Tuesday 15 November 2011

Sadly the young man with the head injury died last night. In the absence of a CT scanner and neurosurgical expertise that’s unfortunately the outcome of many severe head injuries here in Cap Haitien. However overnight a young woman with multiple injuries 24 hours following a road traffic accident was admitted to the ward but poorly assessed by the resident on call. I was told that she had a fractured femur which was correct but it turned out that she had a head injury, fractured mandible, rib fractures and a haemothorax and a pelvic fracture. Nobody had taken the blood pressure since admission but was told that it was 90/60 when seen in the emergency department. This was an ideal opportunity to teach them about the basics of how to assess an unstable and multiply injured trauma patient. Then I was shown a patient who apparently had been on the ward for the last year as a result of a necrotizing infection of his leg under the care of the general surgeons. He had multiple skin debridement followed by skin grafts but no had a fixed equinovarus contraction of his ankle. Obviously his ankle wasn’t splinted and now he probably requires an arthrolysis of the ankle and tendo Achilles lengthening or perhaps an arthrodesis in a functional position. This complication was entirely preventable with proper splinting and physiotherapy.

The operating list started with a hiss and a roar and 2 orthopaedic theatres going by 8 am. I did an internal fixation of a displaced neck of femur fracture in a 47 year old with no fracture table, no image intensifier and nobody having a clue as far as the instrumentation was concerned which was basically a set of 7.0 AO cannulated screws. I did an arthrotomy through a lateral approach and the fracture was reduced open using one of the local residents who just had his breakfast to pull on the patient’s leg. The screws were inserted blind having gauged the length of the screws preoperatively on the opposite side. The fracture was stable after the insertion of 3 screws and the absence of grating on moving the hip in all directions confirmed that the screws had not perforated the femoral head and then it was time to close. The next case was an external fixator for a 4 week old open distal tibia fracture with the wound still open and the bone exposed .This might well be the first stage of a below knee amputation. After that I was told by the anaesthetists that there was no oxygen and that we could not continue with the list. I have the impression that sometimes the anaesthetists use this as an excuse if they don’t feel like doing another case. However they then did 2 Caesarian sections and we were allowed back into theatre in the afternoon to do an above knee amputation in a patient who had be on the ward for 5 months following a road traffic accident in which he suffered an open distal femur and distal tibia fracture as well as severe skin loss around the distal thigh and knee. When I first saw him when I arrived he had a complete sciatic nerve palsy with no active movement below the knee and basically a useless limb. An amputation was the only solution for this unfortunate young man!

In between cases I was asked to see a 17 year old girl with a large swelling of the distal thigh and a destructive lesion of the femur on Xrays consistent with an osteosarcoma. The prognosis for her is awful in the absence of chemotherapy and tumour surgery expertise she will probably have an amputation and die of metastases.

Although this might not sound like a lot of work for one day it was a great achievement by Haitien standards.



Wednesday 16 November 2011



The day started with a number of presentations by the house surgeons on aspects of the anatomy of the musculoskeletal system and today the topics were anatomy of the knee and ankle. As they have no data projectors about 20 people huddle in front of a laptop to get a view of the screen. The presentations were well done and were very comprehensive but they did not make the link with the clinical application of their anatomical knowledge.

The ward round followed and we saw 1 admission from the previous night with a severe grade 3b open tibial fracture and the resident on call had actually taken the patient to theatre, debrided the wound and applied an external fixator just as I taught him. That was very pleasing to see and I congratulated him for a job well done. Then I was shown a young man who had been on the ward for 2 weeks with a diagnosis of open tibial fracture. No Xray was available and when I asked the residents how old the fracture was they told me a couple of months. I asked them to open the bandage on his leg and there was a wound with a piece of white bone sticking out. I asked the resident to check whether the fracture was healed and it was pretty clear that there was no movement at the fracture site and obviously the bone had healed. I then asked him to take a forceps and tug at the bone as I suspected a sequestrum which is a piece of dead bone in chronic osteomyelitis. And surprise surprise a reasonably sized piece of tibia came out from the depth of the wound which will allow the wound to heal and the infection to settle down. He was discharged later in the day with antibiotics and advice to get his wound dressed regularly at the local hospital. Sequestrectomy on the ward round what about that?

Whilst one of the residents did a tibial nailing I helped out with the outpatient clinic which was very busy today. There were quite a number of new fractures and we did a manipulation of 2 distal radius and one supracondylar fracture in a child under local anaesthetic without to much teeth grinding! The sheer number of fractures and the lack of anaesthetic services forces one to reduce fractures in a suboptimal manner but there are unfortunately no other options.

Then I saw a 10 year old boy with a crouch gait as a result of cerebral palsy. I used him as a teaching case for the residents who knew very little of that condition. Finally I taught one of the new residents how to suture an extensor tendon injury in a young girl with a machete cut to the dorsum of the hand. By that stage everybody had left the clinic so I threw my backpack over my shoulders and walked home. Overall it was a very good day!