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Chapter 32: Orthopedics

INTRODUCTION

Treating orthopedic and related soft-tissue injuries can be problematic when medical equipment is scarce, especially in settings with high levels of injury (e.g., wilderness, war) or where having a disability is a threat to survival (e.g., treks, battles, subsistence economies). Extremity injuries are the primary cause of injury-related disability in many countries, especially in the developing world.1 In developed countries, they account for about 6% of all adult emergency department visits.2

The World Health Organization (WHO) has developed a list of essentials for treating extremity trauma at facilities with different levels of treatment capability throughout the world (see the “Facilities” section in Chapter 5). Table 32-1 suggests what equipment and skills may need to be improvised in situations of scarcity.

TABLE 32-1Worldwide Essentials for Diagnosing and Treating Extremity Injuries
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TABLE 32-1 Worldwide Essentials for Diagnosing and Treating Extremity Injuries
Facility Level
Resources Basic GP Specialist Tertiary
Ability to recognize neurovascular and disability-prone injuries E E E E
Basic immobilization (sling, splint) E E E E
Wrap pelvic fractures for hemorrhage control E E E E
Hand injury assessment and basic splinting E E E E
Spine board availability/use D E E E
Proper management of immobilized patient D E E E
Radiology available D D E E
Closed reduction of fractures/dislocations PR PR E E
Compartment pressure measurement I D D E
Operative wound management I PR E E
External fixation (or pins and plaster) I PR E E
Skeletal traction I PR E E
Skin traction I PR E E
Tendon repair I PR E E
Hand injury debridement and repair I PR E E
Amputation I PR E E
Fasciotomy for compartment syndrome I PR D E
Internal fixation I I E E

Abbreviations: D, desirable; E, essential resources; GP, general practioners’ hospital; I, irrelevant; PR, possibly required.

Modified with permission from Mock et al.3

This chapter discusses the diagnosis and treatment of fractures and dislocations, including emergency amputations.

DIAGNOSIS OF FRACTURES, DISLOCATIONS, AND SOFT-TISSUE INJURIES

Lacking radiographs or other imaging capability, clinicians need to rely on physical signs and symptoms to make presumptive diagnoses of fractures and dislocations. Table 32-2 lists the common signs and symptoms of fractures, with a comment about their diagnostic utility. Radiographs and ultrasound are included in the list to identify their relationship with the physical examination. Many factors affect the usefulness of imaging as a diagnostic tool, including its technical quality and the skill of those interpreting the images.

TABLE 32-2Usefulness of Clinical Information for Diagnosing Fractures (10 = Most Useful, 1 = Least Useful)
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TABLE 32-2 Usefulness of Clinical Information for Diagnosing Fractures (10 = Most Useful, 1 = Least Useful)
Open fracture with observable bone fragments (10)...

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