Neglected Musculoskeletal Injuries Anil K Jain, Sudhir Kumar
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Neglected Musculoskeletal Injuries – Magnitude of ProblemCHAPTER 1

Anil K Jain,
Sudhir Kumar
Injuries are major cause of death and disability globally. Mortality rates from injury are higher in low and middle income countries compared with high income countries due to increased use of motorized transport and less developed roads and trauma care system1,2. For every person who dies from injury, many more are injured resulting in temporary or permanent disability. The combined rates of extremity injury from falls and road traffic accidents ranged from 1000 to 2600/100000 per year in low and middle income countries compared to 500/100000 per year in High income countries.2 Musculoskeletal injuries needing urgent care are often amongst the commonest conditions at the first referral health facilities. Often these facilities lack specialists such as orthopedic surgeon, trauma surgeon, general surgeon, anesthesiologist, emergency and critical care physician. They are initially being treated by non specialist doctors, nurses, clinical officers, technicians and paramedics. Such persons working in difficult, isolated circumstances with limited equipments have limited capabilities for urgent referral to more specialized centers. By the time the patients reach a specialized tertiary care centre they have malunited or ununited limb bone fractures or established infected non unions or nonunions with broken implant or mal positioned implants (Figs 1.1 to 1.4). Each injury when reported for the first time would have bony and soft tissue problems.3 The soft tissues of these extremities may be indurated, the muscles are scarred with contracture of adjacent joints. Skin may be scarred or adhered to the bone or has a raw area covered with infected granulation tissue with weeping wound. To treat such soft tissues, it requires repeated debrima and skin coverage procedures. One may need to do an additional planning for adjacent joints to bring them into a functioning position either by distraction method or gradual mobilization.
The causation of neglected trauma may be:
  1. Poly trauma patients with craniocephalic trauma and damage to chest, thorax or abdomen.
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    Figs 1.1A and B: X-rays lateral view of cervical spine (A) shows 8 weeks old dislocation of C5 and C6 (B) Lateral X-ray of dorsal spine shows. 4months old fracture L1 with kyphosis
    2
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    Figs 1.2A to C: AP X-ray of left hip shows (A) dislocated hip with bipolar prosthesis in situ and head of femur and trochanter are seen (B) nonunion fractures neck of femur because of late presentation (C) nonunion neck of femur with resorption of neck with implant in situ
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    Figs 1.3A and B: X-ray of left hip shows (A) dislocated hip as a sequelae to septic arthritis (B) one year old neglected dislocation left hip with fracture acetabulum. The patient reported after one year for treatment
    These life-threatening clinical problems have taken precedence over fractured bones for treatment and hence are reported as neglected trauma.
  2. The patients who had been advised unjustified, prolonged and unsuccessful conservative treatment. Most of the time such fractures are closed or grade I open injury which may report with ununited or malunited fractures.
  3. Improperly treated fractures in suboptimal operation theatre conditions may develop infected nonunion or implant failure. The fractures when internally fixed by implants which do not provide biomechanical stability at fracture site may result in implant failure. It requires removal/revision of the implants and augmentation procedure for fracture union. The removed plate or a broken intramedullary nail requires additional procedure with underlying osteopenic bones.
  4. Injuries not diagnosed in time: A fracture or dislocation may be missed during initial treatment. This usually occurs when dislocation of hip or fracture neck of femur is missed along with femoral shaft fracture where attention is diverted towards most glaring injury. The cervical spine injuries are missed in association with head injury or obvious dorsolumbar fractures with paraplegia or a ligament injury of knee is missed in fractures of tibia and femur.
 
STRATEGIES
The problems are multifold in these cases.4 The neglected musculoskeletal problem may be a single bone fracture. The treatment strategy here may include problem of skin coverage, persistent infection, implant removal, stabilization of fracture, augmentation of healing potential of bone and graded weight bearing mobilization to achieve healing with mobile joints with good functional outcome. In those cases where more than one bone is involved in one limb, the problem increases in term of deformity, malunion or nonunion. Here again besides soft tissue problems and augmentation of healing potential, we need to rationalize the treatment for correction of deformity, plan stabilization of all fractures in 1 or 2 stages.3
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Figs 1.4A to E: X-rays (A) lateral view of femur shows nonunion of subtrochanteric region with broken implant (B) ununited radius fracture with implant in situ (C) nonunion of humerus with implant failure (D) neglected dislocation of elbow in a child (E) neglected fracture dislocation of wrist
The autograft has limited availability hence has to be used judiciously. The plan of surgery should be such that besides fracture stability, mobilization of adjacent joint is planned. Multiple fractures in more than one extremity warrants planning about the stages of surgery, i.e., upper limb or lower limb or both at one stage or in stages. How and when rehabilitation is to be instituted so as to achieve functional mobile joint are important considerations. Each bone and limb has to be evaluated independently for deformity and fracture configuration. The method chosen may be a combination of open reduction internal fixation or compression distraction method of Ilizarov. Summarily no cook book solution can be offered. The plan of treatment has to be individualized. Even after surgical treatment, repeated visits to the hospital have to be planned for rehabilitation strategy.
The patients must be informed about the treatment plan in terms of chances, problems and obstacles to the success of treatment and final outcome. The expected outcome in terms of function of the adjacent joints needs to be prognosticated. It is also the responsibility of the orthopaedic surgeon to educate their patients of the late complications likely to occur such as avascular necrosis of femoral head in a dislocated hip or fractures neck of femur, and late osteoarthrosis in intra-articular fractures even after correction of malalignment.
REFERENCES
  1. Mock C, Cherian MN. The global burden of musculoskeletal injuries challenges and solutions. Clin Orthop Relat Res 2008;466(2)306–16.
  1. Richard A, Spiegel DA, Coughlin R, Zirkle LG. Injuries: the neglected burden in developing countries. Bull World Health Organ. 2009;87:246.
  1. Jain AK. Editorial Remarks in symposium on “Treatment of Neglected Trauma”. Clin Orthop Relat Res 2005;431:2–3.
  1. Onoprienko GA, Buatchidze OS. Treatment of neglected complicated multiple musculoskeletal injuries. Clin Orthop Relat Res 1995;320:24–7.