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Bone Fixation
Synopsis
Fractures are prevalent worldwide, regardless of the economic status of the country. In low-income or middle-income countries, fracture treatment may be lacking or suboptimal. Acute fractures and complications such as malunion and nonunion have serious consequences that often interfere with community participation and prevent productive work. Restoration of skeletal stability can be life-changing and can offer the patient an opportunity to seek gainful employment, earn wages, participate in the community, and feed his or her family. Bone fixation is an integral part of global surgery. There are numerous methods to achieve bone stability. The technique applied is dependent on the surgeon, available implants, and ancillary equipment. This chapter will discuss the principles and techniques of bone fixation for fractures, malunions, and nonunions in countries with limited means and minimal equipment.
Introduction
The Lancet Commission on Global Surgery has determined that universal access to safe, affordable surgical and anesthesia care saves lives, prevents disability, and promotes economic growth. Modest estimates show that 5 billion people worldwide lack access to basic surgical care in low-income or middle-income countries. Furthermore, 11% to 15% of the world's disability is due to surgically treatable conditions. Injuries cause 5.7 million deaths yearly and leave many more persons impaired and disabled. Skeletal stabilization via bone fixation is part of the remedy to lessen disability and is necessary to reduce or alleviate limb impairment.
Preparation
Robert Acland, MBBS, FRCS, was a pioneer in anatomy, plastic surgery, and microsurgery. Acland stated that “preparation is the only shortcut you need,” emphasizing the need for preparedness at surgery. A similar principle applies to surgery in imperfect environments. The more information available beforehand regarding the conditions and the anticipated surgical cases, the more the team can organize and prepare. This tenet is especially applicable to surgeries that require bone fixation. This effort requires collaboration between the constituents residing in the host country and the surgical team participating in the trip. If the anticipated case list is known, the team can work with corporate partners to obtain the appropriate internal or external fixation devices. Recurrent and routine missions foster this relationship because a future surgical list can be generated for subsequent trips, leaving ample time to garner the equipment.
Indications/Techniques
Indications for bone fixation include acute fracture management, malunion, nonunion, and bone loss due to infection and tumor. The technique varies dependent on the surgeon's expertise and available resources. In low-income or middle-income countries, the resources may be limited. The surgeon should survey the available equipment including implants, drills, and x-rays. The presence or absence of these commodities will influence the technique of bone fixation. The KISS (Keep it simple, stupid) principle is a design principle noted by the U.S. Navy in 1960. This principle states that most systems work best if they are kept simple rather than complicated. Therefore simplicity should be the key goal, and unnecessary complexity should be avoided. This principle is directly applicable to fracture fixation in countries with limited means and scarce equipment.
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