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The Challenges of Orthopaedic Trauma Care in the Developing World
Introduction
This chapter proposes an overview of the challenges in meeting the increasing needs for trauma care in low- and middle-income countries (LMICs). The epidemiologic aspects of the burden of injuries are discussed elsewhere in this book (see Chapter 2 ), as is the nonsurgical management of fractures (see Chapter 7 ), so a special effort was made to keep overlaps to a minimum. Topics addressed in this chapter include the following: a systematic approach to trauma care; barriers to access; resources; education; the role of the World Health Organization (WHO); management of common pediatric and adult injuries, with special mention of the Surgical Implant Generation Network (SIGN) system; and different avenues for orthopaedic volunteerism.
For most surgeons in high-income countries (HICs), trauma care is synonymous with surgical treatment. This is not the case for LMICs: most trauma care, at least initially, is provided in the informal sector (traditional healers, bonesetters, nurses, pharmacists, etc.), and most of the care provided in the formal sector is conservative (i.e., nonsurgical). The benefits of competent surgical care over conservative management, in appropriate environments, are well documented for many orthopaedic injuries, starting with this textbook. For a myriad of reasons detailed in the following discussion, this is too often unavailable in resource-poor settings, where the results of conservative treatment are the standard of care. The worldwide increases in economic development, life expectancy, and motorization translate into an epidemiologic transition from communicable diseases to noncommunicable diseases and injuries. There is proportionally less premature death and more life lived with disability. The burden of injuries is disproportionally shouldered by LMICs: the 2013 WHO report on global road safety showed that 94% of all traffic deaths and 90% of disability related to road traffic injuries (RTIs) occur in LMICs. Estimates are that RTIs alone killed more than 1.5 million people in 2015, permanently disabled the same number, and temporarily disabled between 10 and 50 times more. An aging population comes with an increase in “insufficiency fractures” and degenerative joint disease (DJD) and inflammatory arthropathies (IAs). All these combine to create a “perfect orthopaedic storm,” and the resources to manage it are woefully lagging behind. The following sections discuss and analyze the necessary determinants to best meet these daunting challenges.
Improving Trauma Care Systemwide Globally: the World Health Organization's Guidelines for Trauma System Development
Background
Injury has become a huge global health problem. Each year more than 5 million people die from motor vehicle crashes, violence, and other forms of injury. Of these injury deaths, 90% occur in LMICs. In addition to the need for improvements in injury prevention, such as road safety, there is a need for improvements in trauma care globally. One study showed significant disparities in outcome after injury among countries at different economic levels. Case fatality rates for serious injuries (Injury Severity Score >9) rose from 35% in high-income Seattle, Washington, to 55% in middle-income Monterrey, Mexico, to 63% in low-income Kumasi, Ghana. Thus mortality rates for the seriously injured are nearly twice as high in low-income settings as in high-income ones. If we could eliminate these disparities and bring injury case fatality rates in LMICs down from their current high rates to the rates in HICs, we could potentially save 2 million lives per year.
Many millions more people are left with temporary or permanent disabilities from their injuries. One of the leading causes of injury-related disability is extremity injury. One study from Ghana showed that the vast majority (78%) of injury-related disability is due to extremity injuries, in comparison to a higher proportion of disability from more difficult-to-treat neurologic injuries in HICs. Disabilities from such extremity injuries should be readily amenable to improvements with quality orthopaedic care and rehabilitation.
These discrepancies in outcome are due to several types of problems, such as deficiencies in human resources (skills, training, staffing) and physical resources (equipment, supplies). The effort to improve these resources is often hampered by financial restrictions, with many countries having only small sums per capita per year to spend on health. Despite these barriers, many committed individuals and their institutions have been making notable progress, often working against considerable odds. A few brief examples are presented next.
Case Studies of Individual Institutions
In the prehospital setting, increased numbers of ambulance stations (to allow more rapid dispatch) decreased the response times to reach injured victims in Mexico. Improved training, in the form of more regular use of in-service courses, led to an improved process of care in the field. The net result was a decrease in mortality from 8.2% to 4.7% among transported trauma patients.
In the hospital setting, regular use of continuing medical education for trauma care (in the form of the Advanced Trauma Life Support Course) led to significant improvements in the use of appropriate treatments for severely injured patients in Trinidad. The net result was a decrease in the mortality of such seriously injured patients at the main hospital caring for injured patients in Trinidad, from 67% to 34%.
In Thailand, the main trauma hospital in Khon Kaen instituted a basic trauma quality improvement program. This program identified a high rate of medically preventable deaths and several correctable problems, such as inadequate resuscitation for shock, delayed surgery for head injuries, and problems with record keeping and communications. Low-cost corrective action was instituted to target these problems, including improved communication within the hospital by use of radios, better supervision of junior doctors through increased senior staffing in the emergency department (ED) at peak times, and improved reporting on and monitoring of trauma cases. These improvements resulted in a decrease in mortality among all admitted trauma patients from 6.1% to 4.4%.
In terms of orthopaedic care, one hospital in Malawi instituted a protocol for open fractures that emphasized primary external fixation, scheduled sequential débridement, coverage of exposed bone through local muscle flaps, controlled secondary healing, and early mobilization, all low-cost techniques that could be delivered well in the local circumstances and with the economic resources available. The hospital reported recovery of normal function in 80% of patients, functional results similar to those in HICs.
These are obviously just a few brief examples. Many of the readers of this textbook likely have similar success stories to report from their own institutions. The question now is how to build on such individual institution experiences and make more progress globally.
Global Efforts to Improve Trauma Care
There are several potential avenues to pursue to promote improvements in trauma care globally, such as through international professional and/or academic societies. Another avenue that has been increasingly influential but that many clinicians are not as familiar with is the WHO. In this section, we highlight some of the work being done on trauma care by WHO.
In the past 12 years, the WHO's Department of Noncommunicable Diseases (NCDs), Disability, Violence, and Injury Prevention published three sets of policy recommendations, primarily aimed at ministries of health and designed to strengthen trauma systems in countries at all economic levels but especially in LMICs. Prehospital Trauma Care Systems gives recommendations on ways to institute or improve formal ambulance services (i.e., emergency medical services [EMS]). It also addresses steps that can be taken in areas where such formal ambulance systems are not affordable or feasible. This includes such efforts as building on existing informal systems of prehospital transport and care, such as by providing training (and, where appropriate, providing equipment) and better organizing those members of society who are already providing prehospital first aid, such as fire service, police, commercial drivers, or other members of the lay public.
In terms of care at hospitals and clinics, the WHO worked collaboratively with the International Society of Surgery and other partners to create the Guidelines for Essential Trauma Care. The goal of this project was to set reasonable, affordable, minimum standards for trauma care services worldwide and to define the resources needed to actually provide these services even in the poorest parts of the poorest countries. In part, this publication sought to do for trauma care globally what the Committee on Trauma (COT) of the American College of Surgeons (ACS) has done for trauma care in North America with its Resources for Optimal Care of the Injured Patient. However, the recommendations were oriented toward countries that had only ten to hundreds of dollars per capita to spend for health, versus thousands of dollars per capita in HICs.
The Guidelines for Essential Trauma Care lay out 11 core essential services that every injured person should realistically be able to receive ( Box 3.1 ). The International Society of Surgery has endorsed these as the “Rights of the Injured.”
Box 3.1
From Mock CN, Lormand JD, Goosen J, et al. Guidelines for essential trauma care. Geneva: World Health Organization, 2004.
Essential Trauma Care Services
-
Obstructed airways are opened and maintained before hypoxia leads to death or permanent disability.
-
Impaired breathing is supported until the injured person is able to breathe adequately without assistance.
