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Musculoskeletal Trauma 211

The minimal access surgery with the aid of an image intensifier in the
developed world is gradually being practiced in Nigeria and can be
helpful in intraarticular fractures.
Postoperative Complications
Fortunately, nonunion of fractures is extremely rare in children. In
addition, fairly significant fracture angulation will correct itself with
the remodeling process that occurs during healing. Infection of an open
fracture leading to osteomyelitis is a dreaded complication because it
can be extremely difficult to treat, requiring long-term antibiotics and
debridement of the bone to achieve control.
Prognosis and Outcomes
Fortunately, children have very resilient bones, and most fractures,
including some with significant angulation, will heal without complica-
tion. Vitamin D deficiency and malnutrition can lead to delayed or poor
wound healing. Lack of tetanus prophylaxis can be life-threatening
following major soft tissue trauma, as the tetanus organism is common Figure 32.2: Orthofix in place to treat open infected fracture of the tibia.
in the soil.
For open fractures, prognosis is directly affected by the availability
of health care. Open fractures require treatment within 4 to 6 hours of
injury. If open wounds at a fracture site are not treated by that time, the
risk of infection increases markedly (Figure 32.2).
Dislocations, once promptly recognised and reduced, result in
excellent outcome with a full range of movement and stable joint.
Unfortunately, ignorance and cultural beliefs and (to a little extent)
poverty in developing countries have led to late presentations,
condemning many joints.
Prevention
Because there are very little continentwide or even countrywide paedi-
atric trauma data, injury prevention is a difficult task in Africa. Clearly,
motor vehicle usage is increasing, and motor vehicle crashes place
children at high risk for major musculoskeletal injuries. Surgeons should
advocate for children riding in the back seat, wearing proper restraint
devices, and using car seats or booster seats where available. Children
are far more likely to die when they are unrestrained and ride in the front Figure 32.3: Traditional bonesetters’ splints in use.
passenger seat of the vehicle.
In urban environments, falls from heights, particularly from upper
levels of multistorey buildings, are a significant cause of major injury
and death. The placement of window guards, which prevent toddlers
and small children from falling out of upper-storey windows, has been
associated with a significant reduction in injury and death in densely
populated urban neighborhoods in New York City. This pioneering
work is an example of a paediatric surgeon advocating for the safety
of children.
10
In rural areas, many fractures are due to falls from economic trees.
Better fruit harvesting techniques should be promoted.
Firearm trauma is also common in Africa, and more likely due
to political (civil war or communal clashes) than criminal (robbery)
reasons, compared to Western countries. 11,12 In a study from Nigeria,
more than 40% of casualties involved noncombatants (mainly
government workers and students), and the most common skeletal
injury from gunfire was a femur fracture. Firearm injury prevention in
12
Africa is an enormous challenge due to political unrest and high levels
of gun ownership. 11,12
Finally, surgeons must advocate to limit or end the practise of
traditional bonesetting (Figure 32.3). Complications of traditional
bonesetting include nonunion or malunion (Figure 32.4) and wet
gangrene, requiring amputation. Nonunion or malunion typically
13
requires open reduction and internal fixation. Death from sepsis has
also occurred. Nevertheless, one recent study demonstrated that 14
of 46 patients admitted in a hospital with a known fracture opted for
treatment by a bonesetter. The availability of health care facilities, the Figure 32.4: Volksmann’s ischaemic contracture of the wrist from tight traditional
cultural environment, and the financial status of the patient were among
bonesetter’s splint.