Manyazewal, D

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AJOL - African Journals Online

78 ISSN 2073-9990   East Cent. Afr. J. surg  COSECSA/ASEA Publication    -East and Central African Journal of Surgery .  July/ August 2014 Volume 19 No. 2      78  Patterns of Fractures and Their Current Hospital Management in Eastern Ethiopia:   A Six-Years Prospective review.  D. Manyazewal  Orthopedic Surgeon, Dilchora Hospital, Dire Dawa, Eastern Ethiopia. Correspondence to: Manyazewal Dessie,  E-mail: mdortho.dessie3 @gmail.com  Background: Fracture is a common problem that contributes greatly to the clinical load of a hospital. Their management especially those that require in-patient treatment and operative fixation is becoming a considerable burden on health care systems. There is very little relevant information on the pattern of fractures occurring in developing countries especially from those in tropical zones. The objective of this study was to identify the patterns of fractures and to assess the existing fracture management in Dilchora Referral Hospital, Eastern Ethiopia.  Methods: This prospective audit was conducted by the author who recorded the relevant findings on every patient with a fracture admitted to his orthopedic ward from January 2005 – February 2011. Patients who received any neurosurgical or general surgical procedures were excluded from this audit. Results: A total of 1354 patient with one or more fractures, 975 Males (72%), and 379 Females (28%) were admitted during the six year study period. The majority (71%) of the patients  were aged between 15-54 years, while  237 (18%) were under 15 Years. Only 154 (11%) were over 54 years. The bones involved included Tibia/Fibula (25%), Femur (22%), Ankle (15%), Pelvis (7%), Radius/Ulna (6%), and humeral shaft (5%). Closed fractures accounted for 1037 (77%) and open fractures for 317 (23%). Plaster was applied for 654 fractures (48.4%), Traction for 241 (17.8%), and open reduction with internal Fixation for 201 (14.4%).  External Fixations were used for 43 (3.2%), Debridement for 97 (7.9%) and other techniques for 118 (8.7%).   Conclusion:   With the shortage of orthopaedic implants and instruments it is possible to achieve very good results for most of the fracture patterns managed conservatively.   Introduction Musculoskeletal trauma is the ninth leading cause of death world wide1-4 and is the highest in the age group of 18-44 years5,14,15,16. Fractures due to motor vehicles are the foremost cause of morbidity and death particularly in young people2,14,15. Fracture is a common problem that contributes greatly to the clinical load of a hospital6,7,14. With the increasing cost of medical services in general the management of fractures, especially those that require inpatient treatment and operative fixation is becoming a steadily increasing burden on health care systems8. Most fractures result in a temporary loss of function for the patient and also a loss of work time for the parents, children or other carers of the injured person. With the growing number of elderly people in the population osteoporotic fractures which are associated with a higher rate of morbidity and mortality have become a real challenge for all concerned9,10.  The current literature on the patterns of fractures is based mainly on data collected in developed countries11,12 and there is very little relevant information on the patterns of fractures encountered in developing countries especially from those in tropical zones13. The objective of my audit was to identify the patterns of fractures and to assess the existing management of patients admitted to Dilchora Referral Hospital in Eastern Ethiopia. Patients and Methods Dilchora referral Hospital is the only government health facility providing specialized Orthopedic and Trauma management in the Eastern part of Ethiopia and has a catchment population of about 5 million. The Hospital has 230 beds of which 24 are for Orthopedic and 79 ISSN 2073-9990   East Cent. Afr. J. surg  COSECSA/ASEA Publication    -East and Central African Journal of Surgery .  