Surgery at The District Hospital

Surgery at the District Hospital: Obstetrics,
Gynaecology, Orthopaedics and

Traumatology
edited by
John Cook
Formerly Consultant Surgeon
Department of Surgery
Eastern General Hospital
Edinburgh, Scotland
Balu Sankaran
Formerly Director
Division of Diagnostic, Therapeutic and
Rehabilitative Technology
World Health Organization
Geneva, Switzerland
Ambrose E. O. Wasunna
Medical Officer
Clinical Technology
Geneva, Switzerland
and
Professor of Surgery
University of Nairobi
Nairobi, Kenya
illustrated by
Derek Atherton
Elisabetta Sacco
and Patrick Virolle

Geneva
1991
________________________________________________
The World Health Organization was established in 1948 as a specialized agency of the United
Nations serving as the directing and coordinating authority for international health matters
and public health. One of WHO’s constitutional functions is to provide objective and reliable
information and advice in the field of human health, a responsibility that it fulfils in part
through its extensive programme of publications
The Organization seeks through its publications to support national health strategies and
address the most pressing public health concerns of populations around the world To respond
to the needs of Member States at all levels of development. WHO publishes practical
manuals, handbooks and training material for specific categories of health workers;
internationally applicable guidelines and standards, reviews and analyses of health policies,
programmes and research: and state-of-the-art consensus reports that offer technical advice
and recommendations for decision-makers. These books are closely tied to the Organizations
priority activities, encompassing disease prevention and control, the development of equitable
health systems based on primary health care, and health promotion for individuals and
communities. Progress towards better health for all also demands the global dissemination
and exchange of information that draws on the knowledge and experience of all WHO’s
Member countries and the collaboration of world leaders in public health and the biomedical
sciences
To ensure the widest possible availability of authoritative information and guidance on health
matters. WHO secures the broad international distribution of its publications and encourages
their translation and adaptation By helping to promote and protect health and prevent and
control disease throughout the world, WHO’s books contribute to achieving the
Organization’s principal objective the attainment by all people of the highest possible level of
health.
Reprinted 1993, 1998
WHO Library Cataloguing in Publication Data
Surgery at the district hospital: obstetrics, gynaecology, orthopaedics and traumatology /

edited by John Cook, Balu Sankaran, Ambrose E. O. Wasunna,
1. Surgery - methods 2. Genitalia, Female - surgery
3. Hospitals, District 4. Labor complications - surgery
5. Orthopedics 6. Pregnancy complications - surgery
7. Surgical equipment 8. Wounds and injuries - surgery
I. Cook, John II. Sankaran, Balu III. Wasunna, Ambrose, E. O.
ISBN 92 4 154413 9
(NLM Classification: WO 100)
© World Health Organization 1991
Publications of the World Health Organization enjoy copyright protection in accordance with
the provisions of Protocol 2 of the Universal Copyright Convention. For rights of
reproduction or translation of WHO publications, in part or in toto, application should be
made to the Office of Publications, World Health Organization, Geneva, Switzerland. The
World Health Organization welcomes such applications.
The designations employed and the presentation of the material in this publication do not
imply the expression of any opinion whatsoever on the part of the Secretariat of the World
Health Organization concerning the legal status of any country territory, city or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries.
The mention of specific companies or of certain manufacturers’ products does not imply that
they are endorsed or recommended by the World Health Organization in preference to others
of a similar nature that are not mentioned. Errors and omissions excepted, the names of
proprietary products are distinguished by initial capital letters.
The contributors alone are responsible for the views expressed in this publication.
Printed in Switzerland
89/8331 - Atar - 7500
93/9666 - Atar - 2000
97/11609 - Atar - 1000
Preface
This handbook is one of three 1 published by the World Health Organization for the guidance
of doctors providing surgical and anaesthetic services in small district hospitals (hospitals of
first referral) with limited access to specialist services. The advice offered has been
deliberately restricted to procedures that may need to be carried out by a young doctor with
limited experience in anaesthesia, surgery, or obstetrics, using the facilities that can
reasonably be expected in such hospitals. Wherever possible, the drugs, equipment, and
radiodiagnostic and laboratory procedures described conform with WHO and UNICEF
recommendations.
1
Also available: Anaesthesia at the district hospital and General surgery at the district hospital.
Although the handbooks contain detailed descriptions and illustrations, the advice they offer
is no substitute for practical experience. The reader is expected to have been exposed to all
the relevant techniques during undergraduate or early postgraduate education. When
necessary the text indicates which patients should be referred for specialized care at a higher
level, as it is important to developing health services that young doctors and their superiors
understand the limitations of practice at the district hospital.
It has, of course, been necessary to be selective in deciding what to include in the handbooks,
but it is hoped that any important omissions will be revealed during field testing. WHO
would also be pleased to receive comments and suggestions regarding the handbooks and
experience with their use. Such comments would be of considerable value in the preparation
of any future editions of the books. Finally, it is hoped that the handbooks will fulfil their
purpose - to help doctors working at the front line of surgery throughout the world.
The three handbooks have been prepared in collaboration with the following organizations:
Christian Medical Commission

International College of Surgeons
International Council of Nurses
International Federation of Gynaecology and Obstetrics
International Federation of Surgical Colleges
International Society of Burn Injuries
International Society of Orthopaedic Surgery and Traumatology
League of Red Cross and Red Crescent Societies
World Federation of Societies of Anaesthesiologists
World Orthopaedic Concern.
Acknowledgements
The traumatology and orthopaedics section of this handbook has been prepared in
collaboration with the International Society for Orthopaedic Surgery and Traumatology
(SICOT), which reviewed and endorsed the draft manuscript and illustrations. The
International Society for Burn Injuries reviewed and endorsed the draft manuscript and
illustrations for the chapter on burns.
The editors would like to acknowledge the valuable suggestions received from: Professor J.A.
Boswick, Professor of Surgery and Chief, Hand Surgery Service, University of Colorado
School of Medicine, Denver, CO, USA; Dr J.C. Cobey, Chairman, Health Volunteers
Overseas, Washington, DC, USA; Dr A. Trias, Orthopaedic Surgeon, Barcelona, Spain; and
Mr J.N. Wilson, formerly President, World Orthopaedic Concern, and Consultant
Orthopaedic Surgeon, Royal National Orthopaedic Hospital, London, England.
Acknowledgements are also due to Churchill Livingstone, Edinburgh, for permission to adapt
drawings from Rintoul, R.F., ed. Farqubarson’s textbook of operative surgery (6th edition,
1978) for Figures 21.3H and 23.3K; from Powell, M. Orthopaedic nursing and rehabilitation
(9th edition, 1986) for Figures 19.2C and 24.1E; and from Wilson, J.N., ed. Watson-Jones
fractures and joint injuries (6th edition, 1982) for Figures 15.2D and 19.1A, B.
Contributors
Professor R. Baveja, Professor and Head, Department of Obstetrics and Gynaecology,

Motilal Nehru Medical College, Allahabad, India
Mr J. Cook, formerly Consultant Surgeon, Department of Surgery, Eastern General Hospital,

Edinburgh, Scotland
Professor K.G. Gürsu-Hazarli, Director, Department of Plastic and Reconstructive Surgery,

Hecettepe University Medical School, Ankara, Turkey
Dr B. Sankaran, formerly Director, Division of Diagnostic, Therapeutic and Rehabilitative

Technology, World Health Organization, Geneva, Switzerland
Professor S.M. Tuli, Professor of Orthopaedics and Director, Institute of Medical Sciences,
Banaras Hindu University, Varanasi, India
Dr A.E.O. Wasunna, Medical Officer, Clinical Technology, World Health Organization,

Geneva, Switzerland, and Professor of Surgery, University of Nairobi, Nairobi, Kenya
Introductory notes
This handbook describes a limited number of surgical procedures. They have been chosen as
appropriate for the doctor who does not have a formal surgical training, but who nevertheless
has experience, gained under supervision, of all the relevant techniques. With the exception
of tubal ligation and the insertion of intrauterine devices (IUDs), which may be an important
part of national family planning programmes, the procedures included are considered
essential for saving life, alleviating pain, preventing the development of serious
complications, or stabilizing a patient’s condition pending referral. Operations that require
specialist skills or that could add unnecessarily to the doctor’s workload have been avoided,
and simple but standard surgical techniques have been selected whenever possible.
Nevertheless, certain procedures that may appear technically difficult (for example subtotal
hysterectomy and burr-hole craniotomy) are included because they may offer the best chance
of saving a patient’s life.
The handbook is split into two main sections - obstetrics and gynaecology, and orthopaedics
and traumatology - and covers the more specialized topics not included in Cook, J. et al., ed.
General surgery at the district hospital (Geneva, WHO, 1988). The reader is referred to the
book on general surgery for a discussion of basic surgical principles and techniques, fluid and
electrolyte therapy, blood transfusion, and the management of shock and to the list inside the
back cover of the present book for details of other WHO publications of related interest.
Details of anaesthetic techniques suitable for use at the district hospital are given in Dobson,
M.B. Anaesthesia at the district hospital (Geneva, WHO, 1988).
Obstetrics and gynaecology

The obstetric procedures described here are those that are essential at the district hospital for
treating the major complications of pregnancy and childbirth and for preventing maternal
death. Although most normal deliveries are conducted by midwives or traditional birth
attendants rather than by medical officers, a description of normal labour and delivery has
been included as a basis for recognizing complications. The gynaecology section of the book
provides details not only of general gynaecological procedures but also of female sterilization
and IUD insertion, and includes a chapter on biopsies, which may be useful when the
provision of a pathology report can be assured and when the suspected disease can be treated
at the district hospital.
Orthopaedics and traumatology
Details are provided here both of basic orthopaedic techniques and of the management of
specific fractures, dislocations, and other injuries, as appropriate at first referral level. Closed
treatment of fractures has been recommended because internal fixation (open or closed) may
be technically beyond the competence of the general duty doctor and can have disastrous
results in the hands of the inexperienced working with limited resources. Although recovery
is slow, closed treatment has over the years proved to be effective and safe for most common
fractures.
A final section of the text briefly describes the treatment of various bone and joint infections
and other lesions, since timely intervention can often prevent the development of serious
complications. Chronic infections, other bone diseases, and congenital deformities are
mentioned only to draw attention to the need for referral.
Obstetrics
1. Complications of pregnancy
The two main complications of pregnancy that will require treatment at the district hospital
are antepartum haemorrhage, due to placenta praevia or abruptio placentae, and eclampsia.
Surgery at the District Hospital: Obstetrics, Gynaecology,

Orthopaedics and Traumatology (WHO; 1991; 207 pages)
Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Antepartum haemorrhage
Printable version Eclampsia
2. Delivery
Export document as HTML 3. General obstetric procedures

file Help
4. Postpartum procedures
5. Aborted pregnancy
Export document as PDF file

Gynaecology
Annex 1. Surgical trays and equipment for specific

procedures
Annex 2. Essential surgical instruments, equipment, and

materials for the district hospital
Selected WHO publications of related interest
Back Cover
Haemorrhage in the last trimester of pregnancy should be taken particularly seriously.

Painless and unexplained haemorrhage in a multigravida is usually due to placenta praevia.
Abdominal pain and bleeding with pre-eclamptic toxaemia in a primigravida suggest
accidental haemorrhage caused by abruptio placentae.
Diagnosis
In cases of placenta praevia, haemorrhage occurs from an abnormally situated placenta. The
placenta praevia is classified according to the relation between its edge and the internal os. A
posteriorly situated placenta is more dangerous than an anterior placenta praevia. Bleeding is
always revealed, with the blood bright red, though it may cease spontaneously. The degree of
the patient’s pallor corresponds to the amount of blood lost. There is no tenderness in the
abdomen, the uterus is soft and relaxed, the presenting part may be high or abnormal, the
fetal parts are easily palpable, and fetal heart sounds are usually present. The patient may
show signs of hypovolaemic shock. Vaginal examination can cause severe bleeding, making
the need for delivery urgent, so in general it should be avoided. If it is absolutely necessary, it
should be done under sterile conditions in the operating room and then only if preparations
have been made for immediate blood transfusion and vaginal delivery or caesarean section.
Abruptio placentae - premature separation of the normally situated placenta with resultant
retroplacental bleeding - can be of the revealed, concealed, or mixed type. The causes include
toxaemia, trauma, sudden uterine decompression, or a short umbilical cord. In the revealed
type, the amount of external blood loss is consistent with the condition of the patient. In the
concealed type, there is usually no visible vaginal bleeding, yet the patient is pale and the
uterus tender, markedly hypertonic, and “woody” hard. In severe cases of abruptio placentae,
fetal heart sounds are absent, and there is the risk of a coagulation defect if treatment is
delayed.
Abruptio placentae is classified from grade 0 to grade 3 according to its severity. Grade 0 is
diagnosed after delivery, when the retroplacental clot is noticed. There are usually no
symptoms associated with this grade. Grades 1-3 are classified according to the amount of
bleeding, maternal hypovolaemia, and the presence or absence of fetal heart sounds. In Grade
2 the patient is in hypovolaemic shock, but fetal heart sounds are present. In Grade 3 there is
death of the fetus.
Differential diagnosis
Differential diagnosis should include ruptured uterus, cervical polyp, carcinoma of the cervix,
varicose veins of the vulva or vagina, disseminated intravascular coagulation, and bleeding
haemorrhoids.
Investigations
Measure the patient’s haemoglobin level and test the urine for sugar and protein. Send a
sample of blood for grouping (including Rh factor) and carry out a serological test for
syphilis. Determine the bleeding and clotting times, clot-retraction time, platelet count, and
prothrombin time.
Equipment
See trays for Caesarean section and Episiotomy, Annex 1, pages 187 and 188.
Management
Immediately administer 15 mg of morphine by intramuscular injection, if this was not already

done before the patient was brought to hospital. Examine the patient to determine the cause of
the haemorrhage, but do not carry out vaginal examination. Ascertain the amount of bleeding,
the gestational age, and the fetal condition, and then decide upon the line of treatment.
Placenta praevia
If the bleeding is diminishing or shows signs of stopping, if the duration of pregnancy is less
than 36 weeks, if fetal weight is less than 2500 g, and if labour is not yet established, the
patient can be put on expectant treatment. Vaginal examination is not necessary. Prepare for
possible blood transfusion.
If bleeding persists, if the gestational age is 36 weeks or more, and if the fetal weight is more
than 2500 g, pelvic examination is permissible provided that trays for both episiotomy and
caesarean section are to hand. Check for any local lesions by speculum examination, but if
bleeding is excessive and a major degree of placenta praevia is suspected, avoid speculum
examination in favour of immediate caesarean section. If a minor degree of placenta praevia
is detected and if the patient is in labour and the presentation is favourable for vaginal
delivery, rupture the membranes. Check for lacerations after delivery.
A lower-segment caesarean section is the treatment of choice for a major degree of placenta
praevia. If the placenta obstructs delivery, either incise it or deliver the baby around the
placental edge. Prompt delivery will reduce maternal and fetal haemorrhage.
Accidental haemorrhage (abruptio placentae)
In cases of accidental haemorrhage of the revealed type, if bleeding stops on admission to the
hospital or if it is minimal, consider expectant treatment, especially if there is a need to
prolong the pregnancy. If bleeding continues, however, examine the patient in the operating
theatre, with trays to hand for both episiotomy and caesarean section, to decide upon a further
course of action.
If bleeding is moderate to severe, start blood transfusion as soon as possible. If the cervix is
favourable, rupture the membranes to expedite delivery. Start the patient on an oxytocin drip
of 2 IU in 500 ml of 5% (50 g/litre) glucose at the rate of 15 drops/min. Gauge the response
to treatment by the patient’s pulse and blood pressure, by the nature of uterine contractions
and the progress of labour, and by the fetal condition. Lower-segment caesarean section is
indicated if there is poor progress of labour, failure of the uterus to relax between
contractions, fetal distress, or increased bleeding.
In cases of accidental haemorrhage of the concealed type, signs of hypovolaemic shock are
usually evident. You can roughly estimate the amount of blood that is trapped by the feel and
size of the uterus. The volume of blood required for transfusion will be approximately four
times the estimated increase in the volume of the uterus. This amount may be life-saving and
is unlikely to lead to overloading, but keep a careful watch for such signs. If the clot-
retraction test has indicated that there is a coagulation defect, give fresh blood or, if available,
fresh frozen plasma. If the clot formed in the test dissolved after 30 min at body temperature,
suspect fibrinolytic activity, which may be an indication for referral for hysterectomy.
General management consists of oxygen administration and the recording of pulse, blood
pressure, and hourly urine output. Note the height of the uterine fundus. When the patient’s
blood pressure has improved, rupture the membranes and start her on an oxytocin drip. If
delivery is nor complete within 4 - 6 hours, caesarean section is indicated. Watch for
postpartum haemorrhage.
Complications
Possible complications include postpartum haemorrhage, disseminated intravascular

