
Generally speaking a tourniquet can be left in place for a maximum of two hours, but there will be some tissue swelling as a result. A good practice is to release the tourniquet for ten minutes after one hour, and then reapply it for the second hour. This prevents some tissue hypoxia and may reduce the post-operative edema.
Blood pressure cuffs can be used for tourniquets. The extremity can be exsanguinated adequately by simply elevating it above heart level for one minute for an arm and two minutes for a leg. This can also be accomplished by applying a tight wrapping, such as by an Esmarch rubber bandage, which is removed after inflation of the tourniquet. The tourniquet should be wide. No padding is necessary under it, and may even cause problems due to wrinkling of the padding.
A simple tourniquet for a finger can be provided by a 1 /2' wide Penrose drain in a "U" around the base of the finger, drawing it tight, and then applying a clamp across the "U" before releasing the traction. Do not use rubber bands or other narrow bands, as these may cause damage to the finger blood vessels or nerves.
POST-OPERATIVE FEVER
Blood in the tissues can cause a foreign protein reaction with a low-grade fever: This is usually seen during the first 24 hours post-op. It is seldom more than 1 degree F. elevation.
Another cause of immediate post-op fever may be atelectasis.
Fever coming on after a lapse of 24 to 48 hours may signify infection, but it may also be caused by:
Gout -- the stress of surgery may precipitate an attack of acute gout. This especially true in developed countries, where gout is common.
Malaria -- many people in primitive situations have chronic malaria, which their immune system is apparently handling all right. The stress of surgery, or of trauma, may upset this immune-system protection and the patient may develop malarial symptoms. There may or may not be a positive MP smear. When this is strongly suspected, we usually treat the patient with a therapeutic dose of Chloraquin, or Fansidar, or sometimes just with quinine. Prompt reduction of the fever indicates a correct diagnosis.
WARNINGS ABOUT LOCAL ANESTHESIA
This is for the non-surgeons: Never use local anesthetic solutions containing epinephrine for anesthetizing fingers, toes, or penises. The prolonged vasoconstriction from the epinephrine may result in gangrene. Use only "plain" Xylocaine, for example.
A FEW COMMENTS REGARDING FRACTURES
I do not intend to discuss each and every fracture--these are well covered in the books I mentioned earlier. I would like to make a few comments in general about some points in closed fracture care, however.
The general aim in fracture care is to get an "adequate" reduction, and hold it there until healing occurs. "Adequate" is different for different fractures:
Fractures in children: In the growing child substantial correction of angular defects in bones can occur near the ends of the bones. It is not essential to get perfect angular alignment of fractures near the ends of growing bones. HOWEVER, ROTATORY MALALIGNMENT WILL NOT CORRECT WITH GROWTH.
Forearm - the interosseous space between the radius and ulna is important for pronation and supination, and should be preserved. "Bayonet" apposition of the shafts of the radius and ulna may be allowable in young children, but not in adults. In adults near-anatomic reduction is the goal.
Wrist: - the proper length of the distal radius is important regarding radio/ulnar deviation; the angulation of the distal radial articular surface is important for flexion/extension.
Fingers: Here the close-anatomy does not allow significant deviation from normal without impairing the proper gliding of tendons. Near-anatomic reduction is the goal. Passive motion of the joints once weekly during the first two weeks will minimize the sticking of the tendons to the fracture-site. Generally immobilization of finger fractures is discontinued at about three weeks--before good callus is evident on the x-ray. This allows for gentle active motion, with the use of protective splinting except during periods of guarded exercise, for another three weeks.
If there is contracture of the small joints after the fractures have healed, rubber bands can be used to slowly overcome these contractures. The patient must be advised NOT to forcibly try to correct the contracture, as this will cause further harm. Steady, gentle pressure from rubber bands will slowly relieve the contracture. The rubber bands should be worn continuously, and exercises done against the resistance of the rubber bands.
REFLEX SYMPATHETIC DYSTROPHY: This can occur in any area, but is especially common in the hand. The symptoms are pain out of proportion to the injury, accompanied by swelling of the hand. The patient is reluctant to exercise the fingers. When this is suspected, immobilization is discontinued and gentle active motion is instituted. A well-healed fracture in a frozen hand is worthless! It is better to forget the fracture and try to get motion back into the hand.
Gravity: Blood behaves just like water -- it runs downhill. In the hand especially, allowing the hand to hang down can result in marked swelling, with resultant loss of motion. It is very important to keep the hand elevated ABOVE HEART LEVEL for at least the first 24-48 hours after an injury, and then periodically as necessary for control of edema. This is true for other fractures as well, but for most other fractures the edema is not so potentially devastating.
