to Trauma in Austere Environments

Fig. 17.1

(a) This patient arrived in the OPD with an IV line in place and bottle strapped to a wooden pole wrapped in cloth for easier grip. Note bamboo splint over a swath of material protecting her left closed femur fracture. Local clinics and first aid posts often have slatted bamboo splints readymade for immediate use. (b) Child arriving in hospital from clinic on moto taxi with IV line in place

Remove previously applied bandages and splints; sutures should be removed if there is any doubt concerning the cleanliness, tension, suitability of the repair, or the extent of the underlying injury, especially with the possibility of an open fracture or infection. Complete disrobing may be difficult due to crowding, lack of curtains or private exam rooms, and culture. In certain societies, examining female patients, even by a female doctor, can lead to misunderstandings. A female staff member should be present; ask what is appropriate; explain what you plan to do and why. Families and patients used to offhand treatment in autocratic health systems usually respond positively when treated with respect and given thoughtful explanations [1].

Pay special attention to the feet during the physical exam. Rubber flip-flops are common footwear, and children often go barefoot, making crush and deep avulsion wounds common (Fig. 17.2). Foot wounds often have a distally based degloved, flap component. A minor but unaddressed foot injury can give more long-term disability than an open femur fracture.

../images/270913_2_En_17_Chapter/270913_2_En_17_Fig2_HTML.png — Fig. 17.2

(a) Avulsion of dorsum of foot—traction injury from a car’s tire running over child’s foot after she was knocked down. (b) Appearance after cleaning. (c) Appearance after sharp debridement. In children these wounds often develop enough granulation to accept an STSG. Soft tissues that have lost bone can be used as a fillet flap

X-rays, if the facilities are available, should be taken, but do not let the lack of advanced imaging or inadequate pictures interfere with clinical judgment. Patients with suspected femur fractures are often given one proximal femur x-ray and a distal femur x-ray in another plane (Fig. 17.3). A full complement of trauma films is unlikely, while the logistics of additional views after admission to a ward can be complicated. Digital films and processors are rare except in the private setting (Fig. 17.4). View boxes are few in number, and x-rays are often viewed and assessed while held up to a window or light (Fig. 17.5), leading to faulty readings and missed subtleties. A white lab coat taped to the window will improve the detail of an x-ray read through window light (Fig. 17.6).

../images/270913_2_En_17_Chapter/270913_2_En_17_Fig3_HTML.png — Fig. 17.3

A surgeon holding an x-ray up to light from a window because there is no view box in the operating theater. Note x-ray is inadequate to assess the extent of injury of the hip, proximal femur, or knee

../images/270913_2_En_17_Chapter/270913_2_En_17_Fig4_HTML.png — Fig. 17.4

X-rays drying outside

../images/270913_2_En_17_Chapter/270913_2_En_17_Fig5_HTML.png — Fig. 17.5

Pelvic x-ray of child with AVN of R hip due to sickle cell disease read through window light

../images/270913_2_En_17_Chapter/270913_2_En_17_Fig6_HTML.png — Fig. 17.6

The detail of the x-ray shown in Fig. 17.5 is improved when a white lab coat is interposed between the window and x-ray

Many middle-income countries are developing trauma systems, but few hospitals in low-income countries have the staff and facilities for good triage. Emergency departments (ED) can be chaotic (Fig. 17.7) with triage based on the demands of a powerful family or the perceived importance of the hospital staff hierarchy. It may not make medical sense.

../images/270913_2_En_17_Chapter/270913_2_En_17_Fig7_HTML.png — Fig. 17.7

A family member has been given the task to manually ventilate his relative while a nurse and doctor perform medical chores and other family members observe

Hospitals may not have staff for night cases, or obstetrics may take precedence, leaving trauma cases until the next morning, the next afternoon, or a couple days later. Hospitals that require payment up-front for services or overcrowded facilities in which the patient cannot obtain a bed can delay the initial surgical treatment. To avoid unnecessary frustration, try to find a modus operandi that will give the patient the best treatment within the systemic limitations. Remember, there is often more than one way to treat an injury that gives a good outcome.

If the injured patient is unable to go to the operating room in a timely manner, clean the wound in the emergency department under whatever sedation, systemic analgesia, or local anesthetic is available, using the cleanest fluid. Apply a bulky sterile or clean dressing. Splinting and elevation of all extremity injuries help relieve pain and prevent further local injury. Hospitals may have Steinmann pins and frames for traction, but do not be surprised if handed a mallet with which to hammer in the pin. Due to lack of equipment and supplies, improvisation is common.

Degloving Injuries

Degloving injuries—whereby large swathes of skin are lifted, avulsed, or abraded from the underlying muscle—often include a significant crush as well as a shearing element. The tissue damage is often more extensive than it initially appears (Fig. 17.8).

