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CLOSE THIS BOOKMinor Surgical Procedures in Remote Areas (MSF, 1989, 172 p.)
Chapter 6: treatment of trauma
VIEW THE DOCUMENTFractures and disIocations: the basics
VIEW THE DOCUMENTShoulder and arm trauma
VIEW THE DOCUMENTTrauma of the lower limb
VIEW THE DOCUMENTPeriod of immobilization for major fractures

Minor Surgical Procedures in Remote Areas (MSF, 1989, 172 p.)

Chapter 6: treatment of trauma

Fractures and disIocations: the basics

It is possible to treat major fractures and dislocations in isolated areas, without sophisticated surgery or radiography.

A service can be provided with the minimal material, producing a satisfactory reduction and total recuperation of the fracture.

It should be noted that in certain areas traditional fracture treatments exist (clay plasters, medicinal plants, bamboo lattices.) which sometimes produce good results but more frequently lead to catastrophic deformities and reduction of mobility. Be aware that immobilisation for a long period is sometimes unacceptable.

Diagnosis of a fracture

This is often easy: pain, abnormal movement, abnormal position, bruising, deformity, reduced function. It is dangerous to look for a fracture by palpating; it causes pain, etc.

It is sometimes difficult but necessary to have an X-ray. If this is not possible (no evacuation possibilities, no hospital) and in doubtful cases, it is better to immobilise the fracture in a posterior plaster rather than in a full circular plaster. For example, in children when a forearm fracture is suspected, for which only an X-ray will confirm the diagnosis, a splint maintained with a bandage will produce good results, and with no risk.

Looking for complications

· Skin: Look for a wound or puncture. All wounds with fractures require dressings and antibiotics (penicillin or ampicillin).

· Pulses: look carefully for peripheral pulses.

· Paralysis: explore the nerves.

· Multiple trauma: A fracture may hide other trauma, always give priority to hemorrhage, to cardiovascular problems, etc.

ATTENTION: In isolated areas, treatments are deliberately chosen for their simplicity, but obviously other methods exist. Moreover, certain fractures and dislocations have deliberately been omitted because they are rare or because they require sophisticated treatment which would not be available in an isolated dispensary in the third world.

Constructing a plaster

Material

· Plaster of Paris rolls of 2 to 3 metres length, 10,15 or 20 cm width. Application time: 2 to 5 minutes Drying time: 24 to 48 hours Stock in a dry place, maintain the airtight packing, and throw away damp rolls.

· Tubular stocking of different diameters

· Cotton

· Container with tepid water

· The construction of a plaster requires at least two people, to hold the limb, to reduce it and to maintain it in right position.

Technique
(Figures 113a to 113c)

Fitting the tubular stocking

The diameter of the stocking must be chosen according to the type of fracture; it must not be too tight, it must not produce folds and it must cover the limb. It must be longer than the plaster at both ends. Rather than unrolling it before application, it is better to carefully unroll the stocking over the limb.

Application of the cotton

1/2 cm thickness covering all bony projections and flexor skin folds.

Immersion of the plaster rolls in water

Remove from the packing material

Take in both hands, the left hand holding the free end of the roll, and unfurl several centimeters.

The right hand holds the unrolled plaster.

Immerse the roll, thus maintained, with both hands.

Maintain the plaster in the water until all the air bubbles have disappeared.

Squeeze out the water, continuing to hold the free end of the plaster.

Unrolling the plaster

Apply the plaster from the proximal end of the limb, ensuring that several centimeters of the stocking are showing.

The plaster is unrolled over the limb and must not be tightened, this helps to prevent ischemia.

The different rolls of plaster must overlap.

Four or five rolls are usually needed.

Smooth each plaster roll with the palm of the hand before applying the next roll.

The assistant continues to hold the plaster with the hollow of the hand and never with the fingers. The application must be perfect and must not produce dangerous plaster folds at the flexural creases which can cause severe constriction (just like a tourniquet).

Each end of the stocking should be folded back onto the plaster.

The plaster should continue to be held in position by the assistant until it is dry and hard.

The plaster may be reinforced in the flexural creases with a splint prepared in advance: usually 5 or 6 plaster rolls.

Special precautions
(Figures 114a to 114d)

A PLASTER MUST IMMOBILISE ADJACENT JOINTS.

To prevent vascular/nerve compression, it is almost obligatory to split a circular plaster from top to bottom. The plaster can be split using a scalpel just before it is completely dry.

