Orthopedic Activity in Field Hospitals Following Earthquakes in Nepal and Haiti : Variability in Injuries Encountered and Collaboration with Local Available Resources Drive Optimal Response.

BACKGROUND: Field hospitals have been deployed by the Israel Defense Forces (IDF) Medical Corps in numerous disaster events. Two recent deployments were following earthquakes in Haiti in 2010 and in Nepal in 2015. Despite arrival in similar timetables, the mode of operation was different-independently in Haiti and in collaboration with a local hospital in Nepal. The pathology encountered in the two hospitals and the resultant treatment requirements were significantly different between the two events. The purpose of this study was to analyze these differences and their implications for preparation and planning of future deployments. METHODS: Data were obtained from IDF records and analyzed using SPSS™ software. RESULTS: 1686 patients were treated in Nepal versus 1111 in Haiti. The caseload in Nepal included significantly less earthquake-related injuries (26 vs. 66 %) with 28 % of them sustaining fractures versus 47 % in Haiti. Femoral fractures accounted for 7.9 % of fractures in Nepal versus 26.4 % in Haiti with foot fractures accounting for 23.8 and 6.4 %, respectively. The rate of open fracture was similar at 29.4 % in Nepal and 27.5 % in Haiti. 18.1 % of injured patients in Nepal underwent surgery, and 32.9 % of which was skeletal compared to 32 % surgical cases (58.8 % skeletal) in Haiti. 74.2 % of patients in Nepal and 34.3 % in Haiti were treated for pathology unrelated to the earthquake. CONCLUSIONS: The reasons for the variability in activities between the two hospitals include the magnitude of the disaster, the functionality of the local medical system which was relatively preserved in Nepal and destroyed in Haiti and the mode of operation which was independent in Haiti and collaborative with a functioning local hospital in Nepal. Emergency medical teams (EMTs) may encounter variable caseloads despite similar disaster scenarios. Advance knowledge of the magnitude of the disaster, the functionality of the local medical system, and the collaborative possibilities will help in planning and preparing EMTs to function optimally and appropriately. However, as this information will often be unavailable, EMTs should be capable to adapt to unexpected conditions.

Pediatric Orthopedic Injuries Following an Earthquake: Experience in an Acute-Phase Field Hospital.

BACKGROUND: Following the 2010 earthquake in Haiti, the Israel Defense Forces Medical Corps deployed a field hospital in Port au Prince. The purpose of this study was to characterize the injuries sustained by the pediatric population treated in the hospital and examine the implications for planning deployment in future similar disasters. METHODS: Medical records of children treated in the hospital were reviewed and compared with medical records of the adult population. RESULTS: A total of 1,111 patients were treated in the hospital. Thirty-seven percent were aged 0 to 18 years. Earthquake-related injuries were the cause of admission in 47% of children and 66% of adults. Forty-seven percent of children with traumatic injuries sustained fractures. Seventy-two percent were in the lower limbs, 19% were in the upper limbs, and 9% were in the axial skeleton, with the femur being the most common long bone fractured compared with the tibia in adults. There were four functional operating theaters, and treatment guidelines were adjusted to the rapidly changing situation. Soft tissue injuries were treated by aggressive debridement. Fractures were stabilized by external fixation or casting. Amputation was performed only for nonviable limbs or life-threatening sepsis. Children were more likely than adults to undergo surgery (44% vs. 29% of trauma patients). To maximize hospital surge capacity, minor procedures were performed in the wards under sedation, and patients were discharged after an average of 1.4 days, with subsequent follow-up in the clinic. CONCLUSION: Children constitute a high percentage of patients in a developing country. The epidemiology of pediatric injuries following an earthquake differs significantly from that encountered in everyday practice and compared with that in adults. Children sustain a significantly higher percentage of femoral fractures and are more likely to require surgery. The shift to nontraumatic reasons for admission occurred earlier in the pediatric population than in adults. Organizations providing post-earthquake relief are usually geared toward adult populations and will require supplementation of both manpower and equipment specifically suited for treatment of pediatric patients. Early deployment teams should be adequately staffed with adult and pediatric orthopedists.

External fixator frames as interim damage control for limb injuries: experience in the 2010 Haiti earthquake.

