Easter was not that big a deal in my house growing up. I remember waking to find a basket on the kitchen table with various candy and sweets - mostly Reese's products (Note: If you're every trying to bribe me, consider Reese's Peanut Butter Cups your go-to move!). Early on, there was usually an egg hunt with more candy to be procured once the eggs were opened. Church wasn't that different from a regular week. For whatever reason, the ladies at church made a big deal about getting new Easter dresses to wear to church. 'Holy Week' did not even enter my vocabulary until graduate school because my faith tradition argued that we celebrated Easter - i.e. the resurrection of Christ - every week. Lent was only what you found in... well, never mind. You get the idea.
Now that we live in Michigan, it is so interesting how significant Easter is here, even to people who have no interest in theological or religious discussions on a regular basis. I assume it has to do with the heavy permeative influence of Catholicism and Lutheranism within this region, traditions built around liturgies and religious calendars. People at coffee shops, the hospital, drive-throughs, and grocery stores all wish one another 'Happy Easter.' That didn't happen in west Tennessee. People whom you would have no idea they knew what church was openly state they are going to church this Sunday and (most of them) are excited about it. The culture seems to come alive with religious discussion and a willingness to consider a story larger than themselves.
The Easter story is the ultimate story of hope - a hope very different than optimism. Optimism is the belief that things will eventually get better. Hope is rooted in faith in a person - one who lives despite having tasted death - who is in control regardless of how bad the situation is and whether or not the situation ever improves. Easter matters, not because of candy and bunnies, but because the human life replays the story of Holy Week - death, burial, resurrection - over and over and over again.
Many are living this story, but the one that continues to fill my thoughts is Will Gray. Will is a high school friend and teammate who lives in southern California with his wife Angie. Will was diagnosed with cancer a few months ago and recently found out it has spread throughout his body. He plans to come home with hospice in the next day or so with the medical staff having stated his condition is 'incurable.' Will is one of the most gifted individuals I have ever met. He exudes vitality, strength, and creativity in his pursuit of blessing others via his passion for music, life, and the kingdom of God. Will is one of those guys that everyone who knew him anticipated the day when his vibrance would be unleashed on the world and the world would be better off because of it.
This being Holy Week could not be more appropriate. We are all stunned and grieve with Will, Angie, and their families as they in some way live out the story of Holy Week. They sit perhaps in Gethsemane praying that this cup would be taken from them with the hard-to-swallow realization that Friday may come sooner than any of us want. People all over the world ask that 'incurable' no longer be part of Will's story. I ask that. Friday comes for all of us. And yet, the best part of Holy Week is that the week does not end on Friday. Sunday's still coming. Sunday exists beyond our graveyards, tombstones, and funerals. Sunday is the day life is re-infused into every dark corner of despair and death by the God who has already been there, sat in Gethsemane, and experienced the sting of Friday. Sunday says that our story, our voice, and our impact on the world do not end on Friday. We continue to pray that Friday will not come for Will for many years and we pray for a world with Will in it. However, we also know (and Will knows) that Friday does not get the final word. Holy Week ends on Sunday. And because of Sunday, fear and despair are replaced with love and hope in the one who is in control regardless of God's answer to our prayers for Will. Whether his cancer remains 'incurable' or not, Will's faith, voice, and spirit remain 'incurable.'
Easter is a big deal!
Go to www.goteamgray.com to see more of Will's story!