-
Pneumothorax and hemothorax are promptly recognized and relieved.
-
Bleeding (external or internal) is promptly stopped.
-
Shock is recognized and treated with intravenous (IV) fluid replacement before irreversible consequences occur.
-
The consequences of traumatic brain injury are lessened by timely decompression of space-occupying lesions and by prevention of secondary brain injury.
-
Intestinal and other abdominal injuries are promptly recognized and repaired.
-
Potentially disabling extremity injuries are corrected.
-
Potentially unstable spinal cord injuries are recognized and managed appropriately, including early immobilization.
-
The consequences to the individual of injuries that result in physical impairment are minimized by appropriate rehabilitative services.
-
Medications for the previously listed services and for the minimization of pain are readily available when needed.
To ensure the availability of these services, the Guidelines for Essential Trauma Care delineate 260 individual items of human resources (skills, training, staffing) and physical resources (equipment and supplies) that should be in place at the range of healthcare facilities globally, going from small rural clinics, to small hospitals, to large hospitals, to tertiary centers. Items are designated as either essential, meaning they are applicable in countries at all economic levels, or as desirable, referring to those that are more costly and more applicable in middle-income circumstances or in larger hospitals in low-income countries. These resource recommendations were intended to be a flexible matrix, to be adjusted based on the circumstances of the particular country. Addressed in these 260 items is the spectrum of trauma care, including initial resuscitation, definitive care of injuries to all body regions, and longer-term rehabilitation. Orthopaedic issues are addressed in several sections of these recommendations, including extremity injury, spinal injury, and rehabilitation.
General examples of what these recommendations are trying to promote, first looking at low-income circumstances as in most of Africa and much of Asia, are as follows:
- 1.
Rural clinics caring for the injured should have capabilities for rapid basic first aid, which many do not. It is important to note that in rural areas of low-income countries, much of the care of the injured, even seriously injured, does occur in such small rural facilities.
- 2.
Smaller hospitals (such as those staffed by general practitioners) should have capabilities for the placement of chest tubes, airway maintenance, and certain minimum blood-transfusion capabilities, which many do not have.
- 3.
Larger hospitals, including tertiary care centers, should have capabilities for endotracheal intubation on an emergency basis (which is problematic for many) and basic trauma quality improvement programs, which very few have.
- 4.
Similar recommendations pertain to middle-income countries. However, there is greater emphasis on the resource items categorized as “desirable” given the higher level of resources available.
The Guidelines for Essential Trauma Care were intended to be part planning guide for individual hospitals/clinics and ministries of health and part advocacy statement to be used by whomever wishes to promote improvements in trauma care in their area. Through both of these mechanisms, it was hoped that the guidelines would serve as a catalyst to promote real, on-the-ground improvements in trauma care globally. Although much more does need to be done, there has been considerable progress in implementing the guidelines. The guidelines have received high-level political endorsement from a wide range of individual country professional groups, including the Ghana Medical Society, the Academy of Traumatology (India), and the Mexican Association for the Medicine and Surgery of Trauma, among others. They have been utilized in developing national health policy in Colombia, Mexico, Sri Lanka, and Vietnam.
The guidelines have also been the basis for systemwide needs assessments in several countries, providing for the first time an internationally applicable metric for countries at all levels to use to assess their hospitals and trauma systems. These needs assessments give some idea of the priorities for ways in which trauma care can be strengthened cost-effectively and systematically. These assessments have addressed orthopaedic care. Selected items of relevance to orthopaedics from these assessments are included in Table 3.1 . In terms of human resources, large hospitals were found to be fairly well staffed by fully trained orthopaedic surgeons, except in Africa, where general surgeons did much of the orthopaedic work. At small hospitals, only those in better-resourced Mexico had partial coverage by orthopedists. At other smaller hospitals, either general surgeons or general practitioners provided care for orthopaedic injuries, with this level of hospital being solely staffed by general practitioners at the hospitals evaluated in Ghana.
Table 3.1
Resources for Management of Orthopaedic Injuries at 49 Hospitals in Four Countries: Ghana (G), Vietnam (V), India (I), and Mexico (M)
From Arreola-Risa C, Mock C, Vega Rivera F, Romero Hicks E. Evaluating trauma care capabilities in Mexico with the World Health Organization's Guidelines for Essential Trauma Care. Pan Am J Public Health . 2006;19:94–103; Nguyen S, Mock CN. Improvements in trauma care capabilities in Vietnam through use of the WHO-IATSIC Guidelines for Essential Trauma Care. Inj Control Safe Prom . 2006;13:125–127; Nguyen TS, Nguyen HT, Nguyen THT, Mock CN. Assessment of the status of resources for essential trauma care in Hanoi and Khanh Hoa. Vietnam Injury . 2007;38:1014–1022; Quansah R, Mock CN, Abantanga F. Status of trauma care in Ghana. Ghana Med J. 2004;38:149–152; Mock CN, Nguyen S, Quansah R, Arreola-Risa C, et al. Evaluation of trauma care capabilities in four countries using the WHO-IATSIC Guidelines for Essential Trauma Care. World J Surg . 2006;30:946–596.
| Small Hospital | Large Hospital | |||||||
|---|---|---|---|---|---|---|---|---|
| G | V | I | M | G | V | I | M | |
| Number of facilities evaluated | 8 | 8 | 14 | 4 | 2 | 5 | 1 | 7 |
| Human Resources: Acute Care | ||||||||
| Nurse in emergency department | 2 | 3 | 2 | 2 | 2 | 3 | 3 | 2 |
| Doctor for emergency call a | 2 | 3 | 3 | 3 | 3 | 3 | 3 | 3 |
| General surgeon a | 1 | 2 | 1 | 2 | 2 | 3 | 3 | 3 |
| Orthopaedic surgeon a | 0 | 0 | 0 | 2 | 0 | 3 | 3 | 3 |
| CE course for doctors b | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 2 |
| CE course for nurses c | 0 | 1 | 0 | 1 | 0 | 1 | 0 | 1 |
| Physical Resources: Extremity Injury | ||||||||
| Skeletal traction | 1 | 1 | 0 | 1 | 2 | 3 | 3 | 3 |
| External fixation | 0 | 1 | 0 | 1 | 1 | 3 | 3 | 2 |
| Internal fixation | 0 | 2 | 0 | 1 | 1 | 3 | 3 | 2 |
| Radiography | 1 | 2 | 2 | 3 | 2 | 3 | 3 | 3 |
| Portable radiography | 1 | 0 | 0 | 1 | 2 | 1 | 2 | 3 |
| Image intensification | 0 | 0 | 0 | 0 | 0 | 1 | 1 | 1 |
| Limb prosthetics | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 |
| Physical Resources: Spinal Injury | ||||||||
| Operative capabilities for spine management | NA | NA | NA | NA | 0 | 1 | 1 | 3 |
| Physical Resources: Wound Care | ||||||||
| Skin grafting | 1 | 2 | 1 | 2 | 2 | 3 | 3 | 3 |
| Tetanus prophylaxis (toxoid and antiserum) | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 |
| Human Resources: Rehabilitation | ||||||||
| Specialized rehabilitative nursing | NA | NA | NA | NA | 0 | 1 | 0 | 2 |
| Physical therapy | 1 | 1 | 0 | 1 | 1 | 3 | 1 | 2 |
| Physical medicine and rehabilitation specialist | NA | NA | NA | NA | 0 | 2 | 1 | 2 |
| Administrative Functions | ||||||||
| Trauma-related quality improvement program | NA | NA | NA | NA | 0 | 0 | 0 | 0 |
| Trauma cases integrated into broader quality improvement programs | 0 | 2 | 0 | 1 | 1 | 2 | 1 | 1 |
| Trauma registry with severity adjustment | NA | NA | NA | NA | 0 | 0 | 0 | 0 |
Adequacy of resource based on Guidelines for Essential Trauma Care assessed as follows:
NA—not applicable for that level
0—absent
1—inadequate, available to less than 50% of those who need it
2—partly adequate, available to greater than 50%, but not everyone who needs it
3—adequate, available to virtually everyone who needs it
Facility descriptions are as follows:
-
Small hospital: In Africa, called a district; in India, called a community health center. Usually doing some type of surgery but with a more limited range of specialists. Usually with around 50 to 200 beds.