All plasters must be put under surveillance and therefore hospitalisation for at least 24 hours is necessary.

Never hesitate to open and make a new plaster if there is the slightest hint of compression or poor reduction.

Always make a window in the plaster at the level of the folds.

Always elevate the plaster during sleep or confinement to bed.

Always write on the plaster the date it was applied and the time needed for the fracture to heal.

Do not hesitate to reconstruct a heavy plaster or reinforce a weak plaster. Always consider the constraints of living in a rural area.


FIGURE


FIGURE

Making a plaster splint

(Figures 115 to 119)

Prepare 12 to 15 thick plaster rolls the length of the limb to be immobilised.

Place the dry plaster rolls in a stocking of adequate length and width.

Immerse the stocking splint in tepid water until all the bubbles have disappeared (usually a little longer than the time required for a simple plaster roll), then spread out and flatten on a hard surface.

Apply the splint in the correct position on to the surface of the limb to be immobilised.

Wrap, without constricting, with non-elastic bandage.


FIGURE


FIGURE


FIGURE


FIGURE


FIGURE

Instructions to follow for open fractures

· General anesthetic (ketamine) if the patient is fit.

· Treat the wound in the best possible aseptic conditions (operating theater, using sterile drapes and gloves etc.)

· Remove foreign bodies, excise bone splinters and necrotic tissue, and clean abundantly with chlorhexidine (+ cetrimide) (see table page 7).

· If the wound is recent and clean, attempt to close the skin.

· If skin tissue is lacking, cover the wound with sterile vaseline compresses and soak with polyvidone iodine (see table page 7).

· If possible, give anti-tetanus prophylaxis and systemic antibiotic therapy (procaine penicillin or PPF: 5 MUI/day for at least 5 days, or ampicillin: 3 or 4 g/day in an adult).

· Immobilise on a plaster splint (not a circular plaster to begin with)

· Apply regular dressings under strict aseptic conditions.

· As soon as the wound is healing, the splint can be changed for a circular plaster with a window cut over the wound to allow external care.

Shoulder and arm trauma

Fracture of the clavicle

Diagnosis
Pain, loss of shoulder movement and subcutaneous projections of the bony fragments.

Look for complications

Pulses, paralysis of nerves to the arm.

Treatment

· Reduction:
The operator stands behind the patient, who is seated on a stool, places his knee between the shoulder blades and pulls on the patient's shoulders.

· Maintenance:
Figure of 8 bandage. The best material to use is long tubular stocking filled with cotton. The bandage forms two rings which pass across the delto-pectoral muscles and the armpit, and are tied in a knot on the back.

This bandage must be re-tied every 3 or 4 days and left in place for 3 weeks.


FIGURE

Dislocation of the acromio-clavicular joint

Diagnosis

Often difficult without X-ray: exquisite pain at the level of the joint with mobility at the extremity of the clavicle.

Treatment

Reduce by pressing on the clavicle.

Immobilise by applying a sticky bandage (perforated adhesive tape), crossed and double thickness under the elbow.


FIGURE

Dislocation of the shoulder

Diagnosis

In the anterior-inferior variety, which is the most frequent: pain, reduced movement, deformity of the shoulder, the arm abducted and externally rotated, and a reduced glenoid space.

Look for complications

Ensure adequate pulses, finger mobility (brachial plexus), and sensation at the tip of the shoulder (circumflex).

Treatment

· Reduction: under general anesthetic (ketamine IM: 5 mg/kg) The patient lying on a table, counter-extension applied by an assistant holding a folded drape in the axilla, across the thorax and pulling towards the other shoulder. The operator places his stockinged foot in the axilla of the patient without pressing on the vascular/nerve bundle, and abducts the arm. A movement is felt as the humeral head re-enters the glenoid cavity.

· Immobilisation: 3 weeks in a sling in order to prevent recurrence.


FIGURE


FIGURE


FIGURE

Fracture of the neck of the humerus

Diagnosis Acute pain, reduced shoulder movement, swelling, large brachio-cephalic bruise, and the arm internally rotated (pathognomonic of this fracture).

Look for complications

Damage to the vascular/nerve bundle in non-engaged fractures with displacement.

Treatment

If the fracture is engaged without displacement, a support bandage for 15 days and then physiotherapy.

If the fracture is displaced, it must be reduced under general anesthesia (ketamine IM) as with a dislocation, and immobilised with a support bandage.