Saturday, March 30, 2013
Tuesday, March 5, 2013
Kenya: Other Interesting Cases
Case #1: 9 yr Male, Right Tibial Osteomyelitis (Bone Infection)
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| 9 year old precious boy with right tibial osteomyelitis (bone infection) with chronic draining sinuses. See xrays and picture of his leg below. |
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| 9 yr Male: Right Tibial Osteomyelitis (For non-medical folks, the bone shouldn't look like that!) |
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| 9 yr Male: Chronic Osteomyelitis with draining sinuses. |
Case #2: 50 yr Male, Radius & Ulna Fractures (Forearm)
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| Left Radius & Ulna shaft fracture. 50 year old male with history of polio and severe hip & knee flexion contractures. |
Case #3: 65 year Male, Ankle Fracture-Dislocation
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| Example of the Poor Medical Care provided at some of the local government hospitals. 65 year old male with a closed ankle fracture-dislocation who presented to a government hospital. Ankle was splinted where it was without any attempt at reduction. He showed up at Tenwek after his fibula eroded through the skin and had a large open wound. He was washed out multiple times and was pending a below-knee-amputation when I left the hospital. |
Case #4: 55 year female with Right Pertrochanteric/Subtrochanteric hip fracture
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| Right Hip Fracture |
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| Postop: Piriformis entry femoral recon nail used along with a cerclage cable to achieve fixation. |
Case #5: 24 yr Female, Right Subtrochanteric Femur Fracture
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| Right Subtrochanteric Femur Fracture |
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| Postop: Right Antegrade Femoral SIGN Nail |
Case #6: 19 year Male, Closed Clavicle Fracture, tenting the skin
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| Closed Clavicle Fracture, button-holed through trapezius muscle belly |
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| ORIF Clavicle Fracture, 3.5 mm Recon Plate |
Case #7: 25 year Male, Grade 3 Open Tibia/Fibula Fracture
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| Right Distal Tibial Shaft Fracture with large soft tissue defect. Treated definitively with External Fixation. |
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| Grade 3 Open Tibia & Fibula Fracture with Soft Tissue Defect. |
A fantastic orthopedic experience...!!
Kenya: Pelvis & Acetabular Frxs
Few fractures are shipped to experts more quickly than the mention of a pelvic ring or acetabular (hip socket) fracture. They are among the most complex fractures seen by an orthopedic surgeon and are typically the result of high energy trauma - car wrecks, motorcycles, jumping off of a high structure, etc. In the US, people who treat acetabular fractures and pelvic ring injuries surgically are traumatologists - orthopedic surgeons who after residency spent at least a year specializing in complex fracture care including these fractures. Kenya, however, does not have traumatologists. They have orthopedic surgeons (if they're lucky) who do not have the luxury to specialize into only treating one part of the body. If they don't fix the fracture, no one will. Tenwek is blessed to have two wonderful orthopedic surgeons who both wind up taking care of whatever comes through the door - 'whatever' can be alot of different things! While I was there at Tenwek, we had a run of several pelvic ring injuries and acetabular fractures that were fixed. Enjoy!
More to come...
Case #1: 30 year old male s/p RTC with bilateral acetabular fractures. He presented with bilateral hip dislocations and had bilateral traction pins placed upon presentation.
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| Right Posterior Wall Acetabular Fracture. Hip was unstable with range of motion and required ORIF with 3.5 mm Recon Plate. Left comminuted posterior wall acetabular fracture with intraarticular fragments. Intraarticular fragments were removed and the hip was stable during range of motion. In the OR, we did the left side first in the lateral position with a peg board, closed him up, and then flipped him over and fixed the right side. (Sorry, no postop xrays) |
Case #2: 27 year old female involved in a RTC. First went to government hospital and told to go to Tenwek. Arrived 48 hours after sustaining her injury.
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| Right Vertical Shear Sacroiliac Joint Disruption with Left Pubic Root Fracture and Pubic Symphysis Disruption. |
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| Postop: S1 & S2 Trans-Sacral Trans-Iliac Percutaneous Screw Fixation. Decision was made not to fix front of pelvic ring because of the extent of surgical approach required to fix it. |
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| Another Postop |
Case #3: 35 year old male who presented (on my first call night) with left hip dislocation. Hip was reduced but found to have intraarticular fragments and large Hill-Sachs lesion of femoral head.
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| Left hip dislocation, Posterior Wall Acetabular Fracture |
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| CT Scan: Left Posterior Wall Acetabular fracture, Intraarticular Fragment, Hill-Sachs lesion of Femoral Head |
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| Postop: ORIF Left Posterior Wall Fracture, Removal of Intraarticular Fragments, 3.5 mm Recon Plate |
Case #4: 29 year old male who sustained a Right Acetabular Fracture and Right Distal Radius/Ulna fracture in a ... you guessed it - road traffic crash!
