Aira Hospital

As mentioned elsewhere the most neglected area in health care in this country is psychiatry. Orthopedics comes second. I use to say that the only fracture treatment generally available is Plaster of Paris or neglect - sometimes in combination. Being an orthopedic surgeon, I have tried hard to upgrade the orthopedic service at Aira hospital, in particular fracture treatment.

Upper arm fracture successfully treated with a locally made splint

 

Most often the fractures are treated by local bone setters with surprisingly good result, but sometimes things go awfully wrong, and on several occasions we have been forced to amputate an extremity in gangrene due to “local malpractice”.

Arm gangrene caused by mistreated elbow fracture	After amputation

 

 

When referred to Aira hospital, the patients often arrive with the fractured limb immobilized with a piece of cartoon.

 

Traction is a well proven, and in the right hand, a safe method. The draw backs are extended hospitalization with high cost for the patient, and a series of potential complications like muscle wasting, joint stiffness, osteoporosis, bed sores, thrombosis, pin infection, malunion, mental depression etc.

Elbow fracture in traction	Femur fracture in traction	Tibia (lower leg) fracture in traction

 

For the patient it is a great advantage if the fracture can be fixed and stabilized with either Plaster of Paris or by surgery. Early mobilization promotes bone healing, and all the complications of traction treatment can be avoided.

Plaster of Paris is a time-honored method, cheap, efficient, and easy to apply.

 

 

External Fixation.  Pins inserted in the fractured bone ends are fixed together with an external device, which immobilizes the fracture. Since the original equipment is extremely expensive, wooden splints fixed to the pins were used initially. Primitive as it may seem, the fixation is surprisingly stable and efficient.

Open fracture of tibia (lower leg)	Due to bullet injury

X-ray of fracture	Leg in external fixation with wooden frame after muscle flap and skin graft
Stable fixation	Fracture healed

 

Gradually more modern and adequate second hand orthopedic equipment has come into use, and has by now practically replaced the wooden frame.

 

This method is used mainly for very comminuted and instable fractures, as well as open (compound) fractures with great risk of infection, and often in need of further surgical interventions, such as muscle flaps and skin grafts, to cover soft tissue defects.

 

Internal Fixation: The fracture is fixed with metal devices applied directly to the fractured bone. Flexible nails or pins inserted in the medullar canal are very easy to apply and give excellent stability. In Aira hospital Rush Pins and Ender Nails are standard. These techniques are obsolete in the western world, but extremely useful and appropriate in our set up. The method is very useful for fixating fractures of the shaft of a leg or arm.

Rush Pin:

Femur fracture	Bending a Rush pin
Inserting the Rush pin	Immediate mobilization
X-ray before surgery	X-ray after surgery

 

Ender Nail: Originally constructed for treatment of pertrochanteric femur fractures (hip fractures), the nails are applied with great success for stabilizing fractures of the femoral shaft.

Patient with femur fracture on the operating table	Inserting an Ender nail
Perfect fracture reduction	Early mobilization
X-ray before surgery	X-ray after surgery

 

 

Pins.  Some fractures, for instance elbow fractures in children (supracondylar fractures), can be fixed with small pins.

X-ray of elbow fracture	X-ray after reduction and pin fixation

 

 

Collar and cuff. Some simple fractures like upper arm and collar bone fractures need only fixation with a collar and cuff, which we make out of sponge madras cut into suitable dimension. 

 

We do not use rigid intramedullary nails fixation for the reason that they will not provide sufficient stability without intramedullary drilling and/or additional transfixating screws, expensive and sophisticated procedures not applicative here. Neither do we use internal plating since the sterility in the operating theatre is insufficient, and a part from that too expensive a technique for our extremely limited financial resources.