FIGURE


FIGURE


FIGURE

Fracture of the shaft of the humerus

Diagnosis

Pain and reduced mobility. Shortening of the arm with angulation, usually antero-lateral. Brachial bruising.

Look for complications Paralysis of the radial nerve: inability to raise the hand.

Treatment

HANGING cast: brachio-ante-brachio-palmar, leave the upper part of the arm free and elevate the wrist with the plaster. This plaster should be set to correct the angulation, and should be maintained for 6 to 8 weeks.


FIGURE

Fracture of the lower humerus

A variety of supra-condular fractures are common in children.

Diagnosis

Intense pain, reduced movement of the elbow.

The elbow is swollen, the fore-arm is shortened, but the triangle between the olecranon, epitrochlear and epicondyle is preserved.

Look for complications

(Figures 131, 132)

There is a risk of compression to the humeral artery, and the median, cubital and radial nerves. Urgent reduction is necessary.

Treatment

(Figures 133, 134)

Reduction: under general anesthesia or local/regional anesthesia. An assistant holds the arm at a distance from the elbow. The operator takes the fore-arm with both hands and places it in pronation. Then traction should be applied along the axis of the humerus, followed by flexion of the elbow.

· Immobilisation with a POSTERIOR PLASTER SPLINT for 30 days.


FIGURE


FIGURE


FIGURE

Dislocation of the elbow

Diagnosis

Pain and reduced movement.

Deformed: thickening of the elbow, projection of the olecranon posteriorly, and shortening of the fore-arm.

The olecranon loses its normal conformity with the epitrochlear and the epicondyles: the isosceles triangle.

Look for complications

Palpate the pulses, explore the territory of the 3 nerves and look for associated fractures.

Treatment

· Manual reduction under general anesthesia (ketamine IM: 5 mg/kg) or local/regional anesthesia.

Place the two hands on the patient's arm and push with the two thumbs on the olecranon process (Figure 135a).

If this method fails, pull with both hands on the forearm of the patient, while an assistant applies counter traction with a sling passed in front of the upper arm, ensuring that it does not apply pressure to the flexor fold of the elbow (Figure 135b).

· Immobilisation for 2 to 3 weeks in a posterior plaster splint.


FIGURE

Fracture of the two bones of the fore-arm

Diagnosis
Pain, reduced movement, some deformity, and sometimes shortening.

Look for complications

The fracture is often open, requiring cleaning, dressing and antibiotic therapy (for example in an adult, ampicillin: 4 g/day in 4 doses for 5 days).

Check pulses, explore the nerves (radial, raise the fingers, separate and then bring the finger together).

Treatment

In a child it is possible to reduce the fracture and then plaster, but in an adult, the treatment is usually surgical because of the formation of callus under the plaster which ultimately limits pronation and supination.

· Reduction under general anesthetic or regional/local anesthetic. This reduction is easy in a child: traction on the hand by the operator while the assistant applies counter-extension to the flexed elbow.

· Immobilisation plaster (Figures 136,137) Elbow at right angles, protected in the flexural fold with cotton, the hand midway between pronation and supination, the plaster covering the brachiopalmar surface as far as the metacarpal joints, leaving the fingers free. IMMEDIATELY SPLIT THE PLASTER. Immobilisation: 3 months for an adult, 45 days for a child.


FIGURE


FIGURE

Fracture of the distal radius

Colles fracture is the most frequent.

Diagnosis

Pain, reduced movement of the wrist. Characteristic "bent fork" deformity of the wrist (Figure 138).

Treatment

· Reduction under general anesthesia or local/regional anesthesia. Local anesthesia is possible following rigorous aseptic technique. Inject 10 ml of 1% lidocaine into the hematoma of the fracture. The left hand of the operator takes the patient's fingers and applies axial traction. The thumb of the right hand presses on the back of the bent fork deformity. Then, flex the palm of the hand and incline it cubitally (Figures 139a, 139b).

· Immobilisation for 30 days in a forearm plaster, the wrist in a neutral position. This plaster must leave the metacarpal phalangeal joint of the thumb free and should reach the metacarpal phalangeal joints of the other fingers (Figure 140a). If surveillance of the plaster cannot be assured, do not cover the elbow with the plaster (Figure 140b).