BACKGROUND: An earthquake occurred in Haiti on January 12, 2010. The center of earthquake and the most extensive damage occurred near the capital Port-au-Prince. There were an estimated 230,000 deaths with more than 250,000 others injured. The Israeli Defense Forces Field Hospital (IDF hospital) is a military unit composed of army-recruited (volunteer) medical personnel that was sent to Haiti to serve as a stand-alone center for early response until larger medical missions could become functional and take on the task of more sophisticated and long-lasting medical support. This study describes the use of external fixator frames for orthopedic damage control whereby bone stabilization in conjunction with soft tissue care serves as a stopgap until more comprehensive therapy is forthcoming. METHODS: Data were collected from patients' files (generated at the IDF hospital) regarding the use and immediate outcome of limbs stabilized by external fixator frames. RESULTS: During the 10 days of the IDF hospital's activity, a total of 1,111 patients were admitted; 244 surgical procedures were performed under general or regional anesthesia and of these, the orthopedists performed 221 (90%) surgical procedures. Seventy-three fractures were stabilized operatively by application of an external fixator. Most of the frames were applied on fractures (closed and open) of the lower limbs (48 on femur and 24 on tibia/fibula). All procedures were performed in a field-style operating room. Sterile technique was possible only for elements actually inserted into the patient. Limb alignment was based on manual palpation: intraoperative fluoroscopy was not available; soft tissue care followed bone stabilization. No patient died. All patients completed urgent stabilization at the IDF hospital and were transferred to other facilities or discharged for home care. CONCLUSIONS: We describe "orthopedic damage control" using external fixator frames for bone stabilization and soft tissue care as a viable approach in the context of a mass casualty scenario. Technical aspects are described in detail in addition to the advantages and limitations of this approach, which could serve as guidelines for future military and civilian scenarios where large-scale orthopedic damage control would be practiced.

Extensor mechanism reconstruction: a novel technique for bone patella allograft post partial patellectomy failure.

Extensor mechanism disruption, whether due to patella fracture or tendon rupture, generally occurs after low-energy trauma and frequently involves an indirect mechanism. When the fracture is comminuted and reconstruction is impossible, a partial or total patellectomy may be indicated. Although some authors advocate total patellectomy, partial patellectomy remains the standard treatment, especially for young and active patients. In the rare instance of a failed tendon repair after partial or total patellectomy, inadequate tissue is usually available for adequate restoration of the extensor mechanism. Extensor mechanism allograft, using the tibial tuberosity, patellar tendon, patella, and quadriceps tendon in continuity or the Achilles' tendon with calcaneal bone-block in continuity has been reported for extensor mechanism repair after total knee arthroplasty in patients who did not undergo patellectomy. We present a novel technique, using the bone patellar tendon bone allograft to reconstruct a posttraumatic defect of the extensor mechanism in a 28-year-old, active patient with a failed partial patellectomy following fracture of his patella. Union of the allograft was seen on x-ray after 4 months. After 6 months, the patient reached full range of motion and returned to his previous sporting activities.

The fixion proximal femur nailing system: biomechanical properties of the nail and a cadaveric study.

The treatment of choice for early mobilization of hip fracture is surgery, which traditionally employs side plates and screws or intramedullary nails. We examined the biomechanical properties of a new proximal femoral nail system. The new expandable Fixion proximal femur nailing (PFN) system, made of stainless-steel alloy, consists of a nail, a peg and an anti-rotation pin. Upon positioning, the nail and peg are expanded to their maximal diameter. The current biomechanical study investigated: nail bending strength and stiffness, fatigue properties and hip peg strength. A cadaveric study that determined the effect of the expandable peg on the femoral head included subsidence testing, pull and torsion testing and intra-osseous pressure (IOP) measurements before and after expansion. Biomechanical properties of the new nail met ASTM F384 guideline requirements. The cadaver study yielded equivalent results for the pullout test between the peg and the hip screw, but found the peg superior in the torsion strength test. IOP during peg insertion and expansion was substantially lower than the threshold pressure that causes avascular necrosis. The biomechanical tests found the new system to be safe and able to provide good abutment of the nail to the bone. We conclude that the Fixion PFN system proved to be an effective proximal femur fracture fixation device.

Avulsion of the triceps tendon during acceleration stress.

The authors present a rare case of triceps tendon avulsion associated with +5 G-force and muscle straining. Although failure of musculoskeletal system, mainly the cervical spine, secondary to high-G exposure has been reported, this is the first report they have found of a triceps tendon avulsion. Furthermore, unlike other traumatic triceps avulsions reported, the pilot involved had no known predisposing factors. Awareness of the possibility of such an injury must be maintained when a pilot of high performance aircraft presents with elbow pain.

