Richard A. Gosselin David A. Spiegel Michelle Foltz Editors Global Orthopedics Caring for Musculoskeletal Conditions and Injuries in Austere Settings 123 Global Orthopedics Richard A. G osselin (cid:129) David A. Spiegel M ichelle F oltz Editors Global Orthopedics Caring for Musculoskeletal Conditions and Injuries in Austere Settings Editors Richard A. Gosselin, MD, MPH, MSc, FRCS(C) Department of Orthopedic Surgery Institute for Global Orthopedics and Traumatology University of California San Francisco San Francisco , CA , USA David A. Spiegel, MD Division of Orthopaedic Surgery Children’s Hospital of Philadelphia Associate Professor of Orthopaedic Surgery University of Pennsylvania School of Medicine Philadelphia , PA , USA Honorary Consultant in Orthopaedics and Rehabilitation Hospital and Rehabilitation Centre for Disabled Children Janagal, Kavre , Nepal Michelle Foltz, MD Columbus , MT , USA ISBN 978-1-4614-1577-0 ISBN 978-1-4614-1578-7 (eBook) DOI 10.1007/978-1-4614-1578-7 Springer New York Heidelberg Dordrecht London Library of Congress Control Number: 2014934421 © Springer Science+Business Media New York 2014 This work is subject to copyright. 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Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) To Sherry and Pearl who made all of it possible – RAG To Maryam and Sophie, my partners, and all my colleagues at HRDC – Drs. Ashok Banskota, Bibek Banskota, Om Shrestha, Tarun Rajbhandary, Ishor Pradhan, Prakash Sitoula, Abhiram Singh, Saroj Rijal, and Babu Kaji Shrestha – DAS To Orty with respect and love – MF Pref ace T he burden of musculoskeletal diseases and conditions in low and middle income countries (LMICs) has increased substantially over the past 15 years, while the resources to address this are grossly inadequate. In particular, the development-fueled epidemic of injuries primarily affects young males dur- ing their most productive years, and the resulting disabilities have a profound impact on the individuals, their families, and society as a whole. The aging of populations in these same countries has unleashed the mus- culoskeletal co-morbidities of chronic diseases, further increasing stresses on limited health care resources. The consequences can be social, economic, and/or political. Despite evidence of an “epidemiologic transition”, in which non-c ommunicable diseases are eclipsing communicable diseases, only 10 % of global resources for health care are allocated for conditions that account for 90 % of the world’s disease burden. Funding for musculoskeletal condi- tions is negligible when compared with the resources directed to other health problems such as the infectious diseases. A ccess to health services is limited for large segments of the population in developing countries, and many of those who present for care do so at a late stage in their disease. This makes the treatment of these “neglected” condi- tions more challenging, requires more complex and less cost-effective solu- tions, and often results in undesirable outcomes. In many cases, salvage treatments are all that can be offered. For every orthopedic patient who reaches a clinic or hospital, many more will have fi rst been seen by a tradi- tional healer or bonesetter. Even in district and provincial hospitals, most orthopedic problems are handled by nurses, orthopedic technicians, general practitioners, and general surgeons; orthopedic surgeons are usually found only in tertiary centers in major cities. The general standards and use of technology in orthopedics in LMICs rarely match those in richer parts of the world, and health services are depen- dent on the available human, material, monetary, and institutional resources. Wide variations in access to and utilization of health services are seen both between and within developing countries, especially when comparing rural and urban communities. Disparities often refl ect a growing gap between the rich and the poor within each setting, rather than a “north-south”, “developed- underdeveloped”, or “1st-3rd world” division. G lobalization has changed the dynamics of health care and has increased awareness of the inequities in services available in austere environments. This has led to a great interest in global health and international volunteerism, vii viii Preface as evidenced by the extraordinary response to recent natural disasters. In addition, institutions from high income countries have developed and pro- moted programs and initiatives that aim to improve education and services in LMICs. Enhanced access to travel and communication offers unprecedented opportunities to improve orthopedic services worldwide. Given this information, how can interactions between practitioners from resource rich and resource poor settings lead to better care for patients throughout the world? We cannot overemphasize the value of the exchange of information and experiences between colleagues from these different envi- ronments, encouraging the concept of a “two way street”. Surgeons from places in which resources are readily available must necessarily adapt their knowledge and skills in a relevant manner when working in austere environ- ments. Challenges include evaluating and treating familiar conditions, such as trauma and infections that present late or with complications that are rarely seen in the West, and unfamiliar conditions such as osteoarticular tuberculo- sis, the residua of poliomyelitis, and the sequelae of untreated congenital deformities. Colleagues practicing in resource constrained environments will be exposed during these interactions to problem solving skills and technolo- gies from resource rich environments, and they must determine to what extent the information can be adapted to their needs. Contextual variables must be recognized and addressed when choosing among treatments. Management must be individualized and adapted to the local environment, taking into account the desires of the patients and their families, the anticipated needs for activities of daily living, and the physical demands of work, the local resources, and the potential for rehabilitation. What may seem an obvious treatment in one setting may be inappropriate or harmful in another, and the differences are often subtle. O ur goal is to create a text book that is unique in scope, based on the expe- riences and insights of authors from a wide variety of settings around the world. This shared endeavor pairs surgeons from resource rich settings who have experience working in austere environments, with surgeons who work daily in diffi cult conditions in LMICs to make a balanced text that will be benefi cial to all practitioners treating orthopedic conditions where resources are limited. This book does not pretend to address all musculo-skeletal condi- tions, but rather explores an array of commonly seen problems and solutions. There is not much “evidence” on which to base some of the recommenda- tions, other than experience, but more importantly, we hope the principles implied by these recommendations will guide the practitioner to a rational approach. Not one of the authors will be in 100 % agreement with what is written. Rather, we have tried to tap into the cumulative experience of all authors, which totals well over 500 years. The word “surgery” has been omitted from the title, recognizing that the management of musculoskeletal conditions and injuries in austere settings is largely non-operative. While some surgical techniques and approaches are described, this is not the main focus of the book. The primary aim is to provide volunteers or others engaged in elective or relief work in teaching and/or s ervice provision with sound, basic principles and tools for the appropriate and effective management of orthopedic conditions. The needs are great, and a Preface ix surgeon working in a resource constrained setting will have his or her percep- tions regarding the fi eld of orthopedic surgery expanded and enhanced in ways that few other learning experiences offer. We hope in the end, the reader will appreciate the limitations of austere environments, and have acquired the knowledge to address both familiar and unfamiliar conditions in these settings. A child with paraplegia wanted to play badminton, so a custom frame was constructed in the workshop. While some conditions cannot be cured, something can always be done to improve the lives of our patients (Courtesy of the Hospital and Rehabilitation Centre for Disabled Children, Janagal, Kavre, Nepal)