FIGURE


FIGURE


FIGURE

Fracture of the scaphoid

(Figure 141)

Diagnosis

Difficult to diagnose without an X-ray. Pain on pressing the anatomical snuff box, pain on traction and pressure at the base of the thumb.

Treatment

Split brachio-palmar plaster, covering the proximal two phalanges of the thumb, and maintained for 6 weeks.

Anterior dislocation of the lunate

Diagnosis

(Figure 142)
Difficult without an X-ray. Pain, reduced movement of the wrist, no bent fork deformity, the wrist is thickened and sometimes there are pins and needles from compression of the median nerve.

Treatment

(Figure 144)
Under general anesthetic, traction on the fingers for 30 minutes or more, after which the dislocation will reduce itself. Then maintain immobilised in an anterior splint for 20 days.

Dislocation of the carpus

Diagnosis

(Figure 143)
Difficult without an X-ray. Pain and immobility of the wrist, the distal ends of the radius and ulnar are in position on palpation, but there is a "bent fork deformity" at the level of the carpal bones.

Treatment

(Figure 144)
The same principles apply as for reduction of a dislocation of semi-lunaris. Immobilise in an anterior splint, wrist to the right, fingers flexed, thumb free.


FIGURE


FIGURE


FIGURE


FIGURE

Fractures of the metacarpals and phalanges

Diagnosis

Sometimes difficult, masked by developing edema around the fracture, especially in the case of a fractures of a metacarpal: deformity, angulation, rarely shortening.

Treatment

(Figures 145,146, 147)

· Reduction of the fracture by simple alignement, under local anesthesia, local/regional or general anesthesia.

· Immobilisation using a "ball made with plaster of Paris": the operator makes a ball out of plaster and it is held in the palm of the hand. The fractured finger is strapped to the ball with an adhesive tape. In cases of a fracture of a metacarpal, the ball is first fixed to an anterior forearm splint which is held in position with a bandage leaving the fingers free.

The hand and fingers should be immobilised in a functional position.


FIGURE


FIGURE


FIGURE

Trauma of the lower limb

Fracture of the neck of the femur

Diagnosis
In general the clinical signs are easy: shortening of the limb, external rotation of the buttock, impossible for the patient to lift the leg into decubitus.

Treatment

Traction for 90 days for an adult.

Fracture of the shaft of the femur

Diagnosis
Obvious signs: shortening of the thigh, deformity, huge hematoma (watch out for "shock"!).

Treatment

Traction-suspension for 90 days for an adult. Do not forget to look for complications: pulses, nerves, contaminated wound. Give antibiotic therapy if the fracture is open.

SUSPENDED SKIN TRACTION

(Figure 148)

In the absence of material (transtibial wire), skin traction can be applied using a bandage attached to the skin by large bands of non elastic adhesive tape, applied along, not around the limb, from the thigh to the heel and connected to a board maintaining the ankle at right angles to prevent a resulting deformity.

The board is attached to a cord which is suspended, by weights of 1/7 body weight, on a pully. Traction should be in the axis of the limb, counter traction coming from the patient resting in bed at an angle of 45° to the horizontal.

In adults, it is difficult to maintain this traction for 3 months: the state of the skin must be checked each day, the bandages will become unstuck and will need changing. If this traction is impossible to maintain, it can be replaced with a pelvic-leg plaster, for the remainder of immobilisation, but as late as possible, for example on the 45th day. This type of traction not only produces a reduction of the fracture but also allows the quadricep muscle to be exercised.


FIGURE

TRACTION FOR CHILDREN

(Figures 149a, 149b)

Indication

Fracture of the femur in children aged 8 - 10 years.

Technique

The same principal as for skin traction in the adult, but the limb is suspended vertically by a weight equivalent to 1/7 of the child's body weight, the buttock elevated above the lying position (gallow's traction).

Construct a frame passing above the bed from which a pulley can be hung.

This traction is maintained for 3 weeks and is then replaced with a pelvic-leg plaster for 15 to 20 days (Figures 150,151,152).


FIGURE


FIGURE

MAKING A PELVIC-LEG PLASTER

Indications

Fractures of the femur

Technique

Requires several assistants, 3 if possible, to maintain the alignment of the limb (the line passing between the anterior superior iliac spines, the edge of the patella and the first interdigital space), the knee flexed at 15° and the ankle at right angles.

Start with a plaster splint positioned posteriorly which will reinforce the plaster.

Do not forget to protect the skin folds and the bony prominences with cotton.