July/ August 2014 Volume 19 No. 2      79  Trauma patients. There is only one specialist orthopedic surgeon available but general surgeons and general practitioners provide some orthopedic and trauma care. This audit was conducted by the author who recorded the relevant findings on every patient who had been admitted with a fracture from January 2005 - February 2011 and who did not need either any neurological or general surgical management. Results  A total of 1354 patients with one or more fractures, 975 were Males (72%), and 379 Females (28%) were admitted from   January 2005 – February 2011(Table 1). Of this grand total 963 (71%) who presented were in the age group of 15-54 years, 237 (18%) were younger than 15 years, and 154(11%) were over 54 years old (Table 1).   Of the fractures 983 (73%) were in the lower limb, 295 (21.5%) were in the upper limb and 76 fractures (5.7%) were in other sites (Table2). The specific bones involved included the Tibia/Fibula 337 (25%), Femur 303 ( 22%), Ankle 203 (15%), Pelvis 88 (6.5%), Radius/Ulna79 (5.7%), Humerus shaft 68 (5%), Olecranon 54 (4%), Supracondylar Humerus 43 (3.2%) and Other bones 179 (13%)(Table 3).  There were 1037 (77%) closed and 317 (23%) compound fractures (Table3). A closed reduction with the application of plaster was done for 654 fractures (48.4%). Traction was used to treat 241 fractures (17.8%). Open reduction & Internal Fixation was necessary for 201 fractures (14.4%).  External fixation was used for 43 fractures (3.2%), Debridement was necessary for 97 fractures (7.2%) and other methods of treatment were required for 118 fractures (8.7%). Tables 4 and 5 show the Distribution of all cases of fracture by age at presentation and gender.    Table 1.  Distribution of all cases of fracture by Age of presentation and gender at Dilchora hospital    Age of presentation  in years                               Gender      Total              Male       Female        <15 Years         173(13%)        64(5%)       237(18%)      15-54 Years         703(52%)      260(19%)       963(71%)       >54 Years           99(7%)        55(4%)       154(11%)     Total         975(72%)      379(28%)       1354(100%)  Table 2. Distribution of all cases of fracture by Age and gross anatomical Location of the fracture at Dilchora hospital   Age  of presentation in Years                         Location of fracture    Total  Upper limb # Lower Limb  # Other Site  #  <15 Years 135(10%)    102(8%) - 237  (18%) 15-54 Years 153(11%)    744(55%) 66(5%) 963  (71%) >54 Years      7(0.5%)    137(10%)  10(0.7%) 154  (11%) Total 295(21.5%)  983(73%) 76(5.7%) 1354(100%) 80 ISSN 2073-9990   East Cent. Afr. J. surg  COSECSA/ASEA Publication    -East and Central African Journal of Surgery .  July/ August 2014 Volume 19 No. 2      80   Table 3. Distribution of fracture by Specific Anatomical site of fractures and type  Specific Anatomical Site                Severity of the fracture         Total  Closed Compound     Tibia-fibula # 137(10%) 200(15%) 337(25%)    Femoral #   283(20.5%) 20(1.5%) 303(22%)    Ankle # 163(12%)               40(3%) 203(15%)    Pelvic bone#    88(6.5%) - 88(6.5%)   Radio-ulna # 69(5%) 10(0.7%) 79(5.7%)   Humeral shaft # 56(4%)               12(1%) 68(5%)   Patella Fracture 27(2%) 4(0.3%) 54(4%)   Supracondylar  Humerus  # 40(3%) 3(0.2%)    43(3.2%)   Olecranon # 54(4%) - 31(2.3%)   Calcaneal  #   17(1.3%) 4(0.3%) 21(1.6%)   Epiphyseal injury         15(1%) - 15(1%)   Lateral Condylar  Humerus #         13(1%) - 13(1%)   Scapular # 11(0.8%) - 11(0.8%)   Galeazi #  9(0.7%) - 9(0.7%)  Montegia # 3(0.2%) - 3(0.2%)  Spine # 34(2.5%) - 34(2.5%)  Mandible # 12(0.9%) 20(1.5) 32(2.4%)  Nasal bone # 6(0.4%)     4(0.3%) 10(0.7%)  All # 1037(77%) 317(23%) 1354(100%) Table 4. Distribution of all Cases of Fracture by Site of Fracture and Management at Dilchora Hospital   Site of #                   Applied fracture Management options     Total POP Traction ORIF Ex. Fix      Debridement        Other     Tibia #  259 (19.1%) -    5(0.4%) 3(0.2%) 70(5.2%) - 337(25%)  Femoral #  12 (0.9%) 170 (12.6%)     121   (8.9%) - - - 303(22%)  Ankle # 162(12%) -    1(0.07%) 40(3%) - - 203(15%)  Pelvic bone # - 56(4.1%) - - - 32(2.4%) 88(6.5%) Radius-ulna # 67(5%) - 2(0.2%) - 10(0.7%) - 79(6%) Humerus # 54(4%) - 2(0.2% - 12(0.9%) - 68(5%) Patella #  12(0.9%) - 42(3.1%) - - - 54(4%) Supracondylar humerus #  25(1.9%) 15(1.1%) - - 3(0.2%) -    43(3.2%) Key:  # = Fractures.   Ex. Fix = External fixation.           ORIF =Open reduction and internal fixation  81 ISSN 2073-9990   East Cent. Afr. J. surg  COSECSA/ASEA Publication    -East and Central African Journal of Surgery .  