SIGN Disaster Relief Handbook

This is an effort to transmit and gather orthopedic information about treatment of disaster victims. I seek your input as we learn more from earthquake in Haiti. Please add your comments within this document or in a separate document and return to [email protected] . With your help we can document the lessons learned from Haiti and use them to be better prepared for the next phases of treatment required in Haiti and for future disaster relief responses. My goal is to use this as a skeleton which may serve as guidelines for the surgeons serving in Haiti and gather information for future disasters. Lew Zirkle.

Characteristics of Disasters

Each disaster has its own characteristics. The fractures are different due to the racial differences in the strength of the bone in different countries, composition and strength of the buildings and time of day of the disaster. Other factors include the level of training and practices of orthopedic surgeons of various countries and medical personnel skills as well as the hospital and medical infrastructure. The authorities of each region should prepare a list of those who can be enrolled as disaster response teams with their emergency contact numbers. A protocol for setting up a base camp, chain of command, transportation of victims, triage, documentation and treatment as well as referral for proper treatment should be prepared.
SIGN surgeons have developed innovations and techniques to treat their patients using the principles of fracture healing. Their facilities are similar to those in disaster facilities as many do not have the equipment that North American surgeons use. We can learn much from our fellow surgeons in developing countries.

Medical Facilities

We must decide the minimum conditions where soft tissue treatment of open fractures should occur. We must be more stringent about these conditions especially when closed fractures are treated by external fixation or internal fixation. These are universal principles which must be followed. A closed fracture is rarely an emergency and the initial treatment may compromise further treatment if not appropriate. The instruments and implants must be sterile according to universal standards. The pot sterilizer can sterilize using electrical current or a stove. Indicator tape is necessary to verify sterilization.
The operating room personnel must observe the standard precautions regarding sterile technique. Perhaps ultraviolet lights could be considered in temporary operating rooms. These would provide sterilization of the air and the medical personnel and patient must cover the skin which is a major source of infection. We must always use universal precautions.

Patient records

A number on a wristband which is recorded on a database would identify the patient. These numbers and patients name could be entered into a central database. In case the patient is unconscious and personal details are not available then the location from which the patient was located and at least two identification marks should be recorded. Many patients change hospitals and their records would be preserved. Certainly hospital records could accompany the patients also (?laminated). This database will allow surgeons to evaluate treatment given in order to improve future treatment. For universal acceptance (among the relief agencies) it will need to cover non-orthopaedic trauma as well.
Suggestions for minimal data-set for a record of post-disaster treatment (Myles Clough)

• Unique Patient ID Number or code
  • Code could include Hospital, Gender, DOB, Patient Initials
• Date of Injury (yyyymmdd)
• For each injury
  • Diagnosis (type (fracture, laceration, rupture etc), location (organ, bone, side), classification if available)
  • Open/Closed (Gustilo type)
  • Current Status (date(yyyymmdd), wound status, infection, bone healing, alignment, neurovascular status)
  • Treatment Record. For each treatment episode - date, procedure, (outcome. To be added later if appropriate)
  • Current management (Date, procedure, investigation, follow-up plan) (Date, procedure and outcome may need to be transferred into the Treatment Record section at the next contact, or automatically)
  • Complications (infection, mal-union, nonunion, compartment syndrome, neurovascular loss)
  • Outcome (date, impairment)

Uploading of images to the (putative) database would be desirable
Generation of a paper updated record to be placed in the chart with copy to the patient would be essential.

Initial surgery-open fractures

This is often done without C-arm or even electricity. Equipment to compensate for these deficiencies will be discussed in section of disaster response innovation.
Open fractures- Wound should be covered with a sterile dressing and limb splinted. If sterile dressings are not available then the wound should be covered with clean clothing. If conventional splints are not available then various common objects like card board boxes, newspapers, magazines, wood blocks etc can be used as modified splints. Thorough debridement and irrigation is necessary. This should be accomplished on a timely basis under sterile conditions followed by covering the wound with a sterile bandage. The wound may be closed depending on surgeons discretion. If the wound can be closed, internal fixation may be accomplished if available and the surgical setting is satisfactory. Immobilization is necessary to decrease infection so external fixation can be used if the wound cannot be closed or the proper internal fixation is not available. I do not believe plates are satisfactory treatment for femur or tibia shaft fractures. We hope to learn more about the initial treatment from our small database of patients treated in Haiti. One criteria for external fixation is reduction of the fracture or immediate transportation of the patient to another facility.
If the open wound cannot be closed, the decision to use silver dressings or negative pressure wound therapy is determined. Economical methods to accomplish both have been devised in developing countries.

