First outpatient clinic

The registrars had organised for a number of complex paediatric cases to attend the clinic for me to see. And the cases were fascinating and excellent teaching cases!!! In the absence of investigations, except the odd Xray, one has to rely mainly on the history and clinical examination. Well taking a history in Haiti is not straight forward: most patients are very poor historians indeed. They tell you stories which don’t make sense and don’t really answer your questions. You have to repeatedly rephrase the question until you get a satisfactory answer.

Fortunately clinical examination is very satisfying as the disease is often very advanced and clinical findings obvious.

1^st case

                                                                            

 

18 month old child with antero lateral bowing of the tibia on the left side without any clinical signs of neurofibromatosis. Spine, hips, knees and ankles were normal. Earlier xrays showed an almost 90 degrees angulation but on clinical examination I had the impression that the deformity was less. Repeat Xrays confirmed this and also showed bony abnormalities in the middle third of the tibia consistent with osteo fibrous dysplasia of the tibia. This condition has the tendency to correct itself with time and I recently saw a case in New Caledonia with spontaneous full correction at skeletal maturity. The registrars were talking about doing an osteotomy and I told them that in children one has to know the natural history as a number of conditions get better by themselves and are made worse by surgery.

2^nd case:

 

 

A fascinating case of lovely twin brothers , aged 4 years, with severe genu valgum or ‘knock knees’. One had a bilateral deformity and the other only had the deformity on the left side. The deformities measured about 50 degrees  and the knees had a full range of movement. The rest of the examination was normal. Xrays didn’t show any obvious bony abnormality but confirmed that the deformity was in the knees. I am not quite sure about the specific cause of the deformity but feel that it is likely to have resulted from a differential growth occurring at the level of the distal femoral physis. My plan is to carry out a guided growth procedure which aims at slowing down the growth medially which will gradually lead to a correction of the deformity. In the past staples were used and placed across the growth plate medially and nowadays small ‘8’ plates are used. None of these are available at the hospital: so you have to think laterally! Number 8 wire Kiwi attitude is very helpful in these situations. So with Dr Cherubin we took some old Shermann plates and had them cut to size at a local metal workshop outside the hospital ( street store!!). Very quick and efficient.

 

 

 

 

3^rd case:

 

 

 

 

Again a fascinating case. A four year old boy with multiple lower limb deformities including severe untreated clubfeet. He had Achilles tenotomise at some stage but otherwise no scars meaning no surgery! He had well developed pads over the head of both tali on which he was weight bearing with both feet turned around completely. Both hips were dislocated and there was a kyphoscoliosis at the level of the thoraco lumbar junction with normal overlying skin. Motor and sensory function was mainly preserved with some wasting of the legs consistent with the clubfoot deformity.

No Xrays were available but from a diagnostic point of view I thought this was probably spina bifida.. As far as management is concerned I didn’t think that surgery had anything to offer as his gait was reasonably functional despite the severe deformities. Any surgery would risk making things worse and putting his gait out of balance and him off his feet.

 

4^th case:

 

 

 

A lady in her 40’s with bilateral leg wasting involving mainly the anterior compartment and drop feet. The history was difficult to elicit but I had the impression that her gait had gradually deteriorated over many years. She had distal sensory signs so old polio was unlikely.Her proximal muscles and spine were fine and to me it looked like Charcot Marie Tooth disease. A part from foot drop splints I had nothing to offer her.

 

Then we saw the usual acute trauma cases and neglected dislocations /fractures in children as well as adults. As patients have to pay for hospital services many cannot afford to go to the hospital. That’s Haiti and only the Haitians can change the system. My aim here is to teach and not get involved in ’politics’ i.e. hospital  management.