Synopsis

Fractures are prevalent worldwide, regardless of the economic status of the country. In low-income or middle-income countries, fracture treatment may be lacking or suboptimal. Acute fractures and complications such as malunion and nonunion have serious consequences that often interfere with community participation and prevent productive work. Restoration of skeletal stability can be life-changing and can offer the patient an opportunity to seek gainful employment, earn wages, participate in the community, and feed his or her family. Bone fixation is an integral part of global surgery. There are numerous methods to achieve bone stability. The technique applied is dependent on the surgeon, available implants, and ancillary equipment. This chapter will discuss the principles and techniques of bone fixation for fractures, malunions, and nonunions in countries with limited means and minimal equipment.

Introduction

The Lancet Commission on Global Surgery has determined that universal access to safe, affordable surgical and anesthesia care saves lives, prevents disability, and promotes economic growth. Modest estimates show that 5 billion people worldwide lack access to basic surgical care in low-income or middle-income countries. Furthermore, 11% to 15% of the world’s disability is due to surgically treatable conditions. Injuries cause 5.7 million deaths yearly and leave many more persons impaired and disabled. Skeletal stabilization via bone fixation is part of the remedy to lessen disability and is necessary to reduce or alleviate limb impairment.

Preparation

Robert Acland, MBBS, FRCS, was a pioneer in anatomy, plastic surgery, and microsurgery. Acland stated that “preparation is the only shortcut you need,” emphasizing the need for preparedness at surgery. A similar principle applies to surgery in imperfect environments. The more information available beforehand regarding the conditions and the anticipated surgical cases, the more the team can organize and prepare. This tenet is especially applicable to surgeries that require bone fixation. This effort requires collaboration between the constituents residing in the host country and the surgical team participating in the trip. If the anticipated case list is known, the team can work with corporate partners to obtain the appropriate internal or external fixation devices. Recurrent and routine missions foster this relationship because a future surgical list can be generated for subsequent trips, leaving ample time to garner the equipment.

Indications/Techniques

Indications for bone fixation include acute fracture management, malunion, nonunion, and bone loss due to infection and tumor. The technique varies dependent on the surgeon’s expertise and available resources. In low-income or middle-income countries, the resources may be limited. The surgeon should survey the available equipment including implants, drills, and x-rays. The presence or absence of these commodities will influence the technique of bone fixation. The KISS (Keep it simple, stupid) principle is a design principle noted by the U.S. Navy in 1960. This principle states that most systems work best if they are kept simple rather than complicated. Therefore simplicity should be the key goal, and unnecessary complexity should be avoided. This principle is directly applicable to fracture fixation in countries with limited means and scarce equipment.

Implants

Inventory of the implants is a prerequisite for any surgery, especially bone fixation that requires drills and internal fixation devices, such as Kirschner wires, Steinman pins, stainless steel wire, intramedullary devices, screws, and/or plates. The availability of external fixation should also be assessed, especially in cases with substantial comminution and bone loss. The KISS principle can be applied to external fixation with placement of half pins that are connected with methyl methacrylate or a similar product ( Fig. 2.4.1 ).

Tibia Fracture Treated With External Fixation Combining Half Pins, a Window Frame, and Methyl Methacrylate.

Ancillary Equipment

Power drills and reliable electricity and/or battery power are often limited in availability, dependability, and number. Working power drills are a luxury that will facilitate bone fixation. Our group (Touching Hands Project) often brings battery-powered drills and extra batteries. The batteries are not sterilized but are dropped into a sterile glove and manipulated into the drill. The sterile glove covers the end of the drill that houses the battery. Hand drilling may be necessary in countries that do not have power equipment or in cases where the drill breaks or malfunctions. In those instances, the surgeon must adapt to the hardship and proceed forward ( Fig. 2.4.2 ).

During Surgery, the Only Available Power Drill Broke.

(A) Hand drill was retrieved. (B) Case was completed using the hand drill.

Reliable electricity is dependent on the local environment. Power grids can be unstable, and loss of electricity is a real concern. The surgeon and anesthesiologist must be prepared to maintain a safe operating room until the generator or power grid recovers the electricity. Headlights and even mobile phones with a light source can illuminate the surgical field after a power outage ( Fig. 2.4.3 ).

Headlights Are Invaluable During Surgery in Austere Environments.

(A) Touching Hands Project team members (Scott Kozin, MD and Mark Baratz, MD). (B) Lights out in OR with headlights illuminating the surgical field. The surgical field is further illuminated by mobile phone flashlights.

(Courtesy George Nanos, MD.)

Operating Schedule

The limited number of implants, saws, and drills directly impacts the surgical schedule. In addition, the “turnaround” time for sterilization must be considered. Often the equipment can be utilized only once during the day, and bone fixation cases must be staggered during the duration of the mission.

The bone fixation cases should be well planned with respect to approach, technique, and fixation. Ingenuity, creativity, and planning are integral to the success of the operation. Pre-operative templating for any osteotomy, including implant selection and internal fixation technique, will circumvent mishaps. The surgeon wants to avoid any intraoperative improvising using whatever items are at hand (MacGyver principle).