[Updates in osteogenesis imperfecta].

Osteogenesis Imperfecta, a heterogenous group of inherited disorders, is characterized by both bone fragility and low bone mass. Since the Sillence classification of the disease, significant progress has been made in understanding the molecular, histological and genetical pathogenesis of the disease, and it led to expanded nosology. The multidisciplinary approach including rehabilitation, medications and surgery, may significantly improve the quality of life and prolong life expectancy.

Pediatric orthopedic injuries following an earthquake: experience in an acute-phase field hospital.

BACKGROUND: Following the 2010 earthquake in Haiti, the Israel Defense Forces Medical Corps deployed a field hospital in Port au Prince. The purpose of this study was to characterize the injuries sustained by the pediatric population treated in the hospital and examine the implications for planning deployment in future similar disasters. METHODS: Medical records of children treated in the hospital were reviewed and compared with medical records of the adult population. RESULTS: A total of 1,111 patients were treated in the hospital. Thirty-seven percent were aged 0 to 18 years. Earthquake-related injuries were the cause of admission in 47% of children and 66% of adults. Forty-seven percent of children with traumatic injuries sustained fractures. Seventy-two percent were in the lower limbs, 19% were in the upper limbs, and 9% were in the axial skeleton, with the femur being the most common long bone fractured compared with the tibia in adults.There were four functional operating theaters, and treatment guidelines were adjusted to the rapidly changing situation. Soft tissue injuries were treated by aggressive debridement. Fractures were stabilized by external fixation or casting. Amputation was performed only for nonviable limbs or life-threatening sepsis. Children were more likely than adults to undergo surgery (44% vs. 29% of trauma patients). To maximize hospital surge capacity, minor procedures were performed in the wards under sedation, and patients were discharged after an average of 1.4 days, with subsequent follow-up in the clinic. CONCLUSION: Children constitute a high percentage of patients in a developing country. The epidemiology of pediatric injuries following an earthquake differs significantly from that encountered in everyday practice and compared with that in adults. Children sustain a significantly higher percentage of femoral fractures and are more likely to require surgery. The shift to nontraumatic reasons for admission occurred earlier in the pediatric population than in adults. Organizations providing post-earthquake relief are usually geared toward adult populations and will require supplementation of both manpower and equipment specifically suited for treatment of pediatric patients. Early deployment teams should be adequately staffed with adult and pediatric orthopedists. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Global responsibility in mass casualty events: the Israeli experience in Japan.

OBJECTIVE: To describe humanitarian aid following the 2011 earthquake and tsunami in Japan. SETTING: A field hospital deployed in a small Japanese coastal village devastated by a major tsunami. PATIENTS: Thousands of Japanese refugees with minimal access to medical care. RESULTS: After well-coordinated diplomatic efforts, our medical delegation was the first foreign team to deploy in Japan. Our facility served as a regional referral center for specialized medical treatment. CONCLUSIONS: Following major disasters, even highly modernized countries will face an urgent surge in the need of medical resources. These situations emphasize the need for global responsibility to provide assistance.

Orthopaedic management in a mega mass casualty situation. The Israel Defence Forces Field Hospital in Haiti following the January 2010 earthquake.

Following the January 2010 earthquake in Haiti, the Israel Defence Forces (IDF) established a field hospital in Port au Prince. The hospital started operating 89 h after the earthquake. We describe the experience of the orthopaedic department in a field hospital operating in an extreme mass casualty situation. The hospital contained 4 operating table and 72 hospitalization beds. The orthopaedic department included 8 orthopaedic surgeons and 3 residents. 1111 patients were treated in the hospital, 1041 of them had adequate records for inclusion. 684 patients were admitted due to trauma with a total of 841 injuries. 320 patients sustained 360 fractures, 18 had joint dislocations and 22 patients were admitted after amputations. 207 patients suffered 315 soft tissue injuries. 221 patients were operated on under general or regional anaesthesia. External fixation was used for stabilization of 48 adult femoral shaft fractures, 24 open tibial fractures and 1 open humeral fracture. All none femoral closed fractures were treated non-operatively. 18 joint reductions and 23 amputations were performed. Appropriate planning, training, operational versatility, and adjustment of therapeutic guidelines according to a constantly changing situation, enabled us to deliver optimal care to the maximal number of patients, in an overwhelming mass trauma situation.