July/ August 2014 Volume 19 No. 2      81   Key:   # = Fractures .  POP: Plaster of Paris.  ORIF: Open reduction and Internal Fixation.                   Ex. Fix :  External Fixation.  Rx = Treatment.  Debride = Debridement                                                                                                                                             Discussion  This study has revealed that males sustained fractures more commonly (72%) than the females (28%), and that the highest incidence of fracture occurred among those aged 15-54 years (71%). These people are of productive age and had predominantly suffered musculoskeletal trauma. This finding is consistent with many other reports1,2,,6,14,15    The lower limb was found to be the commonest site of the fracture necessitating admission to my orthopaedic ward (73%). Injury to the upper limb (21%) was less common and this is in agreement with other studies6,14,16.  It was also evident that the incidence of lower limb fractures necessitating admission among people of working age is significantly higher than that of children under the age of 15 years. Hospital studies from Malaysia showed similar findings 6. More than two-thirds of bone injuries occurred in the Tibia/Fibula, Femur, Ankle, Radius/Ulna and Humerus and other studies also showed similar findings1,6,16. It is interesting that closed fractures were found to be the leading cause of admissions in our ward. A study done at the Mayo hospital in Lahore showed a comparable result1.  The conservative (non-operative) management using plaster casting or traction is the main stay of treatment for most fractures in our ward (66.2%) and this was due to limited facilities for Internal Fixation. This is also comparable to the management used in the Mayo hospital 1.   Most of the closed fractures (48.4%) admitted to our hospital are treated by manipulation and then maintained in the reduced position by the use of plaster. In addition to its application in most closed fractures plaster casts are also of use in our hospital for the management of type I open fractures of Tibia/Fibula. While the insertion of interlocking nails within six hours of the fracture is common practice for this type of injury in high income countries1. In our area this is not feasible due to unavailability and cost, and as patients often arrives late.   Table 5. Distribution of all Cases of Fracture by Site of Fracture and Management at Dilchora Hospital   Site of #                  Applied fracture Management options Total POP Traction ORIF Ex. Fix      Debride        Other Rx   Calcaneal # 21(1.6%) - -  - -    21(1.6%) Epipyseal # 15(1%) -  - - - 15(1%) Lateral condylar  humerus # 9(0.7%) - 4(0.3%) - - - 13(1%) Scapular # - - - - - 11(0.8%) 11(0.8%) Galeazi # 9(0.7) -  - - - 9(0.7%) Montegia #  3(0.2%) - - - - - 3(0.2%) Spine # - - - - - 34(2.5%) 34(2.5%) Mandible # - - 1(0.07%)   - 31(2.3%) 32(2.4%) Nasal # - - - - - 10(0.7%) 10(0.7%)  All # 654 (48.4%) 241 (17.8%) 201 (14.9%) 43 (3.2%) 97 (7.2%) 118 (8.7%) 1354 (100%) 82 ISSN 2073-9990   East Cent. Afr. J. surg  COSECSA/ASEA Publication    -East and Central African Journal of Surgery .  July/ August 2014 Volume 19 No. 2      82  Traction is the second commonest method of non-operative treatment   used in 17.8% of our patients.  All extra capsular hip fractures and many adult femoral shaft fractures in our hospital were managed by skeletal traction unlike the practice in high income countries where internal fixation with Interlocking nails and dynamic hip screws are the choice of treatment. It is also our custom to use skin traction for Intracapsular hip fractures in the elderly as we do not have materials for either internal fixation or arthroplasty in our hospital. It is clear that the use of such techniques avoids the disadvantages of traction by shortening the length of hospital stay and by allowing early mobilisation of the patient.  In addition the lack of additional facilities such as C-arms and Image Intensifiers make operative treatment for such fractures impossible in our hospital and probably throughout Ethiopia.  In fact only 201(14.9%) of our patients with fractures were managed by open reduction and Internal fixation.  