Fractures in children in south eastern Nigeria.

OBJECTIVES: To evaluate the pattern of fractures in children in the south eastern region of Nigeria, seeking to highlight the planning and designs of buildings, roads and playgrounds to prevent paediatric fractures. DESIGN: Retrospective review of paediatric patients with fractures who presented at the only tertiary referral centre in the region. SETTING: A university teaching hospital situated in the south eastern corner of Nigeria. SUBJECTS: 102 paediatric patients treated for fractures between January 1993 and December 1995. MAIN OUTCOME MEASURES: Causes of fractures and their anatomical distribution. RESULTS: 71 boys and 31 girls were treated for fractures. The commonest cause of fractures was road traffic accidents accounting for 50% of the patients, followed by falls and collapsing mud walls. Most of the fractures seen (58 patients) were of the green stick type. The femur was the commonly fractured bone (25 patients) followed by the radius (22 patients) and humerus (20 patients). Road traffic accident victims presented earlier at the hospital than victims of other causes. Also lower limb fracture patients presented earlier than patients with upper limb fractures. CONCLUSION: Paediatric fractures are amenable to conventional conservative therapy and open reduction became necessary in long neglected cases with associated malunion. Since the causes of fractures are largely preventable, public enlightenment campaigns, provision of pedestrian pathways, care on the part of school authorities and proper structural construction of the traditional houses may help reduce the number of cases of fracture in our environment.

Bone disorders in sickle-cell disease.

Sickle cell disease involves many organs but musculo-skeletal problems present most often with bone pain, the most common reason for admission to hospital. Two separate pathological abnormalities cause these lesions. Sickling of the red cells produces thromboembolic infarcts in bone leading to pain, crises and sometimes osteomyelitis; increased destruction of sickle red cells produces haemolysis, an increase in erythroblastic activity and expansion of the bone marrow cavity. Dactylitis, avascular necrosis of the head of the femur particularly, osteomyelitis, retardation of growth and leg ulcers are commonly encountered Management is by standard orthopaedic principals. At operation care must be taken in the use of a tourniquet, adequate oxygenation is required and the possibility of acute renal failure must be recognised.

Traumatic finger amputations in Bulawayo.

A prospective study of 20 patients with traumatic amputations of the fingers and a thumb was carried out during a six week period at Mpilo Central Hospital, Bulawayo. Most of the adult injuries (17 patients) resulted from industrial accidents (76.5 pc) while two out the three children sustained their injury from domestic accidents. Inadequate safety precaution, ignorance and human error contributed significantly to the injuries. Safety education and preventive measures both at home and in industry should be inoculated into the daily life of individuals.

Coping with osteomyelitis.

PIP: Osteomyelitis, or infection of the bones, is a common orthopedic condition in the young in developing countries which causes severe deformity and morbidity. Acute osteomyelitis is of hematogenous origin, and in adults it results from infected open fractures or a leg ulcer from Staphylococcus aureus (over 80%), or mixed with Streptococcus pyogenes, Pseudomonas spp, Proteus spp, Escherichia coli, and Salmonella typhi. In a classic case of acute osteomyelitis, a child under 10 presents severe bone pain, pyrexia of 39-40 degrees Celsius, and inability to use the limb. Blood culture is positive in 60% of cases, and white cell count is elevated to around 20,000/ml indicative of leucocytosis. After 12 weeks of intense infection in the bone, chronic osteomyelitis sets in. A large abscess develops in the subperiosteal soft tissue extending into the tissue planes. Discharging sinuses and fistulae appear along with bony deformity. In advanced cases, X-ray shows complete separation of the dead bones (sequestrum) or a defect in the length of bone. In acute osteomyelitis, treatment calls for the limb to be splinted and elevated. The usual regimen is to give 500 mg iv cloxacillin every 6 hours for 24-48 hours in combination with intra-muscular gentamicin (40 mg, every 8 hours) and analgesics as well as small doses of pethidine for 24 hours. Antibiotic therapy must continue for 8-12 weeks with a follow-up X-ray at 3 months to confirm complete recovery. In chronic osteomyelitis, which can linger for year, subcutaneous and subperiosteal abscesses should be drained without sequestrectomy until involucrum has formed. Public awareness has to be increased about urgent medical attention at an early stage to avoid amputation in very severe cases in adults.^ieng

Hyperpyrexia in spinal injury patients.

We studied 13 spinal injury patients who had hyperpyrexia during an 18 month period (September 1984-March 1986) to discover if differences existed in the core temperature of patients with tetraplegia and those with paraplegia, and the contribution of these differences to the final outcome. Children were excluded from this study as well as patients with any sign of infection on first admission, patients with multiple injuries, and those referred from peripheral hospitals more than one week after injury. Patients with tetraplegia (C3-C7) had persistently high and uncontrollable core temperatures (average 39.5 degrees C) while those with paraplegia (T4-L5) showed lower core temperatures which were still high (average 38.1 degrees C). The difference in the average high core temperature (1.4 degrees C) is statistically significant. The lowest average core temperatures were about the same in tetraplegics and paraplegics (just over 35 degrees C). Four patients died: 3 tetraplegics and one paraplegic. Antipyretic analgesics were ineffective in reducing the high core temperatures.

Hip dislocations in chronic osteomyelitis.

