Interesting cases so far. . . . .

Man, have my eyes been opened here at Tenwek!!  This week has been more educational than I could have ever imagined.  The pathology here is wild.  I'll show you some amazing cases below.

In addition to learning about interesting orthopedic problems, I've also learned a lot about God's grace, mercy and provision as it relates to medicine.  Tenwek hospital is considered a referral center by African standards.  It's a teaching institution with residents, conferences, American Drs. and the whole bit.  But, despite all of that, it can still be pretty primitive at times.  Equipment is old or hard to come by, resources are limited and many modern diagnostic modalities aren't available.  This all makes practicing medicine and orthopedics rather difficult and frustrating at times.  But where there is difficulty and frustration, there is also a chance for God's power and glory to shine.  The standards here are slightly different than the US.  Some patients do very well and recover without incident whereas others' outcomes aren't quite as good and often times are horrible.  As docs here we are truly dependent on the Lord and His mercy to help.  That's where the Tenwek motto "We treat, Jesus heals." comes from.  In 1959, the founder of Tenwek Hospital, Dr. Ernie Steury, realized that in this setting that was all he could bank on.  As Tenwek grew from 1 Dr. then to 44 today, that mentality and culture has persisted.  It has led to a busy hospital where people come from all around, passing several other hospitals, to come to Tenwek where "the words are kind and the hands are gentle". This mindset leads to humility, which leads to God's grace that ultimately leads to healing for these patients.  This is scriptural.  Proverbs 3:34 says that "God opposes the proud but give grace to the humble".  This way of thinking is so counter cultural to the ideals of modern medicine in the States.  There, it's all about ego and what I did to make the patient better.  We applaud and share our good cases and are criticized for our failures.  While there's a place for critique for learning purposes, the attitude of the heart must be right and one must realize that he or she is simply a vessel with God-given gifts through which He works.  This lesson has been all too evident over the past week as I have had some cases that went great, some that didn't go so well and some that were so complex that I simply had nothing to offer but the love of Jesus.  It's been a great learning experience from that standpoint, and I hope that I can translate that mindset back to my work in the States.

Now for some interesting cases.  This one below is a followup from a previous post.  It is an olecranon (elbow) and ulna fracture from a panga (machete) attack.  The wounds were infected when we first took him to the operating theatre (as they call it here) which precluded fixing the fractures with plates and screws.  So, I did something I've never done before.  I placed an external fixator across the ulna and the olecranon.  Ex-fixes are very common, but I've never seen one spanning an olecranon fracture.  The wound is still too infected to place hardware so this may be definitive treatment.  We'll see.

This one is also follow-up and I apologize but it's a terrible x-ray (very common here at Tenwek!).  This was the first hemi-arthroplasty (partial hip replacement) that I did here for a hip fracture.  For the orthopods, this is the old Austin-Moore unipolar hip (pretty old-school, huh?!).

Here is one more follow-up.  Earlier I showed a 3 month old ankle fracture that was still dislocated with significant cartilage damage.  It was too late to fix it so the only option was a fusion.  

This is just one picture of the many spine problems that I've seen here.  Metastatic cancers to the spine and Tuberculosis of the spine (Pott's disease) are very common.  We see them some in the US but have the technology to make diagnoses.  Here there is no CT scanner and no MRI.  That has made the work-up of these lesions difficult.  Here is a lesion in the L3 vertebrae.  It involves the vertebral body and the posterior elements (the back part of the vertebrae) which is unusual for a tumor.  However, it doesn't have the usual look of TB of the spine (endplate destruction).  We biopsied this and we'll see what it is.  Any thoughts from my colleagues out there, Jeremiah, Graham, anyone???

Here is a routine midshaft femur fracture, traditionally treated with a rod in the US.  There is a special rod designed for 3rd world orthopedics that doesn't require live, intra-operative x-ray (fluoroscopy).  It's called the SIGN nail, and although we do have fluoro here, we do a lot of these.  I had never seen or done a SIGN nail although I have done many rods at home.  It was a cool system and a good thing to have in your bag of tricks.

Now here's one you don't see everyday back home.  This is an 8 year old child with the sequela of untreated hip dysplasia.  This problem is common in the states but is usually recognized by a few months of age and treated appropriately with either bracing or surgery.  This child obviously never knew she had it and now has a permanently deformed hip as a result.  There are some reconstructive surgical options for her and we're sending her to a pediatric specialist here in Kenya for that.  This is just one of many cases in which you can see the natural history of a disease when left untreated.

Here is a distal tibia/fibula fracture that was open (ie. there was a traumatic wound associated with the fracture).  I was able to fix the fibula and restore the joint surface for the ankle with one screw and place an external fixator to keep it stable while it heals. 

Infection is very common here.  The x-ray below is a case of a child with a year and a half of persistent left hip pain.  It was thought that he just had some bruising from a minor trauma but after looking at his x-ray it's evident that he has something eating away at his joint, a sign of a chronic joint infection.  It's likely TB.  We have him scheduled to wash out the joint and culture it to see what it is.  Again, something you'd never see in the states.

This is a picture of a chronic elbow dislocation in a 17 year old.  This would never happen back home.  Apparently is pretty common here.  An elbow dislocation is easily treated by setting it back in place and nothing more.  Now this kid has no range of motion and will require a complex operation to clean out the scarred joint and put it back in place.  One of my staff back home, Dr. Stewart, would have a blast with this!!!

The next couple of pictures are of a 29 year old gentleman with an enlarging, smelly, draining mass on his left knee for a few years.  He decided to come to the Dr. now.  Unfortunately for him, he likely has an osteosarcoma, a malignant bone tumor.  The only treatment at this point is an above the knee amputation which he had today.  Hopefully the tumor hasn't metastasized and he has a chance at surviving.  Otherwise, his prognosis is poor.

These next two cases are two we did today and although simple, were so very gratifying.  This boy is 15 and is obviously very knock-kneed.  This is cosmetically displeasing, functionally limiting and predisposes him to early knee problems.  Thankfully this is one of the few things I've seen here that we see commonly back home, and I was able to teach the guys here how to do a simple operation that will cause this kid's legs to straighten as he grows.  This is one of those moments where God's grace is evident.  I felt so honored and humbled to be able to help this kid but even more so, to teach the locals how to help hundreds more just like him.  This was one of the most rewarding things I've done so far.  I thank God for giving me the skill and knowledge to do this and for the divine providence of His timing.  I can't take any credit for it. . . .all the glory goes to Him. 

I know this probably doesn't make sense to most of you, but since this boy still has open growth plates, he still has growth left in his bones.  By placing one screw on the inside of each knee, growth there is harnessed and the outside of each knee then grows relatively more, leading to straightening of the knee.

This last one was one we did today that was also so rewarding.  This guy had a motorcycle accident and an open tibia fracture that we ex-fixed and washed out.  It ultimately got infected and as you can see we had to remove a lot of dead skin and tissue.  We see this commonly in the US too and treat these wounds with a machine called a Wound Vac.  It's a suction dressing that has revolutionized wound care over the past 5-10 years.  Well, Tenwek has never had a wound vac machine. . . . . . until this week!!!!!  Again, what amazing providence!!!  The surgeons and staff were so excited to have this machine that a company in America donated (about $80K worth!!) but nobody knew how to use it.  This is something I do everyday.  It's so easy, but it was so rewarding and humbling to place it and teach them how to use it.  It will undoubtedly revolutionize wound care here too.