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: Aretrospective 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.Key words: Challenges, civilian conflicts, crisis, disaster, mass casualty, trauma, violenc

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 1141hours (±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. Keywords: Posterior hip dislocation; associated injuries; injury severity score. Nigerian Journal of Medicine Vol. 17 (3) 2008: pp. 346-34

Lipoma arborescens of the knee: a rare tumour in a black woman. A case report

A 69 year old Nigerian female presented with a two-year history of intermittent swelling, pain and restriction of movement of the right knee. At open arthrotomy and synovectomy, a huge encapsulated yellowish lobulated fatty mass with frond-like appearance was delivered from the suprapatella and popliteal fossae. It weighed 520g and histology showed clusters of adipocytes with abundant pale cytoplasm as well as clusters of collagen fibres with elongated nuclei and bipolar cytoplasmic processes consistent with lipoma arborescens (LA). There is no recurrence at three years of regular follow-up. On the sheer size of this rare lesion, we have designated LA weighing 500gms or more giant LA.Key words: Knee joint,Giant lipoma arborescens, open synovectomy

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 6hours, 32 (68.1%) were reduced within 7-12hours. 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 12hours. 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. Keywords: Traumatic posterior dislocation of the hip, time of reduction, complicationsNigerian Journal of Medicine Vol. 17 (2) 2008: pp. 163-16

Is There a Place for Girdlestone's Excision Arthroplasty in Modern Treatment of Hip Pathology? A Multi-Institutional Retrospective Study on the Indications and Outcome

Background /Objectives: Primary Resection Arthroplasty as described by Girdlestone is not a common procedure done nowadays and is currently reserved for the treatment of septic hip and prosthetic implant infection and as a salvage procedure when reconstruction is impossible primarily forcontrol of pain. The aim of this study is to retrospectively evaluate the indications for and the outcome as a primary surgical technique and evaluate the usefulness in a technically advancing world of total hip arthroplasty.Materials and Methods: This is a ten year retrospective study (2000-2009) carried out at five hospitals in North Central, Nigeria. Case notes were reviewed and patients that met a set of criteria and had a minimum follow-up of 24 months were recruited. Outcome measures were limb length discrepancy (LLD), hip control, pain control, muscle stiffness and satisfaction obtained. Visual Analogue scale (VAS) and Harris Hip Score(HHS) were also computed. All analysis was done on Epi-Info version 3.5.1(2008) with means all to one decimal place.Results: Thirty-nine patients out of 51 patients met the inclusion criteria comprising 27(69.2%) males and 12(38.8%) females with a mean age of 52(±17.6) years. The indications were severe osteoarthritis 18(46.2%); fracture neck of femur 7(17.9%); neglected fracture-dislocation of the hip in 6(15.4%); avascular necrosis of the femoral head in 5(12.8%) and septic arthritis in 3(7.7%). The pre-operative LLD was 1.89±0.8 (range 1-4cm) compared to post operative LLD of 4.3(range 3-5cm). Pre-operative VAS was 7±1 and post operative was 1±0.8. Pre-op HHS was 46±10 compared to post-op score of 79±3(mode 81). Fifteen(38.5%) had good hip control, 14(35.9%) had some control requiring walking stick for long distance walk and 10(25.6%) had poor control and required walking stick for walking. Age (p<0.05) and indications (p<0.05) significantly affected outcome. Twenty (51.3%) had no pain post operatively, 18 (46.2%) had mild pain but no need for analgesics and one(2.6%) had mild pain requiring occasional analgesics. Fourteen (35.9%) were satisfied and happy, 18(46.2%) felt better but actually expected more while seven (17.9%) were not satisfied at all.Conclusion: GRA is very good for pain control otherwise it is associated with poor outcome found to be unsatisfactory to most patients.Keywords: Girdlestone Resection Arthroplasty, hipprosthesis, Pain control, satisfaction

Fibrodysplasia Ossificans Progressiva: A Rare Crippling And Disabling Disorder

Fibrodysplasia ossificans progressiva, (FOP), the most disabling condition of extra skeletal ossification is a rare genetic disorder which causes immobility through progressive metamorphosis of skeletal muscles and soft connective tissue into a second skeleton of heterotopic bone. It presents classically at birth with clinical features that make diagnosis certain. It is however frequently misdiagnosed because of its rarity, and paucity of knowledge. This may lead to a delay in presentation with its antecedent effect on morbidity, or outright harmful interventions that lead to increased morbidity and mortality. At present there is no cure.We report two patients who presented with progressive stiffness of joints involving the shoulders, neck, knees, and hips as well as nodular swellings in the trunk and diffuse swellings of the appendicular skeleton. One of the patient had multiple interventions Intra-muscular injections, biopsies, and incisions by unorthodox medical practioners with associated worsening of her conditions. In addition to the nodular swellings and heterotopic ossification they were found to have symmetrical malformation of the great toes a classical feature of Fibrodysplasia ossificans progressiva (FOP) which when recognized early can make diagnosis certain and avoid interventions that tend to worsen progression of the disease. The need to draw attention of the medical world to this rare disabling disease prompted us to review the literature of Fibrodysplasia ossificans progressiva.Key Words: Fibrodysplasia ossificans progressiva, symmetrical big toe malformation,absence of cure

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. Keywords: Congenital amputation, limbs, scar, amniotic bands. Nigerian Journal of Medicine Vol. 17 (4) 2008: pp. 457-45

Unexplained right upper quadrant abdominal pain? do not forget the cervical spine

Background: Right upper quadrant abdominal pain is a common reason for consulting a gastroenterologist. Commonly, it portends pathological processes occurring in the liver, gall bladder, or the gut however, unusual causes have been reported. We report cervical intervertebral disc prolapse causing right upper quadrant abdominal pain.Methods: Case report utilizing medical records of a 40 year old male who presented with unexplained right upper quadrant abdominal pain.Results: A self-referral for magnetic resonance imaging of the cervical spine revealed compression of the cervical spine at C3/C4, C4/C5 and C5/C6 levels from disc prolapse and osteophyte. He was managed conservatively with cervical collar and physiotherapy with complete resolution of symptoms.Conclusion: Prolapsed intervertebral discs affecting the cervical spine should be considered in the evaluation of the patient with unexplained right upper quadrant abdominal pain.Keywords: Cervical Spine, Disc Prolapse, Upper Quadrant Abdominal Pai

Glove Punctures in Orthopedics and Trauma Surgery: Frequency and Nature of Occurrence

Background: Glove punctures are a common occurrence in surgical practice and especially in orthopedic practice. Intact gloves protect members of the operating team from transmission of blood borne infections. Glove punctures however expose the members of the operating team to body fluids and increase the risk of these infections. With the prevalence of conditions such as HIV, Hepatitis B and C, this study aims at determining the rate of and factors that determine glove perforations.Methodology: Gloves were collected from consecutive orthopedic procedures, and were tested using the standardized water leak test The gloves were assessed for leaks and a control group of unused gloves from the same pack was tested similarly after each procedure.Results: A glove perforation rate of 7.7% (119/1548) was found with operative perforation rate of 48.2%. The surgeons' glove was the most frequently perforated 19.3% (85/440). The Index finger and thumb were the most commonly perforated digits 70.8% and 15.6% of perforations respectively. The outer glove had a higher rate compared to inner glove 80.7% to 19.3% respectively. Surgeries lasting more than 90minutes were associated with more perforations (70.4%).Conclusion: The use of double gloving techniques is advocated and a change of outer gloves for prolonged procedures is encouraged as this will reduce the risk of exposure.Key Words: Glove, Punctures, Orthopedics, surgery