During our tours of the country’s different hospitals we observed that fractures of the lower limb are generally treated by traction or casting. This may be adequate treatment for more minor fractures but for the more complex injuries of the tibia and femur, the results usually leave much to be desired. This is because a long period of immobilisation is necessary leading to joint stiffnes, muscle wasting as well as boredom and depression due to prolonged bed rest. These methods demand frequent X-Rays to ensure the broken bones are well positioned, but in Burundi the patient must pay for each X-Ray so usually they are not done. Thus the usual result is a stiff, shortened and crooked leg with weak and wasted muscles.
Surgery with internal fixation of fractures allowing early joint movement and crutch walking is a better option for these patients. But surgery demands surgical expertise, proper equipment and sterile technique, all of which are frequently lacking in Burundi. Otherwise, infection and failure to heal can result, a disastrous complication that can lead to a worse result that non-operative treatment (unless the expertise exist to deal with it).
In Burundi, as in other African countries, people with injuries or bone infection often wait a long time before coming to the hospital. Usually, it is a question of costs; it is cheaper to see the local (traditional) healer and only after his treatment fails does he or she come to the hospital. He or she may be refused admission to hospital or to surgery because of inability to pay. All hospitals in the country, both public and private, charge fees because they are under-funded by the government . Frequently, therefore, by the time the surgeon gets to the patient the fracture have begun to heal with deformity or, in the case of open fractures, are infected.
Congenital clubfoot affects one in every thousand newborns and in Burundi often goes untreated. The children then begin to walk on their deformed feet thus aggravating the deformity. If these same children were treated as newborns by weekly manipulations and casting of their feet using the Ponseti method ( www. Ponseti.info/parents ) they would almost all grow up with normal feet. Although this method was devised for newborns, it has also been applied with some modifications to children of walking age and the results are most encouraging.
Acute childhood haematogenous osteomyelitis (blood-borne bone infection) is common in Burundi as it is in all poor countries. It is almost never treated early (when it could be cured) and frequently goes on to chronic osteomyelitis that lasts the patient’s lifetime. Chronic osteomyelitis can also follow open fractures and operations of fracture that become infected.
The best way to make an immediate impact and to prevent injured people from becoming permanently handicapped is to introduce modern fracture treatment in as many hospitals as possible and to intervene soon after injury using appropriate surgical techniques when needed.
It is worth noting that often the injured person is the bread-winner or the family of the mother of young children. Thus if we restore this patient to health we are helping the entire family to avoid worsening poverty and social dependency.