Management of the mass casualty from the 2001 Jos crisis.

BACKGROUND: We report our experience in the hospital management of mass casualty following the Jos civil crisis of 2001. MATERIALS AND METHODS: A retrospective analysis of the records of patients managed in the Jos civil crisis of September 2001, in Plateau State, Nigeria. Information extracted included demographic data of patients, mechanisms of injury, nature and site of injury, treatment modalities and outcome of care. RESULTS: A total of 463 crisis victims presented over a 5 day period. Out of these, the records of 389 (84.0%) were available and analyzed. There were 348 (89.5%) males and 41 females (10.5%) aged between 3 weeks and 70 years, with a median age of 26 years. Most common mechanisms of injury were gunshot in 176 patients (45.2%) and blunt injuries from clubs and sticks in 140 patients (36.0%). Debridement with or without suturing was the most common surgical procedure, performed in 128 patients (33%) followed by exploratory laparotomy in 27 (6.9%) patients. Complications were documented in 55 patients (14.1%) and there were 16 hospital deaths (4.1% mortality). Challenges included exhaustion of supplies, poor communication and security threats both within the hospital and outside. CONCLUSION: Most patients reaching the hospital alive had injuries that did not require lifesaving interventions. Institutional preparedness plan would enable the hospital to have an organized approach to care, with better chances of success. More effective means of containing crises should be employed to reduce the attendant casualty rate.

Removal of orthopaedic implants: indications, outcome and economic implications.

INTRODUCTION: The removal of implants after fracture healing has always been a topical and controversial issue. Undisputed however, is the removal of implants which are associated with complications. In this paper, we evaluated the indications, the outcome and economic cost to the patient and the health system of routine removal of implants after union. PATIENTS AND METHODS: This is a two-year comparative, prospective study carried out in three hospitals in North Central Nigeria. All patients who presented for implant removal and consented to the study were recruited. Fracture union was confirmed both clinically and radiological. Direct costs of treatment paid for by the patients and number of absences from work and school were used as economic indices. RESULTS: Forty-seven patients comprising 20(42.6%) males and 27(57,4%) females, mean age of 31.6 (±13.4) years were analysed. Forty-two (89.4%) had fixation with plates and screws, three (6.4%) had screws with cerclage wire and two(4.2%) had tension band wiring. Patient request was the main indication for removal in 34(72.3%), surgeon's request without symptoms in 7(14.9%),six(10.7%) were symptomatic comprising four(8.5%) due to postoperative chronic osteomyelitis and intractable pain in two(4.3%). Total cost of implant removal was $33,293.59 ($ 708.37 ±22.10; range $366.97-1,100.92). Total cost of removal in patients with symptomatic implants-in-situ was $3,678,90( $ 613.15±14.50) One patient had a refracture. Mean duration away from work or school was 16 days. CONCLUSION: Routine removal of implants after fracture union constituted great waste of highly needed cash in both direct cost and loss of man-hour especially in a dwindling economy in an era of evidence based Medicare and best practice. It is recommended that each hospital adopts strict criteria for implant removal.

Congenital amputation involving the hands and feet: a case report.

BACKGROUND: Congenital amputation of the limbs is not uncommon. However, it is very rare when this involves both the upper and lower limbs. METHOD: This is a case report of a child who presented with congenital amputation involving both the upper and lower limbs. RESULTS: The patient was a 10-day-old baby girl that was delivered by a 21-year-old woman. She is the first and only child of the woman, whose pregnancy was uneventful and was carried to term. There is no family history of congenital anomalies. The findings on examination were: amputation of the index, middle and ring fingers at the level of metacarpophalangeal joints on both hands and a partial amputation (at the level of the middle phalanx) of the left little finger. There were forefoot amputations on both lower limbs. Scars were noticed over the amputation stumps with no associated congenital anomaly. CONCLUSION: Congenital amputation involving all limbs as an isolated entity is a rare condition; the cause of which is probably as a result of congenital amniotic bands.

Traumatic posterior dislocation of the hip: distribution and severity of associated injuries.

INTRODUCTION: Posterior hip dislocation is a major orthopaedic injury resulting from high-energy trauma. Morbidity and mortality is very high usually resulting from the associated injuries sustained during the trauma. We carried out this study to find out the usual associated injury distribution and severity in our environment. PATIENTS AND METHOD: This is a five-year prospective multi-center study All patients who presented were recruited into the study. Indices noted included source and time of injury, time of presentation at casualty, associated injuries, injury severity score and the treatment. Presentation was classified as early if less or equal to six hours. RESULT: There were 47 patients comprising 36(76.6%) males and 11 (23.4%) females. Forty-six (97.9%) cases resulted from motor vehicular accidents. Mean age was 32.4(+/-9.7) years with 29(80.8%) being less than 40. Thirty-one (65.9%) patients sustained 53 serious injuries that merited admission comprising significant craniofacial laceration 13(24.5%); long bone fractures 12(22.6%); acetabular fractures 9(17.0%); pelvic fractures 9(17.0%); splenic rupture 2(4.3%) and urethral rupture in one (2.1%). These injuries were in combinations. Thirty-two (68.1%) presented early, with twenty-nine (90.7%) presenting within two hours of injury. The mean Injury Severity Score was 20.3 (+/-7.9). Fifteen patients presented late with a mean of 1141 hours (+/-1021) or 6.8 weeks. Ten (66.7%) had no associated injuries while 5(33.3%) had associated injuries comprising three (20.0%) cranio-facial lacerations and two (13.3) had humeral fractures. The mean injury score was 9.0 (+/- 8.0). No mortality was recorded. CONCLUSION: This study documented that there was high rate of associated injuries in traumatic posterior hip dislocation each warranting admission on its own merit. These injuries take precedence in the emergency care of patients with posterior dislocation of the hip. The role of public enlightment on road safety measures cannot be over-emphasized and a case is made for training of the populace in essential basic life support.