-
Large hospital: Provincial, regional, with at least one or more category of specialist. Usually over 200 beds but not including tertiary care centers.
a Available 24 hours per day, 7 days per week in hospital or promptly available on call from home.
b Continuing education (CE) course on trauma care, such as Advanced Trauma Life Support, National Trauma Management Course, or local equivalent; the ideal is that all doctors who provide first-line trauma care in emergency departments and all general surgeons who provide trauma care are credentialed in such an in-service training course.
c Continuing education (CE) course on trauma care, such as Trauma Nursing Core Course or local equivalent; the ideal is that all nurses who provide first-line trauma care in emergency departments are credentialed in such an in-service training course.
With nonspecialists providing much of the orthopaedic and other trauma care, continuing-education courses are an important opportunity to strengthen such care. All four countries had such courses available, such as Advanced Trauma Life Support (ATLS) in Mexico, the National Trauma Management Course (NTMC) in India, and other similar locally developed courses in the other countries. However, coverage by such courses was suboptimal. In small hospitals, far less than 50% of front-line trauma care providers (e.g., doctors working in the ED or surgeons taking trauma calls) had such training. Even in large hospitals, in most countries, less than 50% of front-line trauma care providers had such training. The situation for continuing education for nurses was even bleaker (see Table 3.1 ).
Capabilities for rehabilitation were particularly deficient. Ratings showed significant deficiencies in the availability of human resources for rehabilitation, whether fully trained physician specialists or other providers such as physical therapists (PTs), were considered. PT coverage was especially limited in availability at small hospitals (see Table 3.1 ).
In terms of physical resources for the care of extremity injuries, the main essential items for orthopaedic trauma care were fairly well supplied at big hospitals. Portable radiography services were limited. Capacities at small hospitals were much more limited. It should be pointed out that the ratings pertain to the level of care that would be expected for that level, not for the highest level. Hence, these are the ratings compared with the essential trauma care standard for small hospitals, not large. Related to the shortages of human resources for rehabilitation, the availability of prostheses for amputees was extremely limited in all circumstances (see Table 3.1 ).
Many times, the problems with availability of physical resources were not the presence or absence of the equipment but periods of inactivity while waiting for repairs, lack of supplies (such as film), or requirements for payment in advance before receiving services, which limited the availability of diagnostic tests to all who needed them. There were several instances in which a mismatch of human and physical resources decreased the availability of some services. For example, in Ghana, one large hospital had an image intensifier (C-arm). However, there were no staff members trained to use it, and the machine lay idle. In India, several small hospitals had x-ray machines and trained staff. However, the facilities were greatly limited in the number of plates (films) that they received each month. Thus many persons needing radiographs could not receive them. Many such problems could be easily remedied cost-effectively through better organization and planning.
In all countries and at all levels, there was a dearth of administrative functions to monitor and ensure the availability of trauma care, including trauma registries and trauma quality improvement programs.
In addition to pointing out opportunities for affordable and sustainable improvements in trauma care capabilities, these needs assessments have served as a stimulus for action. For example, a needs assessment conducted in the network of healthcare facilities managed by the Hanoi Health Department in Vietnam showed multiple deficiencies in low-cost but important items of human training and physical resources. These items were addressed by improved organization and planning, with no additional budgetary allotment for trauma care. Repeat assessments every 2 to 3 years since that time have documented steady improvement in the availability of both skills levels and physical resources.
Further details of the development and implementation of the Guidelines for Essential Trauma Care and the related Essential Trauma Care Project are available on the WHO website at http://www.who.int/violence_injury_prevention/services/en/ .
Given the aforementioned dearth of administrative functions to monitor and ensure the quality of trauma care, the WHO has also developed Guidelines for Trauma Quality Improvement Programmes. This publication gives guidance on institution and development of trauma quality improvement programs, suitable for countries at all economic levels. It gives advice on simple, feasible methods, such as how to get more out of mortality and morbidity (M&M) meetings. It also explains how to increase the methodologic rigor of such meetings, such as with the technique of panel reviews on preventable deaths. It describes more complex techniques, such as the use of audit filters, monitoring for complications and sentinel events, and risk adjustment. Finally, no matter what methods are used to identify problems, the publication emphasizes how to take corrective action to fix these problems and to prove that the problems have been fixed (“closing the loop”).
Taken together, these three WHO guidelines (Prehospital Trauma Care Systems, Guidelines for Essential Trauma Care, Guidelines for Trauma Quality Improvement Programmes) represent widely endorsed and simple, yet effective, comprehensive methods to improve the care of the injured globally. They have been utilized in 51 countries thus far, including countries at all economic levels and on most continents. Methods of utilization include use as a basis for needs assessments and situation analyses to identify priorities for affordable and feasible improvements, use in the development of educational programs, and use in the development of legislation and health policy. Despite this wide utilization, several shortcomings have been identified. Geographically, there has been limited use of the guidelines in Eastern Europe or the Middle East (even though one or more of the publications have been translated into Russian and Arabic). Linguistically, most publications that report utilization of the guidelines are in English, even for reports coming from Latin America or Francophone Africa (even though one or more of the publications have been translated into Portuguese, Spanish, and French). In terms of specific methods of utilization, most reports on needs assessments detail one-time endeavors rather than use in actually stimulating improvements or in monitoring changes over time. In terms of educational programs, most reports detail use in continuing education (in-service) courses, rather than use in developing curricula for longer education (such as in the curricula of schools of medicine or nursing). Finally, only a few countries have used the guidelines in the way that would be most effective, instituting the guidelines in health policy and legislation, although there have been several interesting examples of the use of the guidelines for the development of health policy for EMS, especially in Latin America.
Thus priorities for future utilization of these guidelines include wider dissemination in Eastern Europe, the Middle East, Latin America, and Francophone Africa. Priorities also include increasing the use of needs assessments to stimulate and monitor improvements, use in the development of curricula in professional schools, and implementation in health policy and legislation.
The Role of the WHO: the World Health Assembly Resolutions on Trauma and Emergency Care Services and on Essential Surgical Care
In an effort to promote greater implementation of improvements in trauma care, three additional actions have been taken: adoption of World Health Assembly (WHA) Resolution 60.22, adoption of WHA Resolution 68.15, and creation of the Global Alliance for Care of the Injured.
The WHA is the governing board of the WHO. It consists of the ministers of health of all 194 member states. Its resolutions direct the WHO's activities and have considerable influence on policies in individual countries, as well as the actions of nongovernment organizations and funders. In 2007 the WHA adopted a resolution on trauma and emergency care services: WHA 60.22, “Health Systems: Emergency Care Systems.” WHA Resolution 60.22 called on governments to improve care for victims of injury and other medical emergencies and listed 10 actions that governments could take to achieve this, including identifying a core set of trauma services and developing methods to ensure and document that such services are provided to all who need them (recommendations directly from the Guidelines for Essential Trauma Care).