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| Postop: Right Transverse Posterior Wall Acetabular Fracture. Percutaneous fixation attempted to reduce the articular stepoff along the posterior column. Posterior wall fragment was minimally displaced. Fracture did not compress well likely because surgery occurred nearly 3 weeks after the injury. Percutaneous fixation has been used at Tenwek a handful of times with good results if the fractures are fixed acutely. |
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!
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...
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.
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| Right Tibial Plateau Fracture involving both side of the knee joint with significant comminution. |
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| 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. |
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| 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
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| Left Tibial Plateau Fracture |
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| Axial (Cross-Section) CT Scan through fracture |
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| Postop AP Xray. Pleased with Articular Reduction and Overall Mechanical Alignment |
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| Patient is able to bend his knee right away and to partially bear weight with his hybrid fixator in place. |
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| 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. |
More to come...
Saturday, March 2, 2013
The SIGN Nail
There aren't too many organizations that get me excited about what they are doing like SIGN Fracture Care International. www.signfracturecare.org. Surgical Implant Generation Network (SIGN) was begun just over a decade ago by Dr Lewis Zirkle, an orthopedic surgeon in eastern Washington with a big heart and an even larger vision of "creating equality of fracture care throughout the world," particularly the poor.
Trauma is rampant in developing countries and with over 5 million people killed annually in road traffic crashes (RTCs), it has rightly been named the "neglected epidemic." Many more than that experience permanent disability. The majority of people affected by RTCs are young males, often the financial providers of their families in developing countries. The impact of a femoral shaft fracture - the most common musculoskeletal injury seen - is immense not only in the pain and recovery endured by the patient but the economic burden borne by the patient's family. The mainstay of treatment for femoral shaft fractures in developing settings is traction. For those that don't know, a traction pin (basically a metal pin roughly the size of a pencil) is placed through the unbroken tibia and then weight is hung via a rope off the end of the bed. The patient lies in bed for roughly 6-8 weeks in hopes that the weight has realigned the bones good enough to heal straight. Too often this does not happen. Too often the fracture heals crooked (Malunion), doesn't heal at all (Nonunion), or becomes infected via the traction pin (Osteomyelitis). Here in the US and other developed countries the mainstay of treatment is a femoral nail - a large rod placed down the middle of the bone - that allows early mobililty, weight-bearing, and far superior alignment and union rates. Until the SIGN nail, such technology was reserved for the wealthy (i.e. Us). The SIGN nail has literally revolutionized the way long bone fractures (femur, tibia, humerus) are treated around the world.
Case in Point: Femoral Malunion
As of today, over 110,000 nails have been placed in over 300 hospitals throughout 50+ countries around the world. The nail is a solid, stainless steel nail that does not require power instrumentation, real-time x-ray imaging (fluoroscopy), or special fracture tables, all of which are typically utilized here in the USA. The nail has proximal and distal interlocking screw capabilities with a ingeniously engineered means of placing the screws. The same nail can be placed in both the tibia and femur. And the nail is completely FREE to the patient! Attention continues to be focused on international orthopedic work and SIGN is uniquely positioned to empower and equip surgeons all over the world to work toward Dr Zirkle's dream of fracture care equality.
We used the SIGN nail multiple times while I was in Kenya. My first case there at Tenwek was a retrograde SIGN nail on a young 25 year old man with a femoral shaft fracture after a RTC. Since Dr Galat arrived a few years ago, over 600 nails have been placed at Tenwek Hospital.
Thank you to Dr Zirkle and his team in Richland, Washington for your service to the least of these among us!