Although a previous local study showed comparable Incidence of operation (14%)17 Our fixation rate is lower Compared to the fixation rate (25%) in the Mayo Hospital, Lahore 1. Thus limited facilities for internal fixation were the main reason for lower fixation rate in our Hospital.   Most of our fractures with associated wounds are treated by debridement and immobilisation with a posterior Gutter Plaster.  The 7.2% of all our patients with these fractures requiring debridement is comparable to the proportion of debridement in the Mayo Hospital, Lahore (6%) but the proportion of these patients for whom we were able to use external fixation in our hospital (3.2%) is significantly lower than the rate of application in the Mayo hospital (16%). This is simply due to our shortage of external fixators. Conclusion  In spite of the shortage of orthopaedic implants and instruments very good results can be  obtained for most of the fracture patterns by conservative management.    Recommendation  Conduct a nationwide Study to asses the existing fracture management practice in Ethiopia and its results. Additional effort has to be exerted by the Governments and other stake holders to improve the quality of the existing fracture management in health facilities at all levels.    Acknowledgment To Professor Geoffrey Walker for his help with this manuscript. References 1. Kahlon I.A.,Hanif A.and Awais S.M.,Analysis of Emergency Care of Trauma Patients with References to the Type of injuries, Treatment and Cost,ANNALS VOL 16.NO.1 JAN.-MAR.2010; 28-31. 2. Bhatti AM, Ajaib MK, Masud TI, et al. Road Traffic injuries in Pakistan: Challenges in estimation through routine hospital data. J Ayub Med Coll Abbottabad 2008; 20 (3): 108-11.  3. Di-Bartolomeo S, Sanson G, Michelutto V, et al. Epide-miology of major injury in the population of Friuli Venezia Giulia - - Italy. Injury, Int. J care injured 2004; 35: 391-400.  4. Mock C and Cherian MN. The global burden of muscu-loskeletal injuries: challenges and solutions. Clinical orthopaedic and related research. 2008; 466 (10): 2306-16.  83 ISSN 2073-9990   East Cent. Afr. J. surg  COSECSA/ASEA Publication    -East and Central African Journal of Surgery .  July/ August 2014 Volume 19 No. 2      83  5. Lino W, Segal AB, de Carvalhol DE, et al. Statistical analysis of infantile-juvenile Orthopaedic trauma in a tropical metropolis Orthopaedic emergency room. ACTA ORTOP BRAS 2005; 13 (4): 179-82.  6. Saw A, Sallehuddin A Y, Chuah U C, Ismail MS, Yoga R, Hossain MG, Comparison of fracture patterns between rural and Urban populations in a developing country, Singapore Med J 2010;51(9):702-708. 7. Hemmila MR,Jakubus JL, Maggio PM, et al. Real money:complications and hospital costs in trauma patients.Surgey 2008:144:307-16. 8. O’Keefe GE,Majer RV.Diehr P, et al.The complications of trauma and their associated costs in a level 1 trauma center.Arch Surg 1997:132:920-4. 9. Koh LK,Saw SM,Lee JJ,Leong KH,Lee J.Hip fracture incidence rats in Singapore 1991-1998. Osteoporosis Int 2001;12:3118. 10. Bergstrom U, Bjornstig U,Stenlund H,Jonsson H,Svensson. Fracture mechanisms and fracture pattern in men and women aged 50 years and older: a study of a 12-year population-based injury register, Umea. Osteoporosis Int 2008;19:1267-73. 11. Donaldson LJ.Cook A,Thomson RG.Incidence of fractures in a geographically defined population.J Epidemiol Community Health 1990;44:241-5. 12. Sanders KM, Nicholson GC, Ugoni AM,et al. Fracture rates lower in rural than urban communities: the Geelong Osteoporosis Study.J Epidemiol community health 2002,56:466-70. 13. Lau EM, Lee JK, Suriwongpaisal P, et al. The incidence of hip fractures in four Asian Countries: the Asian Osteoporosis study(AOS).Osteoporosis Int 2001;12:239-43. 14. Manyazewal dessie.  Major limb trauma in Eastern Ethiopia, East and Central African Journal of Surgery Volume 14 Number 1 – March/April 2009:84-87. 15. The burden of musculoskeletal conditions at the start of the new mellenium: Report of a WHO scientific group.(2003:Geneva,Switzer Land) 16. Ahmed Elias, Chaka Tezera, Orthopedic and Major Limb Trauma at Tikur Anbessa University Hospital. East and Central African Journal of Surgery,Vol.10,No.2,November 2005,pp43-49. 17. Biruk Lambisho, Woubalem Zewde, Major Orthopaedic Procedure, East and Central African Journal of Surgery, Volume 11 Number 1-April 2006,pp 32- 40.  