coagulation, renal failure, and, rarely, acute pituitary necrosis.
Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Printable version
Eclampsia
2. Delivery
Export document as HTML 3. General obstetric procedures

file Help
Gynaecology

procedures

Back Cover
Eclampsia
Eclampsia is a convulsive state that usually develops from severe pre-eclampsia, although it
can appear without the preceding pre-eclamptic toxaemia. About half of all cases of
eclampsia present before parturition, but the disease can develop at any time during
pregnancy or before, during, or after labour.
Diagnosis
Impending eclampsia is characterized by generalized or localized headache, visual

disturbances, restlessness, epigastric pain, nausea and vomiting, and oliguria. Examination
may reveal hypertension, albuminuria, and retinal changes. An eclamptic seizure follows a
characteristic sequence. The premonitory stage, which lasts for about 30 s, is characterized by
twitching of the hand and facial muscles and rolling of the eyes. This stage is followed by a
phase of tonic convulsion, again lasting about 30 s. The patient has a slow respiratory rate,
opisthotonos, and marked cyanosis. The third stage lasts about 1 min, during which there are
clonic convulsions with alternate contraction and relaxation of the limb muscles. Cyanosis
gradually passes off. Other features of the third stage are frothing at the mouth, biting of the
tongue, and urinary and faecal incontinence. Finally, the patient lapses into a deep coma.
Differential diagnosis should include epilepsy, meningitis, cerebrovascular accident,

strychnine poisoning, and hysteria.
Investigations
As for normal delivery, measure the patient’s haemoglobin level and test the urine for sugar
and protein. Send a sample of blood for grouping (including Rh factor). Test for bleeding and
clotting times and carry out a serological test for syphilis. In addition, if possible, check blood
levels of urea and uric acid.
Management
Eclampsia should be treated immediately in hospital, the main consideration being for the
mother’s life. The aim is to prevent asphyxia, control the fits, prevent and treat complications,
and effect a safe and speedy delivery.
If you first see an eclamptic patient at home, provide deep sedation by a slow intravenous
injection of 10 - 20 mg of diazepam (or 15 mg of morphine sulfate), insert a mouth gag, and
place the patient in the semiprone position. Once the fits are controlled and sedation takes
effect, transport the patient to hospital, with a note detailing the treatment already given.
Inquire of the patient’s relatives about the onset, duration, and number of fits and about the
patient’s parity, antenatal care, and health during pregnancy. Carry out a quick but thorough
clinical examination. Record the duration of pregnancy; the patient’s pulse rate, blood
pressure, and temperature; the amount of oedema; the condition of the lungs; and the fetal
heart rate. Catheterize the patient’s bladder and record urinary output.
Prevention of asphyxia
Once the patient has been transported to hospital, nurse her in the semiprone position in a
quiet, dark room. She may become markedly cyanosed during convulsions. Aspirate
secretions from the throat and administer oxygen intermittently through the nose.
Control of fits
Administer diazepam intravenously, starting with a slow injection of 20 - 40 mg followed by
an infusion of 80 mg/litre in 5% (50 g/litre) glucose at the rate of 30 drops/min.
As an alternative, give 50 mg of chlorpromazine and 25 mg of promethazine intramuscularly

soon after admission, followed by 100 mg of pethidine and 50 mg of chlorpromazine in 20 ml
of 5% glucose intravenously. Then start an intravenous infusion of 1 litre of 10% glucose
containing 100 mg of pethidine, and adjust the drip rate according to the patient’s response.
Further doses of pethidine may be given as required, but the maximum dose that should be
given in 24 hours is 300 mg. After 4 hours, repeat the intramuscular injection of
promethazine. After another 4 hours, follow this with 50 mg of chlorpromazine given
intravenously, and continue this alternating regimen for 24 to 48 hours.
Control hypertension, for example with 20 mg of hydralazine by infusion. Regulate the dose
according to the blood-pressure response. If there is tachycardia, venous congestion in the
neck, or persistent cyanosis despite the administration of oxygen, give a slow intravenous
injection of 0.1 mg of digoxin, followed by 20 - 40 mg of furosemide.
Obstetric management
Once the patient is fully sedated, verify fetal heart sounds and carry out abdominal and
vaginal examinations. In many cases, spontaneous labour will have started, in which case
rupture the membranes artificially. During the second stage of labour, perform a low forceps
delivery with episiotomy to reduce the maternal efforts. If labour has not begun, but the fetal
lie and presentation and the pelvis are favourable, rupture the membranes and put the patient
on a drip of 2 IU of oxytocin in 500 ml of 5% glucose at the rate of 15 drops/min. Monitor
the progress of labour, the uterine contractions, and the patient’s pulse and blood pressure.
Surgical induction is contraindicated if the fetus is dead. Caesarean section is indicated in
cases of cephalopelvic disproportion, fetal distress, or oblique lie, or if the fits are not
controlled within 4 - 6 hours of starting treatment.
General treatment
General care of the patient includes turning, to avoid pressure sores, emptying of the bladder,
and attention to bowel activity. Total daily fluid intake should be limited to 1000 ml plus the
volume of urine output for the previous 24 hours. Aspirate secretions from the upper
respiratory passages every 2 hours.
After delivery, continue to administer sedatives and also, if necessary, antihypertensive drugs
for at least 24 hours.
Complications
Possible complications include inhalation pneumonia, accidental haemorrhage, vasomotor

collapse, bilateral renal cortical necrosis, and cardiac failure.
2. Delivery
Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
2. Delivery
Printable version
Normal delivery
Premature labour
Export document as HTML Low forceps delivery

file Help
Vacuum extraction
Lower-segment caesarean section

Breech delivery
3. General obstetric procedures
Gynaecology

procedures


Back Cover
Normal delivery
Labour is the physiological process by which the uterus expels the products of conception.
The classical signs of the onset of labour are painful, regular uterine contractions, “show”,
and cervical effacement with dilatation. True labour is differentiated from false labour in that
false labour is associated with abdominal pain and irregular uterine contractions that do not
lead to cervical shortening and dilatation.
Assessment
Take the mother’s history, and review the prenatal records. Carry out a physical examination
to detect any systemic disorder and to determine the fundal height, the fetal lie and
presentation, the fetal heart rate, the degree of cervical dilatation and effacement, the station
of the fetal head, and the fetal position and attitude. Assess the size of the pelvis.
Investigations
Measure the mother’s haemoglobin level and test the urine for sugar and protein. Send a
sample of blood for grouping (including Rh factor) and carry out a serological rest for
syphilis.
Equipment
See tray for Episiotomy, Annex 1.
Management
Because the onset of labour delays gastric emptying, the mother should avoid taking food or
fluids by mouth; she should be put on an intravenous drip of glucose/saline or be given plain
water and antacids orally. In early labour, she may move about or sit on a chair, provided that
the fetal head is not free-floating and that the membranes are intact. After rupture of the
membranes and during active labour, however, the mother should remain in bed. Monitor and
record her pulse rate and blood pressure hourly. Auscultate the fetal heart rate every 15 min
during the first stage of labour, and after every contraction during the second stage. Begin
auscultation towards the end of a uterine contraction and continue for 30 s after the
contraction has stopped.
During labour, cervical dilatation proceeds with a characteristic pattern, which can be plotted
against time (for example on a “partograph”). The process is divided into two well-defined
phases: the latent phase (from 0 to 4 cm of dilatation) and the active phase (from 4 to 10 cm
of dilatation). The mean duration of the entire dilatation phase is 8 hours in primigravidae and
5 hours in multigravidae.
For delivery, the mother should be allowed to choose the most comfortable position. Prepare
the vulva, proximal thighs, perineum, and anal area with an anti-septic solution. Drape the
abdomen and legs, and place a drape under the buttocks. The objective during delivery is to
allow a slow, controlled delivery of the head to prevent fetal or maternal soft-tissue injury.
Perform an episiotomy, if necessary, at the time that the head distends the vulva and
perineum. After the occiput has disengaged from the symphysis pubis, place the flat of your
hand over the vertex and exert slight pressure to prevent rapid extension of the head. After
the delivery of the head, gently aspirate fluid from the baby’s nose, mouth, and oropharynx
via a soft catheter. Palpate the neck for the presence of coils of umbilical cord. If the cord is
found, slip it over the baby’s head or cut it between clamps. Support the head as the baby’s
body rotates. Then grasp it in both hands over the parietal bones and exert gentle downward
traction until the anterior shoulder is delivered beneath the symphysis.
With the birth of the anterior shoulder, check whether there is a multiple pregnancy; provided
that there is not, administer 0.25 mg of ergometrine or, if this is unavailable, 2 IU of
oxytocin. Apply gentle upward traction to deliver the posterior shoulder over the perineum.
The remainder of the body should deliver spontaneously, and the baby can then be handed
over to an assistant. Normally, the expulsion of the placenta should not take more than 5 min.
Once the uterus is contracted, this process can be facilitated by controlled cord traction. After
expulsion of the placenta, inspect the cervix; any tears or lacerations should be stitched. If an
episiotomy has been made, carry out repair. During the first few hours after delivery, keep the
patient under observation for post-partum haemorrhage.

Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
2. Delivery
Printable version
Normal delivery
Premature labour
Export document as HTML Low forceps delivery

file Help
Vacuum extraction

Breech delivery
Gynaecology

procedures

Back Cover
Premature labour
Premature labour is defined as labour occurring between day 141 and day 249 of pregnancy
(between the 20th and the 37th week) when the fetal weight is 500 - 2500 g. The predisposing
factors include habitual abortion, previous induced abortion, incompetence of the cervix,
uterine anomalies, recurrent infection of the urinary tract, asymptomatic bacteriuria,
physically demanding work during pregnancy, low socioeconomic status, hypertension, pre-
eclampsia, multiple pregnancy, antepartum haemorrhage, abdominal surgery during
pregnancy, febrile illness, and gross fetal anomaly.
Prevention
Prevention of pre-term labour is important. All pregnant women, but especially those who are
predisposed to premature labour, should be given general advice on the importance of good
nutrition, the hazards of smoking, and the need for rest. In patients with an incompetent
cervical os, cervical cerclage (suture) applied at 12 weeks of gestation can be effective.
Diagnosis
The diagnosis is confirmed by a history of regular uterine contractions, by abdominal

palpation, and, on vaginal examination, by evidence of progressive cervical effacement and
dilatation.
Investigations
syphilis. In addition, when possible, test the urine for micro-organisms.
Management
Management depends upon how early the patient reports for medical help. Patients reporting
early with the cervix partially effaced, but with dilatation of less than 2 cm, should be treated
conservatively with a view to prolonging the pregnancy to give fetal organ systems time to
mature. Certain patients treated conservatively fail to respond and go into progressive
premature labour. Patients presenting late with the cervix fully effaced and with dilatation of
more than 2 cm are in progressive premature labour, which requires active management.
Conservative management
Conservative treatment consists of bed rest, preferably in hospital; sedation; and, if available,
the administration of drugs to relax the uterine muscles, for example isoxsuprine, terbutaline,
ritodrine (all given intravenously or orally), or ethanol (given intravenously).
Contraindications to the use of these drugs include pre-mature rupture of the membranes,
chorio-amnionitis, fever of unknown origin, heart disease, cardiac dysrhythmias,
thyrotoxicosis, severe antepartum hemorrhage, cervical dilatation of more than 2 cm, fetal
distress, or intrauterine death.
First calm the patient by giving 10 mg of diazepam intramuscularly every 8 hours.

Administer other drugs as appropriate. For example, if you are using isoxsuprine, start an
intravenous infusion of 100 mg in 500 ml of 5% (50 g/ litre) glucose at the rate of 1.0 - 1.5
ml/min. Gradually increase the drip rate to 2.5 ml/min or until the uterus becomes calm.
Check the mother’s blood pressure and both the mother’s and the fetal heart rate regularly.
Discontinue the drip once the uterus has remained tranquil for 6 hours, and give the patient
10 mg of isoxsuprine intramuscularly every 3 hours for 24 hours and then every 6 hours for
the next 48 hours. If she goes into progressive premature labour, proceed with active
management as described below.
Active management
The aim of management of progressive premature labour is to minimize birth asphyxia and to
prevent the development of respiratory distress syndrome. Rupture the membranes and start
the administration of antibiotics. Monitor labour in the usual manner with special
consideration for maternal nutrition and hydration and fetal condition.
Caesarean section is sometimes indicated, for example in cases of fetal distress, breech
presentation, or placenta praevia, but vaginal delivery is usually preferable. When the head
presents at the vulva, perform a wide episiotomy to prevent intracranial injury. To give the
baby the advantage of a few extra millilitres of blood, wait until pulsations cease before
clamping the cord.
If there is doubt about the maturity of the fetal lungs, and provided there is time before
delivery, give the mother 4 mg of betamethasone intravenously every 8 hours for a total of
six doses, to prevent respiratory distress syndrome in the new-born baby. Contraindications to
this treatment are maternal infection, maternal heart disease, or rupture of the membranes.
After delivery, keep the premature baby warm and provide adequate nutrition.
Low forceps delivery
Although forceps delivery has largely been replaced by vacuum extraction, it is a procedure
still undertaken in many developing countries where vacuum extraction is not yet in wide
use.
Limit the use of obstetric forceps in delivery to the gentle lifting out of the fetal head at the
pelvic outlet.
Indications for low forceps delivery are maternal distress and conditions associated with a
threat of maternal distress, such as cardiac disease, pulmonary tuberculosis, thyroid disease,
eclampsia, and severe anaemia.
Fetal indications include:
• fetal distress, as indicated by a fetal heart rate of more than 160/min, or less than 120/min, and
the passage of meconium;
• conditions that may give rise to fetal asphyxia, for example cord pro-lapse at full cervical
dilatation, eclamptic seizures in the mother, and an after-coming head in breech presentation;
and
• a prolonged second stage of labour, especially if the fetal head has not advanced for 20 min,
or in a primigravida if active bearing down has continued for about 40 min.
Assessment
Carry out a general assessment and follow the progress of labour as for normal delivery. In
addition, examine the patient for signs of maternal distress: a dry tongue, a rising pulse rate,
pyrexia, and dehydration.
Provided that the fetal head is in low midcavity, obstetric forceps can be applied for delivery
in case of: occipito-anterior position (with complete rotation of the fetal head), persistent
occipito-posterior position or face-to-pubis presentation, and after-coming head in breech
presentation. However, if the sinciput is palpable, forceps should not be used.
Investigations
syphilis.
Equipment
See tray for Episiotomy, Annex 1 and add a pair of low obstetric forceps.
Technique
Once the second stage of labour has started, the patient should be given a regional anaesthetic
by pudendal block or a general anaesthetic. Place her in the lithotomy position, clean and
drape the area, and catheterize the bladder. Then check for the following before proceeding:
full dilatation of the cervix, the absence of membranes, complete rotation of the fetal head,
and the station of the head below the ischial spines. Check the forceps blades to ensure that
they will lock correctly. Apply the left blade first, guiding it into the uterine cavity along your
right palm (Fig. 2.1A - D). Similarly apply the right blade along the inserted left hand (Fig. 2.
1E, F). Lock the forceps and apply traction during uterine contractions, first downwards and
backwards (Fig. 2.1G, H), gradually levelling out, and finally upwards and forwards in the
case of the occipito-anterior position (Fig. 2.1I - L). Perform an episiotomy with the
crowning of the head. Once the head reaches the pelvic outlet, lift it out using the forceps.
Fig. 2.1. Low forceps delivery. Applying the left blade of delivery forceps (A - D);
applying the right blade (E, F). Right-hand illustrations show position of forceps in
relation to fetal head and mother’s pelvic bones. Locking the forceps and applying
traction downwards and backwards (G, H); applying traction gradually upwards (I-L).
Illustrations H and J show position of forceps in relation to fetal head and mother’s
pelvic bones.
After delivery, inspect the cervix and repair any tears. Stitch the episiotomy in layers and
apply a sterile pad.
Complications
Possible complications include fetal asphyxia and intracranial haemorrhage; maternal

