Treatment outcomes of distal tibia fractures among adult patients at Moi Teaching and Referral Hospital, Eldoret, Kenya

Background: The treatment of distal tibia fractures remains challenging since they are prone to higher rates of complications. Treatment options are expanding and although their indications, advantages and disadvantages have been discussed in literature, controversy still exists over the clinical efficacy and cost-effectiveness of each option. This has led to different orthopaedic surgeons employing different operative treatment options based on their experience, preference and patient characteristics.Objective: This study sought to describe the patients’ characteristics and treatment of distal tibia fractures at MTRH and compare the outcome results of the various treatment options.Design: A prospective observational study design was used. Adult patients with distal tibia fractures admitted during the study period were included through consecutive sampling.Methods: A total of 76 patients were followed up. Data including injury aetiology, fracture types and classification, treatment and complications were collected. Functional outcome was assessed using Olerud and Molander Ankle Score (OMAS) at 6 months after treatment. Data was collected between October 2015 and March 2017 using a structured questionnaire and analyzed using STATA version 13 at 95% confidence level. Chi square test was used to determine the significance of associations between categorical variables.Results: The median age was 40.0 (30.0, 52.0) years, with a male-to-female ratio of 1.7:1. Most common causes of injury were RTA in 37 patients and falls in 29 patients. There were 48 closed and 28 open injuries. According to Arbeitsgemeinschaftfür Osteosynthesefragen (AO)/ Orthopaedic Trauma Association (OTA) classification, there were 40 (52.6%) type A, 28 (36.8%) type B and 8 (10.6%) type C fractures. Twenty-five (32.9%) patients were treated non-operatively, 28 (36.8%) patients underwent internal fixation with plating and 23 (30.3%) patients were treated using external fixation method. Non-operative treatment was mostly used for closed injuries (80%) whereas majority of open fractures (82%) were treated operatively (P=0.033). Complications occurred in 48 (57.8%) patients, including 30 (62.5%) wound infections, 21 (43.7%) malunions and 3 (6%) chronic osteomyelitis. Infections were significantly higher among external fixation treated patients (P=0.002). At final follow up the functional outcome using OMAS was excellent in 11(14.5%) patients, good in 28 (36.8%), fair in 17 (22.4%) and poor in 20 (26.3%) patients. OMAS scores were significantly high in patients treated with plating and low in patients with comminuted fractures, complications and open injuries (P<0.001).Conclusion: Distal tibia fractures mostly occurred in young males. Road traffic accidents and falls were the commonest causes. Treatment by plate fixation resulted in significantly higher functional outcome scores and lower rate of complications compared to non-operative treatment.Recommendation: Distal tibia fractures should be treated operatively by plate fixation to improve treatment outcomes.Keywords: Distal tibia fracture, OMAS, Treatment outcom

The course of the radial nerve in relation to the humerus: a cadaveric study in a Kenyan adult population

Background: The radial nerve arises from the posterior cord of the brachial plexus. It descends distally to the spiral groove of the humerus. The upper and lower margins of this groove form important landmarks relative to the acromion process, medial and lateral epicondyles of the humerus.Objective: To describe the course of the radial nerve in relation to the humerus in a Kenyan adult population.Methods: Dissections were done on fifty-nine left sided formalin fixed adult upper extremities obtained from the Human Anatomy Laboratory of Moi University. Data was recorded and analysed using SPSS version 21.Results: The average humeral length was 314.4 ± 21.4mm. The radial nerve was located 140.8 ± 17.2 mm from the tip of the acromion. It exited the spiral groove 185.1 ± 21.7mm from the tip of the acromion and 132.1 ± 19.4 mm from the lateral epicondyle. The midpoint of the nerve at the spiral groove to the medial epicondyle was about half the humeral length.Conclusions: The radial nerve was located at the middle third of the humerus shaft. The midpoint of the nerve while in the groove relative to the medial epicondyle was about half the humeral shaft length.Keywords: Spiral groove of the humerus, Humerus shaft fractures, Triceps muscl

Degloving injuries: Patterns, treatment and early complications among patients at a Teaching Hospital in Western Kenya