We present two cases of spontaneous dislocation of the hip joint due to chronic osteomyelitis of the upper femur. Spontaneous hip dislocations occur in certain pathological conditions such as poliomyelitis (Ingram, 1980), cerebral palsy (Howard et al., 1985), osteomyelitis and neurofibromatosis.

Medical problems in off-shore oil drilling in Nigeria.

This paper discusses the surgical and medical problems affecting off-shore oil drilling workers in the south-eastern Atlantic coastline of the Nigerian territorial waters; about 50-60 kilometers from land. There were a total of 1300 attendances at the off-shore clinic within 12 months, ie 3.6 daily for a workforce of 110, were successfully managed by 2 well-trained industrial staff nurses who were supervised by an experienced base doctor on-shore. Although, most of the patients were treated for minor medical and surgical conditions such as headaches, malaria, cuts and bruises, a few acute emergencies arose which had to be taken on-shore by helicopters, for subsequent management. Four accidental deaths occurred during the period, one of them was clearly preventable but there were no major disasters. This demonstrated the effectiveness and significant role which well-trained nurses can play in industrial health.

Ipsilateral axillary nerve palsy and corneal ulceration complicating severe measles. A case report.

A three-year-old boy, who was previously healthy, had a severe attack of measles which resulted in left corneal ulceration with blindness and axillary nerve palsy on the same side with subglenoid subluxation of the humerus. The recovery of the function of the nerve after one year of intensive physiotherapy was negligible. This is an unusual complication of measle as peripheral nerve involvement is rare.

Chronic osteomyelitis. Use of ipsilateral fibular graft for diaphyseal defects of the tibia.

Acute haematogenous osteomyelitis is a major disease in this area, affecting 10% of the children seen in orthopaedic clinics. Few patients report early enough to benefit from antibiotic treatment, so the majority are seen quite late, usually in the chronic stage with discharging sinuses or chronic ulcers. In adults, chronic osteomyelitis results from inadequately treated open fractures. Injudicious sequestrectomy or very severe disease may lead to loss of length of the bone. A 5-year-old boy and a 30-year-old man suffered loss of length of tibia (averaging 8 cm). In an experimental work, a non-vascularised ipsilateral fibular graft was used to bridge the gaps in both tibiae, fixation was achieved with a tubular plate in one instance and an intramedullary rush nail in the other case. Both patients bore weight at 4 and 6 months, respectively. Amputation should therefore be avoided.

The problems and prevention of burns in developing countries.

Burns are rapidly assuming greater importance as a cause of ill health in the developing nations. The major factors include gross ignorance of fire prevention, the quick spread of slums and the persistence of old traditional customs and beliefs. One hundred and forty-one new cases of burns were treated at the University of Calabar Teaching Hospital (UCTH) in a 2-year period from January 1984 to December 1985. A large proportion of the patients (91, or 64.5 per cent) were minor burns, while 40 (28.4 per cent) were serious burns, and 10 patients (7.1 per cent) suffered major burns. Thirteen patients (9.2 per cent) left hospital against medical advice or absconded without completing their treatment. There were six deaths (4.3 per cent), most of the deaths occurred in the major burns group. Lack of drugs and intravenous fluids, delay in bringing the patients to hospital, ignorance, superstition and old cultural and traditional beliefs contributed to the morbidity and mortality. Most of the burn injuries were caused by domestic accidents and were therefore preventable.

Hospital management of massive burns in the developing countries.

Nine patients with massive burns (over 50 per cent of total body surface area) were treated at the University of Calabar Teaching Hospital during a 2-year period (January 1984 to December 1985). The patients, aged between 9 and 50 years, consisted of three young females and six males. Five of the patients (55.6 per cent) survived and were discharged between 20 and 150 days after admission, while four patients (44.4 per cent) died, three of them within the first 72 h of admission. Delay and inadequate fluid resuscitation and overwhelming infection were the major factors in the morbidity and mortality of this series.

Management of civilian gunshot wounds in a Nigerian general hospital.

In a 3-year period (1981-1984), 52 male patients aged 10-60 years were treated for fresh gunshot wounds. The injuries varied from minor soft tissue injuries to major organ and tissue damage, and were all sustained by low-velocity missiles. Six of the patients (11.5%) died of their injuries or complications while 46 (88.46%) survived and were discharged after 1-15 weeks (a mean hospital time of 3 weeks). Some of the patients were treated before referral and for some there was a delay of more than 48 h before definitive specialist treatment. Mortality was related to the severity of wounding and the delay before treatment.

Irreducible dislocation of the metacarpophalangeal joint of the thumb due to tendon interposition.

Two cases of irreducible dorsal dislocation of the metacarpophalangeal joint of the thumb are reported. In both cases, there was interposition of the tendon of flexor pollicis longus. Open reduction was required to achieve successful reduction.

Plantar fasciitis.

Thirty patients presenting with the heel pain syndrome, commonly referred to as "plantar fasciitis", were studied prospectively over a two year period. The pain was associated with a calcaneal spur in 21 patients (70%). In a control series of 25 patients without heel symptoms, calcaneal spurs were present in only 4 out of 50 heels (8%). This difference is highly significant (p 0.001). Seven patients (22%) in the plantar fasciitis group complained of ipsilateral sciatica.

Cement burns of the heels.

Two artisans working on machinery sustained thermal burns (9 per cent and 5 per cent, respectively) of both heels and lower legs from hot cement powder. The burned areas took 4-6 weeks to heal following intensive treatment and the workers only returned to work after 10 weeks.