Tuesday, February 23, 2010

Sri Lanka: Hundreds need reconstructive orthopedic surgery - MSF

Many patients who had surgery during the time of fighting between the Sri Lankan army and the Tamil Tigers (LTTE) that were operated on initially under emergency conditions have developed infections, particularly of the bone. The wounds, mostly caused by exploding shells and bullets, have not healed.

Dr. Inga Osmers, an MSF orthopedic surgeon, stops by a patient's bed and reviews the X-ray. An internal plate is clearly visible, attached to the bone beneath the skin. "We can see on the X-ray that the two bones are still far apart and we can see this little hole on the skin, which we call a fistula," the surgeon explains. "It is a sign of infection, a natural discharge channel. It is not very visible or striking, but underneath it, the infection has already done quite a bit of harm." Infections are very frequent in the case of war wounds, when a foreign body enters; here, most often, small shell fragments. The risks are even higher when there are many wounded patients at one time and not enough surgical resources to intervene quickly under optimal conditions.

Speaking to the patient, Inga says, "Here's what I can do: open the wound, clean it, remove the internal fixator and replace it with an external one to reduce the presence of foreign bodies in the wound. But that means you'd have to stay in the hospital for at least another several weeks. The other possibility is to wait and hope that the wound will heal, with the fistula allowing pus to drain out. I'll let you think about this for a while. Do you know when you have to go home?" The answer is no. Over the last few weeks, large numbers of displaced persons have been returning home. MSF patients are worried that hospitalisation will prevent them from going back. That's why the medical staff is careful not to perform lengthy treatments - except in the case of medical urgency - without talking it over with the patient first.

Clean, stabilise and treat to encourage healing

Leaning against the bed of an 18 year-old patient, Ingma explains the situation to the young woman. "We cleaned the wound by removing the infected tissues and bits of bone, and placed an external fixator on your leg to stabilise it. During the operation, we also took tissue samples for analysis. This will tell us what kind of infection you have and which antibiotics will be effective."

Wounded on April 20, this young woman had been transferred to a functioning hospital more than three days later. There, she would not agree to amputation. Five weeks later, she left the hospital with a cast and crutches. She was in constant pain, but it was bearable. The pain worsened in early November. She went to a clinic at the Menik Farm camp, where the Ministry of Health doctor referred her to the MSF hospital. She learned that the wound had not healed inside the cast and that pus was seeping out. An X-ray at the hospital revealed that the bone had not set and had become infected.

Finding patients who need surgery

In many cases, patients return home before having an operation that could ensure they would have the best possible use of their limb. "There are certainly several hundred patients who need reconstructive surgery," says Dr. Patrick Herard, an MSF consulting surgeon. "There is really no urgency. It's more a question of future quality of life than of life or death. However, they would have to agree to new operations, which will mean weeks, even months, of hospitalisation to preserve or improve the use of the wounded limb. We have experience in this kind of operation, specifically with our program in Amman, Jordan, for wounded Iraqis. MSF has developed expertise in second and third-line surgery for war wounds."

When these wounded patients return to their families and their homes, requests for this kind of surgery will probably increase.

© Medecins Sans Frontieres

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