Medical care following earthquakes: Clinical, organizational, and logistic challenges.

The orthopedic load following earthquakes exceeds that caused by any other disaster. This is due to the large number of musculoskeletal injuries due to falling debris, coupled with the widespread damage to general and medical infrastructure, causing a huge imbalance between surgical needs and the ability to address these needs, necessitating a switch in mindset and operational mode. Clinically, the operational mode will be that of damage control surgery, considering "life before limb" with only lifesaving and limb-saving procedures being performed during the acute phase of the event. Open wounds are treated by thorough debridement, and fixation is performed using plaster casts or external fixation. Open reduction and internal fixation of closed fractures will be deferred until the surge subsides or the patient reaches a fully functional medical facility. Organizational and logistic needs will be addressed considering the "4 S's": space, staff, supplies and system. Geographical changes will be necessary in the hospital, shifting activities from damaged structures to safe ones or to open spaces. Field hospitals may be erected on the hospital grounds or on an independent site. Medical staff will be overloaded, especially traumatologists, orthopedic and plastic surgeons, anesthesiologists, and surgical nurses. This can be addressed by the recruitment of supplementary personnel, task shifting, and on-site training. Supplies will be augmented from nonfunctional hospitals and other external sources, and the hospital system will switch to surge mode with appropriate work shifts and emergency standard operation procedures. All this necessitates preplanning, preparing, and drilling in order to mitigate the effects of this disastrous event.

Humanitarian Medical Aid Mission in the Middle of a Pandemic - Israeli Experience in Equatorial Guinea.

INTRODUCTION: In March 2021, a series of explosions shook a military base in Bata, Equatorial Guinea. As a response to government officials' request, the Israel Defense Forces Medical Corps (IDF-MC) deployed an emergency aid team that faced two major challenges: (1) understanding the scenario, the injury patterns, and the needs of the local medical system; and (2) minimizing the coronavirus disease 2019 (COVID-19) outbreak threats. This report describes the team design, the activities performed before and during the deployment, analyzes the pathology encountered, and shares lessons learned from the mission. SOURCES: Data were collected from the delegation protocols and IDF medical records. All activities of the Israeli delegation were coordinated with the local government. OBSERVATIONS: The local authorities reported that a total of 107 people were killed and more than 700 people were wounded. The team was the first international team to arrive at the scene and assisted the local medical teams to treat 231 patients in the three local hospitals and 213 patients in field clinics in the villages surrounding Bata. The COVID-19 pandemic influenced the operation of this mission, and caution measures were activated. ANALYSIS: Unplanned explosions at munitions sites (UEMS) are a growing problem causing the medical teams to face unique challenges. By understanding the expected challenges, the team was reinforced with a plastic surgeon, portable ultrasound devices, a large amount and a variety of antibiotics, whole blood units, and freeze-dried plasma. Rehabilitation experts were needed in some cases in the week following the injury. An important key for the success of this kind of medical aid delegation is the collaboration with the local medical teams, which enhances patient care.

A practical method for real-time detection of pedicle wall breaching during funneling.

BACKGROUND: A reliable, real-time method for the detection of pedicle wall breaching during funnelling in spine deformity surgery could be accessible to any surgeon assisted with neuromonitoring. METHODS: Fifty-six consecutive patients (1066 pedicles), who were submitted to spinal deformity surgery from December 2013 to July 2015 were included in the study group. A control group of 13 consecutive patients (226 pedicles) with spinal deformity surgery were operated on from January to December 2013 and were excluded from finder stimulation. In the study cohort, continuous stimulation during funnelling was delivered via a finder and subsequently a compound muscle action potential (CMAP) threshold was determined. Following funnelling, manual inspection of the pedicular internal walls was performed. The CMAP thresholds were compared with the results of palpation to determine the sensitivity and specificity of the technique for detecting pedicular breaching. To cover common ranges of damage, the medial and lateral breaches were compared and the concave-apical breaches compared to the non-apical or convex-apical breaches. In addition, a pedicle screw test was estimated for all patients. RESULTS: ROC analysis showed 9 mA cut-off to have a sensitivity of 88.0% and a specificity of 89.5% for predicting pedicular breaching, with an area under the curve of 0.92 (95% confidence interval 0.90-0.94; P < 0.001). Using 9 mA threshold as an alert criterion, funnelling at the concave-apical pedicles showed significantly more true and false positive alerts and fewer true negative alerts when compared with the non-apical and convex-apical pedicles (P < 0.001). Medial breaches had significantly lower stimulation thresholds than lateral breaches (P < 0.001). Thresholds of screw-testing were significantly higher for study than for control-patients (P = 0.002). CONCLUSIONS: Finder stimulation has a considerably higher sensitivity and specificity for prediction of pedicular breaching, most prominent for medial breaches. Screw-testing displayed significantly better results in patients undergoing the finder stimulation technique, as compared with the control group. The main advantages of our method are its high safety level and low cost, which may be critical in less affluent countries. LEVEL OF EVIDENCE: III.