In 2015 the WHA adopted a resolution on surgical care: WHA 68.15, “Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage.” WHA Resolution 68.15 called on governments to improve surgical and anesthesia services and listed nine actions that governments could take to achieve this, including increasing access to surgical care through methods like task-sharing, where appropriate, and monitoring and evaluating the capacity for, quality of, and access to surgical services at hospitals nationwide.
These WHA resolutions are probably the single greatest expressions of support for trauma care (including related emergency care and surgical care) from governments worldwide. The WHA resolutions carry a lot of weight in orienting the WHO's own activities. However, they are taken up variably by country governments. They are most useful if concerned individuals and organizations use a resolution to advocate for and promote its recommendations. In this regard, readers are referred to recent publications that give some suggestions about how the resolutions can be utilized to promote increased political support for trauma care within country governments and to lobby for increased funding. These references also contain the full text of the WHA resolutions.
In 2012 the WHO founded the Global Alliance for Care of the Injured, in collaboration with a number of other stakeholders, including international professional societies, nongovernmental organizations (NGOs), and country governments. The Global Alliance is primarily oriented toward promoting advocacy for increased attention to trauma care. Further information on the Global Alliance and ways to become involved with it can be found at http://www.who.int/violence_injury_prevention/services/gaci/en/ .
There are many examples of successful innovative programs and efforts aimed at improving trauma care at individual hospitals in LMICs. There is a need to expand on what is being done and make more sustained progress globally. The WHO's Guidelines for Essential Trauma Care represent a method to accomplish this by providing, for the first time, an internationally applicable metric for countries to use to evaluate and monitor resources for trauma care in their hospitals and systemwide. The WHO guidelines on prehospital care and on trauma quality improvement programs also offer methods to strengthen trauma care systemwide. Further, WHA Resolution 60.22 on trauma and emergency care services and WHA Resolution 68.15 on surgery and anesthesia provide high-level political endorsement for improvements in trauma care globally. Likewise, the creation of the WHO Global Alliance for Care of the Injured provides an avenue for increased political advocacy for increased attention to and investment in trauma care. Orthopedists and other trauma care clinicians can effectively utilize all of these in their own efforts to promote systemwide improvements in trauma care in the areas where they work.
In addition to the technical aspects, trauma care must be viewed within broader societal and economic considerations. Although much can be improved in trauma care through better organization, planning, and training, more extensive improvements are hampered by poverty. Most countries can spend only very little on health. In addition, the specific policies of international organizations compound the problem. For example, World Trade Organization (WTO) rules keep many medicines unaffordable for the average person in the world. World Bank and International Monetary Fund policies often dictate restrictions on how much some governments can spend on healthcare as part of loan-repayment conditions. Some African countries spend more on repaying debt than they do on healthcare.
Care of the injured would be strengthened by measures that would allow greater funding of the health sector, including many measures currently being discussed, such as debt relief, relaxation of restrictions on health-sector financing, and requiring World Trauma Organization proceedings and rulemaking to be open and democratic, which they currently are not. In addition to our own technical work, we, as individuals and as societies of professionals, need to be aware of and address these bigger global economic issues.
Barriers to Access
Only a fraction of the population in LMICs will ever receive treatment from a trained orthopaedic surgeon. Gross deficiencies in the availability, utilization, and/or quality of orthopaedic services result in an enormous burden of disability in LMICs, and the magnitude has yet to be quantified using existing health metrics. The barriers to accessing care for orthopaedic injuries are complex, often overlap, and relate to both an individual's willingness to seek medical attention and the ability of the health system to provide timely, effective, safe, and affordable services. The relative importance of individual barriers will of course depend upon the local context. Improving the delivery of musculoskeletal (MSK) trauma care services will require a multidisciplinary, multisectoral effort aimed at eliminating these barriers by educating patients and their families and also addressing deficiencies at the level of the health system. Strong advocacy efforts, including the mobilization of key stakeholders and civil society, will be required to influence decision makers.
The definition of “access” has been debated, and several authors have attempted to describe it. McIntyre et al. suggested that access be viewed as a multidimensional concept based on the interaction of individuals and the health system and defined access based on availability (spatial access), affordability (financial access), and acceptability (cultural access). Obrist et al. suggested availability, affordability, acceptability, accessibility, and adequacy, highlighting the importance of the quality of services. A systematic review concerning barriers to surgical care suggested that these be grouped according to (1) social/cultural, (2) financial, and (3) structural factors. The authors emphasized the importance of cultural factors and stressed the need to overcome financial and geographic accessibility. The Lancet commission has presented deficiencies in access according to a “three-delays” framework. The first delay involves seeking care, and contributing factors may be financial, geographic, cultural, or educational or may be due to a reduced awareness of or confidence in available health services. The second delay involves reaching care and may relate to local road infrastructure, the availability of a vehicle or public transportation, and costs. The third delay is in receiving care, due to deficiencies in infrastructure, physical resources/supplies, or human resources.
From a practical standpoint, barriers may be characterized based on the individual and the health system, which resonates with a health system framework promoted by the WHO. This focuses on the interrelationship between people (demand) and six system “building blocks” (supply): (1) governance, (2) service delivery, (3) human resources, (4) medicines and technologies, (5) financing, and (6) information. Table 3.2 illustrates a host of barriers according to this scheme, as well as measures that may be considered to address these barriers, and one recent paper provides a conceptual basis for strengthening surgical care within health systems.
Table 3.2
Barriers to the Delivery of Orthopaedic Care
| Barriers | Possible Solutions | |||
|---|---|---|---|---|
| Demand Side | Patient and Family | Culture and/or Religious Beliefs |
|
|
| Financial |
|
|
||
| Geographic | Distance |
|
||
| Terrain | ||||
| Season/weather | ||||
| Mechanism of transportation | ||||
| Supply Side | Health System | Governance | Policies |
|
| Monitoring/oversight | ||||
| Lack of trauma care guidelines |
|
|||
| Service Delivery | Infrastructure |
|
||
| Physical resources and supplies |
|
|||
| Mechanisms for transport and referral |
|
|||
| Convenience or hours of business |
|
|||
| Human Resources | Number of providers |
|
||
| Distribution of providers |
|
|||
| Education of providers or quality of service |
|
|||
| Gender |
|
|||
| Job dissatisfaction |
|
|||
| Medicines and Technology | Lack of essential equipment and supplies |
|
||
| Health Information System (HIS) | Inadequate data on orthopaedic burden of disease and epidemiology |
|
||
| Lack of monitoring (disease burden, service availability, outcomes) |
|
|||
| Financing | Inadequate government expenditure on health |
|
||
Factors that lead a patient and/or his or her family to utilize health services have received less attention than system-level barriers. In the absence of formal medical services, a sizeable percentage of the rural population in LMICs will likely prefer to have their injured cared for by traditional healers and bonesetters for a variety of reasons. Out-of-pocket expenses commonly serve as a deterrent to utilizing formal health services, and thousands of families in LMICs are pushed below the poverty line each year due to unforeseen healthcare costs. In some settings there may be a fear of hospitals or of receiving surgical care. These issues can only be addressed by first studying perceptions concerning injuries and facility-based care within the local communities and then engaging the community in discussions and perhaps educational programs. Another solution may be to engage the traditional practitioners, gain a better understanding of their treatment methods, and then work with them to develop the system for service delivery. Any such efforts will fall short of expectations unless quality services are available to the public.
