Orthopaedics at Tenwek: Cold Trauma Center of Excellence

As I mentioned before, the Ortho service is consistently busy. It seems like we are constantly playing catch up, because, in reality, that is exactly what we are doing. Most of what we deal with is trauma...the broken bones from boda boda (motorcycle) accidents, matatu (bus) accidents, people getting beat up in family disputes or arguments with neighbors, and kids falling out of trees (no monkey bars here to fall off of).

[side note: as I type this, two Kenyan kids are mking fun of the hair on the top of my feet and asking why its not on the sides. Good question.]

Unfortunately, a lot of these injuries show up several weeks or months later. You may have heard of cold trauma. This trauma often has freezer burn. Sometimes we can help, sometimes there is nothing we can do. Here are a few examples:

Man in his early 40s with a femur fracture that was treated with herbal medications. It didnt work. I bet he doesnt believe in vaccinating his kids, either.

63yo Male with untreated tibia plateau fracture. His lateral plateau collapsed and now has the deformity below.

He now has a 20 deg valgus deformity and his knee gives out every time he takes a step.

Bilateral femoral neck fractures that are a year old? Some infectious process? Malignancy? Who knows.

Man in his late 30s that had some sort of hip fracture in 2009. It looks some sort of fixation was attempted but now his hip is ankylosed and he needs a total hip. Unfortunately, that costs about 4 years worth of income so it is unlikely that he will get one.



6 year old girl with tibia fracture that has been open for 9 months. We're trying to save her leg so all the dead bone (sequestrum) has been removed, which was about half of her tibia. We will wait for the soft tissues to heal and then try something crazy like a vascularized fibula transfer.



80 something year old woman with unstable intertroch fracture, at least a month old. We put a nail in her (PTN from Biomet), but unfortunately she still isnt really getting out of bed and is having problems healing her incisions, partly because she lays in her own urine and partly because she doesnt really eat.



16yo boy came with 3 day old talar neck fracture dislocation. He has almost a 100% chance of getting AVN and our main trauma guy was gone. So, a visiting Sports guy scrubbed with me and I fixed my first ever talus. Now, we pray for a miracle.



Mid 40s woman from Uganda came with this humerus shaft fracture that was "fixed" about a year ago. She has no function of her radial nerve and even her ulnar nerve function is weak. So a 4th year resident and I took this plate out, freed up the radial nerve (which I was convinced had been cut but fortuately was continuous), took out about 5-6cm of avascular bone, and put on a new plate. We'll see if anything improves.



This large woman from Lake Victoria had an unstable intertroch fixed at another facility several months ago. Unfortunately, they used a plate meant for the distal femur and put it in the greater trochanter instead of the head. Needless to say, that didnt work. (continued below)



Since her femoral head had not been violated, we took out her old plate, took down the nonunion, did an osteotomy to correct her varus, then put in a long DHS. She walked out of the hospital with a walker after a few days.

The last one for now is a 32yo guy that had an accident in 2012 and had an unstable intertroch fracture. He was intially treated at the national hospital with not so good results.

2012 - treated with an angled blade plate that hasnt been used regularly in America for about 30 years

Plate broke in 2013

Revised to a cephalomedullary nail in 2014. This is a perfect example of the right surgery performed incorrectly. First of all, the nail is supposed to enter the piriformis fossa on the other side of the greater trochanter. But if the fracture site is staring right at you, why not just slide a nail in? The screws are supposed to go in the middle of the femoral head, not partway up the neck.

Of course this failed and he showed up to us with constant pain, a shortened leg, and an inability to sleep for 3.5 years.

This is his leg in the OR. You can see the screws and the top of the nail sticking out the side of his leg. No wonder it hurts to roll over on that side.

We took out his nail, performed a valgus osteotomy so he could regain some of his leg length, put in a DHS and let him start bearing weight right away. He walked out of the hospital two days later.

So thats at least a sample of the cold trauma cases we get to deal with. Hopefully they provided a little insight into the challenges we face here. I'll post more interesting cases later, including some of the open tibias we manage.