The Adventure of Living in the Kingdom of God

Tuesday, March 5, 2013

Kenya: Tibial Plateau Fractures

A few orthopedic trauma cases I saw while at Tenwek and how we put them back together! Many orthopedic surgeons enjoy fixing fractures because of the chance to help people often in desperate need, the chance to use to their hands similar to a carpenter, and for the chance to problem solve - to work like MacGyver pull off a great result with what you have. No two trauma cases are exactly the same and one has to be able to think on their feet in the midst of the case to figure out what can be done. I have tremendous admiration for the people at Tenwek and the work that is done there. They certainly don't have the luxury of any implant by any company like we have at our disposal here in the United States. However, they consistently treat incredibly severe injuries with limited resources and do a magnificent job for the people of the western Kenya.

Tibial plateau fractures (fracture at the top of the tibia - shin bone - involving the knee joint) are a perfect example. These fractures can range from simple splits in the joint surface all the way to comminuted (smashed) fractures where the top half of the tibia is basically not connected to the rest of the leg below the break. These fractures are often difficult to treat by experts here in the United States with ample resources. Here in the United States, we have specially-designed plates for each side of the tibia (even the back of the tibia) with screws in them that allow you to capture the fragments of a badly broken tibial plateau and restore the anatomy. These plates are really nice...and really expensive...which means Tenwek doesn't have them.

Tenwek, being a mission hospital, is subject to donations from surgeons, orthopedic companies, hospitals, etc with implants that have either expired or just simply aren't used. One such device is the ringed external fixator - a device shaped like a horseshoe that rests outside the skin attached to wires drilled through the bone and coming out both sides. Basically, you turn the bone into a pin cushion and then attach these rings to the wires to stabilize the fracture. Very few people in the US are trained to use these and those tend to be in large academic centers. Tenwek, somewhere along the road, received a large donation of these devices that sat on a shelf until Dan Galat, a Mayo Clinic trained orthopedic surgeon there at Tenwek, found them. He had never put one on before coming to Tenwek but with limited resources, you do what you can with what you got!  So, here is what he did!

 Case #1: 50 year old male involved in a RTC. Came in on my first call night. Closed right comminuted tibial plateau fracture.

Right Tibial Plateau Fracture involving both side of the knee joint with significant comminution.

Postop: First two cannulated compression screws are placed in the largest fragments around the joint surface to pull them together. Second, small wires are place through the bone around the joint surface and out the skin. The ringed fixator is attached. Distally, two standard external fixation pins are placed in the tibia and then connected to the ring via long bars.

Result: Hybrid Ringed External Fixator for a severe Tibial Plateau Fracture. One advantage is that the patient can bend their knee immediately because it doesn't cross the knee joint like most external fixation devices. Patient had a great result and was able to walk with partial weightbearing on this a week after surgery.
Case #2: 38 yr old male involved in a RTC with a left comminuted closed Tibial Plateau Fracture
Left Tibial Plateau Fracture

Axial (Cross-Section) CT Scan through fracture

Postop AP Xray. Pleased with Articular Reduction and Overall Mechanical Alignment
Patient is able to bend his knee right away and to partially bear weight with his hybrid fixator in place.

These Hybrid Ringed Fixators will stay on for 3 months barring any disastrous infections from the pin sites. The patients are instructed in doing daily pin site care and caring for the device as a whole.
Before Tenwek, I had certainly never seen these devices used to fix fractures. I had only read about them in textbooks. These are prime examples of using what you have to do what you can do! Such is the life of an orthopod in a developing, limited resource setting.

More to come...

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