On the health system side, with regard to governance, few countries have included surgical care in their national health plans, and we estimate that few countries have developed, implemented, and monitored the policies and regulations to support the provision of trauma care services. As such, mandates at the local, regional, and global levels should be sought to promote and enforce such standards. Political support will be required to move the agenda forward, and this may also be viewed as a barrier. Insufficient data concerning the burden of MSK injuries and a lack of metrics to capture the burden preclude our ability to document the magnitude of the problem. Shiffman has developed a conceptual framework to explain why certain global health issues receive attention and others do not, based on (1) the power of the actors, (2) the power of ideas portraying the issue (frames), (3) the political contexts in which the actors operate, and (4) the nature of the issue itself. Shawar et al. have applied this framework to global surgery, finding that the community is fragmented, lacks a unifying leadership, has yet to develop guiding institutions, and has not developed a strategy on how to address the problem and position the issue for the public and politicians, who often have misperceptions as to the cost and benefits of surgical care. While the Millennium Development Goals may be viewed as an excellent policy window, and improvements in MSK trauma care would certainly impact those goals related to alleviating poverty, improving maternal health, and improving child health, the window was not captured. The recent World Health Assembly resolution on “strengthening emergency and essential surgical care as a component of universal health coverage” is encouraging and may provide a means to advocate for improvements in MSK trauma services globally.
Recognizing the importance of injury prevention, service delivery remains the cornerstone of MSK trauma care services. This requires an organized system, including prehospital care, in-hospital care, and rehabilitation. Mechanisms for communication, transportation, and referral between the tiers of the health system are critical. As healthcare programming over the past few decades has focused on “vertical” or disease-specific initiatives (HIV/AIDS, tuberculosis [TB], maternal health, etc.), improvements in health indicators have been realized, but they have often come at the expense of overall health system function. This has led to renewed interest in “horizontal” programming, efforts aimed at strengthening the health system, and promotion of universal access to extend services to the more remote and marginalized segments of a population. Although surgical care has traditionally been neglected by the public health community due to the perception that it is resource intensive, is costly, and benefits only a fraction of the population, evidence is amassing to refute these perceptions. As such, a worthy goal is to provide universal access to a package of “essential” MSK trauma care. These services are priority interventions that address conditions with the largest public health burden, are highly successful, and are cost-effective. Essential surgical care, including trauma care, certainly resonates with the concepts of horizontal programming and health systems' strengthening. Specific interventions for MSK injuries will vary depending on the local context but should likely include irrigation and débridement for open fractures, the closed treatment of common fractures and dislocations, skeletal traction, fasciotomy, and amputation. The use of more sophisticated treatments and/or technologies may be appropriate at secondary or tertiary referral facilities, depending on the local resources. The WHO has developed guidelines to assist health planners with prehospital care and trauma care guidelines and also developed a basic training package for the delivery of surgical and anesthetic services for the primary referral level of district hospitals. These materials serve as a starting point and should be augmented by other educational programs and training materials. Strengthening the delivery of services will require improvements in the availability of skilled providers and also in the provision of adequate infrastructure and physical resources to allow practitioners to care for patients. Mechanisms for financing must be available to support the delivery of services and minimize out-of-pocket expenses for patients. Recognizing that the development of insurance programs would be desirable, innovative financing solutions that are contextually relevant will need to be pursued, such as public–private partnerships, or partnering with NGOs and/or global health initiatives. For example, stakeholders interested in maternal and child health might be interested in strengthening care for the injured to help reach those Millennium Development Goals relating to child and maternal health.
Deficiencies in human resources have received the greatest attention in the literature and relate to not only the absolute number of trained surgical providers but also their distribution. The few surgeons tend to be located at tertiary centers in major cities, leaving most of the population without access to a trained surgical provider. Reasons cited for the problems with distribution include inadequate resources to deliver services, poor remuneration, few opportunities for continuing medical education and career advancement, and limited opportunities for other family members, including education for their children. A sizeable number of patients will be treated by traditional healers. Strategies to address this human resource crisis have included the training of general surgeons, medical doctors, and/or paraprofessionals to provide surgical care (task shifting). Orthopaedic clinical officers (OCOs) care for the majority of orthopaedic problems in rural Malawi, and surgically trained paraprofessionals are active in several other countries in sub-Saharan Africa, including Uganda and Mozambique. Surgeons from resource-rich countries may also contribute to the education and training of health providers caring for orthopaedic patients.
Even if caregivers have the appropriate knowledge and skills, they must have the resources, or medicines and technologies, to utilize their training. Numerous studies have identified gross deficiencies in the availability of essential surgical services at the district-hospital level in LMICs, including infrastructure and physical resources/supplies, in addition to human resources. One report noted the similarities between modern-day facilities in LMICs and hospitals at the time of the US Civil War. A recent study focusing on MSK surgical services at 883 facilities in 24 LMICs noted, for example, that only 26% of facilities with less than 100 beds could treat an open fracture, 31% could drain a septic arthritis or osteomyelitis, and 46% could manage a closed fracture. Only 27% of these smaller hospitals had uninterrupted availability of a radiography machine, 40% had splinting/casting materials, and 69% had sterile gloves. Further data from service availability and readiness assessments (SARAs) in eight African countries suggest that even when facilities are expected to offer a service, they often lack the readiness to deliver the service during an inspection at the time of a site visit. Having a qualified surgical provider is hardly enough; he or she must have safe anesthesia, the basic equipment required to care for the injured, and the ability to adequately monitor the patient whether or not a surgical procedure is required.
Finally, the health information system (HIS) is responsible for data collection and analysis, as well as the dissemination of information to inform the allocation of resources and the delivery of services. There is limited information on the burden of MSK injuries in LMICs, their economic impact, and the efficacy and cost-effectiveness of interventions aimed at reducing the burden. Such knowledge is required to assess the burden of disease and unmet need for trauma care, the educational requirements for caregivers, the quality of service delivery, the impact of programs to strengthen the delivery of trauma care, and others. Research must be supported, and monitoring and evaluation frameworks can be utilized to inform decision making, resource allocation, and progress tracking with health system interventions such as the integration of essential surgical care.
Education
With the increasing awareness of the enormous burden of injury and the stark disparity between developed and developing countries, recent initiatives have been established in an attempt to mitigate the impact. Through education and training of basic trauma care and principles, knowledge and skills can be transferred at the undergraduate, medical school, and postgraduate levels. To that end, professional societies and independent NGOs have been established that target various aspects of education in trauma care in developing nations.
Among the more prominent professional societies is the International Association for Trauma Surgery and Intensive Care (IATSIC), an affiliate of the International Surgical Society (ISS). The IATSIC was established in 1989 with a primary purpose of facilitating communication and education for the care of the injured. The educational component includes local courses known as Definitive Surgical Trauma Care (DSTC) courses, which attempt to teach principles similar to those of the American College of Surgeons ATLS adapted for low-resource environments. The IATSIC has also worked with the WHO in the development of the Guidelines for Essential Trauma Care, which help to establish a basic standard for human and material resources for trauma care systems in LMICs.
NGOs have been similarly established to address the educational needs for trauma care in developing countries. A prime example is the Primary Trauma Care Foundation (PTCF). Established in 1996, the PTCF seeks to teach trauma care principles through locally based courses. The PTCF curriculum includes a free trauma care manual for teaching, which has been used for courses in over 60 countries worldwide. Notably, each 2-day course is followed by a 1-day instructor course, which aims to empower local practitioners to spread knowledge within their communities.
Through these organizations, continuing education helps not only to maintain skills but also impacts new knowledge, challenges old dogma, and develops best practices for each context and region. Furthermore, these courses target not only doctors and nurses but also other key personnel, such as community health workers, hospital personnel, and potential first responders, who can thus be better prepared to meet the challenge of the growing burden of trauma. Successful training programs for lay first responders are well documented. Other programs have focused on the training of nonphysician “orthopaedic technicians,” and their contribution to trauma care in many underresourced countries cannot be overstated.