../images/270913_2_En_17_Chapter/270913_2_En_17_Fig8_HTML.png — Fig. 17.8

On initial debridement, the extent of damage of this distally based flap was unrecognized. The tissue under the flap was not explored, and the flap was reapproximated under tension

Degloving injuries with flaps need to be closely evaluated. Explore and clean under all exposed undermined tissue, removing nonviable components. If the skin appears viable and the edges bleed, try to tack it loosely back in place but under no tension. Dress the extremity with loose, splinted dressings, and recheck in 1–2 days in the operating room to assess tissue demarcation. Even with optimal treatment, patients with degloving wounds are difficult to treat. The dead space under the flap and dying, damaged tissue make a great culture media, and patients can become ill very quickly (Fig. 17.9).

../images/270913_2_En_17_Chapter/270913_2_En_17_Fig9_HTML.png — Fig. 17.9

Circumferential degloving injury of left leg, with loss of skin from mid-thigh to midfoot after the leg was run over by a heavy vehicle at work. The patient was hypertensive and diabetic, and the leg was not salvageable

Open Fractures

In countries where the motorbike and bicycle are the usual form of transport, open fractures are common, with open tibial fractures the most common. Patients often present after 2–3 days without treatment or with inadequate treatment, making good outcomes difficult or impossible (Fig. 17.10).

../images/270913_2_En_17_Chapter/270913_2_En_17_Fig10_HTML.jpg — Fig. 17.10

(a) This patient was a passenger on a motorcycle taxi. He spent 2 days in another hospital without treatment. At the time of his presentation, the wound had a foul odor and the soleus muscle was necrotic. (b) The major bone fragments seen in his x-ray had no soft tissue attachments

Prophylactic IV antibiotics appropriate to the injury, local availability, or hospital protocols are a mainstay in open fracture treatment and need to be given as early as possible. First- or second-generation cephalosporins are the frontline antibiotics with an aminoglycoside added for higher-grade open fractures and penicillin, Flagyl, or clindamycin added to cover specific contamination [2]. The incidence of antibiotic resistance in developing countries is a considerable problem due to uncontrolled prescribing practices by untrained personnel, ready availability without prescription, and irrational patient demand [3]. Though nonmedical use of antibiotics in agriculture appears less prevalent, in some countries second- or third-generation cephalosporins are frontline antibiotics that patients with noninfectious problems expect to receive. Pay attention to tetanus immunization and cover aggressively, as patients often do not remember if or when they were vaccinated.

The Gustilo classification of open fractures focuses on the extent of soft tissue injury and is widely used globally. Classification is most accurate when done at the end of debridement in the operating room (OR), though an assessment in the ED helps set the parameters for the initial treatment (Box 17.2).

Box 17.2 Gustilo and Anderson Classification of Open Fractures

Type I

Clean wound smaller than 1 cm in size. Assumes a simple fracture pattern.

Type II

Soft tissue injury >1 cm but <10 cm without extensive soft tissue damage. Assumes minimal degloving and periosteal stripping and not more than moderate contamination or comminution.

Type III

High-energy injuries, with substantial soft tissue injury, periosteal stripping, and/or some degree of crush. Segmental fractures, bone loss, farmyard injuries, and high-velocity GSW.

Type IIIA

Large soft tissue injury or flap, though usually less than 10 cm. Adequate soft tissue remains to cover the bone.

Type IIIB

Extensive soft tissue injury, bone loss, devascularization, and/or massive contamination. Inadequate soft tissue to cover bone without a flap.

Type IIIC

Fractures with major arterial injury requiring repair.

As in other open injuries, clean and splint the open fracture in the ED following local protocols. The controversy in the West concerning the appropriate time frame open fractures should be taken to the OR exists in developing countries, with the addition of rules and protocols that can prolong the time to debridement.

In the OR, apply an inflatable tourniquet, if available, even if you do not think you will use it. Prepping and draping procedures are often a matter of faith and precedent with nursing staff, who may resist well-meaning suggestions. If the prep appears substandard, ask to prep again, even a third time, until the wound and extremity are as clean as the situation allows. Due to lack of draping material, the initial washout may take place using a non-sterile rubber drape and a plastic apron.

After removal of gross contamination, copious irrigation, and wound excision, re-prep and drape the patient. Enlarge and expose the deeper tissues underlying the wound. Remove all muscle that is discolored, of mushy consistency, fails to contract when irritated, and does not bleed when cut.

If the skin injury does not appear to be full thickness, it is sometimes safe to leave moderately damaged skin for further consideration at an early second OR visit, as skin can be quite resilient. Fascia that is grossly contaminated, infected, ragged, or discolored should be removed. Pieces of bone unattached to soft tissue should be removed. No matter how large or structurally important a piece of cortical bone is, if it is devitalized and has no blood supply, it should be removed. Retain as much periosteum as possible. The goal of debridement is to reestablish a healthy, vascularized soft tissue bed so the injured bone or the bone defect can be covered.

The surgical incisions made to enlarge the wound can be closed without tension at the end of the debridement, but the original wound should be left open and covered with a sterile dressing. Even if it appears that the injury wound can be closed, do not close it. Flaps of skin sutured under tension in an attempt to cover bone will fail, leading to further soft tissue loss, increased risk of infection, and extended hospitalization (Fig. 17.11). Initial debridements of high-grade open fractures are rarely totally satisfactory, especially if done by a surgeon who is inexperienced with trauma in that particular setting.