Trauma is rampant in developing countries and with over 5 million people killed annually in road traffic crashes (RTCs), it has rightly been named the "neglected epidemic." Many more than that experience permanent disability. The majority of people affected by RTCs are young males, often the financial providers of their families in developing countries. The impact of a femoral shaft fracture - the most common musculoskeletal injury seen - is immense not only in the pain and recovery endured by the patient but the economic burden borne by the patient's family. The mainstay of treatment for femoral shaft fractures in developing settings is traction. For those that don't know, a traction pin (basically a metal pin roughly the size of a pencil) is placed through the unbroken tibia and then weight is hung via a rope off the end of the bed. The patient lies in bed for roughly 6-8 weeks in hopes that the weight has realigned the bones good enough to heal straight. Too often this does not happen. Too often the fracture heals crooked (Malunion), doesn't heal at all (Nonunion), or becomes infected via the traction pin (Osteomyelitis). Here in the US and other developed countries the mainstay of treatment is a femoral nail - a large rod placed down the middle of the bone - that allows early mobililty, weight-bearing, and far superior alignment and union rates. Until the SIGN nail, such technology was reserved for the wealthy (i.e. Us). The SIGN nail has literally revolutionized the way long bone fractures (femur, tibia, humerus) are treated around the world.
Case in Point: Femoral Malunion
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| 25 year old male with Right Segmental Femoral Shaft Fracture sustained in a RTC. He was treated at an outside hospital for 6 weeks in tibial skeletal traction and presented to Tenwek Hospital 2 months post injury with his right leg 5+ inches shorter than his left leg and externally rotated with significant pain. |
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| Postop of Same Patient: Antegrade SIGN Nail with Clamshell Osteotomy |
As of today, over 110,000 nails have been placed in over 300 hospitals throughout 50+ countries around the world. The nail is a solid, stainless steel nail that does not require power instrumentation, real-time x-ray imaging (fluoroscopy), or special fracture tables, all of which are typically utilized here in the USA. The nail has proximal and distal interlocking screw capabilities with a ingeniously engineered means of placing the screws. The same nail can be placed in both the tibia and femur. And the nail is completely FREE to the patient! Attention continues to be focused on international orthopedic work and SIGN is uniquely positioned to empower and equip surgeons all over the world to work toward Dr Zirkle's dream of fracture care equality.
We used the SIGN nail multiple times while I was in Kenya. My first case there at Tenwek was a retrograde SIGN nail on a young 25 year old man with a femoral shaft fracture after a RTC. Since Dr Galat arrived a few years ago, over 600 nails have been placed at Tenwek Hospital.
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| Getting ready for my first case - Retrograde Femoral SIGN Nail |
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| Postop First SIGN nail case |
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| Postop 1st Case |
Thank you to Dr Zirkle and his team in Richland, Washington for your service to the least of these among us!
Kenya - part 4
My first night on call! We arrived at the hospital a couple days before New Years having landed in Nairobi a few days earlier to spend time with precious friends and celebrate the birth of the their new daughter. I received a tour of the hospital by Mrs Patsy Gaw, a retired RN from Nashville who has been to Tenwek several times with her husband David Gaw - a retired orthopedic surgeon from Nashville. Seeing firsthand the hospital campus and the many patient wards left me with a deep sense of respect for the work going on at Tenwek and the sense of calling upon the people who call Tenwek home.
Tenwek is one of the few hospitals in the area with emergency services 24 / 7 / 365. There are several government hospitals that many people will go to first but if it is too complicated for them to handle (which is most things), they refer them to Tenwek. Orthopedics has been a strong point of Tenwek for many years even before the arrival of Dr Galat because of Dr Chupp, a general surgeon who because of the immense orthopedic need started doing orthopedic cases with the help of his Campbell's Orthopedics textbook and delivered fantastic care for a decade or more prior to Dr Galat's arrival. Needless to say, Tenwek has built a reputation of offering excellent orthopedic care for many years and the people of western Kenya know it.
My first call night was somewhat busy, not so much because of the number of patients that came in but the severity of the injuries seen. New Years Day during the day with remarkably quiet but the evening brought work. I received a call from the general surgery intern Liz (by the way, she is absolutely awesome!) who said " I have three patients to run by you. You should probably come see them." I walked up the hill to Casualty (we call it the Emergency Room), a medium-sized room with curtains to divide patients' beds from each other.
#1: 50 year old male involved in a RTC (Road Traffic Crash) with bilateral lower extremity fractures - a Left severely comminuted distal femur fracture. A right comminuted tibial plateau fracture. Both injuries were thankfully closed (no bones sticking out).