There has also recently been an increased interest in “global health” in the academic circles of many HICs. Global health is now an area of focus for many American universities: Harvard, Johns Hopkins, Utah, and the University of California, San Francisco (UCSF), to name a few. The benefits of bilateral academic partnerships are also well documented. The capacity for international collaboration has become a criterion for an increasing number of students at all levels in their selection of an institution. Some institutions, such as UCSF, offer global health programs at the master's or doctorate level. Others, such as the UCSF's Institute for Global Orthopaedics and Traumatology (IGOT), offer fellowships at the undergraduate and graduate levels. Many surgical programs across the country now offer optional surgical rotations in resource-poor countries, as well as visiting fellowships for national trainees. This is also true of some professional associations, such as the American Academy of Orthopaedic Surgeons (AAOS), through its international committee, and organizations such as Orthopaedics Overseas and its volunteer programs.
All these opportunities are gaining momentum because it is now widely accepted that training and teaching are much more likely to have a sustainable impact than activities focused on the delivery of care.
Pediatric Trauma (Management of Common Injuries)
Although the principles of management for pediatric fractures and dislocations are covered in detail in other sections of this text, several important differences must be acknowledged when planning treatment for the same injuries presenting for care in LMICs. An image intensifier is rarely available to help assist with closed reduction or to facilitate minimally invasive treatment strategies such as percutaneous fixation or closed intramedullary (IM) nailing. Implants are often unavailable or must be purchased by families from the market. Due to deficiencies in access to medical care, a subset of patients presents days to weeks (or months) after their injury ( Fig. 3.1 ). The treatment must be individualized in these circumstances, recognizing that solutions are more complex, costly, and less likely to achieve a suitable outcome. Although a subset of fractures will require open surgical treatment to achieve the best results, for example, displaced intraarticular fractures or open fractures, wound sepsis is a significant risk when open procedures are performed in environments with questionable sterility.
Fortunately, the majority of pediatric fractures presenting acutely are amenable to nonoperative management, and traction is available in most environments. An understanding of the mechanism of injury is essential to guide closed reduction, and meticulous casting technique is required. It is important to recognize the remodeling potential based on the patient's age and the location and plane of motion of the deformity. Most remodeling is due to asymmetric physeal growth, with the remainder from appositional bone growth in the concavity of the deformity, with concomitant resorption of bone on the convexity. Displaced physeal fractures carry a significant risk of growth disturbance and require follow-up care to identify partial or complete physeal arrest. Manipulation (or remanipulation) should be avoided for 7 to 10 days after the injury due to the risk of iatrogenic physeal damage. In circumstances where patients are delayed in presentation and have significant growth remaining, it is best to wait until the fracture has healed and remodeled, reserving corrective osteotomy for that subset of cases with unacceptable deformities or loss of function. When future growth is of no concern, remanipulation or open realignment can be performed because little or no remodeling can be expected.
The management of neglected fractures and dislocations is challenging and must be individualized. Treatment decisions are based on the resources available locally, as well as the opportunities for rehabilitation and follow-up care. The most appropriate strategy depends on the time since injury, individual characteristics of the fracture, patients’ current level of symptoms, and anticipated function in the future. We will briefly outline the principles of management for selected injuries, which have received attention in the medical literature, recognizing that the same principles may be applied in other circumstances. The results following treatment of neglected injuries may be inferior to those presenting acutely; however, it is possible to improve the patients’ symptoms and function in the majority of cases.
The management of neglected, displaced supracondylar humerus fractures can be quite challenging in the absence of an image intensifier when patients present days to weeks after the injury. One can expect some excellent remodeling of translation and some remodeling of sagittal plane malalignment. Little remodeling will occur in the coronal or axial plane. When an image intensifier is available, it is likely that closed reduction and percutaneous fixation can be achieved up until approximately 5 to 7 days after injury. Traction has also been reported to be successful in cases between 1 and 3 weeks after injury, especially in the presence of significant swelling, although a subset of cases healed in some varus. After this time, options include open reduction or allowing the fracture to heal and performing an osteotomy at a later time. Caution should be observed in performing any open surgery during the period of greatest inflammation, anecdotally between approximately 7 days and 4 weeks, given the risk of stiffness and heterotopic bone formation. This has led to the suggestion that treatment should be delayed and that osteotomy should be performed after complete healing. One study from Thailand has suggested that an early corrective osteotomy, after the period of heightened inflammation, may result in adequate outcomes. Patients with a healed but malaligned fracture will require an osteotomy, most commonly for cubitus varus, and various techniques have been described. Some displaced fractures will heal with adequate coronal alignment; however, posterior translation of the distal fragment results in impingement, which blocks elbow flexion. Removal of an anterior bone block may improve or restore flexion in selected cases ( Fig. 3.2 ). Alternatively, an osteotomy can be performed to realign the fracture and restore range of motion. It is of paramount importance to mention that malunions do not often lead to significant impairment of function, in which case a corrective osteotomy is purely cosmetic in nature. Parents and older patients should be well informed of potential risks versus benefits.
Neglected lateral condyle fractures may result in pain and progressive valgus deformity with or without tardy ulnar nerve palsy. Treatment options include observation; fixation and bone grafting to achieve union, often in a stable but nonanatomic position; and distal humeral osteotomy with ulnar nerve transposition ( Fig. 3.3 ). The fractured surfaces remodel over time, making anatomic reduction very difficult, and fractures that are displaced significantly are very difficult to mobilize without extensive soft tissue stripping, which might result in avascular necrosis (AVN) and persistent nonunion. Care should be taken to avoid posterior dissection. Selected cases with delayed union or a nonunion may be amenable to percutaneous fixation with a compression screw, as long as the fragment is not severely rotated. In this manner, the local blood supply is not disturbed, although repositioning of the fragment may be minimal. A lateral approach can be used to expose the nonunion anteriorly, and the fracture surfaces can be curetted before fixation. Local bone graft has been utilized, and fixation is achieved in a position that maximizes the range of motion, often in a nonanatomic position.
Chronic Monteggia lesions present with a variety of symptoms, including pain, decreased range of motion, instability or popping sensation, a deformity, and even a posterior interosseous nerve palsy. Adaptive changes including enlargement of the radial head may be observed and may preclude achieving a stable articulation. Typically, the ulna is shortened due to either a malunited fracture or plastic deformation, and restoration of ulnar length is critical to facilitate a stable reduction of the radial head. Reconstruction most commonly involves realignment of the ulna along with open reduction of the radial head with annular ligament reconstruction using the triceps fascia (Bell–Tawse procedure) or forearm fascia or by a free tendon or fascial graft ( Fig. 3.4 ). A Kirschner wire (K-wire) is commonly placed across the radiocapitellar joint for temporary fixation (2 weeks). Excision of the radial head may be considered for symptomatic relief in cases where reconstruction is not feasible.
Neglected elbow dislocations typically present with loss of motion, pain, and significant limitations in function. If the patient is asymptomatic and has a functional range of motion, observation is the best option. For those with chronic symptoms, several options are available. The technique reported most frequently has been an open reduction, which may be performed via a posterior approach or the medial and lateral approaches. The ulnar nerve should be isolated and protected. Barriers to reduction include soft tissue contracture, scar tissue within the joint, new bone formation, and periarticular calcification. The articular cartilage is often softened, which may make defining the plane in between fibrous tissue and articular cartilage difficult. Once the barriers to reduction are removed, a large K-wire has been used between the olecranon and the distal humerus for 2 weeks, after which range-of-motion exercises are started. Most authors have advocated a V-Y lengthening of the triceps, and in most cases stable reduction could be maintained. Range of motion is typically improved but is reduced in comparison with the contralateral elbow. Patients with a coexisting fracture seem to have a less favorable outcome in comparison with those sustaining an isolated dislocation. The use of an external fixator, usually in concert with open surgical procedures, has also been reported. Options for salvage include excisional arthroplasty, prosthetic replacement, or arthrodesis. It remains unclear which of these options offers the best long-term results, given the limited number of cases in the literature and the absence of prosthetic technologies and the environment where these neglected injuries are encountered most frequently.