Application of information technology within a field hospital deployment following the January 2010 Haiti earthquake disaster.

Following the January 2010 earthquake in Haiti, the Israel Defense Force Medical Corps dispatched a field hospital unit. A specially tailored information technology solution was deployed within the hospital. The solution included a hospital administration system as well as a complete electronic medical record. A light-weight picture archiving and communication system was also deployed. During 10 days of operation, the system registered 1111 patients. The network and system up times were more than 99.9%. Patient movements within the hospital were noted, and an online command dashboard screen was generated. Patient care was delivered using the electronic medical record. Digital radiographs were acquired and transmitted to stations throughout the hospital. The system helped to introduce order in an otherwise chaotic situation and enabled adequate utilization of scarce medical resources by continually gathering information, analyzing it, and presenting it to the decision-making command level. The establishment of electronic medical records promoted the adequacy of medical treatment and facilitated continuity of care. This experience in Haiti supports the feasibility of deploying information technologies within a field hospital operation. Disaster response teams and agencies are encouraged to consider the use of information technology as part of their contingency plans.

The discoid meniscus.

Discoid lateral meniscus is an intra-articular knee disorder typically presented in the young population and during adolescence. Different types of meniscal disorders and varied forms of presentation have been reported. The natural history depends on the type of anomaly and the presence of symptoms. Management of the disorder should be directed toward the resolution of the symptoms while preserving meniscal tissue and function. Modern surgical techniques enable suturing and preservation of meniscal tissue. The clinical manifestations, diagnostic modalities and criteria, accompanying conditions and practical management considerations are reviewed.

The importance of the valgus stress test in the diagnosis of posterolateral instability of the knee.

BACKGROUND: The diagnosis of posterolateral instability of the knee is often based on a typical indirect mechanism of injury, a history of "giving way" and a positive dial test. Our search of the English literature revealed no mention of including the valgus stress test in the diagnostic protocol for posterolateral instability. HYPOTHESIS: Based on our experience, we hypothesised that a medial collateral ligament (MCL) tear will also produce a positive dial test and that a valgus stress test would provide differential diagnostic information. METHODS: The MCL's of 14 fresh cadaveric knees (7 cadavers) were cut to simulate a grade 3 tear, taking care not to damage the medial retinaculum or the posteromedial stabilisers of the knee. The amount of tibial external rotation (the dial test) was measured for each knee before and after transection of the MCL. RESULTS: The results of the dial test after transection of the MCL were similar to those stemming from a solitary injury to the posterolateral corner. There was a significant increase in external rotation of the knee in 30 degrees and 90 degrees of flexion. More over, external rotation in 30 degrees was significantly greater than external rotation in 90 degrees of knee flexion. CONCLUSIONS: Whenever suspecting a posterolateral complex injury, one has to carefully perform a valgus stress test in 0 degrees and 30 degrees. Although the support of a clinical study is needed in order to make a definite conclusion, the dial test is probably not reliable in the presence of medial instability, and alternative diagnostic measures should be used.

The femoral head expandable peg: improved periimplant bone properties following expansion in a cadaveric model.

PURPOSE: The femoral head expandable peg offers a new concept of bone-device purchase treating proximal femur fractures. We describe the expansion influence on both the periimplant bone properties and the intraosseous pressure. METHODS: A 10 x 8 mm cannulated peg consisting of a stainless steel oval-shaped transversely sectioned rod was tested on 13 femoral heads retrieved from patients with subcapital fracture treated by hemiarthroplasty. Normal saline solution was used to expand the diameter of its membrane from 7.8 to 10.5 mm, resulting in abutment of the distal peg to the compacted cancellous bone of the femoral head. The intraosseous pressure was monitored using a 1.4 mm drill-hole. RESULTS: Dual-energy X-ray absorptiometry and microradiography demonstrated increased periimplant bone density following peg expansion, without significant increase in the intraosseous pressure. CONCLUSION: The new implant afforded improved periimplant bone density, less trabecular damage and preservation of bone stock, all contributing to reliable biomechanical support and potentially decreasing the high complication rate following screw fixation in osteoporotic femora. Further studies are needed in order to establish clinical safety and efficacy.