Establishing a COVID-19 treatment centre in Israel at the initial stage of the outbreak: challenges, responses and lessons learned.

Anticipating the need for a COVID-19 treatment centre in Israel, a designated facility was established at Sheba Medical Center-a quaternary referral centre. The goals were diagnosis and treatment of patients with COVID-19 while protecting patients and staff from infection and ensuring operational continuity and treatment of patients with non-COVID. Options considered included adaptation of existing wards, building a tented facility and converting a non-medical structure. The option chosen was a non-medical structure converted to a hospitalisation facility suited for COVID-19 with appropriate logistic and organisational adaptations. Operational principles included patient isolation, unidirectional workflow from clean to contaminated zones and minimising direct contact between patients and caregivers using personal protection equipment (PPE) and a multimodal telemedicine system. The ED was modified to enable triage and treatment of patients with COVID-19 while maintaining a COVID-19-free environment in the main campus. This system enabled treatment of patients with COVID-19 while maintaining staff safety and conserving the operational continuity and the ability to continue delivery of treatment to patients with non-COVID-19.

Characteristics of Clinically Asymptomatic Patients with SARS-CoV-2 Infections, Case Series.

Up until now, there is much debate about the role of asymptomatic patients and pauci-symptomatic patients in severe acute respiratory syndrome novel coronavirus 2 (SARS-CoV-2) transmission, and little is known about the kinetics of viral ribonucleic acid (RNA) shedding in these populations. This article aims to describe key features and the nature of asymptomatic and pauci-symptomatic SARS-CoV-2 infected patients. The cohort consisted of six participants, three pairs, which were infected with SARS-CoV-2 during February 2020 on board the Diamond Princess. Of the six confirmed (reverse transcription polymerase chain reaction [RT-PCR]) cases, four were initially diagnosed in Japan and two upon their arrival to Israel. Duration of infection was between four days and up to 26 days. Of the six patients, three were completely asymptomatic and the others were pauci-symptomatic. All five patients in whom a computerized tomography (CT) scan was performed had lung pathology. In one patient, infectivity was tested using cell culture and a cytopathic effect was demonstrated. A serology test was performed in three of the patients and all three had a positive immunoglobulin G (IgG) four to eight weeks after disease onset. This case series demonstrates that asymptomatic and pauci-symptomatic patients may play a role in infection transmission by demonstrating probable transmission among asymptomatic spouses and by demonstrating a viable virus via a cell culture. Additionally, asymptomatic and pauci-symptomatic patients can have lung pathology and developing IgG antibodies.

Improving Management of Limb Injuries in Disasters and Conflicts.