Patterns of Fractures and Their Current Hospital Management in Eastern Ethiopia: A Six-Years Prospective review

66 ISSN 2073-9990   East Cent. Afr. J. surg  COSECSA/ASEA Publication    -East and Central African Journal of Surgery .  July/ August 2014 Volume 19 No. 2      Identification of the Commonest Snake Species Causing Envenoming and  Fatality  among Snake Bites of  Venomous  Admission in Dilchora Referral  Hospital.   D. Manyazewal.  Consultant Orthopedic Surgeon  Dilchora Referral Hospital, Dire Dawa, Eastern Ethiopia.  Email: mdortho.dessie3@gmail.com   Background: Snake bite is a common medical emergency in developing countries. The identification of snake species is important for optimal clinical management, because it allows clinicians to choose the appropriate treatment, anticipate complications, and  there fore to improve prognosis. Moreover, helps in selection of specific antivenom and avoids antivenom-induced adverse reactions.  The Objective the study is to Identify the commonest Snake species causing envenoming & fatal bites among snake bites of venomous  admission in Dilchora referral  Hospital from  2006-2011. Methods: The diagnosis was based on the history and account of injury, observation of fang marks, snake identification (when possible) and signs and symptoms of envenoming in patients admitted to  orthopedic ward for Supportive therapy without antivenom. Recording of necessary data and analysis were done by the Author. The study was conducted from 2006-2011.  Results: During the study period a total of 110(60 Male 54.5% and 40 Female 45.5% ) envenomed  patients were admitted in our orthopedic ward making male to female ratio 1.2:1(Table 1). Bites in Under 15 years account for 36(32.7%), in 15-44 years for 69(62.7%), in 45-54 years for 5(4.5%)(Table 1). Bite on the upper limb account for 40(36.4%), on the Lower limb for 66(60%) and on the head & trunk region 4(3.6%)(Table 2). Fatal bite account for 7( 6.4%)(Table 3,4 &5). Known Poisonous snakes caused 86(78.2%) of total envenoming (Table5 and Figure 2).  Conclusion:   Viper and Puff adder snakes were the commonest causes of fatal bites  in our Hospital.  Measures to be under taken are recommended.  Introduction    Snake bite is a common medical emergency in developing countries1. Antivenom is the only Specific antidote (treatment) to snake venom and its timely administration reverses all systemic manifestation of envenoming1- 4. WHO estimates that approximately 2,500,000 venomous snake bites per year result in 125,000 deaths world wid,100,000 of which are in Asia and approximately 20,000 in Africa3,4.  In Africa, the annual incidence rate of snake bite in the Benu Valley of North Eastern Nigeria is 497/100,000 population with a case fatality ratio 12.2%2. Study done at a rural South African hospital showed that the case fatality rate for snake bite to be 2.9%6.  It is generally agreed that the case fatality rate of snake bite in developing countries varies from 2% to 10%6-10. The high case fatality ratio of snake bite in tropical developing countries is the result of a combination factors including the scarcity of antivenom, poor health service and problems with transportation from rural areas to health centers2,5. An Intervention including development of treatment protocol, Staff training, monitoring of compliance and patient education decreased  snake bite mortality from 11%(8/72) to 1.3%(3/238) in rural Ghana11.   The identification of snake species is important for optimal clinical management, because it allows clinicians to choose the appropriate treatment, anticipate complications, and therefore to improve prognosis. Moreover, helps in selection of specific antivenom and avoids antivenom-induced adverse reactions6,14,15.   