hypovolaemic shock; injuries such as cervical and vaginal laceration or uterine rupture; and
postpartum haemorrhage or sepsis.
Vacuum extraction
Vacuum extraction is an alternative to forceps delivery. It is indicated mainly in cases of

delayed labour with an incompletely dilated cervix and a low fetal vertex.
Vacuum extraction is contraindicated in acute fetal distress or prematurity.
Assessment
Assess the patient as for forceps delivery.
Investigations
sample of blood for grouping (including Rh factor) and carry out a serological rest for
syphilis.
Equipment
See tray for Episiotomy, Annex 1 and add an apparatus for obstetric vacuum extraction (Fig.
2.2A).
Technique
Employ the largest possible vacuum extraction cup (Fig. 2.2B). Take all aseptic and
antiseptic precautions. Perineal infiltration with local anaesthetic is usually sufficient and will
also be suitable for episiotomy. Otherwise, use a pudendal block. With the patient in the
lithotomy position, retract the perineum with two fingers of one hand and insert the cup with
its open end pointing towards the occiput. Press the cup against the baby’s scalp, as near to
the lambda as possible. Check that no vaginal or cervical tissue has been caught within the
rim of the cup.
Fig. 2.2. Vacuum extraction apparatus. Assembled apparatus (A); suction cap (B).
Instruct an assistant to activate the pump to raise the suction pressure by 0.2 kg/cm2 every 2
min to a maximum of 0.8 kg/cm2. As soon as the vacuum has reached the required value,
begin traction synchronously with uterine contractions. Release the vacuum as soon as the
head crowns, and continue as for a normal delivery. Never apply traction continuously for
more than 15 min.
Complications
Possible complications include cephalhaematoma, intracranial haemorrhage, and sloughing of

the scalp.
Indications for caesarean section include fetal distress, cephalopelvic disproportion, failure of
labour to progress, previous caesarean section (check what the indications were for this),
placenta praevia, malpresentation and malposition, and prolapse of the cord. Caesarean
section may also be indicated in cases of soft-tissue obstruction or scarring, diabetes, poor
obstetric history, toxaemia, abruptio placentae, placental insufficiency, Rh incompatibility,
and failed induction, and in older primigravidae.
Assessment
Examine the patient for pallor, oedema, abnormal blood pressure, and heart and lung disease
and take appropriate action. Determine the fetal lie and presentation, and check for the
presence of fetal heart sounds. For elective caesarean section, a vaginal examination is
generally omitted; in emergencies the need will vary.
Investigations
sample of blood for grouping (including Rh factor) and cross-matching. Test for bleeding and
clotting times and for syphilis. If diabetes is suspected, include a test for fasting postprandial
blood sugar.
Preoperative management
Perform the elective operation about a week before the expected date of delivery. Admit the
patient the day before the operation and give a soap and water enema on the morning of the
operation. Patients in labour should be given an antacid every 2 hours to neutralize gastric
acid and so minimize the effects of any accidental aspiration of gastric fluid. An intravenous
drip should be set up.
Equipment
See tray for Caesarean section, Annex 1.
Technique
The recommended procedure is transperitoneal, lower-segment caesarean section with a

transverse incision into the uterus.
Empty the patient’s bladder by catheterization and then tilt her to her left by placing a pillow
under her lower back on the right. A general or regional anaesthetic should be given. Prepare
and drape the abdomen. Make a midline sub-umbilical incision (Fig. 2.3A). Incise the loose
peritoneum covering the anterior surface of the lower uterine segment and push it downwards
with the bladder (Fig. 2.3B). Make a small, transverse incision in the lower segment of the
uterus crossing the midline 2 cm below the site of peritoneal incision. Widen the incision
bluntly on either side (Fig. 2.3C). Rupture the membranes if they are still intact.
The aim is to deliver the baby as quickly as possible. For head-presentation delivery,
carefully insinuate your fingers between the lower uterine flap and the head and hook them
round the head (Fig. 2.3D). If the head is deeply engaged and difficult to extract, ask an
assistant to dislodge it from the vagina (with gloved hands). A single forceps blade may be
required to deliver it. In breech presentation, deliver the arms and the head carefully so as not
to enlarge the uterine wound unduly. In cases of transverse lie, deliver the breech first after
internal podalic version. An undiagnosed constriction ring may prevent delivery of the head;
in such cases the ring must be cut vertically in the course of caesarean section, although this
can result in a weak scar (ideally, this condition will have been suspected beforehand).
Fig. 2.3. Lower-segment caesarean section. Site of midline subumbilical incision (A);
incising and pushing down the loose peritoneal covering of the anterior surface of the
uterus (B); widening the incision into the uterus (C); hooking the baby’s head with the
fingers (D); inserting the first layer of suture (muscle layer) (E). Inserting the second
layer of suture, taking the muscles and burying the first layer (F); inserting the
peritoneal layer of suture (G).
Extract the fetus. Clean and aspirate fluids from the nose and mouth. Divide the cord between
clamps and ligate it. Give the mother 0.25 mg of ergometrine intravenously, and then remove
the placenta and membranes. Rub the uterus if it is flabby, and, if necessary, start the patient
on a drip of 4 or 8 IU of oxytocin (the amount to be determined according to the patient’s
response) in 500 ml of 5% (50 g/litre) glucose at a rare of 15 drops/min.
Grasp the edges of the uterine incision with haemostatic (Green-Armytage) forceps. Stitch
the incision in three layers. First insert a continuous, muscle-layer stitch of No. 1 chromic
catgut on a half-circle, round-bodied needle; avoid the decidua and take the angles carefully
(Fig. 2.3E). Then take up any unstitched muscle tissue and bury the inner layer of suture (Fig.
2.3F). Finally, close the visceral peritoneum with 0 chromic catgut (Fig. 2.3G). Complete
abdominal toilet and close the abdominal wall in layers. Apply a sterile dressing.
Complications
Possible complications include primary haemorrhage that can lead to hypovolaemic shock,
sepsis with peritonitis, secondary haemorrhage, retrovesical haematoma formation, and
pulmonary embolism.
Breech delivery
Breech presentation occurs when vertex presentation is affected by conditions such as

hydrocephalus, hydramnios, placenta praevia, pelvic contraction, and prematurity.
Diagnosis
Palpate the breech in the suprapubic region. It is softer than the head and less defined in
outline, and usually lies above the level of the brim of the pelvis. The head can be felt at the
fundus; it is hard, round, mobile, slightly tender, and ballotable. The fecal heart sounds are
heard at the level of, or a little above, the umbilicus. Vaginal examination in early labour
reveals the presenting part as lying high, with the cervix dilating slowly and the bag of waters
unusually elongated and sausage-shaped. A foot may be palpable or, late in labour, a buttock.
Meconium may be seen on the examining finger. In incomplete breech presentation, the knee
or foot may be palpable.
Breech presentation should be distinguished from vertex presentation. The vertex can be
confused with an extended breech, or a face or shoulder.
Assessment
Vaginal breech delivery is considered favourable if the following conditions are met: the
gestational age is between 36 and 38 weeks, the fetal weight is estimated as 2500 - 3800 g,
the presenting part is at or below station - 1 at the onset of labour, 1 the cervix is soft and
effaced with dilatation of more than 3 cm, the pelvis is adequately roomy, and the patient has
a history of previous breech delivery of a baby of more than 3800 g or a previous vertex
delivery of a baby of more than 4000 g.
1
Station (in cm) in relation to the level of the ischial spines.
Vaginal delivery is considered unfavourable if one or more of the following conditions are
met: the gestational age is more than 38 weeks, the fetal weight is estimated as more than
3800 g, the presenting part is at or above station - 2 and the cervix is still firm and
incompletely effaced with dilatation of less than 3 cm, there has been no prior vaginal
delivery (or prior vaginal delivery was difficult), the pelvis is android or flat, or there is a
footling or full breech presentation.
Caesarean section is indicated in the presence of toxaemia in the older primigravida or if a

radiograph shows hyperextension of the fetal head. If vaginal delivery is decided upon, then
the progress of labour should be carefully observed and managed as follows.
Investigations
syphilis.
Equipment
See tray for Episiotomy. Annex 1 and add a pair of midcavity obstetric forceps.
Technique
If there are no abnormalities of mechanism or maternal or fetal complications, leave things

strictly to nature and intervene only to assist the delivery when clearly necessary. Upon
rupture of the membranes, carry out a vaginal examination to exclude cord prolapse. As soon
as the buttocks appear, place the patient in the lithotomy position. Anaesthesia should be
provided by infiltration of local anaesthetic, pudendal block, or another type of regional
anaesthetic.
“Iron out” (gently stretch) the vagina and perineum, and carry out episiotomy. Deliver the
legs one at a time. Press on the popliteal fossa, flex the knee, displacing it to the side of the
trunk, move your fingers along the leg towards the ankle, and finally hold the ankle and
deliver the foot and leg. Repeat the procedure to deliver the other leg. With the delivery of
the buttocks (Fig. 2.4A), draw down a loop of the cord. Feel for the arms across the front of
the chest and, if they can be found, deliver them one at a time (Fig. 2.4B). If the shoulders
and arms are extended and cannot be delivered in this way, gently rotate the fetus to bring
first the chest and then the posterior shoulder to the front. Lift out the arm that is now lying in
the anterior position; the other arm can then be delivered easily.
For the delivery of the head, bring the patient to the edge of the table and allow the fetus to
hang downwards over the perineum for 1 - 2 min. This will cause the fetal head to come into
the cavity, at which point the suboccipital region or hair-line over the nape of the neck will
become visible beneath the pubic arch (Fig. 2.4C). Once the hairline is visible, accomplish
delivery by grasping the ankles of the fetus with one hand, aligning the legs, trunk, and neck
in a straight line by a gentle pull, and then exerting a mild, steady abduction force while
slowly lifting the legs and trunk over the mother’s abdomen (Fig. 2.4D). At the same time,
control the escape of the head from the vulva and maintain flexion of the head and neck with
the other hand.
Fig. 2.4. Breech delivery. Delivering the buttocks (A); feeling for the arms for delivery
one at a time (B); the hairline over the nape of the neck is visible (C); lifting the legs
slowly over the mother’s abdomen (D).
The application of forceps is ideal for the delivery of the after-coming head. As an assistant
lifts the body of the child, apply the forceps from the ventral aspect to either side of the head
and deliver it by slow intermittent traction. The forceps blades act as a protective cage for the
head and also allow aspiration of fluids from the respiratory tract.
The method of jaw flexion and shoulder traction may be helpful for delivery of the head
when it is high in the pelvis. General anaesthesia is preferred for this procedure. After
delivery of the shoulders, place the baby on your supinated left forearm with its limbs
hanging on either side; put the middle and index fingers of your left hand over the malar
bones on either side to maintain flexion. Put the fourth and the little finger of your pronated
right hand on the baby’s right shoulder, the index finger over the left shoulder, and the middle
finger on the suboccipital region. Now apply traction in a backward and downward direction
until the nape of the neck is visible under the pubic arch. Ask an assistant to apply suprapubic
pressure during this manoeuvre, to maintain flexion of the head and neck. Carry the baby
upwards and forwards cowards the mother’s abdomen, releasing the face and brow. Finally,
depress the trunk to release the vertex and occiput.
Ligate and divide the cord. Administer 0.25 mg of ergometrine or, if this is not available, 2
IU of oxytocin. Then proceed with the third stage of labour and with episiotomy repair as for
normal delivery.
Complications
Breech delivery is associated with a higher incidence of perinatal mortality, intracranial

haemorrhage, and fetal asphyxia from compression of the cord than is normal delivery.
Possible trauma to the fetus includes dislocation of the cervical spine, rupture of the liver, and
fracture or separation of the epiphyses of the humerus, femur, or the clavicle. Injury to the
fifth and sixth cervical nerves can result in palsy.

Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
2. Delivery
Printable version
Episiotomy
Export document as HTML Artificial rupture of membranes

file Help
Cord prolapse
Symphysiotomy
Internal podalic version
Craniotomy
Gynaecology

procedures

Back Cover
Episiotomy
Episiotomy may be indicated in any primigravida, and in many cases in multigravidae. It is

required in all cases of prematurity, breech delivery, face-to-pubis delivery (persistent
occipitoposterior presentation), or forceps delivery; in cases of previous colpoperineorrhaphy;
when the head fails to advance because of perineal rigidity; and in cases of narrow subpubic
arch when the head has difficulty emerging because of posterior displacement.
Equipment
Technique
Place the patient in the lithotomy position and clean and drape the area. Infiltrate local
anaesthetic into the intended site of episiotomy. During the crowning of the fetal head, insert
two fingers into the vagina, as a guard against cutting into the baby, and make a posterior
mediolateral incision with curved scissors. Divide the whole depth of tissue (Fig. 3.1A - C).
After delivery of the baby, repair the episiotomy in three layers with 0 chromic catgut suture:
the vaginal layer with continuous suture, the musculature with interrupted sutures, and the
skin with interrupted mattress stitches (Fig. 3.1D - F). Apply a sterile pad.
Fig. 3.1. Episiotomy. Line of incision (A); infiltrating tissues with local anaesthetic (B);
making the incision, while inserting two fingers to protect the baby’s head (C);
repairing the wound in three layers by first suturing the vaginal mucosa and submucosa
in one layer (D), then suturing the muscle layer (E), and finally suturing the skin (F).
Complications
Possible complications include vulval haematoma, infection, breakdown of the wound, and
dyspareunia.
Artificial rupture of membranes
Artificial rupture of the membranes is one of the oldest methods of inducing labour; it can
also speed up labour if the first stage is prolonged. No anaesthesia is required, but in the
nervous primigravida, sedation is recommended. Because of the small risk of cord prolapse,
bleeding, and acute fetal distress, the procedure should be carried out under aseptic
conditions, in case a caesarean section is required.
Assessment
Carry out abdominal and vaginal examinations to confirm the lie, presentation, and condition
of the fetus, and to assess the pelvic capacity. Make a complete assessment of the progress of
labour, noting the degree of cervical dilatation and effacement, the consistency and position
of the cervix, and the station of the fetal head. The findings from this assessment can be
presented as a score (Bishop’s score), which is a useful guide to the degree of ripeness of the
cervix (Table 1). The cervix is favourable (induction of labour is indicated) if the score is 9 -
13.
Table 1. Pre-induction score for assessing cervical ripeness
Factors Score
0 1 2 3
Cervix
Degree of dilatation closed 1-2 cm 3-4 cm ≥ 5 cm
Degree of effacement (length) 0-30% 40-50% 60-70% ≥ 80%

(3 cm) (2 cm) (1 cm) (fully effaced)
Consistency firm medium soft -
Position posterior midline anterior -
Fetal head
Station in relation to level of the ischial -3 cm -2 cm -1 cm +1, +2 cm

spines
Maximum score 13 Favourable score 9- Unfavourable score 0-
13 8
Equipment
See tray for Artificial rupture of membranes, Annex 1.
Technique
Artificial rupture of the membranes requires rigid adherence to aseptic technique. Place the
patient in the lithotomy position and empty the bladder by catheterization. To release the
forewaters, pass a finger through the cervix and separate the membranes from the region of
the internal os uteri. Pass a pair of long-toothed dissecting forceps (or an amniohook)
alongside the finger that is inserted in the cervix and tweak the membranes. Ensure the free
escape of the amniotic fluid. Auscultate the fetal heart to confirm that all is well. The onset of
labour is usually rapid, but if after 1 hour contractions have not yet started, administer
oxytocin as a drip of 2 IU in 500 ml of 5% glucose at a rate of 15 drops/min. Increase the drip
rate as indicated by the patient’s response. Clinical monitoring of maternal and fetal condition
and of the progress of labour is essential. If labour fails to progress or if there is fetal distress,
perform caesarean section immediately.
Oxytocin is contraindicated in grand multiparae, in patients who have had a previous

caesarean section or hysterotomy or who have cardiac disease, and in cases of
malpresentation.
Complications
Possible complications include haemorrhage, sepsis, cord prolapse, and laceration of the
cervix.
Cord prolapse
Anticipate possible cord prolapse during labour in multiparae and in cases of hydramnios,
twins, prematurity, cephalopelvic disproportion, and malpresentation.
Diagnosis
The diagnosis of cord presentation or prolapse can be made on routine vaginal examination at
the beginning of labour, or after amniotomy or spontaneous rupture of the membranes. In
cases of cord presentation, cord pulsations can be felt through the intact membranes. Avoid
handling the cord, as it can cause spasm of the cord vessels and subsequent fetal death.
If the fetus is dead and pulsation has ceased, the presenting cord can be mistaken for a hand
or foot.
Equipment
See tray for Caesarean section. Annex 1.
Management
The aim of management is to relieve pressure on the cord, to determine whether the fetus is
alive or dead, and to carry out delivery as appropriate. If the fetus is alive, carry out
immediate caesarean section. While preparations are being made, tilt the patient head-down
to reduce pressure on the cord. If the fetus is dead, but the pelvis and presentation are
favourable, and there is no obstruction, await spontaneous delivery. However, if there is
malpresentation, if the pelvis is contracted, or if there is no progress of labour, caesarean
section is advisable.
In the case of twins, if after delivery of the first baby, cord prolapse occurs for the second
twin, carry out internal version and breech extraction.
Complications
Complications include those of caesarean section and also fetal asphyxia.
Symphysiotomy
Symphysiotomy facilitates the delivery of the fetal head from the pelvic cavity by division of
the symphysis pubis to widen the pelvic outlet. Symphysiotomy is an alternative emergency
procedure that may be undertaken when facilities for safe caesarean section are not available.
Carry out symphysiotomy during the second stage of labour, when the outlet of the pelvis is
contracted and the fetal head is deeply engaged in the pelvic cavity. Symphysiotomy is
contraindicated if the fetus is dead.
Equipment
See tray for Episiotomy, Annex 1 and add a vacuum extraction apparatus and a scalpel blade
and handle.
Technique
General anaesthesia is preferred. Place the patient in the lithotomy position, with the thighs
held in not more than 90° of abduction by an assistant. Clean and drape the area. Insert an
indwelling catheter into the bladder. Avoid injury to the urethra by pushing it to one side with
the index finger of one hand placed in the vagina (Fig. 3.2A). Make a midline skin incision
over the pubis, and then divide the symphysis pubis with a knife (Fig. 3.2B), taking care not
to cut the posterior ligament. Deliver the fetal head by vacuum extraction after episiotomy.
Bring the pubic bones together, repair the skin wound, and support the pelvis with
circumferential strapping. The patient should remain in bed for at least 7 days after operation.
Fig. 3.2. Symphysiotomy. Pushing the urethra to one side with the index finger after
inserting a catheter through the urethra into the bladder (A); dividing the symphysis
pubis (B).
Complications
Complications include injury to the urethra and bladder base, para-urethral haematoma,
urinary tract infection, stress incontinence, painful joint, periosteitis and osteomyelitis, and
subsequent problems with walking and gait.
Internal podalic version
Version is not a common procedure because of the danger of uterine rupture. It may,
however, be indicated in multiparous women, with recently ruptured membranes, in cases of
twin delivery when the second twin has a transverse lie, and in cases of shoulder presentation
or transverse lie when the fetus is small or dead. Rarely, it is indicated in cases of prolapse of
the cord when immediate caesarean section is impossible.
Version is contraindicated in the presence of tonic uterine contraction, when the membranes
have ruptured and the liquor has drained out, and in cases of contracted pelvis. It should not
be attempted late in labour or if there is an impacted shoulder presentation.
Assessment
Assess the general condition of the patient. Examine the abdomen to establish the lie and
presentation of the fetus. Carry out a vaginal examination to determine the degree of
dilatation of the cervix, confirm the presentation, and assess the pelvic capacity. For internal
version, the cervix should be at least half-maximally dilated.
Investigations
syphilis.
Technique
The patient should be given a general anaesthetic. Empty her bladder by catheterization and
place her in the lithotomy position.
Observe aseptic precautions. When the uterus is relaxed, pass your hand into the vagina up to
the breech with fingers and thumb bent into the shape of a cone. Then partially withdraw the
hand along the thigh of the fetus and grasp one or both feet. The heel is the landmark to feel
for, and the limb should not be brought down until you have recognized it. With your hands
working in conjunction, one placed internally and the other externally, fully or almost fully
dilate the os uteri so that the fetus can be extracted, as in cases of breech delivery.
Complications
Possible complications include rupture of the uterus and sepsis.
Craniotomy
Craniotomy consists of perforation and extraction of the fetal head and is indicated in cases
of hydrocephalus and dystocia due to cephalopelvic disproportion when the fetus is dead.
With adequate obstetric care, this operation is rarely necessary. It is contraindicated if there is
a threat of uterine rupture.
The patient usually presents in obstructed labour, but if major cephalopelvic disproportion is
discovered at full term, caesarean section is safer than craniotomy and vaginal delivery.
Assessment
The patient’s general condition is usually poor as the result of prolonged labour.
Carry out an abdominal examination to estimate the approximate size of the fetus, to establish
the presentation and lie, and to verify the absence of fetal heart sounds. Vaginal examination
will confirm the presentation of the fetus and permit assessment of the condition of the cervix
and the pelvic capacity. In cases of hydrocephalus, the head is enlarged and floating, and
there may also be spina bifida. The diagnosis is suggested by the presence of wide cranial
sutures. Hydrocephalus can also present as an obstructed after-coming head with breech
presentation. Radiographs should be taken to confirm the diagnosis if necessary.
Investigations
sample of blood for grouping (including Rh factor).
Equipment
See tray for Episiotomy, Annex 1 and add a cranial perforator (Fig. 3.3A, B) and a pair of
craniotomy forceps or a pair of large, sturdy scissors and a pair of large artery forceps.
Fig. 3.3. Cranial perforators with jaws closed (A) and with jaws open (B).
Technique
Carry out the procedure with the patient under general anaesthesia. As she may be exhausted
and the birth canal already infected, start intravenous infusion of an appropriate fluid and
administer antibiotics immediately. Blood transfusion may also be necessary. Empty the
bladder by catheterization.
In cases of fore-coming head, it is the parietal bone that is perforated; in after-coming head
with breech presentation, the occipital bone; and in face presentation, the orbit.
The closed blades of the perforator come to a sharp point at the tip and have a keen, outer
cutting edge. The handles are separated by metal bars to keep the blades in apposition while
piercing the skull. During the second stage of labour, as an assistant immobilizes the fetal
head by exerting suprapubic pressure, introduce the perforator along the palm of one hand,
taking care to protect the vaginal walls from the cutting edge. Press the point of the perforator
firmly against the head and penetrate the bone with a rotatory movement until the shoulder of
the instrument strikes the skull. Release the crossbars to break the bone. Close the instrument,
rotate it through a right angle, and cut the bone again in the opposite direction. Slip the closed
head of the perforator into the cranial cavity, thoroughly break up the cranial contents, and
express them by suprapubic pressure. As an alternative, the point of a pair of large scissors
can be pushed into the skull through a fontanelle or skull suture. A hydrocephalic head can
also be collapsed by inserting a lumbar puncture needle into the foramen magnum.
Extraction of the fetus can then be by natural delivery or by extraction with craniotomy
forceps or large artery forceps applied to grasp the vault bones. In all cases, the uterine cavity
must be checked after delivery of the placenta to exclude rupture. Administer antibiotics and
leave the bladder catheter in place for 2 - 3 days.
Complications
Possible complications include cervical, vaginal, and perineal lacerations; rupture of the
uterus; hypovolaemic shock and subsequent collapse; and bladder injury.
Repair of perineal, cervical, and vaginal tears
Perineal tears are normally prevented by adequate episiotomy, but can nevertheless occur in
certain circumstances such as delivery of a big baby, occipitoposterior position, face
presentation, forceps or precipitate delivery, and narrow pelvic outlet or subpubic angle.
Tears predispose to postpartum haemorrhage. Cervical and vaginal lacerations bleed

profusely. In postpartum haemorrhage, bleeding is unlikely to come from a contracted uterus,
so the patient should instead be examined for tears. Inspection of the cervix for tears is
routine after any type of vaginal delivery.
Diagnosis
If blood loss has been profuse, the patient may be hypovolaemic. Perineal tears are visible on
local examination: a speculum and swabs held with sponge forceps can be helpful in
examining lacerations. Perineal tears are classified according to the degree of damage. In a
first-degree tear, the fourchette is torn, together with only a small part of the vaginal and
perineal skin. In a second-degree laceration, the perineal body is torn, together with the
posterior vaginal wall, to a variable degree. In a third-degree tear, the damage extends beyond
the anal sphincter into the anal canal. Tears due to direct trauma have ragged edges with
surrounding abrasions and contusions.
Equipment
See tray for Episiotomy, Annex 1 and add a vaginal speculum, No. 1 and 2/0 chromic catgut
sutures, and 2/0 plain catgut sutures.
Technique
All tears should be sutured immediately unless they are already infected. Infected tears
should be cleaned and dressed, but should not be sutured until the infection has cleared;
appropriate antibiotics should be administered.
Perineal tears
For the repair of first-degree and second-degree tears, place the patient in the lithotomy
position and infiltrate a local anaesthetic in the region of the tear. Expose the tear (Fig. 4.1A).
Suture the vagina first with continuous 0 chromic catgut; then the perineal body with three or
four interrupted stitches of No. 1 chromic catgut; and finally the perineal skin with
interrupted stitches of 2/0 plain catgut (Fig. 4.1B - D). Apply a sterile pad.
Repair a third-degree perineal rear with the patient under general anaesthesia. First close the
muscle wall of the rectum and the anal canal with interrupted or continuous 0 chromic catgut,
placing the sutures so as to avoid the bowel mucosa (Fig. 4.1E). Identify the torn ends of the
anal sphincter and approximate them with two or three mattress sutures of 2/0 chromic catgut
(Fig. 4.1F). The repair of the vagina, perineal body, and the skin can then be carried out as
described above. Apply a sterile pad.
Fig. 4.1. Repair of perineal tears. Exposing a perineal tear (A); suturing a tear of the
vagina (B); suturing the perineal body (C); suturing the skin (D). Third-degree tear:
closing the muscle wall of the rectum (E) and suturing the anal sphincter (F).
Cervical tears
Infiltrate a local anaesthetic in the region of the tear. Expose the tear and catch both its edges
with sponge forceps. Stitch the edges together with mattress sutures of 0 chromic catgut.
Take the highest stitch about 1 cm above the apex to include any retracted vessels, after
inserting a preliminary stay suture lower down. Apply a sterile pad.
Vaginal tears
After infiltrating a local anaesthetic, stitch a vaginal tear as described above for a perineal
tear and apply a sterile pad. Tears of the anterior vaginal wall involve the tissues close to the
urethral meatus; the torn edges lie in apposition, and suturing is necessary only when there is
free bleeding. Bladder catheterization is necessary if there is retention of urine as a result of
muscle spasm and swelling.
After-care
Clean and dress the wound daily and after each passage of stool.
Complications
Possible complications such as haematoma in the parametrium, residual recto-vaginal fistula,

and dyspareunia can be prevented by proper surgical techniques.
Drainage of vulval haematoma
Vulval haematoma usually arises from injury during childbirth or as a result of violence. It is
also a possible complication of perineal operations.
Diagnosis
The patient complains of severe pain and swelling in the vulva. Local examination confirms
the presence of haematoma and possibly some signs of the cause.
Differentiate vulval haematoma from Bartholinian abscess, sessile fibroma of the vulva, and
vulval oedema.
Investigations
Measure the patient’s haemoglobin level and test the urine for sugar and protein.
Equipment
See tray for Episiotomy, Annex 1 and add a scalpel with blade.
Technique
General anaesthesia is preferred. If the haematoma is the complication of an operation,

remove the sutures and evacuate the clot. If any bleeding is visible, ligate the vessel(s) and
resuture the wound.
If the haematoma is the result of direct injury at the mucocutaneous junction, incise it,
remove the clots, and ligate the bleeding points. Pack the wound with gauze for 12 hours, and
then apply a dressing and cold compresses twice daily.
Complications
Possible complications include haemorrhage and sepsis.
Manual removal of the placenta
A common third-stage complication of delivery is delay in the expulsion of the placenta,