It has become clear that disaster relief needs to transition from good intentions or a charity-based approach to a professional, outcome-oriented response. The practice of medicine in disaster and conflict is a profession practiced in environments where lack of resources, chaos, and unpredictability are the norm rather than the exception. With this consideration in mind, the World Health Organization (WHO; Geneva, Switzerland) and its partners set out to improve the disaster response systems. The resulting Emergency Medical Team (EMT) classification system requires that teams planning on engaging in disaster response follow common standards for the delivery of care in resource-constraint environments. In order to clarify these standards, the WHO EMT Secretariat collaborated with the International Committee of the Red Cross (ICRC; Geneva, Switzerland) and leading experts from other stakeholder non-governmental organizations (NGOs) to produce a guide to the management of limb injuries in disaster and conflict.The resulting text is a free and open-access resource to provide guidance for national and international EMTs caring for patients in disasters and conflicts. The content is a result of expert consensus, literature review, and an iterative process designed to encourage debate and resolution of existing open questions within the field of disaster and conflict medical response.The end result of this process is a text providing guidance to providers seeking to deliver safe, effective care within the EMT framework that is now part of the EMT training and verification system and is being distributed to ICRC teams deploying to the field.This work seeks to encourage professionalization of the field of disaster and conflict response, and to contribute to the existing EMT framework, in order to provide for better care for future victims of disaster and conflict.Jensen G, Bar-On E, Wiedler JT, Hautz SC, Veen H, Kay AR, Norton I, Gosselin RA, von Schreeb J. Improving management of limb injuries in disasters and conflicts. Prehosp Disaster Med. 2019;34(3):330-334.

Percutaneous aspiration and irrigation technique for the treatment of pediatric septic hip: effectiveness and predictive parameters.

UNLABELLED: Septic arthritis of the hip has been treated traditionally by surgical drainage. Recent reports have described repeated aspirations as an adequate and safe treatment. The aim of the present study was to assess the success of treatment of septic arthritis of the hip by repeated aspirations and to identify predictive factors for failure. Medical records were retrospectively reviewed for all patients treated by ultrasound-guided aspiration and intravenous antibiotics between 2002 and 2010. The demographic, clinical, laboratory, and outcome data were recorded. Findings were compared between patients who responded to this treatment and those who subsequently required surgery. A total of 42 patients fulfilled the inclusion criteria. Of the total 33 responded to repeated aspirations and nine required surgical drainage. The mean age of patients requiring surgery was 8.3 years compared with 2.6 years for those responding to aspirations. Age older than 10 years was associated with a 57% rate of failed conservative treatment compared with 14% for age younger than 10 years. There was no significant difference between the groups in any of the other parameters measured. Follow-up of the operated group after an average of 7.44 years showed no unfavorable results. In children with septic arthritis of the hip, hip decompression may be achieved with repeated aspirations and lavage combined with antibiotics, sparing patients the risks of anesthesia and surgery. Age older than 10 years at admission may serve as the cutoff for initial conservative treatment. The postponement of surgery did not cause any long-term morbidity. LEVEL OF EVIDENCE: Level III; patients compared on the basis of outcome of conservative treatment of septic hip arthritis.

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.

Dexamethasone Therapy for Septic Arthritis in Children.

BACKGROUND AND OBJECTIVE: Prospective studies of children with septic arthritis report that adding dexamethasone to antibiotic therapy contributes significantly to clinical and laboratory improvement. This study sought to evaluate the effect of this regimen outside of a randomized controlled trial. METHODS: The sample consisted of children with septic arthritis hospitalized at a tertiary pediatric medical center in 2008 to 2013. Disease course and outcome were compared between children treated with antibiotics alone or with adjuvant dexamethasone, according to the admitting department policy. RESULTS: The cohort included 116 patients, 90 treated with antibiotics alone and 26 treated with antibiotics+dexamethasone. The groups were similar for age, symptom duration before hospitalization, body temperature, acute-phase reactant levels, and rate of positive fluid cultures (21.6% total). Compared with monotherapy, antibiotics+dexamethasone treatment was associated with a shorter duration of fever (mean 2.3 vs 3.9 days, P = .002), more rapid clinical improvement (mean 6.3 vs 10.0 days to no pain/limitation, P < .001), more rapid decrease in C-reactive protein level to <1 mg/dL (mean 5.3 vs 8.4 days, P = .002), shorter duration of parenteral antibiotic treatment (mean 7.1 vs 11.4 days, P < .001), and shorter hospital stay (mean 8.0 vs 10.7 days, P = .004). Recurrent symptoms of fever and joint pain occurred in 4 patients in the antibiotics+dexamethasone group after completion of the steroid course. CONCLUSIONS: Children with septic arthritis treated early with a short course of adjuvant dexamethasone show earlier improvement in clinical and laboratory parameters than children treated with antibiotics alone.