The treatment of neglected femoral shaft fractures typically involves restoration of both length and alignment, and the specific treatment depends on the duration between injury and treatment. Contractures within the soft tissues develop rapidly, and restoration of length may be a challenge. Limb shortening is due to both overriding a fracture fragment and angulation of the fracture. The injury is encountered during the early phases of healing, and osteoclasis may be performed by closed, percutaneous, or open techniques. Traction can then be applied, or gradual distraction with an external fixator, either as definitive treatment or as a prelude to open reduction and either IM fixation or plating. There appears to be an increased risk of neurovascular complications when acute lengthening of more than 4 cm is accomplished. Some authors have favored acute shortening and fixation as an alternative to a staged approach to treatment. Most of the available literature has concerned results and has involved open reduction, acute shortening, and IM fixation. Some authors have utilized iliac crest bone grafting. At a later time, after the fracture is healed, a realignment osteotomy is required for treatment.
Neglected femoral neck fractures are extremely rare in children, and there is only one report that we are aware of in the literature. In this study, patients were treated by valgus intertrochanteric osteotomy, and the authors used preoperative traction when there was more than 4 cm of shortening. The intertrochanteric osteotomy typically heals before the femoral neck fracture. Regarding young adults, Roshan et al. reviewed 22 studies from the literature and found that adequate results were achieved in 35% to 80% with an osteotomy and internal fixation, with or without bone grafting.
Traumatic hip dislocations are relatively rare in children and usually occur as a result of low-energy injuries. In older children and adolescents, these usually result from higher-energy mechanisms and are more frequently associated with other MSK injuries, including acetabular fractures. Options for treatment include observation, the heavy traction method, open reduction with or without femoral shortening, and salvage procedures such as pelvic support osteotomy, arthrodesis, or joint replacement (when available). The limited information in the literature in the pediatric age group suggests that open reduction with or without femoral shortening may be the most reasonable initial treatment for symptomatic patients ( Fig. 3.5 ). A concentric reduction can be achieved in most, and although AVN is common, this does not seem to impact the results at early to mid-range follow-up. Symptomatic relief was observed with improvement in range of motion, and a stable articulation was restored in the majority of cases. Even if the results deteriorate over time, the need for salvage strategies is delayed.
Adult Trauma
As is true for children, many adult trauma patients in LMICs are first treated by nonphysicians—traditional healers, bonesetters, nurses, even pharmacists—all with different levels of knowledge and experience, with varying degrees of outcomes. Depending on availability, accessibility, and affordability, some will be treated conservatively by general doctors, some conservatively or surgically by general surgeons, a very few by a formally trained local orthopaedic surgeon, even fewer by an academic national orthopaedic surgeon, and an extreme few by a visiting volunteer. Those who make it “up the ladder” are not always completely truthful with their history, for fear of not being treated. Time since injury is often underestimated, sometimes grossly: a surgeon would probably not have attempted a closed reduction of a 3-day-old shoulder dislocation had he known it was in fact 3 months old! Patients may also deny recent illnesses, increasing anesthesia risks, particularly for children.
Another common pitfall has to do with inadequate imaging. Plain radiographs are very often the only diagnostic tools available. They are often of poor quality, do not show both ends of the bones, or are not sharp enough to assess all fracture lines. It is not uncommon for the surgeon to make disagreeable discoveries on postoperative films. Because patients usually have to pay for tests and treatments, the initial admission radiograph is often the only one available, and fracture fragments have often since displaced. The initial radiograph of a simple transverse femur fracture in a muscular young male may look quite “benign,” but reduction and fixation after 4 weeks of bed rest without traction may prove more challenging than anticipated. The same is true for hip fractures.
Spinal Injuries
The incidence of spine fractures is increasing with the number of RTIs. Specialized spinal centers are almost nonexistent in LMICs. When associated with spinal cord injuries, the midterm prognosis is almost uniformly poor, with most patients dying from septic complications from bladder/lung infections or pressure sores. Unstable fractures without neurologic deficit are usually treated with postural reduction or traction and bed rest if displaced and with bed rest and precautions only if undisplaced. In general, spinal surgery is well beyond the normal capacities of most sites.
Cervical Spine
Most displaced fractures can be gradually reduced in skeletal traction if Gardner–Wells tongs or halos are available. Incorporating the halo in a jacket at 4 to 6 weeks or fashioning a plaster Minerva at 6 weeks will further protect healing for an additional 6 weeks. Unfortunately, semirigid or soft collars are often the only orthotics available.
Thoracolumbar Spine
Postural reductions of displaced unstable fractures of the thoracolumbar (TL) spine with bumps, rolls, or bed modifications are usually very poorly tolerated. Bed rest, log rolling, and pressure-sore prevention are usually all that can be done. Prefabricated thoracolumbar spinal orthoses (TLSOs) or corsets are usually not available, so a TL cast can be done at 4 to 6 weeks, often incorporating one hip in extension for the lower lumbar fractures.
Normal sensation is an obvious prerequisite to any kind of casting treatment. Spinal TB may be common in certain areas and add some degree of diagnostic difficulty.
Pelvic and Acetabular Fractures
Pelvic fractures vary greatly in severity. The more severe injuries are commonly associated with lesions to the lumbosacral plexus, the iliac veins and/or arteries, and the lower urinary tract. A thorough neurovascular examination is mandatory and needs to be recorded in the chart. It is also mandatory to examine the perineum for wounds and to do a rectal examination to feel for protruding bony spikes or a high-riding prostate in the male. Inability to void in a conscious patient, especially if a distended bladder is palpable, there is blood at the meatus, or there is a high-riding prostate, is highly suggestive of a urethral injury. A retrograde urethrogram with any available contrast material is a quick and easy procedure to confirm the diagnosis. A cystostomy should be performed without any attempt at retrograde catheterization. Macroscopic hematuria is suggestive of a bladder injury but is also common at 48 to 72 hours when the fracture hematoma is suffusing through the intact bladder wall.
Sophisticated pelvic imaging is rarely available, and a plain anteroposterior (AP) pelvis radiograph is often all that is done ( Fig. 3.6 ). Inlet/outlet views may help for a more accurate diagnosis, but iliac and obturator oblique views are painful and should be done only if surgical treatment is being seriously considered. Clinical examination is thus even more important to assess stability. The sacroiliac areas must always be examined and palpated. Significant bruising or pain should raise suspicion that the posterior sacroiliac ligamentous complex may be involved. Latero-lateral compression and push–pull maneuvers, with anesthesia if necessary, will add valuable information when the radiograph is “borderline.”
Pelvic Ring Injuries
Treatment is directly related to the degree of instability, which is itself based on the integrity of the posterior sacroiliac ligamentous complex, and the Bucholz classification is the simplest. Stable fractures (type 1) such as avulsions or rami fractures are treated symptomatically with mobilization and weight bearing as tolerated. Rotationally unstable but vertically stable fractures (type 2) such as open-book or lateral compression patterns are still relatively stable. Displaced open-book patterns with widening of the symphysis can be treated by postural reduction with the patient lying mostly on one side or the other. There are no indications for pelvic slings. Longitudinal traction may provide comfort initially. Patients should be allowed to mobilize in bed according to pain and to start ambulating on the intact side when active sitting in bed is painless. Vertically unstable fractures (type 3) are truly unstable in all planes. Keep in mind that the residual displacement on the initial AP radiograph may significantly underestimate the amount of initial displacement, as suggested by associated findings such as fractures of the lower lumbar transverse processes or avulsion of the ischial spine or the lateral border of the sacrum. These vertical patterns will usually displace further if the patient is allowed to sit or bear weight before it is “sticky,” usually at 2 to 4 weeks, so skeletal traction is recommended for the duration of the bed-rest period. Weight bearing should start progressively after 6 weeks.