often accompanied by excessive blood loss due to the retained or adherent placenta. Early,
active management is necessary if the patient is bleeding or anaemic.
Diagnosis
The patient may present with a retained placenta after delivery elsewhere. Such patients have
usually lost a lot of blood from the vagina. Examination may reveal a relaxed uterus, possibly
above the level of the umbilicus. The cord may be hanging down from the vulva or avulsed
from its site of attachment to the placenta.
Differentiate retention of the placenta from adherent placenta accreta and other causes of
postpartum haemorrhage, such as imperfect retraction as a result of uterine atony, lacerations
of the cervix or vagina, uterine inversion, and clotting defects.
Investigations
If appropriate tests have not already been done, for example in cases of home delivery,
measure the patient’s haemoglobin level and test the urine for sugar and protein. Send a
sample of blood for grouping (including Rh) and cross-matching.
Assess the extent of blood loss. Hypovolaemic shock may be profound. Treat hypovolaemia
while preparing to remove the placenta manually. While blood is being grouped and cross-
matched, start the patient on a glucose/saline drip and give oxygen.
Equipment
Technique
The patient should be given a general anaesthetic or intravenous diazepam and pethidine.
Prepare and drape the area. Empty the bladder by catheterization and cut the cord short at the
vulva. Insinuate one hand in the shape of a cone into the vagina and follow the cord until you
find the placenta (Fig. 4.2A). With the other hand steady the fundus of the uterus to prevent it
from being pushed up towards the costal margin (Fig. 4.2B). Detach the placenta completely
by sweeping movements of the fingers (kept close together). Once the whole placental mass
is free within the uterine cavity, deliver it by traction on the cord while retaining the hand
inside the uterus for a final exploration of its cavity. Administer ergometrine intravenously
and apply a sterile pad.
Fig. 4.2. Manual removal of the placenta. Insinuating one hand into the vagina along the
cord (A); steadying the fundus of the uterus with the other hand, while detaching the
placenta by sweeping movements of the fingers (B).
Complications
Possible complications include rupture of the uterus, sepsis, and failure to remove the
placenta as a result of placenta accreta, which is an indication for hysterectomy.
Postpartum haemorrhage
Postpartum haemorrhage is defined as bleeding from or into the genital tract during the third
stage of labour that amounts to more than 500 ml. Haemorrhage can result from uterine
atony, lacerations of the genital tract, or retained products of conception. Predisposing factors
include prolonged, stimulated, or precipitate labour; overdistension of the uterus; uterine
anomalies; myomas; subinvolution; general anaesthetic agents; uterine inversion; amniotic
fluid embolism; lacerations of the vulva, vagina, or cervix; uterine rupture; placenta praevia;
antepartum haemorrhage; retained placenta; anticoagulation therapy or clotting defects;
thrombocytopenic purpura; and leukaemia.
Postpartum haemorrhage can be prevented by early detection of risk factors, administration

of ergometrine with the birth of the baby’s anterior shoulder, and routine inspection of the
cervix and vagina for lacerations after delivery.
Investigations
Appropriate investigations will probably have been carried out before delivery. However,
tests to determine bleeding and clotting times and prothrombin time should be repeated.
Equipment
See tray for Episiotomy. Annex 1 and add a vaginal speculum and a Foley catheter, and tray
for Laparotomy. Annex 1.
Management
As soon as postpartum haemorrhage is recognized, begin recording the patient’s pulse and
blood pressure. Catheterize the bladder and begin a rapid intravenous infusion of
physiological saline or Ringer’s lactate solution, to be replaced with blood as soon as it is
available for transfusion. The next priority is to stop the bleeding. Palpate the uterus and
carry out speculum and bimanual examinations with the patient under sedation or, preferably,
general anaesthesia. Any lacerations must be stitched and a retained placenta evacuated
immediately. Correct any inversion of the uterus. In cases of uterine atony, compress and
massage the uterus bimanually (Fig. 4.3) and administer an oxytocic, for example
ergometrine 0.25 mg intravenously and 0.5 mg intramuscularly; this is usually sufficient to
cause contraction of a large, boggy uterus.
Fig. 4.3. Management of postpartum haemorrhage due to uterine atony; compressing

and massaging the uterus bimanually.
If the bleeding continues, undertake a laparotomy, with a hysterectomy as the last resort.
Complication
A possible complication is hypovolaemic shock
Inverted uterus
Inversion of the uterus can be acute or chronic. Acute inversion, which often causes bleeding
and shock, usually occurs during labour, the predisposing factors being fundal insertion of the
placenta, atony of the uterus, and fibroids. The precipitating causes are pulling on the cord
when the uterus is relaxed, pressure of the fundus of the soft uterus, a short cord or a cord
wound several times round the baby’s neck, precipitate delivery especially in the erect
position, and expression of the placenta.
Diagnosis
There may be vaginal bleeding and severe lower abdominal pain with a strong, dragging
sensation; the patient is usually too weak as a result of hypovolaemia to provide a history.
The uterus of a recently delivered patient with complete inversion is not palpable on
abdominal examination. When inversion is minimal (incomplete) there will be cupping,
dimpling, or irregularity of the upper surface of the uterine fundus. Vaginal examination
confirms the diagnosis (Fig. 4.4A). In severe cases, the body of the uterus lies outside the
vagina. The cervix is drawn up and its vaginal portion is palpable as a ring round the inverted
part. Keep in mind that the diagnosis of acute inversion is often missed, the bleeding and
shock being ascribed to severe postpartum haemorrhage.
Management
The treatment of acute inversion of the uterus is immediate repositioning without attempting
to remove the placenta. General resuscitative measures are carried out simultaneously.
Patients with chronic uterine inversion should be treated for sepsis, as necessary, and then
referred.
Investigations
No special investigations are needed before the repositioning of an inverted uterus. Those
specified for normal delivery will usually already have been carried out.
Equipment
Sterile drapes and gloves and a gauze pad are required.
Technique
The patient should be given a general anaesthetic. Place her in the lithotomy position and
clean and drape the area. Using manual and digital pressure, replace the inverted part of the
uterus, starting with the section nearest the cervix (Fig. 4.4B, C), and then give the patient an
intravenous injection of ergometrine. If the placenta is still attached, remove it manually after
repositioning the uterus. Apply a sterile pad.
Fig. 4.4. Repositioning an inverted uterus. Confirming inversion of the uterus by
bimanual examination (A); replacing the inverted part of the uterus (in this case lying
outside the vagina), starting with the section nearest the cervix (B, C).
Complications
Complications can include haemorrhage, hypovolaemic shock, and sepsis. Rarely,

repositioning is difficult. Failure to replace the uterus may necessitate hysterectomy, which
should be done at the next referral level.
Rupture of the uterus
Rupture of the uterus can occur in obstructed labour, at the site of a classical caesarean-
section scar, after injudicious use of oxytoxic drugs, especially in grand multiparae, during
any instrumental delivery, especially if the cervix is not fully dilated, during manual removal
of the placenta or internal podalic version, and in cases of rudimentary uterine horn or
angular pregnancy.
Prophylaxis and recognition of threatened rupture are important. The warning signs during
labour are pain and tenderness, even between contractions, in the region of a previous scar. In
obstructed labour there will also be a retraction ring, detectable by abdominal palpation of the
uterus. In these cases, caesarean section should be carried out immediately. If actual rupture
occurs, immediate surgical intervention and blood transfusion are indicated.
Diagnosis
Typically uterine rupture occurs during labour. The patient experiences a severe bursting
pain, vaginal bleeding, and fainting. Less dramatic rupture is sometimes encountered during
pregnancy, at the site of a lower-segment scar. After rupture, labour comes to an abrupt end,
contractions cease, and hypovolaemic shock ensues. The presenting part cannot be felt in the
pelvis, the fetal parts are easily palpable through the abdominal wall, and the fetal heart
sound is absent. The empty and retracted uterus forms a firm swelling to one side of the fetus.
Investigations
sample of blood for grouping (including Rh factor) and cross-matching.
Management
When rupture occurs, undertake laparotomy as soon as blood transfusion has been started (a
massive blood transfusion of 2 litres or more is usually required). Preferably then proceed to
subtotal hysterectomy, but in hypovolaemic patients or when there is a previous caesarean-
section scar, repair of the tear is simpler and safer.
Equipment
See tray for Caesarean section, Annex 1.
Technique
The patient should be given a general anaesthetic. Clean and drape the abdominal area and
insert an indwelling catheter into the bladder. Open the abdomen through a subumbilical
midline incision. Extract the fetus together with the placenta and evacuate blood clots from
the abdominal cavity. Clamp the sites of bleeding. Proceed with subtotal hysterectomy or
repair of the tear as indicated.
Subtotal hysterectomy
Clamp, cut, transfix, and ligate the round ligaments (Fig. 4.5A - D). In the same way, deal
with the ovarian ligaments and the uterine tubes together, on both sides. Turn down the
anterior peritoneal flap together with the bladder (Fig. 4.5E). Clamp, ligate, and cut the
uterine vessels. Transfix the pedicle with 2/0 thread and ligate it again. Amputate the uterus
at the level of the internal os and stitch together the cut edges of the stump with 0 chromic
catgut (Fig. 4.5F). Carefully inspect the bladder for injury. Repair any tear in the bladder wall
with two layers of continuous 0 chromic catgut. Then, using continuous or interrupted
stitches of 0 chromic catgut, close the peritoneum over the pelvis to cover the pedicles and
uterine stump (Fig. 4.5G).
Close the abdominal wall in layers and apply a sterile dressing. Start antibiotic therapy,
preferably with an initial dose given intravenously.
Fig. 4.5. Subtotal hysterectomy for rupture of the uterus. Clamping, dividing, and
transfixing the round ligaments, ovarian ligaments, and uterine tubes (A-D). Dotted
lines show sites of division. Line of division of the uterus after the anterior peritoneal
flap, together with the bladder, has been turned down (E); closing the cut edge of the
uterine stump (F); closure of the peritoneum over the pelvis to cover the pedicles and
uterine stump (G).
Repair of the tear
Separate the bladder from the lower segment of the uterus by blunt dissection before the
repair, to avoid inadvertently passing stitches through the wall of the bladder. Trim the
ragged margins of the laceration and carry out repair as described for caesarean section. Keep
in mind the possibility of concomitant rupture of the bladder, as well as the danger of
damaging the ureter. In view of the risks of a subsequent pregnancy, any repair should be
accompanied by sterilization.
Close the abdominal wall in layers and apply a sterile dressing. Start antibiotic therapy,
preferably with an initial dose given intravenously.
Complications
Possible complications include haemorrhage and sepsis. Injury to the ureters or bladder can
complicate subtotal hysterectomy.
Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
2. Delivery
Printable version
Export document as HTML 5. Aborted pregnancy

file Help
Evacuation of the uterine cavity
Termination of early pregnancy

Ruptured ectopic pregnancy
Gynaecology

procedures

Back Cover
Evacuation of the uterine cavity
At the district hospital, evacuation of the uterine cavity is indicated in cases of spontaneous
abortion and vesicular (hydatidiform) mole.
Diagnosis
In cases of spontaneous abortion, the patient presents with amenorrhoea, vaginal bleeding,
and pain in the abdomen. Her general condition depends on the amount of blood lost and her
previous state of health. She may be in hypovolaemic shock.
A general examination should be followed by pelvic and vaginal examinations, which will
probably reveal bleeding through the cervical os and possibly products of conception at the os
or in the vagina. The internal os is usually open. The uterus is soft and enlarged, the degree of
enlargement often corresponding to the period of amenorrhoea.
In cases of vesicular mole, the abortion usually presents at about the 12th week of gestation;
some vesicles may have been passed with blood. The degree of uterine enlargement is greater
than expected from the period of amenorrhoea.
Differential diagnosis should include threatened, incomplete, or missed abortion, and ectopic
pregnancy.
Investigations
clotting times and for syphilis.
Equipment
See tray for Dilatation and curettage, Annex 1 and add a suction apparatus and a suction
cannula.
Technique
In cases of spontaneous abortion, give blood early if the patient shows signs of
hypovolaemia. Evacuation may be carried out with the patient under sedation alone, but
general anaesthesia is preferable. Place the patient in the lithotomy position, and clean and
drape the area. Empty the vagina of blood clots. Take hold of the anterior lip of the cervix
with vulsellum forceps. If the cervix is not sufficiently dilated, perform dilatation with
reference to the size of the uterus. Insert a pair of sponge forceps in the uterine cavity and
gently remove the products of conception. Carry out curettage to ensure that the cavity is
empty. Give an intravenous injection of ergometrine.
In cases of vesicular mole, evacuation by suction is the method of choice. Dilate the cervix, if
necessary. Before evacuation, start the patient on an infusion of 4 IU of oxytocin in 1 litre of
5% (50 g/litre) glucose at 30 drops/min. Aspirate the contents of the uterine cavity using a
plastic suction cannula (10 mm internal diameter). The combined effect of the oxytocin and
the removal of vesicles by suction will cause the uterus to contract and retract. Blood
transfusion should be considered with caution, since trophoblastic embolization during
evacuation, pulmonary hypertension, and high-output heart failure can prove fatal. One week
after evacuation, repeat dilatation and curettage to ensure that the uterus is empty.
Hysterectomy, for which referral is necessary, is the treatment of choice in older women who
do not desire more children.
Complications
Possible complications include perforation of the uterus, injury to the bladder or bowel,
haemorrhage, and sepsis
Termination of early pregnancy
Termination of pregnancy should be carried out in line with national or local laws and
regulations on abortion, and then only under exceptional circumstances and only after
obtaining the written consent of the patient and her husband, or as legally stipulated. In
general, women requiring termination of pregnancy should be referred to a higher-level
hospital.
The patient presents with amenorrhoea and other features of the first trimester of pregnancy,
and perhaps with symptoms of a condition for which termination is indicated. The procedure
described here is not suitable for use after the 12th week of pregnancy.
Differential diagnosis should include metropathia haemorrhagica (essential uterine

haemorrhage, for which referral is necessary), vesicular mole, and extra-uterine pregnancy.
Investigations
clotting times and for syphilis. Confirm the diagnosis with a urine pregnancy test.
Equipment
See tray for Dilatation and curettage, Annex 1 and add a suction cannula and a suction
apparatus.
Technique
Evacuation by suction is the technique of choice for medical termination of pregnancy,

although dilatation and curettage (with the patient under general anaesthesia) are acceptable
as an alternative.
The patient should be given a sedative or a general anaesthetic. Place her in the lithotomy
position and clean and drape the area. Retract the vaginal walls and take hold of the anterior
lip of the cervix with vulsellum forceps. Slowly and progressively dilate the cervix, using
dilators up to No. 8 for an 8-week pregnancy, up to No. 9 for a 9-week pregnancy, and so on.
Remove the products of conception with the suction cannula or by curettage (as in dilatation
and curettage. Perform a “check” curettage after evacuation by suction. At the end of
procedure, give 0.25 mg of ergometrine intravenously.
Complications
Possible complications include haemorrhage, perforation of the uterus, bowel or bladder

injury, sepsis, and cervical laceration.
Ruptured ectopic pregnancy
Diagnosis
A typical history of ruptured ectopic pregnancy is of a missed period followed by severe

abdominal pain and vaginal bleeding. Amenorrhoea may not be a feature, however, and some
patients show little disturbance in pulse or blood pressure. Pain is most severe in cases of
tubal rupture, whereas in cases of tubal mole and tubal abortion it is colicky. There is usually
nausea and vomiting associated with fainting. Vaginal bleeding is dark and continuous.
If intraperitoneal haemorrhage has occurred, the patient shows signs of blood loss and
hypovolaemic shock. There are clinical signs of an “acute abdomen”, maximal in the
hypogastrium or in one or the other iliac fossa. On bimanual examination the cervix is
extremely tender to touch and movement, and an adnexal mass may be palpable; there is a
tender resistance in the recto-uterine pouch (of Douglas). If bleeding is localized, there is an
irregular boggy swelling in the adnexa. A tubal mole or haematosalpinx can be distinguished
as a retort-shaped swelling in one of the fornices. Culdocentesis may be useful in confirming
the diagnosis, but it should be carried out in the operating theatre.
Ectopic gestation can be confused with pyosalpinx, haematosalpinx, retroverted gravid

