More cases. . . . . .

I've had a lot of people ask me to keep posting cases because they like to see them.  So, here is a selection of some of the more interesting cases I've done recently.  This one is a bad distal femur (ie. around the knee) fracture.  You may remember this x-ray from a very early post.  This guy has been here since my first day waiting for surgery but we couldn't operate because he had persistent fever.  We finally got that controlled and were able to fix his fracture with a plate and screws. 

Here's the post-operative x-ray.

This next one is just one of the many examples of inappropriate treatment that people can receive in this area.  This person had a hip fracture and a tibia fracture several months ago and was treated in Nairobi.  Unfortunately, both fractures were badly mismanaged and he showed up to our clinic with a hip looking like this and in a lot of pain.  For you lay-folks, his fracture has not healed, it has collapsed because of inadequate fixation (ie. 2 screws in improper position), and his hip joint is almost completely worn away.  The only option for this man is a total hip replacement.  We don't have the tools to do those regularly here, but Tenwek is having a joint camp in March where American surgeons bring their tools and skills and do as many joint replacements as they can squeeze in.  This guy will just have to wait until then. 

This one is a sad case of a young man who sustained a gunshot wound to his thigh and has a terrible femur fracture as a result.  More importantly is the fact that he didn't seek treatment for several days and presented to us with two huge wounds on either side of his thigh, both of which were grossly infected.  He required multiple trips to the OR just to get his wounds clean and we then struggled with whether or not to fix his fracture with a rod in the setting of on-going infection.  We decided it would be better off to not put metal in such wounds so we devised this unique external-fixator to stabilize his fracture as it starts to heal.  I don't think I've ever seen one like this.  Another example of having to be creative!  Hopefully he'll start to heal this and the wounds will stay clean.  Then we can go back later and bone graft into that big defect of bone if it needs it.

Here is another follow-up case.  This guy has an elbow and ulna fracture from a panga (machete) attack.  He also had his ulnar nerve cut from the blow.  You can live with many nerves cut, but the ulnar nerve is pretty important for function of the hand.  We therefore did a nerve graft where we took a segment of another nerve from his leg and transferred it to bridge the gap that the panga had created.  It will take several months for this nerve to grow in and start working but hopefully it will.

Most of what I've done here has been relatively routine.  I've tried to show the more interesting cases.  There's nothing special about this one, but I included it anyway.  This lady had a radius fracture that was casted at an outside facility and was left in obviously poor alignment.  She needed surgery to make it right and thankfully came to Tenwek.  We put a plate and screws across the fracture and now it's much more stable and less painful.  She'll heal this over the course of the next few months.

Here is a 77 year old lady who fell and had a hip fracture, a common story even back home with the aging population and osteoporosis.  The treatment for this is routine and consists of placing 3 screws across the fracture to stabilize it while it heals.  What makes this case interesting for me and my ortho buddies back home is that she wasn't able to undergo anesthesia because she was so sick.  We encounter this problem often in this patient population and we always consider the option of doing this surgery with no anesthesia and only local numbing medicine (lidocaine).  Although this option is occasionally discussed, I've never actually seen it done.  Well, we did it to her!  We're taught that bone doesn't have nerves on the inside, only in the outside layers, the periosteum.  So, theoretically, if you inject Lidocaine into the skin and the outside of the bone where your screws will go in, it shouldn't hurt at all.  That theoretical truth is nice and all, but I was a little nervous to see if that would actually be the case.  Thankfully, it was.  She remained perfectly still and had no pain during the procedure.  I was excited to know that it could actually be done!

One more week in the hospital here.  I'm sure I'll have many more interesting cases to share next weekend.