A prospective evaluation of the management and outcome of traumatic posterior dislocation of the hip--a preliminary report.

INTRODUCTION: Traumatic posterior dislocation of the hip (TPDH) is considered an absolute orthopeadic emergency and the outcome of management and prognosis is time dependent. The optimum time within which reduction should be achieved to yield excellent result has remained an issue of considerable controversy. In this paper we evaluated the influence of interval between injury and reduction of dislocation on the choice and outcome of management of TPDH. METHOD: This is a five year prospective and multicenter study in North-central Nigeria. PATIENTS AND METHODS: Patients with TPDH, who were treated and had a minimum follow up of 24 months, were included in this study. Reduction was achieved under general anaesthsia. Outcome of treatment was evaluated using the clinical criteria proposed by Matta. RESULTS: Forty-seven patients were evaluated comprising 36 (76.6%) males and 11 (23.4%) females. The commonest cause of injury was road traffic accident in 40 (85.1%). Presentation was considered as early if patient presented within 6 hours of injury and late if later than this. Using Thompson and Epstein's (TE) classification of posterior dislocation of the and Pipkin's (P) sub-classification of type 5, there were 10TE1; 25TE2; 9TE3; 2TE4 and 1 TE5P2. TE1 and TE2 make up 74.5% of cases. 32 (68.1%) presented early and 15 (31.9%) late. Thirty nine patients had successful closed reduction comprising 32 that presented early and seven late. The mean interval between injury and reduction was 9.7 (+/- 1.2) hours. Two (4.3%) patients were reduced within 6 hours, 32 (68.1%) were reduced within 7-12 hours. Five patients had open reduction and three had salvage Girdlestone pseudo-arthroplasty. Outcome assessment showed in the closed reduction group, 22 (59.5%) had excellent score, and 11 (29.7%) had good. These patients were all reduced within 12 hours. Two each had fair and poor outcome while two were lost to follow up. Seventeen (36.2%) developed complications comprising 12 (70.6%) who presented late and five (29.4%) who came in early. The commonest complication was avascular necrosis of the femoral head in eight (47.1%), all presented late with intractable pain; eight (47.1%) with pain of unknown origin and one (5.8%) with sciatic nerve injury which resolved on conservative management. CONCLUSION: Reduction of PDH within 12 hours is associated with excellent results and few minor complications.

Short-term antibiotic prophylaxis in implant surgery: a comparison of three antibiotics.

OBJECTIVE: To investigate the efficacy, tolerability and cost effectiveness of three antibiotics in a short-term antibiotic regimen in patients undergoing elective implant surgery. PATIENTS AND METHODS: 89 patients who underwent 101 implantation procedures were enrolled during a period of five years and randomly divided into three groups to receive: (a) Rocephin (Ceftriaxone) 1g intravenously at induction and 1g 12 hours later (Group 1). (b) Zinacef (Cefuroxime) 1.5 g intravenously at induction and 750 mg six hourly for 12 hours (Group 2). Ciprotab (ciprofloxacine) 400mg intravenously at induction and 200mg six hourly for 12 hours (group 3). RESULTS: The patients in the three groups were comparable regarding age, gender, pre-operative length of hospitalization and duration of surgery. The overall surgical site infection rate was 6.9% (7/101) with gram-negative organisms being the most common causative organisms (71.4%). The infection rates of 6.3% in group 1,7.3% in group 2 and 7.1% in group 3 show no statistical significance (P>0.05). The cost benefit ratio for the three drugs showed that treatment with Ciprotab was cheaper than that with Rocephin or Zinacef. Severe complications warranting discontinuation of therapy did not occur in any of the three groups of patients. CONCLUSION: While we can safely conclude that all the drugs have similar efficacy and safely in preventing post-operative wound complications, it appears that Ciprotab is most cost-effective. We recommend that a larger study be undertaken to confirm the predominance of gram-negative organisms in implant surgery.

Chronic osteomyelitis of long bones: reasons for delay in presentation.

BACKGROUND: Chronic osteomyelitis is a common orthopaedic infection and a major medical problem in developing countries. Time is a critical factor in the evolution of the chronic disease as most of our cases are a progression from acute haematogenous osteomyelitis. Our patients present very late. OBJECTIVE: To identify the reasons for this delayed presentation and suggest possible solutions. METHOD: Over three years (2000-2003) in a multi-centre study (2000-2003), we prospectively evaluated patients with both clinical and radiological diagnosis of chronic osteomyelitis. Besides personal data, mode of onset, duration of illness, father's educational status and occupation and reasons for delayed presentation were documented using a questionnaire. Previous surgery was an exclusion criterion. RESULTS: One hundred and thirty-six patients comprising 81 males and 55 females with a mean age of 17.7(2-55) years were recruited. The mean duration between onset of disease and presentation for treatment was 13.3(2-120) months. Sixty-one (44.9%) presented to a health facility were misdiagnosed and inappropriately treated; ignorance was the reason in 37(27.2%) and lack of finances in 32(23.2%). There was no statistically significant association between the father's educational status and occupation and the attitude to hospital attendance. CONCLUSION: Misdiagnosis, ignorance and poverty are the reasons for delayed presentation in patients with chronic osteomyelitis in this environment. A high index of suspicion, accurate diagnosis and appropriate therapy offer the only hope in containing the acute phase. Continuing medical education, improvement in social and medical amenities and the national health insurance scheme are possible ways of overcoming undue delay in presentation for specialist consultation.