67 ISSN 2073-9990   East Cent. Afr. J. surg  COSECSA/ASEA Publication    -East and Central African Journal of Surgery .  July/ August 2014 Volume 19 No. 2      Material and Methods:    The diagnosis of snake bite was based on the history and account of injury, observation of fang marks, snake identification (when possible) and signs and symptoms of envenoming  in all patients admitted to orthopedic ward for Supportive therapy without antivenom (antivenom is not available in our hospital). Identification of known Venomous snakes were performed by the author  using  bed side  20-minutes whole blood clotting test(20WBCT) to snake bite Victims with  clinical sign of swelling  and by comparing dead snakes presented  in our hospital  by patient’s family with Online Pictures of venomous  Snakes of Africa [http://library.thinkquest.org]. Recording of necessary data and analysis were done by the author.   The study was conducted from 2006-2011.                                                               Results   During the study period a total of 110 envenomed  patients were admitted in our orthopedic ward. The males were  60 (54.5%0 and 50 (45.5%) were females. The male to female ratio was  1.2:1. The under 15-years accounted for 36 (32.7%) of the cases of snake bites. The majority (62.7%) of the patients were in the 15-44 years age group (Table 1).   Table1. Number of Envenomed Cases of Snake Bites by Gender and Age in Years from 2006-2011  Age in Years                              Gender Total  Male Female  0-4    6(5.5%)    5(4.5%)   11(10%) 5-14   10(9.1%)    15(13.6%) 25(22.7%) 15-24 14(12.7%)    8(7.3%) 22(20%) 25-34 20(18.2%) 17(15.5%) 37(33.6%) 35-44   6(5.5%)    4(3.6%)    10(9.1%) 45-54   4(3.6%)    1(0.9%)    5(4.5%) +55  - -     - Total 60(54.5%) 50(45.5%) 110(100%)  Table 2. Number of Envenomed Cases of Snake Bite by Main Clinical Syndrome and Location of Bite from 2006 -2011 Clinical Syndrome                       Location of the bite  Total    Upper limb     Lower Limb  Head & Trunk Syndrome 1:Massive Swelling with Incoagulable blood        30(27.3%)        41(37.2%)       - 71(64.5%)  Syndrome 2: Massive Swelling with  Coagulable  blood          7(6.4%)        19(17.3%)       2(1.8%) 28(25.5%) Syndrome 3: Mild swelling only with Coagulable blood          3(2.7%)           6(5.5%)       2(1.8%) 11(10%) Syndrome 4: Neurotoxicity or paralysis             -                -             -        - Total     40((36.4%)         66(60%)      4(3.6%) 110(100%) 68 ISSN 2073-9990   East Cent. Afr. J. surg  COSECSA/ASEA Publication    -East and Central African Journal of Surgery .  July/ August 2014 Volume 19 No. 2      Table 3. Number of Envenomed Cases of Snake Bite by Age in Years and Outcome of Bites Age in Years   Out come of the bite Total  Fatal Non fatal  0-4 2(1.8%)  9(8.2%)   11 (10%) 5-14 - 25(22.7%) 25 (22.7%) 15-24 - 22(20%) 22 (20%) 25-34 2(1.8) 35(31.8%) 37 (33.6%) 35-44 3(2.7%)   7(6.4%) 10 (9.1%) 45-54 - 5(4.5%)    5 (4.5%) +55 - -     - Total 7(6.4%) 103(93.6%) 110(100%)  Table 4.  Number of Envenomed Cases by Clinical Syndromes  and Outcome of the Bites     Clinical Syndrome   Outcome 0f the bite Total      Fatal Non-Fatal  Syndrome 1:Massive  Swelling with                              incoagulable blood 5(4.6%)  65(59.1%) 70(63.7%) Syndrome 2:Massive Swelling with                          coagulable blood 2(1.8%)  24(21.8%) 26(23.6%) Syndrome 3:Mild swelling only  with                            coagulable blood - 14(12.7%) 14(12.7%) Syndrome 4: Neurotoxicity/Paralysis   -    - - Total 7(6.4%) 103(93.6%) 110(100%)   Table 5. Number of envenomed cases by types of snake species identified and Out come                  of the bite from 2006-2011  Types of Snake Species  Identified        Out come of the bite Total        Fatal      Non fatal  1.  