Initial surgery-closed fractures

The fracture should not be treated with external fixation or internal fixation without proper sterile precautions and the proper implants. I saw many patients who had been placed in no traction or external fixation that had not telescoped anymore than those fixed in a telescope position with an external fixator. We are hearing variable reports about pin tract infections. Some facilities report very few pin tract infections and some facilities have routine pin tract infections. This may be due to technique or sterility of the environment or pins. We must study contributing factors.
Initial IM nail interlocking screw fixation can be accomplished in the proper environment with the proper implants. This allows the patient to mobilize and leave the hospital making room for other patients. Initial plate fixation can be done for intra-articular fractures under the same conditions. The skills and judgment of the surgeon are very important in making these decisions.
Studies have shown that injecting the 1 g of Ancef for preop prophylaxis into the involved extremity after the tourniquet has been inflated provides much increased concentration of antibiotic as opposed to systemic injection.

Amputations

We seek input about indications and follow-up prosthesis treatment.

Disaster response innovations

Open reduction of shaft fractures is necessary if C-arm is not available or if the fracture is over one week. The technique is to make a 2 inch incision through skin and fascia. Spread the muscle fibers with a periosteal elevator to decrease the chance of bleeding. The surgeon's fingers should enter the fracture site to determine the exact location. The incision can be extended appropriately without excess extension. If the fracture is over 2 weeks old, the ends of the fractures are freed up and the distracter applied. Be sure to line up the linea aspera for proper rotation.

The SIGN system has been used in 60,000 surgeries in developing countries. Neither C-arm imaging nor electricity is necessary to accomplish SIGN surgery. SIGN can be used if the 2 interlocking screws can be placed in the proximal fragment for proximal shaft fractures of the distal fragment for distal shaft fractures. In addition to being able to consistently achieve distal interlock without C-arm, SIGN offers the advantage of using the bone from the hand reamers for bone grafting, less infection because it is a solid nail with decreased area available for biofilm formation and faster healing due to the compression and distraction from use of slots instead of the holes. The technique can be downloaded from the SIGN webpage, click on SIGN surgeons. The username is sign. The password is 03signtech. The SIGN fin nail can be used in selected fractures. The fin provides the distal interlock.

The SIGN distracter can be used to distract telescoped tibia or femoral shaft fragments especially after 2 weeks from injury. This distracter is used with bone clamps and decreases the need for a long incision as is used when the shaft cortices are placed at 90° and the fracture site extended.

Battery-operated commercial drills can be used as they have the same RPMs as orthopedic drills. Orthopedic drills are certainly superior but the sterilization time may be a factor. The commercial drills can be covered with a sterile drill cover and a sterile chuck extender placed through the grommet in the drill cover in order to ensure sterility of the drill.

Negative pressure wound therapy systems are being developed in the Philippines and Thailand.

Economical silver-coated dressings are being evaluated.

Devices to obtain skin grafts are very necessary.

A cast saw can be obtained by buying an oscillating drywall saw at Sears.

Devices to immobilize a tibia fracture which do not penetrate the skin should be developed.

Silver-coated nails and other devices to decrease infection or prevent recurrence of infection are being developed. Perhaps there are other coatings for nail such as chitosan, iodine, polyglycolic acid containing antibiotics that will become available.

Extended care

It is now over 8 weeks since the earthquake in Haiti. The fractures must be treated differently than the initial treatment. Wounds must be treated differently from initial treatment.

Malunions

• clamshell osteotomy by George Russell

Nonunions

• Non infected-is a great deal of literature comparing bone grafting, exchange IM nail, exchange to plate. It depends on the anatomy of the fracture, location of the fracture.
• Infected-bone loss
• Options include bone lengthening or the Masquelet technique using methylmethacrylate followed by bone graft in 6 weeks.

Question from Dr. Zirkle:
Many questions have resulted from the initial treatment. We are looking at protocols for secondary procedures for infected non-unions. We are studying a new process for silver coating SIGN nails. Please give your input here. We feel that this new process gives a more regulated release of silver and adheres to the nail stronger than previous processes. Suggestions welcome, please post them here.

Osteomyelitis

• Must be excised
• Methylmethacrylate-antibiotic beads

Nonhealing wounds

• Flap techniques
• Negative pressure wound therapy
• Silver-coated dressings – how long after injury are they effective? Are they effective against biofilm?

Rehabilitation

We should seek agencies such as Handicap International and Healing Hands and others so they can join with us now.

We seek input on all these issues. Please send your suggestions. I would like to submit this to OrthopaedicsOne so others may contribute. Lew Zirkle.