uterus, an early stage of uterine abortion, or acute appendicitis.
Investigations
Measure the patient’s haemoglobin level and test the urine for sugar and protein. Test for
pregnancy. Send a sample of blood for grouping (including Rh) and cross-matching.
Management
Treatment for ruptured ectopic pregnancy is surgical. Diagnosis must be made without delay
and laparotomy carried out immediately. Resuscitative measures should accompany
preparations for operation.
Equipment
See tray for Laparotomy, Annex 1 and have equipment for autotransfusion at hand.
Technique
The patient should be given a general anaesthetic. 1 Prepare the skin and drape the area. Open
the abdomen through a midline, subumbilical incision and insert a self-retaining retractor.
Identify the affected tube and inspect the other tube and ovary before proceeding, to ensure
that they are normal (if they are not, a special effort should be made to spare ovarian tissue on
the affected side). Draw out the affected tube and excise it beyond clamps placed across its
cornual end and the free edge of the mesosalpinx (Fig. 5.1A, B). Tie the pedicle with No. 1
chromic catgut (Fig. 5.1C), and close the peritoneum over it. Collect blood for
autotransfusion, if feasible, and evacuate clots from the peritoneal cavity. Close the wound in
layers.
1
A suitable anaesthetic technique for use in cases of ruptured ectopic pregnancy is given in Dobson,
M.B., Anaesthesia at the district hospital (Geneva, World Health Organization, 1988).
Fig. 5.1. Laparotomy for ruptured ectopic pregnancy. Drawing out the affected tube
and clamping the free edge of the mesosalpinx (line of resection indicated by dotted line)
(A, B); tying the pedicle of the tube (C).
Complications
Complications are rare, but may include postoperative sepsis and burst abdomen.
Gynaecology
6. Biopsies
Procedures for obtaining biopsy or cytological samples from the endometrium, cervix, and
vulva are described here for use when arrangements for the dispatch of specimens and for the
receipt of laboratory reports are speedy and reliable. However, the patient whose
management depends on the information received from these reports is sometimes best
referred for specialist care in the first place.
Cytological samples
Cytological samples may be useful for the diagnosis of, for example, infection or early
cervical cancer.
Equipment
A speculum, wooden spatulae and glass pipettes and slides are required.
Technique
Cytological preparations can be obtained from different areas of the female genital tract. The
most usual sites are the lateral vaginal wall, the posterior fornix, and the exocervix. After
introducing an unlubricated speculum, collect cells under direct visual control. Obtain
material from the lateral vaginal wall by scraping with a wooden spatula; this type of sample
is particularly suitable for cytohormonal evaluation. Collect cells from the posterior fornix
either by aspiration through a glass pipette or by scraping with a wooden spatula, and samples
from the exocervix by scraping the entire area around the os, preferably with a wooden
spatula.
Cytological samples
Cytological samples may be useful for the diagnosis of, for example, infection or early
cervical cancer.
Equipment
A speculum, wooden spatulae and glass pipettes and slides are required.
Technique
Cytological preparations can be obtained from different areas of the female genital tract. The
most usual sites are the lateral vaginal wall, the posterior fornix, and the exocervix. After
introducing an unlubricated speculum, collect cells under direct visual control. Obtain
material from the lateral vaginal wall by scraping with a wooden spatula; this type of sample
is particularly suitable for cytohormonal evaluation. Collect cells from the posterior fornix
either by aspiration through a glass pipette or by scraping with a wooden spatula, and samples
from the exocervix by scraping the entire area around the os, preferably with a wooden
spatula.

Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology
6. Biopsies
Printable version
Cytological samples
Endometrial biopsy
Export document as HTML
file Help Cervical biopsy
Vulval biopsy
Export document as PDF file Fixation and packaging of specimens
7. Drainage of abscesses
8. General gynaecological procedures
9. Contraception

procedures

Back Cover
Endometrial biopsy
Endometrial biopsy is used only in cases of infertility, to determine the response of the
endometrium to ovarian stimulation.
Investigations
Equipment
See tray for Dilatation and curettage. Annex 1 and add an endometrial biopsy cannula.
Technique
Carry out the procedure during the patient’s premenstrual phase, on an out-patient basis.
Basal sedation should suffice. Place the patient in the lithotomy position and prepare the area.
Retract the vaginal walls, take hold of the cervix with a pair of vulsellum forceps, and pass a
uterine sound. By suction through the endometrial biopsy cannula, obtain one or two pieces
of the endometrium for histopathological examination (Fig. 6.1A), which will indicate
whether the secretory changes have occurred that identify the cycle as ovulatory.
Fig. 6.1. Biopsies. Obtaining an endometrial biopsy sample by suction through a
cannula (A); using punch biopsy forceps to obtain cervical tissue (B).
Complications
Perforation of the uterus and postoperative sepsis are rare complications.
Cervical biopsy
The indications for cervical biopsy are many, including chronic cervicitis, suspected
neoplasm, and ulcer on the cervix.
Diagnosis
The usual symptoms are vaginal discharge, vaginal bleeding, spontaneous or postcoital
bleeding, low backache and abdominal pain, and symptoms of disturbed bladder function.
Speculum examination may reveal vascular erosion of the cervix, but in intraepithelial
neoplasia no lesion is visible. In cases of invasive carcinoma, the cervix may initially be
eroded or chronically infected. Later it becomes enlarged, misshapen, ulcerated and
excavated, or completely destroyed, or is replaced by a hypertrophic mass; on vaginal
examination, the cervix is hard and fixed to adjacent tissues, and it bleeds on touch.
Investigations
Measure the patient’s haemoglobin level and test the urine for sugar and protein. Take a
sample of vaginal discharge and a smear of the cervix for cytological examination. If the
smear suggests a tumour, refer the patient.
Equipment
See tray for Dilatation and curettage, Annex 1 and add a pair of punch biopsy forceps and
iodine solution. A colposcope, if available, is useful for examining the cervix.
Technique
Examine the cervix, with a colposcope if one is available. So as not to mistake an area of
malignant infiltration, first stain the cervix with iodine solution (2 g of iodine, 4 g of
potassium iodide, and 300 ml of water). A malignant area will fail to take up the stain.
There are several methods of taking a biopsy sample from the cervix; the choice of technique
will depend upon the specific indications in each case. That described here is the “punch”
method.
A punch biopsy is easy to perform and may be done on an outpatient basis. Anaesthesia is
usually unnecessary, but basal sedation is recommended. Place the patient in the lithotomy
position and, after digital examination of the vagina, expose the cervix and select the most
suspicious area for biopsy. Using punch biopsy forceps, remove a small sample of tissue,
making sure that you include the squamocolumnar junction (Fig. 6.1B).
Complications
Possible complications include sepsis and haemorrhage, which can be severe. If bleeding is
excessive, pack the vagina with gauze for 24 hours.
Vulval biopsy
Biopsy of vulval lesions is indicated in cases of suspected leukoplakia, carcinoma (in situ or
invasive), and condylomata. Occasionally, biopsy may identify tuberculosis or
schistosomiasis as the cause of a lesion.
Investigations
Measure the patient’s haemoglobin level and erythrocyte sedimentation rate, and test the
urine for sugar and protein. As necessary, carry out a serological test for syphilis, obtain a
radiograph of the chest to check for tuberculosis, or examine a fresh vulval smear for
schistosomiasis.
Equipment
See tray for Vulval biopsy, Annex 1.
Technique
Place the patient in the lithotomy position, and clean and drape the area. Administer a local
anaesthetic by infiltration of 1% lidocaine. If the vulval lesion is large, excise a portion of it,
ligate any bleeding vessels, and approximate the skin. Small, localized lesions should be
excised completely, together with a margin of healthy skin.
Complications
Bleeding is a possible complication.

Fixation and packaging of specimens
For cytological preparations, quickly spread the cell samples on glass slides after collection
and fix them immediately in absolute ethanol. Immerse the slides in absolute ethanol in
bottles with watertight caps. Fix tissue samples immediately after collection by total
immersion in formaldehyde saline (10 ml of 37% formaldehyde solution + 90 ml of
physiological saline); fixation time is about 48 hours. A capped, plastic bottle with a wide
mouth is a suitable container.
To package both biopsy and cytological preparations, write the name of the patient, the site
from which the sample was taken, and the date of collection in pencil on a stiff piece of
paper. Place the paper in the specimen bottle. Secure the cap of the bottle with adhesive tape
and put the bottle in a metal tube (or box) together with a summary note containing
particulars of the patient, her clinical state, the tentative diagnosis, the type of tissue sent, and
the investigation requested. Place the tube in a wooden or cardboard box, packed well with
non-absorbent cotton wool and dispatch it. If properly prepared, the sample will not
deteriorate even if it is a long time in transit.
Incision and drainage of an abscess are indicated if there is evidence of localized pus, for
example throbbing pain or marked tenderness. Fluctuation is the most reliable sign, though it
may be absent in a tense or deep abscess. Interference with sleep is a pressing indication for
surgery.
Bartholinian abscess
Diagnosis
The patient complains of an acutely painful, throbbing, and tender swelling in the vulva. On
examination, the swelling is evident in the posterior and middle parts of the labium majus,
and the vulval cleft is S-shaped.
Differential diagnosis should include cysts of the canal of the vaginal process (canal of
Nuck), labial hernia, and fibro-adenomas and adenomyomas of the round ligament. All of
these conditions occur in the substance of the labium majus, lateral to Bartholin’s gland.
Investigations
smear of vaginal discharge for examination for gonococci and other organisms.
Equipment
See tray for Incision and drainage of abscess. Annex 1.
Technique
Marsupialization is a popular procedure in the treatment of Bartholinian abscess in chat it is
relatively easy to perform and bloodless. It provides the best chance of a cure, although
recurrence is always possible.
General anaesthesia is preferred. Place the patient in the lithotomy position, and clean and
drape the area. Make a longitudinal incision in the most prominent part of the abscess along
the junction of the vulva and vagina (Fig. 7.1A). Deepen the incision and open the abscess
wall widely. Drain the pus and cake a specimen for bacteriological examination. Evert the cut
margin of the abscess wall and suture it to the skin edge with interrupted stitches of 2/0
chromic catgut (Fig. 7.1B,C). Pack the cavity with petrolatum gauze and apply a gauze
dressing.
Fig. 7.1. Drainage of Bartholinian abscess. Incising the most prominent part of the
abscess along the junction of the vulva and vagina (A); everting the edge of the abscess
wall and suturing it to the skin edge (B, C).
Pelvic abscess
Pelvic abscess can result from infection in the genital or alimentary tracts; from foreign
bodies reaching the peritoneum via the bowel, uterus, or posterior fornix; from rupture or
perforation of an infected uterus; or as a complication of pelvic haematocele.
Diagnosis
The patient complains of diarrhoea, colic, and pain on defecation. Clinical examination
reveals fullness in the recto-uterine pouch (of Douglas) and sometimes signs of peritonitis.
Pelvic abscess can be differentiated from pelvic haematocele by culdocentesis, but this
should be carried out in the operating theatre.
Investigations
smear of vaginal discharge for examination for gonococci and other organisms, and
investigate any other suspected predisposing cause.
Equipment
See tray for Drainage of pelvic abscess, Annex 1.
Technique
A general or regional anaesthetic should be given. Place the patient in the lithotomy position,
and clean and drape the area. After further vaginal examination, retract the vaginal walls and
take hold of the posterior lip of the cervix with vulsellum forceps. Confirm the presence of
pus by aspiration through the posterior fornix. Make a transverse incision in the posterior
fornix and drain the abscess, breaking down loculi with a finger. Take a specimen of pus for
bacteriological examination. Apply a sterile pad.
Complications
Complications are rare, but injury to the bowel is possible.
Haematocolpos
Haematocolpos usually occurs in cases of imperforate hymen. It may also occur in cases of
vulval stenosis resulting from exposure to irritant substances or from infection, trauma, or
dystrophy, but such patients are best referred for treatment.
Diagnosis
The patient complains of amenorrhoea with cyclical pain in the abdomen or acute retention of
urine. Examination reveals a mass in the lower abdomen that is dull on percussion, consisting
of the distended vagina with the uterus perched on top.
Differential diagnosis should include pregnancy, tuberculous peritonitis, pelvic kidney, and
ovarian cyst.
Investigations
smear of vaginal discharge for examination for gonococci and other organisms.
Equipment
See tray for Drainage of pelvic abscess, Annex 1.
Technique
For the surgical treatment of haematocolpos due to imperforate hymen, a general or a

regional anaesthetic should be given. Place the patient in the lithotomy position, and clean
and drape the area. Make a cruciate incision over the bulging membrane. Evert the edges of
the wound and stitch them to the adjacent vaginal tissue with interrupted sutures of 2/0
chromic catgut (Fig. 7.2A, B). Allow the blood to drain and apply a sterile pad. Antibiotic
therapy should be given for 48 hours. Avoid vaginal examination for 1 - 2 months after the
operation.
Fig. 7.2. Drainage of haematocolpos due to imperforate hymen. Site of cruciate incision
over the bulging membrane (A); everting the edges of the incision and stitching them to
the adjacent vaginal tissue (B).
Complications
Possible complications include salpingitis and peritonitis.
Dilatation and curettage
At the district hospital, dilatation and curettage will be required mainly for therapeutic
purposes, most often for treating postabortion bleeding and occasionally in cases of
functional uterine haemorrhage. As a diagnostic procedure, it should be used only if the
doctor is certain of receiving a histological report; however, patients requiring dilatation and
curettage for diagnostic purposes are best referred for specialist care, if possible.
Diagnostic indications include metrorrhagia, infertility, functional uterine haemorrhage,

secondary amenorrhoea (when tuberculous endometritis is suspected), carcinoma of the
endometrium, uterine polyps, and postmolar bleeding (possibly due to choriocarcinoma).
Assessment
Carry out a general examination to check for anaemia and other diseases, followed by a
detailed clinical (including vaginal) examination. Assess the size and position of the uterus
and note the condition of the fornices. Check for ectopic or intrauterine pregnancy. Infection
is a contraindication to dilatation and curettage, except in cases of septic incomplete abortion
(when the patient must also be given antibiotics).
Investigations
Measure the patient’s haemoglobin level and test the urine for sugar and protein. Examine
vaginal discharge for infection.
Equipment
See tray for Dilatation and curettage, Annex 1.
Technique
The patient should be given a general anaesthetic. Place her in the lithotomy position (Fig.
8.1 A), and clean and drape the area. Identify the anterior lip of the cervix (Fig. 8.1B), take
hold of the lip with vulsellum forceps, and introduce a vaginal speculum (Fig. 8.1C, D). Pass
a uterine sound to assess the length and direction of the uterus (Fig. 8.1 E), and then
progressively dilate the cervix with dilators (Fig. 8.1 F).
Introduce a small sponge holder (or polyp forceps) to check for polyps. Then gently curette
each wall and angle of the uterus (Fig. 8.1G). All material obtained should be sent for
histopathological examination, if required for diagnosis. If genital tuberculosis is suspected,
collect a specimen of uterine tissue in physiological saline for culture. Apply a vaginal or
gauze pad.
Fig. 8.1. Dilatation and curettage. The lithotomy position (A); identifying the anterior
lip of the cervix (B); introducing a speculum and taking hold of the anterior lip of the
cervix with vulsellum forceps (C, D); passing a uterine sound to determine the length
and direction of the uterus (E); progressively dilating the cervix with dilators (F);
curetting the uterus (G).
Complications
Possible complications include perforation of the uterus, injury to the bladder or bowel,
cervical tear, extension of pre-existing infection, and rarely amenorrhoea due to trauma.
Polypectomy
Polypectomy is indicated for the treatment of cervical polyps and of pedunculated

endometrial polyps that present through the cervix.
Diagnosis
Symptoms of adenomatous cervical polyp include vaginal discharge that is mucoid,

mucopurulent, or serosanguineous; contact bleeding; menorrhagia; intermenstrual bleeding
and discharge; and uterine colic. Many cervical polyps remain symptomless, however, and
are discovered only on routine examination. On speculum examination, a polyp appears
through the cervical os as a dull, red, and fragile growth. On vaginal examination, it is felt as
a soft, fleshy mass that bleeds on touch.
Differential diagnosis should include carcinoma and sarcoma botryoides. A polyp can also be
confused with extruded products of conception.
Investigations
Measure the patient’s haemoglobin level and test the urine for sugar and protein. Examine
vaginal discharge for infection.
Equipment
See tray for Dilatation and curettage, Annex 1 and add 0 chromic catgut ligature. Ensure that
a suitable diathermy electrode is available.
Technique
A polyp is generally separated as an outpatient procedure, except in cases of large, vascular,

