Most fractures have not healed normally

Interview with Géraldine Jacquemin, who manages Handicap International’s response teams in Haiti’s hospitals.

There has been a lot of talk of amputees, but other traumas exist as well...
A very large number of people have suffered fractures, particularly lower limb fractures. It is not possible to provide optimal case-management in an emergency, since many teams do not have radiology equipment, or materials to stabilise fractures or perform invasive surgery. They have little alternative but to reduce and stabilise fractures “in the dark”. We would usually perform a fracture reduction, that is, we put the bones back in place. Most of the radiographs we are doing now reveal fractures that have not healed in the normal way, and the bones are no longer aligned as they should be. It’s a major disabling factor: it can lead to deformed limbs, joint problems and legs of unequal length. It can also turn into a social disability because the people concerned will not be able to do the same activities as they did before the earthquake, if their work was physically demanding.

Among the traumas you have encountered, what proportion are fractures?
It is difficult to get an overall picture because patients are dispersed throughout the country’s hospitals. Over the last few days, our mobile teams, who perform out-reach work in various neighbourhoods, have met injured people who received care that was not adapted to their injury. However, in the hospitals in which we intervene, we estimate the number of fractures to be three times higher than amputations. It’s an orthopaedic disaster.

How should people with orthopaedic injuries be case-managed?
The first thing to do is to ensure the immediate case-management of patients, helping them to keep their joints flexible and to avoid contractures. This preventive work is necessary to ensure the patient’s condition does not deteriorate.

When the plaster or external fixative is removed, it is important to get the patient mobile and moving their limbs again. If they can stand on one leg, we give them crutches and teach them how to move around with them.

Is it possible to care for a poorly reduced fracture?
If a fracture has not yet healed, we can intervene. Surgery is a possibility. But more than a month after the disaster, patients are still living in tents or in hospitals with poor hygiene conditions. This carries a major risk of infection. Using an internal fixative to unite a fracture is therefore not an ideal solution.

If the fracture is not properly united, an even more complex surgical operation is required.

Have you encountered other types of traumas?
The earthquake caused a lot of neurological traumas. Walls fell on top of people, some of whom were pinned down under the debris and unable to move for several days. We have seen a huge number of neurological traumas resulting from fractures. We have also come across some very serious wounds. Our physiotherapists are working to avoid, once again, the development of contractures in injured limbs, and to reduce complications caused by prolonged immobilzation.

What are conditions like for people with spinal cord injuries?
We have recorded around 50 people with spinal cord injuries, spread over several facilities. But the day before yesterday, I met a paraplegic patient who was living in her own home, and who had not been registered. Most are paraplegic patients, with very few tetraplegic patients. It is therefore obvious that not everyone with spinal cord injuries is currently being case-managed. There may be others dispersed around smaller hospitals. Our goal is to register them and then, with our partners, to look for a solution to bring these patients together, supported by a long-term and specialised case-management plan. It’s a problem that Handicap International knows well, since it has already set up units for people with spinal injuries, particularly in Asia.