Build up the plaster with small splints at the level of the articulation of the thigh.

Find a way of supporting the crutch in order to be able to unroll the plaster bandages around the pelvis.

The plaster must cover the two anterior-superior iliac spines, be supported on the sacrum, and must be free of the anus and perineum. The toes should be uncovered to allow good surveillance of the plaster.

Torsion of the knee

All damage to knee ligaments.

Diagnosis
(Figures 153,154, 155)

Hemarthroses, interarticular pain, abnormal lateral or antero-posterior movements.


FIGURE

Treatment

If hemarthrosis is severe, apply a posterior plaster splint supported with a noncompressing bandage. After 48 hours, drain the, hemarthrosis and place the limb in a knee cylinder which should be split from the buttock to the ankle, the knee flexed at 15°. The plaster should remain for 45 days in severe cases (abnormal knee movements)

Fracture of the patella

Diagnosis
Easy in the case of a displaced fracture by detecting depression between the two fracture fragments.

Treatment
Surgical if possible, otherwise a knee cylinder plaster for 45 days.


FIGURE


FIGURE

Fracture of the two leg bones

Clinical diagnosis

Usually obvious: deformity, shortening and angulation.

Treatment

(Figures 158a to 160)

· Reduction under general anesthesia (ketamine 1M: 5 mg/kg). By the method of "hanging leg": the patient lying on a table, the fractured leg hanging over the edge, the operator facing the patient and supporting the heel of the damaged leg on his knee. Vertical traction is applied (majoring the effects of gravity) to reduce the fracture. The operator's thumb should be placed on the tibial shaft to control the reduction.

- Immobilisation:

The lower leg plaster should be applied from the knee to the ankle with the knee at right angles. When this part of the plaster is dry, the leg should be rested on the table to apply the thigh plaster, knee in 15° flexion with toes uncovered.

This plaster should be maintained for 90 days in adults and 60 days in children under 10 years of age.

If there is an open fracture:

· General anesthetic (ketamine) if the patient is fit.

· Treat the wound in the best possible aseptic conditions (operating theater, using sterile drapes and gloves etc.)

· Remove foreign bodies, excise bone splinters and necrotic tissue, and clean abundantly with chlorhexidine (+ cetrimide) (see table page 7).

· If the wound is recent and clean, attempt to close the skin.

· If skin tissue is lacking, cover the wound with sterile vaseline compresses and soak with polyvidone iodine (see table page 7).

· If possible, give anti-tetanus prophylaxis and systemic antibiotic therapy (procaine penicillin or PPF: 5 MUI/day for at least 5 days, or ampicillin: 3 or 4 g/day in an adult).

· Immobilise on a plaster splint (not a circular plaster to begin with)

· Apply regular dressings under strict aseptic conditions.

· As soon as the wound is healing, the splint can be changed for a circular plaster with a window cut over the wound to allow external care.


FIGURE

FRACTURE OF THE ANKLE

Diagnosis

Easy when there is internal or external subluxation of the malleolus. More difficult when there is an isolated fracture without displacement of the malleolus. Look for discomfort while balloting the ankle bone and moving the foot in a transverse direction (the left hand holding the leg, the right hand supporting the heel and instigating the movement).

Treatment

· Reduction under general anesthesia (ketamine IM 5 mg/kg) with the "removing shoe" maneuver: a hand on the leg, the other supporting the heel and reduce the fracture with the same movement as removing a shoe (Figures 161, 162).

· Immobilisation (Figure 163)

In an ankle plaster, well applied over the malleolus and holding the foot at right angles for 60 days, without weight bearing.


FIGURE

Period of immobilization for major fractures


TABLE 5

SPRAINED AND TORN ANKLE LIGAMENTS

Diagnosis

The differential diagnosis is with a non displaced fracture of the ankle: edema, pain over the external lateral ligament, and look for ballottement of the ankle bone.

Treatment

In all cases, below knee walking cast, for 21 days.

FRACTURE OF A METATARSAL

Diagnosis
Difficult, but sometimes obvious especially with fracture of the 5th metatarsal.

Treatment

Below knee walking cas for 15 days.

FRACTURE OF THE TOE

Diagnosis

Usually obvious: hematoma, displacement.

Treatment

Reduction under local anesthesia if necessary, and splint the fractured toe to the adjoining toe with adhesive tape. The same conditions apply as for dislocations.

Orthopedic treatment (see table 5)

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