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.

Guiding femoral rotational growth in an animal model.

BACKGROUND: Guided growth is most commonly utilized about the knee and ankle for the correction of coronal-plane deformities by the use of plates positioned perpendicular to the physis. Sagittal-plane deformity correction has been described as well. The purpose of our study was to examine the ability to affect axial-rotational growth. Our hypothesis was that placement of plates in an oblique orientation relative to the physis can induce rotational growth deformity. METHODS: Our hypothesis was tested with use of a mathematical model and a bone model and subsequently in a rabbit model. Thirteen six-week-old rabbits underwent a rotational guided growth procedure involving the distal aspect of the right femur, with a sham procedure performed on the left side. Two plates were positioned in an oblique orientation relative to the physis, medially and laterally, to guide either internal or external rotational growth. After the rabbits were killed six weeks after the surgery, the femoral rotational profile was assessed by computed tomography scans of the dissected femora and the growth plates were examined histologically. RESULTS: A significant effect on the rotational profile was found in the treated femora. When the plates were positioned to guide external rotation, the rotational profile was significantly greater in the treated femora (29.0° compared with 11.3° in the sham femora; p = 0.008). There was a positive linear correlation between the right-left difference in rotational profile and the change in inter-plate angle (R2 = 0.72, p = 0.001). Every 1° of inter-plate angle change induced 0.367° of rotational profile difference (p = 0.001). Histologically, a swirling effect of the physeal cell columns was seen in the treated femora. CONCLUSIONS: Guided growth using plates was demonstrated to alter axial-rotational growth in a predictable fashion in a rabbit model. CLINICAL RELEVANCE: Guided growth using plates may be effective for correction of rotational and multiplanar deformities.

Coping with the challenges of early disaster response: 24 years of field hospital experience after earthquakes.

OBJECTIVE: To propose strategies and recommendations for future planning and deployment of field hospitals after earthquakes by comparing the experience of 4 field hospitals deployed by The Israel Defense Forces (IDF) Medical Corps in Armenia, Turkey, India and Haiti. METHODS: Quantitative data regarding the earthquakes were collected from published sources; data regarding hospital activity were collected from IDF records; and qualitative information was obtained from structured interviews with key figures involved in the missions. RESULTS: The hospitals started operating between 89 and 262 hours after the earthquakes. Their sizes ranged from 25 to 72 beds, and their personnel numbered between 34 and 100. The number of patients treated varied from 1111 to 2400. The proportion of earthquake-related diagnoses ranged from 28% to 67% (P < .001), with hospitalization rates between 3% and 66% (P < .001) and surgical rates from 1% to 24% (P < .001). CONCLUSIONS: In spite of characteristic scenarios and injury patterns after earthquakes, patient caseload and treatment requirements varied widely. The variables affecting the patient profile most significantly were time until deployment, total number of injured, availability of adjacent medical facilities, and possibility of evacuation from the disaster area. When deploying a field hospital in the early phase after an earthquake, a wide variability in patient caseload should be anticipated. Customization is difficult due to the paucity of information. Therefore, early deployment necessitates full logistic self-sufficiency and operational versatility. Also, collaboration with local and international medical teams can greatly enhance treatment capabilities.

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.

Fractures and refractures after femoral locking compression plate fixation in children and adolescents.

