Clinical Digest 13

To nail or not to nail...

My area of interest within developing world orthopaedics has slowly but solidly, while in Malawi, become the femoral shaft fracture. Quite understandable given the implications this condition holds here. From my audit of inpatient orthopaedic diagnoses in Ntcheu, I established that this was the commonest one on the adult male and female wards, even commoner than the neck of femur fracture. The same held true on the paediatric ward, ahead of infectious affectations of the bones, joints and soft tissues combined. Given that, of the adults, it tends to affect the younger age group, who are working and economically active, the socio-economic impact is also quite significant. This is compounded by the resultant consequence of impairing the very ability to work of this age group if a less than optimal outcome is achieved following treatment. The history of the management of femoral shaft fractures is quite fascinating indeed, as it reveals many insights into the divergent nature of scientific research (between first and third world). As for the biomechanics and principles of treatment, they are equally fascinating in their own rights. I can certainly comment on the operative and non-operative management of this condition for Malawi. The way this relates to global trends is very interesting.

The management of femoral shaft fractures in developed economies is usually guided by the very latest technology, without being hampered much by cost considerations. The degree of excellence in terms of accuracy of reduction, time to return to normal function and infection rates, to name a few outcomes, could be argued to have come very close to the best it will ever be. The level of research conducted into femoral fractures, and for that matter most medical problems, in most journals tends thus to focus on subtle improvements in one or more outcomes. These improvements, unfortunately, hold little if any relevance to environments where even management approaches from 50 years back or more still pose logistic, financial and other challenges. Apart from helping the district level clinician from understanding the physiology of fracture healing or the properties of metalware they will never get to use, this research is of minimal benefit to them. There is a real paucity of contemporary research into the management of conditions in resource-limited environments. Low resource approaches used in the past often hold serious implementation challenges, given the non-availability of many components they used to employ. These, since the methods have been abandoned, are often no longer widely produced. This in turn, has had the direct effect of boosting up their prices, making them no longer economically favourable. When treating people in a district hospital, which is the typical health care setting for most Malawians, one has to recognise these problems

The gold standard for treating femoral shaft fractures in modern western health settings is through the acute insertion of a locking intra-medullary nail. This can be offered to some but not all people in our central hospitals in Malawi. The majority of our femoral nails however are unlocked (K-nails), thereby offering poor control of rotation, and then also, they represent less than 30% of our patients. Our K-nails, although available, are far from ideal and the only way to keep operating at times is wicked improvisation. To illustrate this, consider a recent case we did where we needed a 38x10 size nail. We had no nails of such a size and to get the diameter had to combine two 8nails. Now if we had two 38zx8 nails, then that would have been job done. But things aren’t that straight forward here as we had only size 42x8 nails and ended sawing 4cm off the combined metallic nails for about half an hour! The rest (majority) are treated like in the district. A large number of our nailings are done for non-unions, after conservative treatment has failed. This (conservative) is the standard treatment for the district and that usually means skeletal traction, typically via a tibial pin.

When I was in the district I observed the management of this fracture closely. Rather than deplore the lack of intramedullary nails and specialists who can insert them, I believe they should focus their energy on finding ways of improving the outcome with the tools they had. The lack of academic presence in the district and the rather poor rewards for the thankless task achieved by the orthopaedic clinicians there mean than little if any effort is spent on finding improvements. I certainly can think of many low-cost, widely available measures that can be employed to improve outcomes like rotational deformity, speed of recovery, length of stay, knee stiffness and pin site infection. All that is required is the dedication of the clinician and their will to spare some time at the beginning to implement these measures. As the nails hopefully become more streamline in the central hospitals, maybe we can start then to work on their implementation in the districts. By that time, also one would hope there’d be enough doctors or senior OCOs in Malawi to undertake this task there.