External fixation in war traumatology: report from the Rwandese war (October 1, 1990 to August 1, 1993)

Modern missiles cause important damage in the tissues. In case of bone injury, apart from the presence of foreign bodies and soil dirt in the foyer, the lesion is characterized by a certain instability caused by the smashing and resulting in the comminutive fractures, as well as severe lesions of the soft tissues. If primary treatment includes the necessity of a large wound excision, of which the modalities have been described for centuries, it also includes a rigorous immobilization of the foyer as precaution against shock and infection. All techniques proposed during former conflicts proved that they are little adapted to the final goal. Their inadequacy may lead to amputation, at any rate to severe sequelae. In war traumatology, opposed to the shortcomings of nonoperative methods and opposed to the prohibitions of intrafocal synthesis, external fixation is considered to be the best among compromises: it stabilizes fractures efficiently without risk, retains the distance between bone fragments, and prevents contracture of the muscles. External fixators promote debridement of the wounds, permit vascular repairs and control of the wounds, allow mobilization of the limbs, improve the injured's comfort, and facilitate evacuation . All types of external fixators can be used, but a number of military imperatives must be taken into account. Fixing of the device must be easy to every user, even with little training. A minimal number of parts must allow a maximal number of assemblies. Easy use implies simplicity, but the assembled set must be stable. It must reduce the reprise of reductions, its compression, and its distraction to a minimal number of acts. Moreover, it must be relatively cheap. In theory, all open war fractures should be treated by means of an external fixator. The problem, however of mass surgery under uncertain circumstances, the limited equipment, and a precarious supplying must be considered. Rwanda was involved in a war from October 1, 1990 to August 1, 1993 (Arusha's agreement). A Belgian medical team from the Military Cooperation had to cope with 4,646 different casualties. We treated 1,129 fractures, and among them 115 fractures of the arm, 122 fractures of the forearm, 80 fractures of the femur (including the neck and the condylae), and 148 fractures of the leg. We had to cope with 315 fractures of the hand, of which 220 fractures were of the metacarpal bone. "Strangely," there were always more lesions of the left hand (9.5%) than the right hand (5.8%), sometimes up to five times (the only exception was met in August 1993). We placed 209 external fixators (of which 20 bridging the joint in case of important impairment), including those used for an arthrodesis. In the majority fo the cases (93.3%), we used the French device Fixateur Externe du Service de Sante des Armees (FESSA). Until March 1993, we had no "orthopedic table." Since March 1988, we had an Image Intensifier, but not very appropriate to an operating room (no mobile C-arm). A more accurate one was lent by the Belgian Medical Service and set up in September 1992. The average time to place an external fixator was about 30 minutes. General practitioners were also trained to handle external fixators. According to the importance of mass casualties, an external fixator was used immediately upon arrival of the wounded or at revision day (5th day after debridement). The only exception were femoral fractures that were at first time-treated by traction for 10 days. Sometimes we had precarious supplying because the supplies had to be ordered in Europe. Sometimes one patient had to wait until material became available from another patient. External fixation was also used for reconstructive surgery, mainly for ankle arthrodesis. In conclusion, it was possible for a very small surgical team, on its own for 18 months, to cope with a lot of difficulties caused by lack of readiness of the Rwandan Armed Forces, lack of organization, and lack of discipline of the R