--- We placed his right leg (tibial plateau frx) in a long leg plaster splint and placed a tibial traction pin in his left leg (femur frx). He was fixed a few days later with a left retrograde femoral SIGN nail and a right tibial hybrid ring external fixator. Will show pics of that later.
#2: 35 year old male involved in a RTC 2 days prior with a dislocated left hip in immense pain. He went to the government hospital who said he should really go to Tenwek.
--- He dislocated his hip two days prior in a RTC and no attempt had been made to reduce it (put it back in the hip socket). We took him to the OR and under sedation worked to reduce his hip. While reducing it, we never got the satisfying 'clunk' we hope for when the hip goes into the joint. It was very unstable and continued to pop back out as soon as we felt it was in. Above, you can see the team there that night in the OR placing a tibial traction pin in his affected leg. As you can see from the CT scan image above, the reason for the hip's instability was a piece from his broken hip socket was pulled into the joint keeping the hip from reducing. He was taken the OR where we extracted the piece of bone from the joint and plated the back wall of the hip. Fixation pics later.
#3: 3 year old girl with a right elbow injury with a displaced and 180 degree rotated lateral condyle fracture after falling out of a tree. She was pinned the next day. Sorry I don't have xrays of her elbow.
Needless to say, there wasn't alot of sleep that night.
More to come...
Tenwek is one of the few hospitals in the area with emergency services 24 / 7 / 365. There are several government hospitals that many people will go to first but if it is too complicated for them to handle (which is most things), they refer them to Tenwek. Orthopedics has been a strong point of Tenwek for many years even before the arrival of Dr Galat because of Dr Chupp, a general surgeon who because of the immense orthopedic need started doing orthopedic cases with the help of his Campbell's Orthopedics textbook and delivered fantastic care for a decade or more prior to Dr Galat's arrival. Needless to say, Tenwek has built a reputation of offering excellent orthopedic care for many years and the people of western Kenya know it.
My first call night was somewhat busy, not so much because of the number of patients that came in but the severity of the injuries seen. New Years Day during the day with remarkably quiet but the evening brought work. I received a call from the general surgery intern Liz (by the way, she is absolutely awesome!) who said " I have three patients to run by you. You should probably come see them." I walked up the hill to Casualty (we call it the Emergency Room), a medium-sized room with curtains to divide patients' beds from each other.
#1: 50 year old male involved in a RTC (Road Traffic Crash) with bilateral lower extremity fractures - a Left severely comminuted distal femur fracture. A right comminuted tibial plateau fracture. Both injuries were thankfully closed (no bones sticking out).
#2: 35 year old male involved in a RTC 2 days prior with a dislocated left hip in immense pain. He went to the government hospital who said he should really go to Tenwek.
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| Xray - Left Hip Dislocation with Posterior Wall Acetabular fracture |
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| Wonderful Team in OR - Liz & Daniel |
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| Tenwek is blessed to have a CT scanner that worked most of the time I was there. It cost $100 for a CT Scan in a region where the average income for most families is around $750/year! Oh, and its powered by 50 car batteries linked in series to provide the power for it (no joke!) |
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| CT Scan: You can see the large divot in the femoral head and the large piece inside the joint. No bueno! |
--- He dislocated his hip two days prior in a RTC and no attempt had been made to reduce it (put it back in the hip socket). We took him to the OR and under sedation worked to reduce his hip. While reducing it, we never got the satisfying 'clunk' we hope for when the hip goes into the joint. It was very unstable and continued to pop back out as soon as we felt it was in. Above, you can see the team there that night in the OR placing a tibial traction pin in his affected leg. As you can see from the CT scan image above, the reason for the hip's instability was a piece from his broken hip socket was pulled into the joint keeping the hip from reducing. He was taken the OR where we extracted the piece of bone from the joint and plated the back wall of the hip. Fixation pics later.
#3: 3 year old girl with a right elbow injury with a displaced and 180 degree rotated lateral condyle fracture after falling out of a tree. She was pinned the next day. Sorry I don't have xrays of her elbow.
Needless to say, there wasn't alot of sleep that night.
More to come...
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