Background: Degloving injuries result from avulsion of extensive portion of skin and subcutaneous tissue from the underlying fascia, muscles and tendons. They commonly occur in orthopaedic surgery with accompanied blood loss, concomitant injuries and contamination.Objective: To determine the pattern, treatment, and early complications of degloving injuries.Methods: A prospective study among 48 patients admitted with degloving injuries at Moi Teaching and Referral Hospital-Kenya between 1st December 2016 and 30th November 2017. The diagnosis was made through physical examination and ultrasonography followed by photo documentation while demographic and injury history were recorded in a questionnaire. Fisher’s exact test of association between pattern of injury and complications was conducted.Results: Median age was 26 (IQR: 18.5, 42.5) years with male to female ratio of 1.5:1. Most (75%) of the injuries were from road traffic accidents commonly (n=23) affecting the lower limbs. Open degloving injuries (n=44) either had single (n=29) or serial debridement (n=15) with the commonest definitive treatment being primary closure (n=22). Closed degloving injuries were either conservatively managed (n=2) or drained (n=2). Only 31.2% of the patients developed complications which statistically was significantly associated (p=0.002) with the patterns of degloving injury.Conclusion: Open degloving injuries affecting the lower limbs were commonest and were mainly treated through primary closure. Early complications were associated with injury patterns and treatment modality. There is need to develop institutional protocols for the treatment of degloving injuries to reduce early complications

Tibial Diaphyseal Fractures: Aetiology, morphology and treatment in adult patients at Moi Teaching And Referral Hospital, Eldoret, Kenya

Background: Tibial Diaphyseal Fractures (TDFs) arise from various forms of trauma and assume different patterns. They are responsible for high morbidity and mortality.Objective: To describe the mechanism of injury, morphology and treatment methods of tibial diaphyseal fractures in adult patients at Moi Teaching and Referral Hospital, Eldoret, Kenya.Methods: A descriptive prospective study on 89 adult patients with tibia shaft fractures. An interviewer administered questionnaire was used to collect data. Association between categorical variables was assessed using Pearson’s Chi Square test.Results: The median age was 28.0 years (IQR: 24.0-40.0) with a male to female ratio of 3.2:1. Most of the TDF (67.4%) were due to Road Traffic  Accidents (RTAs); fall 16 (18.0%) and the least, gunshot 3 (3.4%). Up to 40.9% of the fractures were open type while (59.1%) were closed. Middle 1/3 tibia shaft was the commonest site of fracture at 52.7%. Fibula fracture was the most associated injury at 62.9%. Operative management was donein 61.6%.Conclusion: Road Traffic Accidents were the major cause of TDF with motorcycles injuries leading. Most TDF were closed type; mainly at mid third level. Fibular fractures were the most associated injuries. Treatment of TDF was mainly surgical using locked intramedullary nail. Key words: Tibia Diaphyseal Fractures (TDFs), Road Traffic Accidents (RTAs), Motor Vehicular Accident (MVA

AEROBIC PATHOGENIC BACTERIA IN POST-OPERATIVE WOUNDS AT MOI TEACHING AND REFERRAL HOSPITAL

Background: The emergence of bacterial antimicrobial resistance associated withacquired infections has made the choice of empirical therapy more difficult andexpensive, hence the need for continuous research to determine their sensitivity patterns.Objectives: To identify the common aerobic pathogenic bacteria in post-operative woundsat Moi Teaching and Referral Hospital (MTRH) and determine their sensitivity patternsto routine antibiotics used.Design: Cross-sectional study.Setting: Moi Teaching and Referral Hospital (MTRH) Surgical, Obstetrics and Gynaecologywards.Patients: Sixty three patients chosen by convenient sampling between May and June2001 were included in the study. A total of eighty four isolates were obtained fromthese patients.Materials and Methods: Isolation of pathogens and their antibiotic sensitivitydetermination was conducted in the Department of Medical Microbiology Laboratory,Faculty of Health Sciences, Moi University. The bacteria were cultured on blood agar,MacConkey and Nutrient agar followed by identification using biochemical tests (catalaseurease, coagulase, triple sugar iron). Disc diffusion method on Muller-Hinton agar wasused for sensitivity testing.Results: Staphylococcus aureus species were the most common pathogenic bacteriaisolated from the post-operative wounds. Other organisms included Proteus, Pseudomonasand Escherichia coli. There was a multi-drug resistance pattern observed, withminocyline being the most effective drug against S. aureus.Conclusion: There is need for review of policies on prescription practice on the useof existing therapeutics choice to limit the spread of resistance. This will ensure reducedpatient stay and cost incurred

Effectiveness and complications of SIGN intramedullary interlocking nailing in the management of femoral and tibial fractures at Moi Teaching and Referral Hospital, Eldoret- Kenya: A retrospective study