Africa’s Known most dangerous        snake [http://library.thinkquest.org]        1.1  Saw-Scaled or  carpet Viper      5(4.5%)        58(52.7%)    63(57.3%)     1.2  Puff Adder      2(1.8%) 21(19.1%) 23(20.9%)   -         -        - 2.   Other local  Snake Species        presented to  our Hospital            -       9(8.2%)     9(8.2%) 3.   No Snake identified            -  15(13.6%)      15(13.6%)          Total     7(6.4%)   103(93.6%)  110(100%)  69 ISSN 2073-9990   East Cent. Afr. J. surg  COSECSA/ASEA Publication    -East and Central African Journal of Surgery .  July/ August 2014 Volume 19 No. 2                             Figure 1.  shows the results of 20-minutes whole blood clotting test  for victims of snake bite  With  clinical  swellings. Coagulable blood (Rt. Hand) and incoagulable blood (Lt.Hand)          Figure 2. Shows the two Dead snake species caused envenoming & fatal bites as presented for identification by families  in  Dilchora referral hospital from 2006-2012. Bite on the upper limb accounted for 40 (36.4%), on the Lower limb for 66(60%) and on the head & trunk region for 4(3.6%) of the cases. Massive local swelling with incoagulable blood occurred in 71(64.5%) of the clinical syndrome, Massive local swelling with coagulable blood were seen in  28(25.5%) of the clinical syndrome, Mild local swelling with coagulable blood in 11(10%) of the clinical syndrome and there was no cases presenting with clinical Syndrome of neurotoxicity/paralysis (Table 2 and Figure1).   There were 7 deaths, giving a fatality rate of 6.4% (Table 3,4 and 5). Known Poisonous snakes caused 86(78.2%) of total envenoming (Table 5 and Figure 2).  Discussion  The study has shown that majority (62.7%) of the envenoming occurred in young adults  agd 15-44  years followed by Children under 15 years (32.7%). The finding is in agreement with other reports6,12,13,14.  Most (64%) bite occurred to the lower limb. This is also consistent with many Studies6,12,14.   It is also evident that massive local swelling with incoagulable blood is the commonest (64.5%) clinical syndrome followed by massive local swelling with coagulable blood(25.5%). Such clinical syndromes were documented in bites with saw scaled viper and Viper    Puff Adder 70 ISSN 2073-9990   East Cent. Afr. J. surg  COSECSA/ASEA Publication    -East and Central African Journal of Surgery .  July/ August 2014 Volume 19 No. 2      puff adder snake species respectively13. During the study period there was no single patient admitted with clinical syndrome of neurotoxicity/paralysis  indicating that snake bites due to Cobra and mambas species were rare to find in our hospital13 . Saw-scaled viper and puff adder snakes were the leading species resulting venomous admission and fatal bites in our hospital. Case fatality between syndrome1 and syndrome 2   presentations and between Viper and Puff adder snakes bite  did not show  statistically significant difference (P<0.05).   The identification of snake species is important for optimal clinical management, because it allows clinicians to choose the appropriate treatment, anticipate complications, and therefore to improve prognosis. Moreover, helps in selection of specific antivenom and avoids antivenom-induced adverse reactions6,14,15. Hence, It is crucial for physicians and other Health workers to be familiar with the most common venomous snakes in Ethiopia and the management of their bites in humans.  The proportion of fatal bites 6.4%  documented in this study is higher than the  recent finding 1.3% in rural Ghana11  and  2.9% in South Africa6  However it is significantly Lower than the finding 12.2%  in Nigeria2. Higher proportion of fatal bites  documented in our study is due to lack of comprehensive  Interventions including use of antivenom, development of treatment protocol, Staff training, monitoring of compliance and patient education 11.   