Fresh fractures of the pelvic ring may present with hemodynamic instability that does not respond to fluid resuscitation. Because blood availability is often an issue, and embolization is almost never available, the threshold for external fixation may actually be lower than in resource-rich environments. A pelvic wrap is an excellent initial compression technique but is rarely tolerated for more than 24 hours. It buys enough time to prepare for formal external fixation in the operating room, safely done with an open technique. Although rarely the tool of choice for reduction and fixation of the pelvic ring disruption, it will still allow earlier mobilization of the patient in and out of bed. Unfortunately, more often than not, external fixation becomes the definitive treatment of the fracture. Centers that are comfortable with damage-control surgery, including open pelvic packing, remain few and far between. In austere environments, internal fixation can be either difficult (anything anterior) or very difficult (anything posterior) and is best left to expert hands working in ideal surgical environments.
Acetabular Fractures
Acetabular fractures are rare injuries, usually managed by specially trained pelvic surgeons in highly developed countries. Posterior wall fractures with an unstable or incongruous hip after reduction of the posteriorly dislocated hip are best managed with open reduction and internal fixation (ORIF) when the surgeon is skilled and confident and the necessary instruments and implants are available. If internal fixation is not possible, the joint should still be explored and cleaned, and the fracture treated should be in traction, usually with an “airplane” cast at the ankle to maintain external rotation. All other fractures are usually treated with longitudinal skeletal traction for 4 to 6 weeks, with no weight bearing for an additional 6 weeks. The only exception is the both-column fracture with “neo-congruency,” which is treated with bed rest only. There is no indication for cervico-trochanteric lateral traction using devices such as T-handled corkscrews, as is still commonly seen for “central fracture-dislocations.” They are difficult to insert properly, especially without fluoroscopy; confine the patient to the supine position; uniformly get quickly “soupy”; and are of no proven value.
Lower Extremity Injuries
As with everything else in LMICs, conservative management of lower extremity (LE) injuries has long been the gold standard, but there is a definite trend toward an “orthopaedic transition” to increased surgical treatment and internal fixation. Still, many patients present late or have to wait for prolonged periods (sometimes months!) before their treatment. This combines with the usual lack of intraoperative imaging to make ORIF in such environments even more challenging.
Hip Dislocations
It is not always easy to distinguish clinically between a posterior hip dislocation, a hip fracture, or a fracture-dislocation, but a good AP pelvis radiograph should be diagnostic. Closed reduction of a fresh posterior or anterior hip dislocation should be achieved with adequate anesthesia. A postreduction AP pelvis radiograph also showing the opposite hip is essential to confirm that the reduction is concentric and symmetrical. An interposed fragment will show an aspherical, incongruous, or asymmetrical joint line, and a computed tomography (CT) scan is not necessary to make the decision for an open reduction. If a closed reduction is more difficult than it should be, it is likely the duration has been underestimated. When more than a week out, or when the duration is uncertain, one should be prepared for an open reduction. Postreduction stability is assessed while the patient is still under anesthesia, and the “safe zone” is determined. This will determine further treatment: from nothing to skeletal traction with derotation bar for 3 to 4 weeks. Long-standing dislocations usually present with shortening, the need for some kind of walking aid, and no or mild pain. Surgical treatment is rarely indicated, but if the pain is still significant, options include a Girdlestone arthroplasty (even more functionally disabling) or a staged reduction: extensive soft tissue releases with 2 to 3 weeks of skeletal traction, then repeat surgery. This restores length but at the risk of AVN. Replacement arthroplasty is rarely a possibility.
Hip Fractures
Femoral neck, per-trochanteric, and peri-trochanteric fractures remain the “problem” fractures in LMICs. As the world is aging, their incidence is steadily increasing. They afflict mostly the elderly, who often have associated comorbidities and higher anesthetic risks. Standard surgical care in HICs involves early internal fixation, using fluoroscopy, or prosthetic replacement. In LMICs to this day, lack of access to skilled providers, properly equipped facilities, and/or affordable implants has left prolonged skeletal traction as the most common treatment, with its known morbidity: pressure sores, deep vein thrombosis, stiffness, atrophy, pin tract infection, and malunion or nonunion. Where surgery is not an option, traction should be discontinued in the elderly as soon as pain is tolerable, usually within 2 to 3 weeks. Malunion with shortening and/or malrotation, and nonunion, especially if painless, are less dangerous complications than those related to prolonged bed rest.
Where surgical treatment is possible, it is definitely the best option, particularly for younger patients. Keep in mind that the appearance on the admission radiograph might not reflect the situation at the time of surgery; make sure a recent radiograph has been obtained if possible. This is particularly important where no fluoroscopy is available. Where it is available, closed reduction, even on a radiolucent table only, and percutaneous pinning or fixation with a dynamic hip screw or cervico-trochanteric nail is done in a standard fashion for fractures of the femoral neck or intertrochanteric area. Where there is no fluoroscopy, a wider exposure is needed for intertrochanteric fractures for adequate reduction and “semi-blind” fixation, “feeling” the neck over the anterior capsule, and slowly advancing the drill bit in a push–pull fashion to ensure one is still “in bone.” The rigidity of the fixation is assessed intraoperatively. Even if the reduction is not perfectly anatomical, a rigid fixation will yield better functional outcomes than traction, provided the fracture heals ( Fig. 3.7 ). Femoral neck fractures should be internally fixed in the younger patient, which often means an open reduction, preferably through an anterior approach. Elderly patients are best treated with prosthetic replacement, a more “definitive” procedure, but if hemiarthroplasty is not an option, rigid internal fixation is still preferable to traction. Where the SIGN system is used, the hip construct is usually available, as discussed later in the chapter.
Femoral Shaft Fractures
Femoral shaft fractures are a common orthopaedic injury, on the rise with the increase in high-energy motorized crashes. Skeletal traction remains the most common treatment in LMICs, although the capacity for internal fixation is steadily increasing. All volunteer orthopedists should familiarize themselves with the lost art of skeletal traction, and forgotten gems, such as Charnley's Closed Treatment of Common Fractures or Byrne's Traction Handbook should be mandatory predeployment readings. Access to and affordability of trained surgeons and implants remain the biggest barriers to internal fixation in these austere environments. SIGN surgeons in numerous centers around the world are trying to circumvent these obstacles, as discussed later in the chapter. Even then, late presentation or protracted preoperative hospital stay, with or without traction, presents added technical challenges. And even if the SIGN implant is provided for free to the patient, other costs (operating room [OR] time, anesthesia, blood, ancillary supplies, etc.) still may block surgery. Generalized lack of fluoroscopy makes open reduction mandatory in almost all cases. It is not uncommon to find an irreducible shortening of the bone, requiring trimming of the ends of the fragments. Antegrade or retrograde IM nailing, preferably interlocked, or plates and screws are used for internal fixation. Tourniquets can rarely be used, and these open procedures can result in the loss of quite a bit of blood, so ensuring the availability of blood for transfusion, if needed, is a wise precaution. Malunions, nonunions, and previous hardware failure are not rare and require open management ( Fig. 3.8 ).
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