Background: Interlocking intramedullary nailing is the current state-of-the-art management of the shaft fractures of long bones. Objective: To assess the functional outcome of SIGN nailing of femoral and tibial fractures at Moi Teaching and Referral Hospital. Design: Retrospective analytical, study over a three year period from February 2005 to April 2008. Setting: Orthopaedic Department, Moi Teaching and Referral Hospital, Eldoret. Subjects: All patients with closed or Gustillo Grade I or II open tibial and/or femoral shaft fractures presenting at Moi Teaching and Referral Hospital, Eldoret. Results: Three hundred and eleven patients with tibial and/or femoral shaft fractures were treated at Moi Teaching and Referral Hospital of whom 245(78.8%) were males while 66(21.2%) were females. Total nails fixed were 329 and the oldest patient aged 100 years while the youngest was 13 years.Twelve (3.9%) of the total number of patients presented with ipsilateral fractures, 4(1.3%) had bilateral fractures, 4 (1.3%) had fractures of both the femur and tibia while 1(0.3%) patient had fractures of the femur and humerus. There were 300 closed fractures and 29 open fractures treated with intramedullary nailing. Road traffic accidents were the leading cause of injury. Other causes included falls, assault, gunshot, sports injuries, pathological fractures among others. Prophylactic antibiotics were used in 288 patients. One hundred and thirty four (43.1%) patients turned up for follow up during the same period. There were 23 cases of wound infection, 4(1.2%) broken nails, 6(1.8%) failed distal locking and 2(0.6%) fractures above the nail. Conclusion: Males were found to be more affected than females. Road traffic accidents are the leading causes of trauma. Loss of follow up is one of the major problems still encountered. SIGN intramedullary nailing was found to be the most effective method of fracture management with minimum complications

The management of bone and joint infections at Moi Teaching and Referral Hospital

Background: Bone (cortex and marrow) and joint infection are not uncommon in this health institution. The management of patients with the lesion has posed a challenge yet the institution is in top gear training the surgeons in the field of orthopaedic and trauma surgery. This study aims to lay foundation for development of the management protocol, and further research. Objective: To evaluate the management of Bone and Joint infection in children. Design: Retrospective descriptive study. Setting: Moi Teaching and Refferal Hospital, Eldoret, Kenya. Methods: The relevant data of 85 consecutive patients on aspects of demography and the management in the period 2001- 2006 were recorded into the data sheet (proforma), then analyzed and presented in statistical patterns. Results: Eighty five consecutive patients (47 males, 38 females), ratio M: F =1.24:1. Admission rated at least 14±2SD patients per year. Age: 2weeks-13 years, mean= 7.53 ±3.98SD. Major risk/predisposing factor-trauma. Duration of symptoms: 1 day-2 years, mean=16.44± 11.28SD. Commonest symptomatology included pain, swelling and loss of function more so in the joints than in bones. Of investigations- Laboratory: anaemia, bacterial isolates(33 and 14 patients respectively), while radiological/ imaging: lesions identified in patients’ radiographs, CT- scans and ultrasound scans (49, 3 and 3 respectively). Fifty six patients were diagnosed with arthritis and 39 with osteomyelitis. Treatment of 26 patients was non- operative and 59 were operated. All the patients survived. Hospital stay ranged from 2- 159 days, mean=14.16 ±9.46SD. Follow-up in clinic- 12 patients defaulted, 26 inconsistent while 47 consistent. Conclusion: Bone and joint infections were associated with significant morbidity as shown by high operative intervention and long hospital stay. Delayed presentation as noted could be responsible for the high morbidity

Aerobic pathogenic bacteria in post-operative wounds at Moi Teaching and Referral Hospital

Background: The emergence of bacterial antimicrobial resistance associated with acquired infections has made the choice of empirical therapy more difficult and expensive, hence the need for continuous research to determine their sensitivity patterns. Objectives: To identify the common aerobic pathogenic bacteria in post-operative wounds at Moi Teaching and Referral Hospital (MTRH) and determine their sensitivity patterns to routine antibiotics used. Design: Cross-sectional study. Setting: Moi Teaching and Referral Hospital (MTRH) Surgical, Obstetrics and Gynaecology wards. Patients: Sixty three patients chosen by convenient sampling between May and June 2001 were included in the study. A total of eighty four isolates were obtained from these patients. Materials and Methods: Isolation of pathogens and their antibiotic sensitivity determination was conducted in the Department of Medical Microbiology Laboratory, Faculty of Health Sciences, Moi University. The bacteria were cultured on blood agar, MacConkey and Nutrient agar followed by identification using biochemical tests (catalase urease, coagulase, triple sugar iron). Disc diffusion method on Muller-Hinton agar was used for sensitivity testing. Results: Staphylococcus aureus species were the most common pathogenic bacteria isolated from the post-operative wounds. Other organisms included Proteus, Pseudomonas and Escherichia coli. There was a multi-drug resistance pattern observed, with minocyline being the most effective drug against S. aureus. Conclusion: There is need for review of policies on prescription practice on the use of existing therapeutics choice to limit the spread of resistance. This will ensure reduced patient stay and cost incurred. (East African Medical Journal: 2002 79(12): 640-644