Conclusion    Viper and Puff adder snakes were found to be the commonest causes of   envenoming and fatal bites in our Hospital. Hence procurement of antivenom in our Hospital must ensure the consideration of these two venomous species.  Recommendation 1. Further nation wide study to document the most common venomous snakes species, incidence, morbidity, and mortality of snake bites in Ethiopia. 2. Interventions including use of Antivenom, Development of management protocol, staff training etc. should be implemented to decrease morbidity and mortality of snake bites in Ethiopia. 3. Education of rural communities on snake bite, avoidance of useless or dangerous first-aid  measures, and the importance of rapid transport of victims to treatment centers should be widely implemented.   Acknowledgement   I would like to pass my heart felt thanks to Ato Anteneh Mekonen, Chief librarian Dilchora Hospital, Who helped me in downloading the Online pictures of Venomous Snakes of Africa and the patient’s family who brought the dead snakes to Dilchora Hospital.  References 1.  Stock RP, Massougbodji  A, Alagon  A, Chippaux JP.Bringing antivenom to sub-Saharan   Africa. Nat Biotechnol.2007; 173-177[pub Med] 2. Guti’errez JM,Theakston RD, Warrel DA.Confronting the neglected problem of snake  bite envenoming: the need for Global partner ship.PLoS Med.2006;3(6):e150. 3. Pinho FM, Zanetta DM,Burdmann EA. Acute renal failure after Crotalus durissus snake bite: a prospective survey on 100 patients.Kidney Int.2005;67:659-667. 4. Sitprija V.snake bite nephropathy.2006; 11:444-448. 5. Cheng AC,Winkel K.call for Global Snake bite control and procurement funding.Lancet.2001; 357:1132. 71 ISSN 2073-9990   East Cent. Afr. J. surg  COSECSA/ASEA Publication    -East and Central African Journal of Surgery .  July/ August 2014 Volume 19 No. 2      6. Ogubanjo GA, Management of Snake bites at rural South African hospital,SA Fam Pract 2009; 51(3)224-227.  7. Paul VK. Animal and Insect bites. In:Singh M,ed. Medical emergencies in Children. 2nd  edition.New Delehi:Sage Publications;1993. 8. Hansdak SG,Lallar KS,Pokharel P,et al. A clinico epidemiological study of snake bite in Nepal. Tropical Doctor 1998; 28:223-6. 9. Heap BJ,Cowan GO. The Epidemology of snake bite presenting to British military Dharan during 1989. JR Army med Corps 1991; 137(3):123-5. 10.Kulkarni ML,Anees S. Snake venom poisoning: experience with 633 cases. Ind pediatr 1994; 31(10):1239-43. 11. L.EA Vissera, SAkyei-Faried,D.WA Belcher,Protocol and monitoring to improve snake bite out comes in rural Ghana,Journal Home,Volume98,Issue5,May 2004,pp 278-283.  12.Muguti GI, Maramba A, Washaya CT, Snake bites in Zimbabwe: a clinical study with emphasis  on the need for antivenom. Cent Afr J Med 1994; 40(4):83-8. 13. David A Warrell, Snake bite in sub-Saharan Africa, Africa Health, July 1999,pp5-9. 14. Wangoda R.,Watmon B.,Kisige M, Snake bite management: Experiences from Gulu Regional Hospital Uganda, East and Central African Journal of Surgery, 2004; 9 (1) : 82-86. 15. Alirol E, Sharma SK, Bawaskar HS, Kuch U, Chappuis F (2010) Snake Bite in South Asia: A Review .PLoS Negl Trop Dis 4(1): e603. doi:10.1371/journal.pntd.0000603                                        

Identification of the Commonest Snake Species Causing Envoniming and Fatality among Snake Bites of Venomous Admission in Dilchora Referral Hospital

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Patterns of Fractures and Their Current Hospital Management in Eastern Ethiopia: A Six-Years Prospective review

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