Diseases and Orthopedics

Fig. 11.1

(a) Gas gangrene involving the entire lower extremity of the young male patient who died of sepsis shortly after hip disarticulation. (b) X-rays show gas in the soft tissues and dissecting between muscle planes

../images/270913_2_En_11_Chapter/270913_2_En_11_Fig2_HTML.jpg — Fig. 11.2

Extensive gas gangrene of the entire left upper extremity of an elderly woman, with visible typical copper discoloration of the skin extending to the supraclavicular area. Even a forequarter amputation would not have saved her life

Tetanus

Tetanus is not a surgical condition per se, but it is surprisingly common in many parts of Africa, and a volunteer may have to help with the medical management. Inoculation of the spores of Clostridium tetani , another Gram-positive anaerobic bacillus, in a wound causes the release of the neurotoxin tetanospasmin. The adult form of tetanus occurs after contamination of a traumatic wound, and the neonatal form comes from indigenous umbilical cord dressings made with mud or dung. In the adult, the disease appears after a 1–3-week incubation period. Some of the first signs are trismus or lockjaw, severe spasms of a limb, or unaccountable contracture of a joint, which should alert the clinician to the underlying diagnosis. This progresses rapidly to more generalized contractions (tetani) and systemic involvement with mortality around 30% if untreated (Table 11.1).

Table 11.1

Management of tetanus-prone wounds

Types of wounds likely to favor the growth of tetanus organisms include
Compound fractures
Deep penetrating wounds
Wounds containing foreign bodies (especially wood splinters)
Wounds complicated by pyogenic infections
Wounds with extensive tissue damage (e.g., contusions or burns)
Any wound obviously contaminated with soil, dust, or horse manure (especially if topical disinfection is delayed more than 4 h)
Reimplantation of an avulsed tooth is also a tetanus-prone event, as minimal washing and cleaning of the tooth is conducted to increase the likelihood of successful reimplantation
Wounds must be cleaned, disinfected, and, if appropriate, treated surgically
History of tetanus vaccination		Type of wound	Tetanus vaccine booster	Tetanus immunoglobulin
Three or more doses	<5 years since last dose	All wounds	No	No
Three or more doses	5–10 years since last dose	Clean minor wounds	No	No
		All other wounds	Yes	No
	>10 years since last dose	All wounds	Yes	No
<Three doses or uncertain		Clean minor wounds	Yes	No
		All other wounds	Yes	Yes

In the newborn, incubation is 3–7 days. Generalized contractions appear after a period of irritability and inability to suckle. Mortality is above 70% if untreated [4]. Treatment for both forms of tetanus requires nonspecific supportive measures, including a dark and quiet environment, antibiotic therapy with metronidazole and penicillin, surgical debridement if the patient’s condition permits, and sedation with benzodiazepines. If available, human immunoglobulin should be used; antitoxin is controversial in the neonatal form.

Brucellosis

Brucellosis, caused by aerobic Gram-negative coccobacilli, occurs from contact with animal parts or ingestion of unpasteurized dairy products. One of the disease’s most common manifestations is a monoarticular, chronic, indolent arthralgia, with occasional bouts of severe acute pain. It also mimics spinal TB both clinically and radiographically. Treatment is with streptomycin and doxycycline.

Ulcers

Ulcers are annoyingly common in tropical environments [5]. Both tropical (phagedenic) ulcers and Buruli ulcers (see next section) are manifestations of infections. Tropical ulcers are seen almost only in adults and occur below the knee [6] (Fig. 11.3). They start frequently after an innocuous injury with a painful indurated patch of skin that becomes a pustule over 5–10 days. When this bursts, a full thickness round or oval ulcer is visible. This grows for 4–6 weeks, at which time, the pain subsides. The borders are regular, without undermining.