It’s a sunny Saturday afternoon here. It’s been a week since arriving here and I have more or less fit into the rhythm of the project and the hospital. Work begins at 7:30am with a team meeting at the compound before heading to the hospital for what have so far been full and busy days. Much of the work here is taking care of people with burn injuries, an area in which I received a lot of experience during my residency training and which falls well within my comfort zone. Another large part of the practice here is taking care of people with orthopedic injuries. Unfortunately my training and experience in orthopedics is limited to ER rotations in medical school and the early years of residency, research done after tearing my own ACL in 2004, on the job training from the CAR on my last MSF assignment and some self directed study in anticipation of coming to Rutshuru. Still, this week I’ve been able to get by as an adequate orthopedic surgeon and still keep at least one foot in the comfort zone thanks to three things here in Rutshuru.
One of those things is the experienced and knowledgeable local Congolese staff in the OR and orthopedic ward. The second is the MSF protocols. Doctors and surgeons have different levels of experience with the problems they treat in the field and experienced surgeons often have their own individual and often idiosyncratic ways of treating the same problem. Rather than have the local staff try to learn to do things a new way with each new surgeon, MSF has treatment protocols for common problems to provide standardized care that has been proven effective locally. The third and most important thing has been the other surgeons. The chief of surgery Dr. M is always available for a second opinion (yes, that closed forearm fracture just needs a reduction under anesthesia and a plaster splint) or an encouraging word (don’t worry, placing a supracondylar femoral traction pin in the femur is straightforward and you can do it, no problem). Dr. J, the other surgeon here, also helped me immensely this week. He is a Belgian surgeon currently working as an MSF “flying surgeon”. He has a nine month contract with MSF to go wherever they need him whenever. This was his last week in Rutshuru and he spent part of it teaching me how to do external fixation for open fractures.
A fracture is a broken bone. If the skin, muscle and soft tissue overlying the break are intact, it is a closed fracture. But if the broken bone is exposed by injury to the overlying soft tissue, it is an open fracture. A fracture heals optimally when you can get the pieces of the broken bone to line up in an “anatomic position”, meaning the way they look naturally and keep them there without moving. This is called “reducing” and stabilizing the fracture. Ongoing movement or infection of the bone leads to problems with healing. With open fractures, the risk of osteomyelitis (infection of the bone) and non-union (failure of the fracture to heal) or both is increased compared to closed fractures. In the US, both open and closed fractures are often treated using a technique called open reduction and internal fixation (ORIF for short) where the surgeon makes an incision in the skin exposing the bone and uses a combinations of metal rods, plates, screws and nails to secure the pieces of bone in the “anatomic position”, then sews the skin closed. In Rutshuru, we don’t perform ORIF, primarily due to the risk of infection. The infection risk after ORIF for the treatment of an open fracture increases with the time it takes to reach the hospital and the OR. The difference in pre-hospital transportation times and the causes of open fractures between the DRC and USA make external fixation (Ex-Fix for short) the treatment of choice here. Here it’s not unusual for a patient to be seen days after their initial injury due to transportation issues in a country where the roads are unpaved and unlit, most people don’t have a car and driving after dark for anyone, even an ambulance, carries significant risks of banditry or being mistaken for a military vehicle. Gunshot and blast wounds from military grade weapons resulting in bones being broken in multiple places with injury to the skin and muscle that can’t be sewn closed are a major cause of the open fractures here.
After an Ex-Fix, the patient looks a bit like he is wearing a bionic erector set. The broken bones are stabilized using a series of rigid bars of varying length attached to each other with adjustable clamps on the outside of your body. These bars are attached to your healthy bones above and below the area of the break using metal pins with threaded tips that are screwed into your healthy bone, then clamped to the bars. In Rutshuru, the pins are screwed into the bones with an old-school brace and bit style hand drill. The surgeon screws at least two pins into the bone above the break and clamps a bar between them, another two pins into healthy bone below the break and clamps a bar between those, and then connects the two bars with a third bar using more clamps. Extra pins, bars and clamps are used as needed to make sure the bone fragments are stable and in an “anatomic position”.
My first patient was a 27-year-old woman caught in some type of blast with shrapnel injuries to her left thigh and calf and a piece of the top of her foot missing. She had come to the hospital in the middle of the night, had the bleeding controlled, dressings applied and an x-ray now showed she was missing most of one of the bones in the mid-foot, the navicular bone. The plan was to place an Ex-Fix in the hopes that her foot bones will fuse and she can avoid an amputation. We removed her dressings and saw that the wounds were all clean without any infection nor dead tissue that needed to be debrided. We started with two pins in her shin bone (the tibia) and connected one bar between the two pins. Next we placed three pins in the 1st, 3rd and 5th long bones of her foot (the phalanges), with a bar between the 1st and 3rd and another bar between the 3rd and 5th, essentially constructing a rigid bar bending over the top of her foot. Then using the bars and clamps, we placed one long bar from the shin bar to the left side of the foot and another bar from the shin bar to the right side. J explained the logic behind deciding where to place the pins, how and where he makes his incisions and why, the pitfalls to be avoided, and then he had me place the pins. Like any good surgical instructor, he was impossible to please 100% (the first pin was 1° too far this way, the next 1° too far the other) but when things were done, we had a good result with the Ex-Fix stabilizing the injured foot and ankle in the “anatomic position” but with room to access the soft tissue and bone defect for daily dressing changes.
There is a saying in surgery that “you see one, do one, then teach one” but I’m a slow learner so J stayed to help me with my second patient, a 25-year-old man who had been shot in the left leg a few inches above the ankle. Both of the bones in his lower leg, the tibia and the fibula, had been broken. He was missing a chunk of skin and soft tissue as well as a piece of the fibula but luckily the appearance of the ankle joint on his x-ray, called the mortise, looked normal and intact as was the pulse and sensation in his foot. The far end of the fibula where it makes the ankle joint is important but you can largely do without the rest; the larger tibia accounts for the vast majority of the weight bearing strength in your lower leg. With normal blood flow and no nerve or ankle injury, he should have a relatively normal functioning leg if we can get this to heal. Like the first time, I placed two pins in the tibia above the fracture. In addition to placing pins in three of the phalanges, J had me place another pin in the tibia below the fracture but above the ankle joint. This set-up allowed us to get the two pieces of the tibia lined up in an “anatomic position” with greater stability. At the completion of the operation, we were happy with the result, the fracture stabilized with good access to the open wound for daily dressing changes.
There is nothing like learning about problems and procedures in another surgeon’s area of expertise to give you an appreciation for their knowledge and abilities. In Rutshuru, I’m getting an immersion course in the part of orthopedics that most orthopedic surgeons master before completing their training. In medicine, like in many fields, different specialties often are given stereotypical characteristics. Surgeons in general aren’t considered exceptionally cerebral by our internal medicine colleagues and orthopedic surgeons often are considered to be at the far end of the spectrum. There is a joke that I first heard in medical school that goes “What are the best two years of an orthopedic surgeon’s life?” with the answer being “6th grade”. After experiencing first-hand how difficult and nuanced their work can be, this might be the last time that I repeat that joke making fun of orthopedic surgeons. Especially now that I’m sort of one myself.