or sessile polyps, when the patient should be admitted to hospital. Basal sedation is often
sufficient; otherwise, general or conduction anaesthesia should be used. Place the patient in
the lithotomy position, and clean and drape the area. Expose the cervix and take hold of the
anterior lip with a pair of vulsellum forceps (Fig. 8.2A). Grasp the polyp with sponge forceps
and twist it off (Fig. 8.2B). If the stalk is thick, remove the polyp by ligating and cutting the
stalk (Fig. 8.2C - F). Always cauterize the base to prevent recurrence. Apply a vaginal or
gauze pad.
Fig. 8.2 Polypectomy. Exposing the cervix (A); twisting off the polyp with sponge
forceps (B); removing a polyp with a thick stalk by ligating and cutting the stalk (C - F).
Polypectomy should ideally be followed immediately by dilatation and curettage (with the
patient under general anaesthesia) for the detection of any other intrauterine source of
discharge, such as carcinoma, and treatment of additional polyps in the cervical canal or the
body of the uterus. Polyps should always be sent for histological examination.
Complications
Possible complications include reactionary haemorrhage.
Cervical erosion
Cervical erosion is an indication for cauterization of the cervix.
Diagnosis
Patients with cervical erosion present with mucous or mucopurulent vaginal discharge, low
backache, aching in the lower abdomen with pelvic discomfort, deep dyspareunia, contact
bleeding, infertility, menorrhagia with dysmenorrhoea, and symptoms of disturbed bladder
function. On examination, an erosion is easily recognized as a bright red area continuous with
the endocervix, with a clearly defined outer edge. On digital examination, an erosion feels
soft, but also granular, producing a grating sensation when stroked with the tip of the finger.
It bleeds on touch but is not tender unless complicated by infection.
Investigations
Measure the patient’s haemoglobin level and test the urine for sugar and protein. Fix a
cervical smear for cytological examination and carry out further investigations as appropriate,
for example a serological test for syphilis, a skin sensitivity test for tuberculosis, or
examination of a fresh cervical smear for evidence of schistosomiasis. Any specific
underlying disease that is detected should be treated appropriately.
Equipment
See tray for Cervical cauterization, Annex 1.
Technique
Anaesthesia is unnecessary, but administer a basal sedative. With an electric cautery, make
radial stripes in the affected mucosa, but leave the cervical canal untouched. There will be an
increase in vaginal discharge after cauterization. The patient should avoid coitus for 3 - 4
weeks.
Complications
Possible complications include cervical stenosis (particularly if the endocervix has been
cauterized inadvertently) and haemorrhage
Procidentia
Surgical correction of procidentia (complete uterine prolapse) should not be undertaken at the
district hospital. However, when procidentia is complicated by urinary retention, bladder
catheterization may be indicated to prevent the development of further complications.
Procidentia disturbs urinary flow by compressing the ureters and bladder. The bladder may
also herniate along the prolapsed uterus to present as a cystocele. Bladder compression and
cystocele result in progressive accumulation of residual urine, which predisposes to infection,
urinary frequency, and urgency, or to retention with overflow. Pressure on the ureters leads to
hydro-ureter and hydronephrosis. Rarely, the procidentia may become partially obstructed
and oedematous, precipitating acute urinary obstruction.
Management
Most patients can reduce the prolapsed uterus themselves and are aware that reduction
improves urination. Treat urinary infection and refer the patient, if possible. In cases of acute
urinary retention, catheterize the patient’s bladder before referral.
Twisted ovarian cyst
Torsion is a common complication of ovarian cyst. Parovarian and broad-ligament cysts,

which are freely mobile, pedunculated and small to moderately sized, are the most likely to
undergo torsion. Twisted cysts are most commonly pseudomucinous and both ovaries are
often affected. The pedicle of the cyst is often twisted three or more times. As a result of
torsion, there is venous congestion and interstitial haemorrhage in the tumour, giving rise to
severe abdominal pain with signs of peritoneal irritation. If undiagnosed or untreated, the
tumour may adhere to surrounding structures and later become infected.
Diagnosis
The patient presents with severe abdominal pain that is poorly localized, and possibly with a
subnormal temperature. She may show signs of hypovolaemic shock. Nausea and vomiting
are common. There may be abdominal distension and constipation. The abdominal pain later
becomes constant and localized in the lower abdomen, and the body temperature rises.
Abdominal examination reveals a tense, tender cyst and abdominal rigidity. Culdocentesis
may be useful in confirming diagnosis, but it should be carried out in the operating theatre.
Differential diagnosis should include uterine myoma undergoing red degeneration, and other
causes of “acute abdomen”.
Investigations
Measure the patient’s haemoglobin level and test the urine for sugar and protein. Test for
pregnancy. Send a sample of blood for grouping (including Rh) and cross-matching.
Management
Laparotomy should be undertaken immediately after diagnosis. The aim is to conserve viable
ovarian tissue by cystectomy.
Equipment
See tray for Laparotomy, Annex 1.
Technique
The patient should be given a general anaesthetic. Prepare the skin and drape the area. Open
the abdomen as for ruptured ectopic pregnancy, and extend the incision as indicated by the
size of the tumour. Confirm the diagnosis and inspect the other ovary for further cysts. If the
tumour is adhering to the surrounding structures such as the gut, first carry out careful
dissection. Then clamp the stalk of the cyst, divide it to remove the cyst, and ligate or transfix
the stump with 0 chromic catgut. Close the wound in layers.
Complications
Complications are rare, but may include postoperative sepsis and burst abdomen.
Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology
6. Biopsies
Printable version
Export document as HTML Dilatation and curettage

file Help
Polypectomy
Cervical erosion
Procidentia
Twisted ovarian cyst
Genital injuries
9. Contraception

procedures

Back Cover
Genital injuries
Diagnosis
Carry out a general examination to assess the patient’s condition, and a local examination of
the genital area to check for associated injuries. It is important to obtain information about the
nature of the object causing injury; sharp objects may have penetrated adjacent organs.
If there is allegation of rape, make detailed records, and comply fully with the relevant local
legal requirements. Remember to protect the patient against complications of the alleged
assault, such as sexually transmitted disease (with antibiotics) and pregnancy (with
ethinylestradiol). Be aware that the patient may also be suffering psychological disturbances
that require attention.
Investigations
Management
Administer prophylactic antibiotics and immunize the patient against tetanus. Bladder
catheterization may be necessary. Further examination, with the patient under general
anaesthesia, and surgical repair of injuries are indicated unless the injuries are very
superficial and can be treated by dressing.
Surgical repair of injuries
Equipment
See tray for Minor operations, Annex 1 and add a vaginal speculum, an anterior vaginal-wall
retractor, 0 and No. 1 chromic catgut sutures, and 2/0 plain catgut sutures.
Technique
With the patient under general anaesthesia, carry out a thorough examination. Introduce a
speculum and examine all the vaginal walls, the fornices, and the cervix, and check for tears
of the hymen. Thoroughly clean lacerations with a bland antiseptic and ligate bleeding
vessels. Excision of tissue must be minimal and strictly confined to obviously devitalized
tissues. Repair the lacerations with fine chromic catgut sutures held on fine instruments.
Approximate tissues without tension.
The principles of repair of perineal, cervical, and vaginal tears are outlined on pages 39 - 41.
For the repair of injuries that penetrate into the peritoneum, formal laparotomy is required. 1
Contusions require no specific treatment, but haematoma should be managed as described for
vulval haematoma.
1
For details of the repair of abdominal injuries, see Cook, J. et al., ed. General surgery at the district
hospital (Geneva, World Health Organization, 1988).
Complications
Infection is a possible complication. Others such as haematoma in the parametrium, residual

rectovaginal fistula, and dyspareunia can be prevented by proper surgical techniques.
9. Contraception
Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology
6. Biopsies
Printable version
Export document as HTML 9. Contraception

file Help
Female sterilization
Insertion and removal of intrauterine devices


procedures

Back Cover
The operation described here is a “tubectomy” carried out through a small abdominal incision
(hence the term “minilaparotomy” or “minilap”). An advantage of the procedure is that only a
very short hospital stay is needed, most patients returning home the same or the following
day. The operation can be done concurrently with a delivery or termination of pregnancy;
otherwise, a woman should normally wait at least three months after delivery before being
sterilized.
Counselling
Hold a counselling session with the woman and other persons involved well in advance of the
proposed operation. They should fully understand that its effects are permanent, but that there
are occasional failures. Observe all legal formalities.
Assessment
Carry out a complete physical examination. Sterilization is contraindicated in women with

suspected extensive intraperitoneal adhesions or peritonitis, and in cases of intra-abdominal
or pelvic tumour.
Investigations
As a minimum, measure the patient’s haemoglobin level and test the urine for sugar and
protein.
Equipment
See tray for Tubectomy, Annex 1.
Technique
Catheterize the patient’s bladder to ensure that it is empty. Local anaesthesia and sedation are
sufficient, but general anaesthesia or regional anaesthesia is preferred. Place the patient in a
supine position, and prepare and drape the lower abdomen. Make a midline suprapubic
incision 3 - 4 cm in length. In patients being sterilized during the puerperium, centre the
incision 3 cm below the top of the fundus, and in other cases 3 cm above the symphysis
pubis. Introduce an abdominal-wall retractor, and hook up the uterine tube on one side with a
finger. With tissue forceps, hold up a loop of tube 2.5 cm in length; crush the base of the loop
with artery forceps and ligate it with 0 chromic catgut tied in a figure of eight (Fig. 9.1A - C).
Excise the loop through the crushed area (Fig. 9.1D,E). Repeat the procedure on the other
side. Close the wound in layers.
Fig. 9.1. Tubectomy. Hooking up a loop of the uterine tube (A); crushing the base of the
loop of the tube with forceps and ligating it in a figure-of-eight fashion (B, C); crushed
area (with line of resection indicated by dotted line) (D); excising the loop of the uterine
tube (E).
The patient can be discharged after 24 hours (or earlier if appropriate) with advice to return in
7 days to have the stitches removed.
Complications
Failure of sterilization is the most important complication.

Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology
6. Biopsies
Printable version

file Help
9. Contraception
Export document as PDF file Insertion and removal of intrauterine devices

procedures

Back Cover
Insertion and removal of intrauterine devices
Insertion
Counselling
Before a device is inserted, discuss with the patient the particular method of contraception, its
possible side-effects, and the possibility of failure.
Assessment
Carry out a pelvic examination. Before inserting the device, treat any vaginal discharge;
vaginitis; cervicitis or cervical erosion; and uterine, tubal, or ovarian disease. Insertion of the
device is contraindicated during pregnancy or suspected pregnancy, in cases of unexplained
vaginal bleeding or menstrual irregularities, and in patients who have had a previous ectopic
pregnancy or a septic abortion or puerperal sepsis within the previous three months.
Investigations
sample of vaginal discharge for cytological examination.
Equipment
See tray for Dilatation and curettage, Annex 1 and add the device and its applicator (for
example Fig. 9.2A - C & H - J) and a pair of stitch scissors.
Fig. 9.2. Insertion of intrauterine device. Loop-type intrauterine device (A); applicator
(B); plunger (C); pressing the plunger to release the device (D, E); withdrawing the
applicator after withdrawal of the plunger (F, G). T-type intrauterine device (H);
applicator (I); plunger (J); withdrawing the applicator over the plunger without moving
the plunger (K-M); withdrawing both applicator and plunger (N).
Technique
The best time for insertion of a device is in the postmenstrual phase of the cycle. After labour
or abortion, it is preferable to wait 6 weeks. No anaesthesia is required. Place the patient in
the lithotomy position. Apply an antiseptic to the vagina and cervix, insert a speculum, and
catch the lip of the cervix with vulsellum forceps. Pass a uterine sound to determine the size
and direction of the uterine cavity.
If you are inserting a loop-type contraceptive device, load it into the applicator and pass the
applicator into the uterus up to its flange. Press the plunger to release the device (Fig. 9.2D,
E). Then withdraw the plunger, followed by the applicator (Fig. 9.2F). If you are inserting a
T-type device, load it into the applicator and introduce it up to the fundus of the uterus. Insert
the plunger and then withdraw the applicator over the plunger, while keeping the latter steady
and in place (Fig. 9.2K - M). Finally, withdraw both the applicator and plunger (Fig. 9.2N).
Cut the end of the thread about 3 cm distal to the os.
The patient should rest for 15 - 30 min under observation. Advise her not to use menstrual
tampons for 6 weeks, and instruct her to check from time to time that the device is in place by
feeling for the thread. A further check-up at 3 months is desirable, and thereafter at yearly
intervals.
Complications
The possible complications are many and varied, including fainting and collapse at the time
of insertion, intermenstrual spotting and menorrhagia, dysmenorrhoea and intermenstrual
pain as a result of uterine colic, acute and chronic salpingo-oophoritis, endometritis,
perforation of the uterus, fracture of the device, spontaneous extrusion, and pregnancy (tubal
or intrauterine).
Removal
The device should be changed every 3 years, or as recommended by the manufacturer. It

should be removed permanently upon menopause or if it causes unacceptable symptoms.
Technique
Anaesthesia is not required. Place the patient in the lithotomy position. Apply an antiseptic to
the vagina and cervix. Retract the vaginal walls and take hold of the anterior lip of the cervix
with vulsellum forceps. Remove the device by gentle traction on the end of the thread lying
in the vagina. If any difficulty is encountered, do not exert excessive force but refer the
patient.

