Safari-A complex case
Safari, a 38 year old gardener was referred by the local surgeons to obtain the opinion of the visiting team He had a complex fracture dislocation of the right elbow which had occurred 6 weeks previously.
Attempts to relocate of the joint had not been successful, leaving him with a painful stiff elbow with complete loss of forearm rotation.
His elbow required surgical reduction and stabilisation achieved using a hinged external fixation device to allow for immediate movement. The frame was constructed and the procedure performed was performed with the help of Kenyan colleagues. At follow-up he had a functional range of elbow and forearm rotation movements.
A 34 year old manual worker, Samuel fell from a motorcycle taxi in July sustaining a severe fracture dislocation of his elbow with associated highly fragmented fracture of his ulna. This was managed non-surgically in plaster for 4 weeks as he had no money for operative fixation.
Four months later when we saw him he had pain, significant deformity, a very poor range of elbow movement with no forearm rotation, and non-union of the ulna fracture.
He was taken to theatre and the non-union was taken down. Alignment and rotation were restored; the non-union stabilised, grafted and radial head excised, with establishment of a good range of on-table flexion/extension and forearm rotation. He considerably exceeded his pre-surgical range of movement following the surgery and he was discharged from hospital for further physiotherapy. His treatment costs were covered by KOP and his further follow-up will be a combination of outpatients with the local team for suture removal and X-rays, and again by the KOP team during a follow-up visit after 3 months.
£150 covers the cost of his implants
Mr B – Demonstrating best orthopaedic practice is achievable at CPGH
Mr B is a 39 year old man who is the main bread winner in his household, who was involved in a motorcycle accident.
This tibial fracture was associated with a substantial wound in the skin (compound or open fracture).
For those who can not afford appropriate surgical treatment, infection and non-union of the fracture is likely and will often lead to the requirement for limb amputation.
At the request of the Kenyan surgeons, the KOP team assessed Mr B according to ATLS guidelines to ensure he was stable and commence antibiotics. A decision was made to debride the area, operate and stabilise the injury surgically within 24 hour of injury, according to the British Orthopaedic Association’s Standards for Trauma (BOAST) guidelines used in the UK. These guidelines were designed to be easily applicable in a variety of settings worldwide.
On arrival at theatre the World Health Organisation checklist for surgery was performed and on the ward a clear post-surgical plan including wound, physiotherapy and analgesic needs was arranged. Mr B is now making an excellent recovery following his surgery. Later on that week a 2 hour training session was hosted by the team as an ATLS refresher lead by one of the team members who is an ATLS instructor.
An image intensifier with a retail price of approximately £30,000 was purchased through donations made to Medical Education and Aid to Kenya (MEAK), and shipped over in a container kindly donated by Maritime International.
An image intensifier gives X-Ray imaging during the operation and therefore enables precise location of implants and accordingly allows a huge number of operations to be undertaken in theatre that previously would not have been possible. Hospital staff were overjoyed with the opportunity to receive an Image Intensifier, as the only other unit in Kenya, at a public hospital, is in Kenyatta National Hospital in Nairobi.
Protex generously donated lead aprons to accompany the machine and our radiographer Sue Freeman set it up for them in theatre and gave daily teaching sessions to the local radiographers on how it should be operated with due provision to the problem of ensuring radiation safety in theatre.
Teaching, Learning and Sharing Professional Development
Successful teaching of trauma and fracture management, pain control, patient safety in theatre and recovery are important topics which improve the overall management of the trauma patient’s journey from initial injury to discharge from hospital.
However, the learning is by no means one sided. The enormous amount gained from working with our Kenyan colleagues in a poorer resourced health system greatly benefits UK staff. Improvements in transferable professional skills to the UK team have been demonstrated in follow-up evaluations.