Wednesday, July 29, 2009

Fractures and Gideon

We see a lot of fractures at the hospital. Many are the result of violence of some sort, but we also see a bunch of kids who have fallen from one thing or another and sustained a fracture. We don't have an orthopedic surgeon, but have Jim, a missionary surgeon, who can do almost anything. However, given the number of ortho cases that we see in a week's time, if every fracture needed an open reduction (surgery) that is about all he would be doing. His days are already full of bowel obstructions, hysterectomies, tendon repairs, hernias, pelvic laparotomies, and more, adding 5 open reductions a week, would be asking a lot. So when we have a fracture, we always try to do a closed reduction. I understand, this is not the optimal choice in the US, but it is how we are able to keep Jim going and doing all the surgeries he does and not get totally burnt out. So typically when a pt comes in with a fracture, we get an xray and then try a closed reduction under Ketamine/Valium. We don't have a flouroscopic xray unit, so we reduce it, cast it, and have them come back in 1-2 days for a rexray, and retry if needed. Typically when I look at an xray, not only do I look for a fracture, but also how far the bones are off, how much swelling the pts has, and how far I will need to move them to put them back in place. I do this in order to determine if I am going to be able to do this myself, or if I need reinforcements, typically Jim or Bill. My 120lb frame is strong, but so are bones, and lots of swelling around the fracture makes it even worse. This weekend, I was on call with Alan, a med student. He called that we had a kid with a fracture, so I met him in the ER. The only thing going for us was that the fracture happened that day, but it was a bad one. Gideon's radius and ulna were fractured just below the growth plate, only about 10% of the bones were overlapping, and there was a good bit of swelling. In my mind, the chances of me reducing this weren't very good, but I was on call and thus was the reinforcement. So Alan and I got him under Ketamine and gave it a try. Despite manipulating the wrist as much as I possibly could in an effort to straighten them out, I didn't really feel the bones move. However, I had tried numerous times, and I didn't think it was going to get any better, so we casted him and told him to return on Monday. Fully expecting to need reinforcements come Monday am, I showed the xray to Bill when he happened to walk through the hospital on Sat afternoon. He agreed it was bad, and when I told him I didn't feel the bones move, he wanted to give it a try, but the pt had already left. I even mentioned it to Jim on Monday am rounds telling him I would likely need help. The patient was outside xray when I finished rounds and was walking to my outpatient room. I quickly walked into the xray room to find his film. I was pleasantly surprised to find the radius and ulna almost perfectly aligned, well not exactly perfect, very close anyway. I was very thankful and Gideon seemed happy too.