After a long day, 30-year old Ram Chandra was finishing his work in the forest when he slipped whilst using a chainsaw, which cut into his leg. He is the breadwinner for his family where he has two little children who were waiting for him that day to come home and give some food to them. Instead, because of the accident, he landed in hospital. He arrived from his home in Solukhumbu District – 5 hours’ drive from our hospital – with an open transverse fracture of the lower shaft of his tibia and fibula bones.

Upon arrival at the hospital, he was rushed to the operating theatre for a thorough cleansing of his wound and external fixation to give stability to the fracture and the open wound. The external fixation device we had was not a complete set – there were some missing components, nonetheless it could be applied with reasonable effect. The hospital does not have many ‘Bohler-Braun’ frames for the elevation of injured legs while on bedrest. So, a local style of frame was made out of PVC (plastic pipe).

The gold standard treatment for this type of fracture is inter-medullary nailing, but our rural location means we lack such a nailing system. The open fracture and the large lacerated wound prolonged his stay which was an economic burden for him. After some time, the skin had become healthy enough to be considered for a MIPO (minimally invasive plate osteosynthesis) technique to fix the fracture. In the postoperative period, his ankle and knee movements were assisted by our hospital physiotherapist.

Even though his fracture had been treated, the open laceration wound kept him in hospital for a few more days. It was treated with honey dressings, and then later on, successfully skin grafted. The long duration of his stay at the hospital made him even poorer than he was before the injury. His treatment and the cost of food were covered by the hospital from the Medical Assistance Fund, but his caregiver’s food cost was still a burden to him. Finally, after a month he was discharged from hospital and sent home. He returned two months later for review and we taught him how to fully weight-bear on the healing injured leg.

As his leg improved, he was able to walk freely and started earning bread again for his family. Both his children were happy to get chocolates which he was given from our hospital on his last visit. His story is
a great illustration of the teamwork that happens at Okhaldhunga Community Hospital.

ANKIT SHRIVASTAVA
Orthopaedic Surgeon