Long bones: In most long bones the goal is axial alignment, length restoration, and reasonable apposition (at least 10%). Excessive traction, to the point of distraction of the fracture fragments, must be guarded against, because it may result in non-union. This is particularly true in the case of humeral fractures.
Humeral shaft fractures: Here a simple plaster cuff around the arm (not the forearm), and a neck yoke around the wrist, holding the elbow at right angles, is usually sufficient. Gravity-traction is usually all that is necessary. Hanging arm casts are often too heavy and result in distraction. If distraction occurs, it is best to immediately put the patient into a shoulder spica cast with the arm in "salute position", to remove any effect of gravity that might prolong the distraction. Angular deformity is not terribly significant in humeral fractures, except at the elbow.
Elbow fractures: There is a great variety of these, and the reader is referred to the above-mentioned texts. Just a word of warning here in regard to the need for extreme attention to circulation, to prevent the dreaded ischemic contracture (Volkmann's). If possible, I like to keep the patient in the hospital overnight, after reduction, so the pulse and circulation can be checked by trained personnel. If this is not possible, some member of the family must be carefully taught what to look for and instructed to bring the Patient back immediately in case of problems.
Femur fractures: In children, up to about age six years, femur shaft fractures can be treated by immediate plaster spica and one-half casting, removal of the sole of the foot part on the side of the fracture to prevent the patient from being able to push down on it, and then x-ray, followed by wedging of the cast as needed for correction of any angulation. Over-riding of about 1 - 1 1 /2 cm. is allowed in these young children, because the femur will overgrow due to the fracture-hyperemia. In children over age six years the muscles are powerful enough to cause excessive over-riding, so a period of traction is necessary until the fracture becomes "sticky", and non-tender--then they can be put into a cast and sent home.
Adults with femur shaft fractures, in our institution, are usually treated by skeletal traction for a few days, until their hematocrit stops dropping (supposed to reduce chances of fat embolism) and then internal fixation. When this is not possible, or not indicated by the site of the fracture, we used cast-brace treatment, with protected weight bearing.
Tibia fractures: In our institution these are usually treated by a long leg cast for three weeks first, and then go to a "patellar-tendon-bearing (PTB) cast. In every case, elevation above heart level for the first 24-48 hours is very important. Remember that an intact fibula is like an internal splint, and will greatly stabilize the fracture.
Segmental fractures: These will usually require open reduction and internal fixation, preferably intramedullary pinning.
Clavicle: The only thing usually necessary here is a simple figure-of-eight bandage or clavicle splint until the fracture is no longer tender. It is best not to rely on x-ray evidence of callus in determining when to discontinue the splint. Commonly this requires eight weeks in the splint.
Ribs: The only thing required here is analgesics for relief of pain. Do not use rib belts or taping, as this will reduce pulmonary excursion and may cause atelectasis. Be alert to the possibility of lung damage with pneumothorax, which may require thorocentesis. Multiple rib fractures, with flail chest, may require traction by means of towel clips into the flail segment.
Spine: The important thing to look for in spinal compression fractures is "rabbit-earing!' of the spinous processes. If this is present, it indicates rupture of the interspinous ligament, which makes the fracture unstable. In that case it is best to do a spinal fusion, with interspinous process wiring. If this is not possible, the patient should be put into an extension body cast for twelve weeks.
Calcaneus: Fractures of the os calcis are usually caused by a fall onto the extended leg. Look for concomittant spinal fractures, resulting from the compression of the spine. The most important determinant of outcome of calcaneal fractures is the subtalar joint, and every effort should be made to restore the congruity of that joint. If this cannot be done closed, then open reduction and internal fixation is indicated. Again, the reader is referred to the texts for a more thorough discussion of this fracture and its treatment. If the fracture is treated closed, it is very important to not allow weight bearing for twelve full weeks! If closed reduction is successful, or if the fragment position and subtalar joint is adequate, a simple "slipper cast" is applied, and early ankle motion is encouraged, with no weight bearing.
Hip fractures: With the exception of relatively non-displaced intertrochanteric fractures, virtually all hip fractures should be treated by open reduction and internal fixation. In the first mentioned case, a period of three to four weeks of traction, followed by non-weight-bearing crutch ambulation may be adequate. Full weight bearing should not be allowed before eight weeks, or so, until good callus is visible on x-ray.