BACKGROUND: Locking compression plates (LCPs) are being increasingly utilized in fixation of fractures and osteotomies in the pediatric population. However, plate insertion or removal may pose a risk of femoral fractures or refractures. The goal of this study was to analyze failure patterns associated with LCPs and identify possible contributing factors. METHODS: The sample included all patients who underwent fixation of femoral fractures or osteotomies utilizing straight LCPs at a tertiary pediatric medical center from 2004 to 2009. All were followed up until fracture union. The charts and radiographs were reviewed, and data on demographics, indications, surgical technique, and timing of plate removal were summarized. In cases of failure, the timing, circumstances, fracture location, and refixation method were recorded. RESULTS: Thirty-seven patients underwent 41 straight LCP fixations during the study period. The indication for surgery was acute femoral fracture in 25 procedures (25 patients) and elective osteotomy or limb lengthening in 16 procedures (12 patients). Thirty-five plates were removed after complete clinical and radiographic union. The time from plate fixation to removal averaged 13 months (range, 5 to 34 mo) in the fracture group and 17.6 months (range, 7.5 to 28 mo) in the osteotomy group. Five procedures (12%) were complicated by femoral fractures or refractures: 2 occurred after the index surgery-1 at the proximal screw and 1 through the original fracture site, with plate breakage. Three patients sustained refractures after plate removal, all at the original fracture or regenerate site: 1 after a fall and 2 spontaneously. The average time from plate removal to refracture was 18 days (range, 10 to 30). There were no differences in demographics, timing, or technique between patients with and without complications. CONCLUSIONS: Although LCPs are considered flexible fixators, they may carry the risk of overstiffness, similar to external fixators. Further clinical and biomechanical studies are needed to evaluate risk factors for fractures or refractures, particularly in children. There seems to be an increase in risk of refracture immediately after plate removal. Caution should be taken in the first weeks after plate removal. LEVEL OF EVIDENCE: Level IV.

Short-term after-effect of forearm cast removal in children.

PURPOSE: To investigate the sensation in the hand after forearm cast removal in children. METHODS: The study group included 33 consecutive children who were treated nonoperatively for a forearm fracture at our center over a 1-year period. The children were asked to report any sensation in the ipsilateral hand after cast removal, and the findings were analyzed against background and fracture-related data. RESULTS: The patients ranged in age from 6 to 14 years (median 10.00 years). Seventeen had been immobilized in an above-elbow cast and the remainder in a below-elbow cast. All children treated with an above-elbow cast complained that after cast removal, the hand on that side felt limp, and they had to hold it with the contralateral hand. By contrast, only one child treated with a below-elbow cast reported this sensation (p = 0.0001, Fisher exact test). CONCLUSIONS: Orthopedic surgeons and rehabilitation unit staff should be aware of the possibility of a very short-term sensation of drooping and weakness of the hand after removal of an above-elbow cast in children and prepare the child and parents accordingly in order to lessen unnecessary anxiety.

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.

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.

Dexamethasone therapy for septic arthritis in children: results of a randomized double-blind placebo-controlled study.

BACKGROUND: We evaluated the effect of adding dexamethasone to antibiotic therapy in the clinical course of septic arthritis in children. METHODS: A randomized double-blind placebo-controlled trial was performed. The study group included 49 children with septicarthritis. In addition to antibiotic therapy given, patients were randomly assigned to receive intravenous dexamethasone 0.15 mg/kg every 6 hours for 4 days or placebo. The groups were compared for clinical and laboratory parameters, length of hospital stay, and late sequelae. RESULTS: Mean age was 33±42 months (range: 6 to 161 mo). There was no significant difference between the dexamethasone and placebo groups in age, duration of symptoms, joint affected, or levels of acute phase reactants. Bacteria were isolated from joint fluid in 17 patients (35%) and from blood in 4 patients. Compared with the placebo group, patients treated with dexamethasone had a significantly shorter duration of fever (P=0.021; mean first day without fever 1.68 vs 2.83) and local inflammatory signs (P=0.021; mean first day without pain 7.18 vs 10.76), lower levels of acute phase reactants (P=0.003; mean last day of erythrocyte sedimentation rate>25 mm/h 3.76 vs 8.40), shorter duration of parenteral antibiotic treatment (P=0.007; mean of 9.91 d vs 12.60 d), and shorter hospital stay. No side effects of treatment were recorded in either group. CONCLUSIONS: A 4-day course of dexamethasone given at the start of antibiotic treatment in children with septic arthritis, is safe, and leads to a significantly more rapid clinical improvement, shortening duration of hospitalization compared with those treated with antibiotics alone. LEVEL OF EVIDENCE: I.