Basic techniques
10. Traction
Lower-limb traction
Limb traction is useful for reducing and immobilizing femoral shaft fractures; supracondylar
and intercondylar fractures of the femur; condylar fractures of the upper end of the tibia;
grossly infected or contaminated fractures of the tibia; and severe fractures of the ankle
mortise with subluxation or dislocation or both. Neglected dislocations of the hip and knee,
gross deformities and displacements due to traumatic, infectious, or rheumatoid conditions of
the hip and knee, and deformities after poliomyelitis can all be corrected by continuous
traction.
The most popular form of continuous traction of the extremities is skeletal traction (through
bone). Skin traction, provided by straps of adhesive plaster applied on the skin, is generally
confined to use on children, but can be helpful when transporting adults to hospital. On
anaesthetic limbs, only skeletal traction should be used.
Skin traction
Equipment
See tray and equipment for Skin traction, Annex 1.
Technique
Sedate the patient (anaesthesia is unnecessary). Clean the limb with soap and water, and dry
it. Prepare the skin with an antiseptic solution, preferably methylated spirit, and let it dry. If a
commercial traction set (complete with adhesive tapes, traction cords, spreader bar, and foam
protection for the malleoli) is not available, improvise the apparatus as described below.
Open a roll of adhesive strapping on a clean dry table and spread it with the adhesive surface
up. (Use a size appropriate to the size of the patient; for an adult, a 7.5-cm wide, non-elastic
tape is usually suitable.) For above-knee traction, measure a length of strapping that is twice
the length of the limb from the greater trochanter to the sole of the foot (Fig. 10.1A). Add an
extra 35 - 40 cm to accommodate the spreader and to leave enough space (10 - 15 cm)
between the sole and the spreader to permit movement at the ankle. For below-knee traction,
the length of strapping should be measured from the tibial condyles (Fig. 10.1B). For the
treatment of compound fractures, traction should be applied just distal to the site of fracture
and the strapping should be cut accordingly.
Place a square, wooden spreader of approximately 7.5 cm (with a central hole) in the middle
of the length of strapping that you have spread on the table. Cut another length of strapping
about 35-40 cm long and centre it on the spreader with the adhesive surface down. The
spreader is now sandwiched between the two strappings (Fig. 10.1C).
Holding the patient’s ankle and foot, pull the limb steadily, elevating it from the bed. Instruct
an assistant to hold the spreader with a loop of strapping projecting 10 - 15 cm beyond the
sole of the foot. Apply the strapping to the medial and lateral sides of the limb, still elevated
and held in moderate traction. Protect the malleoli, Achilles tendon insertion, and the head
and neck of the fibula by placing strips of felt or cotton-wool padding under the strapping at
these sites (Fig. 10.1D). For above-knee traction, the adhesive strapping should extend
proximally to the groin on the medial side and to the greater trochanter on the lateral side. To
avoid causing deformity due to external rotation, place the lateral strapping slightly posterior,
and the medial strapping slightly anterior to the mid-lateral and mid-medial lines,
respectively. Ensure that the strapping lies flat on the surface of the limb. Do nor cover the
anterior border of the tibia or encircle the limb with strapping.
Now apply a crepe or ordinary gauze bandage firmly over the strapping beginning 2 - 5 cm
proximal to the malleoli (Fig. 10.1E). Continue bandaging up the limb, over the strappings,
up to the groin (or as appropriate to the level of traction). Elevate the end of the patient’s bed
and attach a traction cord through the spreader with the required weight (Fig. 10.1F, G); this
should normally not exceed 5 kg.
Fig. 10.1. Skin traction. Measuring the limb to determine length of strapping required
(A); levels of tibial condyles, malleoli, and Achilles tendon (B); sandwiching the
spreader between two strappings (C); applying strapping to the leg while protecting the
malleoli (D); bandaging over the strapping (E); attaching traction (F, G).
Contraindications
Do not apply skin traction to a limb with abrasions, lacerations, ulcers of the skin, loss of
sensation, impending gangrene, atrophic skin, or peripheral vascular disease. Skin traction is
also contraindicated in the treatment of marked overriding of fracture fragments or of gross,
long-standing deformities.
Complications
Possible complications include allergic reaction to the adhesive material (usually zinc oxide);
blister formation or excoriation of the skin from the strapping slipping; pressure sores over
the malleoli; and common peroneal nerve palsy. Most of these complications can be avoided
by correct application of the adhesive strapping. The most important cause of common
peroneal nerve palsy is lateral rotation of the limb, resulting in compression of the nerve at
the upper end of the fibula. Avoid this by keeping the patient’s knee joint moderately flexed
(up to 10°).
Skeletal traction
The best site for inserting traction pins is the metaphyseal region of a mature bone. The
specific sites recommended for pin insertion, in order of frequency of clinical use, are
described below (measurements are given for adults).
Proximal tibia (Fig. 10.2A, B): insert the pin approximately 2 cm distal to the tibial tubercle
and 2 cm behind the anterior border of the tibia, from the lateral side to avoid the common
peroneal nerve.
Distal tibia (Fig. 10.2A, B): insert the pin from the lateral side approximately 4 cm proximal
to the most prominent part of the lateral malleolus. Place the pin proximal to the ankle
mortise, parallel to the ankle joint, and midway between the anterior and posterior borders of
the tibia. There will be resistance as the pin passes through both cortices of the tibia anterior
to the fibula.
Calcaneum (Fig. 10.2C): insert the pin 4.5 cm inferior and 4 cm posterior to the tip of the
medial malleolus, from the medial side to avoid damaging the posterior tibial artery and
nerve or entering the subtalar joint.
Insertion of the pin through the distal end of the femur is not recommended at the district
hospital.
Equipment
See tray and equipment for Skeletal traction. Annex 1.
Technique
Skeletal traction is most commonly applied through Steinmann’s pins (Fig. 10.2D) inserted
under local anaesthesia. The patient should be supine. Prepare the skin with antiseptic.
Infiltrate the skin and soft tissues down to the bone with 1% lidocaine (Fig. 10.2E). Make a
small stab incision in the skin and introduce the pin through the incision horizontally and at
right angles to the long axis of the limb. Proceed until the point of the pin strikes the
underlying bone (Fig. 10.2F, G). Ideally the pin should pass through the skin and
subcutaneous tissue, but not muscles.
Pins are best inserted with a T-handle (Fig. 10.2H) or hand drill. Use a mallet only to make a
start in the cortex and always hammer gently. Advance the pin until it stretches the skin of the
opposite side and make a small release incision over its point (Fig. 10.2I).
Dress the skin wounds separately with sterile gauze (Fig. 10.2J). Attach a stirrup to the pin,
and lubricate with sterile petrolatum jelly the sire where it rotates on the pin. Cover the ends
of the pin with guards (Fig. 10.2K), and apply traction (Fig. 10.2L).
Fig. 10.2. Skeletal traction through bone. Sites for insertion of Steinmann’s pins in the
proximal and distal tibia (A, B) and in the calcaneum (C); Steinmann’s pin, introducer,
chuck, and stirrup (D); infiltrating tissues with local anaesthetic (E); making an incision
and inserting the pin (F-I); dressing skin wounds, attaching the stirrup, and covering
the ends of the pin (J, K); applying traction, with the leg supported by a sling (L).
As a rough guide, 1/10-1/7 of the body weight provides adequate traction, though this will also
depend on the degree of displacement of the fracture and the musculature of the limb.
Traction must always be opposed by counter-traction, which can be provided by the weight
of the patient’s body, by elevation of the appropriate end of the bed some 10 - 20 cm, or by
placing a Thomas splint against the root of the limb (see pages 93-94).
When a Thomas splint is used, traction will be more comfortable if the limb is supported by
pillows or pads, which also prevent posterior sagging of the fracture fragments.
Complications
Infection of the pin track is a common complication. Clinically the skin is inflamed; the
wounds are moist; percussion over the bone elicits tenderness; and the pin becomes loose. If
the infection is not controlled by repeated dressings and antibiotics, remove the pin and
employ an alternative method of traction. If the bone is osteoporotic and the traction too
heavy, the pin will cut through the bone. Accurate insertion of the pin avoids complications
from damage to the neighbouring neurovascular bundles and from penetration into a
neighbouring joint. Prevent possible stiffness in the joint or contractures of tendons by
repeated active and assisted exercises.

Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology

Printable version
Basic techniques
10. Traction
Export document as HTML Lower-limb traction

file Help
Skull traction
11. Plaster technique

12. Open fractures and tendon injuries
13. Soft-tissue injuries
Fractures, dislocations and other injuries
Bone and joint infections and other lesions

procedures

Back Cover
Skull traction
Skull traction forms an important part of conservative treatment for conditions such as
pyogenic or tuberculous infections of the craniovertebral region or the cervical spine. This
type of traction can provide rest to the cervical spine; correct recent deformities; or reduce
dislocations or subluxation in traumatic, infectious, and rheumatoid conditions. Cervical
fractures or fracture dislocations, irrespective of cord involvement, are also best treated this
way.
Equipment
See tray and equipment for Skull traction. Annex 1.
Technique
As an alternative to head-halter traction, which is painfully uncomfortable for the patient,

Crutchfield or Cone callipers (Fig. 10.3A) are easier to apply and more comfortable. Prepare
the patient’s scalp and mark it with two lines: one following the midline (sagittal), the other
crossing it to join the mastoid processes (Fig. 10.3B, C). With the middle of the instrument
poised over the mid-line, place the callipers on the transverse line to mark the points of entry
(Fig. 10.4A, B). Plan to insert Crutchfield callipers proximal to the parietal eminence and
Cone callipers distal to the parietal eminence on the transverse line, 5 - 6 cm above the
external meati (Fig. 10.3C).
Fig. 10.3. Skull traction. Cone callipers with spanner (A); marking the scalp with two
lines (B); sites for insertion of Crutchfield callipers (•) and Cone callipers (X) (C).
After infiltrating the selected sites with 1% lidocaine, make stab wounds in the transverse line
and deepen them to the bone (Fig. 10.4C, D). Use a special drill bit with a protective shoulder
to make a hole 3 - 4 mm deep in the outer table of the skull, avoiding penetration of the inner
cortex (Fig. 10.4E - G). Insert the points of the callipers and tighten them to give a secure
hold on the bone (Fig. 10.4H, I). Dress the wounds with strips of sterile gauze and apply
appropriate traction (1/10 - 1/7 of the body weight, i.e., about 5 - 13 kg) (Fig. 10.4J); be sure to
check and tighten the callipers, as necessary, after 1 - 2 days. The lower the level of the
diseased area the heavier the traction required. After 2 - 7 days of heavy traction, reduce and
maintain it at 1 - 2.5 kg in adults.
Fig. 10.4. Skull traction (continued). Marking sites for insertion of Crutchfield callipers
(A, B); infiltrating the scalp with local anaesthetic (C); making a small wound and
deepening it by drilling into the bone (D, F, G); drill bit (E); inserting the points of the
callipers and applying traction (H - J).
11. Plaster technique
Preparation of plaster bandages
Plaster of Paris (POP) bandages are available ready-made from suppliers and these are far
superior to the home-made variety. The popular length is 250 cm and the usual widths used
are 15 cm (6 inches) and 7.5 cm (3 inches). Because of the higher cost of the ready-made
POP bandages, many hospitals in developing countries still prepare their own.
Equipment
See equipment for Making plaster bandage, Annex 1.
Technique
For a POP bandage, employ a dry, cotton gauze (muslin) bandage 500 cm long and 15 cm
wide, with an open weave (20 - 24 strands to 2.5 cm). Place the rolled bandage on a dry table
with a smooth concrete or metal top. Unroll the bandage so that one section is spread evenly
across the table and, with gloved hands, apply the plaster powder (anhydrous calcium sulfate
or gypsum) evenly to the surface of the bandage (Fig. 11.1A). Gently but firmly rub the
powder into the mesh of the cotton bandage. Once this is done, carefully roll up the powdered
length of bandage and begin the same process again with a new section of the bandage (Fig.
11.1B). Continue until the whole bandage is impregnated with plaster powder. The weight of
an average plaster bandage should be 85 - 90% plaster. This plaster bandage can be used
immediately or stored in a dry place for future use.
Fig. 11.1. Making a plaster bandage. A cotton gauze bandage is unrolled as plaster
powder is applied to the surface (A); rolling the powdered gauze (B).
To prepare a plaster slab, unroll the required length of plaster bandage and superimpose layer
upon layer to the necessary thickness (6 - 12 layers). For a narrow slab, first make a thin slab
and then fold it along its length.

Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology

Printable version
Basic techniques
10. Traction
file Help 11. Plaster technique
Export document as PDF file Removal of tight rings and bangles
Application of plaster
Complications associated with immobilization

in plaster
Plaster removal

procedures

Back Cover
Removal of tight rings and bangles
Always remove bangles or rings from an injured limb prior to any operative procedure or
application of a POP bandage.
Equipment
Equipment includes oil or soap, and an Esmarch bandage for limbs or a cotton tape for
fingers.
Technique
Often the object can be coaxed from the limb or digit if it is well lubricated with oil or soap.
Should this fail, the limb or finger can be compressed by exsanguination. To compress a
finger, wind a cotton tape (approximately 0.5 - 1 cm wide) or thread from the tip of the finger
up to the ring (Fig. 11.2A, B). Run the loose end of the tape under the ring, and then gently
unwind the tape or thread by pulling the loose end (Fig. 11.2C - F). As the tape is unwound,
the ring should gradually slip off the end of the finger. The same technique can be used to
remove bangles.
Fig. 11.2. Removal of a tight ring from a finger. Winding cotton tape or thread from the
tip of the finger and passing the loose end under the ring (A - D); pulling the loose end
of the tape or thread to remove the ring (E, F).
Equipment
See equipment for Application of plaster. Annex 1.

Technique
First examine the area to which the plaster is to be applied; identify the bony landmarks and
take measurements for the preparation of plaster slabs (Fig. 11.3A. B). Drain and dress any
skin blisters, and otherwise clean the skin of the area with soap and water, dry it, and clean it
again with methylated spirit. To avoid the serious complications that can result from pressure,
pad all plasters with a uniform thickness of 0.5 cm of cotton wool (Fig. 11.3C, D). Add an
extra layer of padding to protect the bony prominences, especially in areas with no skin
sensation, or if the patient is thin.
Prepare any plaster slabs that you will require (Fig. 11.3E - G). Then soak a plaster bandage
(or a plaster slab, if this is to be applied first) in a deep, wide-mouthed pail filled with water
at room temperature (Fig. 11.3H). For a large plaster, such as a shoulder or hip spica, fill two
or more pails with water to avoid delay during application. Lower the plaster bandage into the
water until it is well covered (Fig. 11.3I). Leave it undisturbed until air bubbles cease to rise,
showing that it is saturated with water. Gently pick up the ends of the bandage with both
hands and lightly squeeze it, pushing the ends together without twisting or wringing (Fig.
11.3J). The plaster is now ready to be applied.
While applying the plaster, ask an assistant to hold the relevant part of the body steady in the
correct position so that ridges do not form inside the plaster (Fig. 11.3K). Throughout
application, work rapidly and without interruption, rubbing each layer firmly with the palm
so that the plaster forms a homogeneous mass rather than discrete layers. Mould the plaster
evenly around the bony prominences and contours. (Remember that the “hold” of the plaster
will not be from its tightness but from its fit.) Leave 3 cm of cotton wool padding at the upper
and lower margin of the cast to protect the skin against friction.
To form a complete plaster cast, apply a light, uniform layer of plaster bandage by winding it
round the padding. With the first layer, apply one or more plaster slabs, carefully moulding
each one with the palm of the hand (Fig. 11.3L, M). Follow this with a few layers of plaster
bandages wound round lightly without tension. Just before the plaster sets, gently fold over
the sharp margins of the cast, leaving the cotton padding exposed (Fig. 11.3N, O). A turn of
plaster bandage will secure the padding over the cast. Continue moulding the plaster until it
sets, the time for this depending upon the quality of the plaster bandage and the ambient
temperature. When the plaster begins to stick to your hands, it is a good indication to stop.
The table below gives the number and width of plaster bandages required for the average
adult patient for various standard plaster casts. With ready-made bandages, fewer are
required.
Fig. 11.3. Application of plaster bandages. Identifying the bony landmarks (A); taking
measurement (B); applying a padding of cotton wool (C, D); measuring plaster bandage
and superimposing and trimming several layers for a plaster slab (E-G); soaking the
plaster bandage (H, I). Squeezing the bandage (J); applying the plaster bandage to the
forearm over the cotton wool (K); applying and moulding a plaster slab (L, M); folding
the margins of the plaster after applying a further layer of plaster bandage (N, O);
application of plaster cast completed (P, Q).
Type of cast Width of bandages Number of bandages

Above elbow 10-15 cm (4-6 inches) 5-10
Below elbow 10 cm (4 inches) 3-6
Below knee 15 cm (6 inches) 5-10
Up to the groin 15 cm (6 inches) 10-20
1 ½ hip spica 15-20 cm (6-8 inches) 30-40
Shoulder spica 15-20 cm (6-8 inches) 15-20
Plaster slab
If major soft-tissue swelling is expected, apply a padded posterior plaster slab extending
approximately two-thirds of the length of the limb. Whenever there is doubt about the
circulation in a limb, apply only a plaster slab. A slab is also adequate protection for fractures
or dislocations around the elbow, hand, and fingers. Mould the plaster slab to the limb and
hold it in position with wet gauze bandages.
An alternative method is to split a full plaster lengthwise down to the cotton wool with a
sharp knife or scalpel immediately after application, before it has time to dry (Fig. 11.4A).
With a plaster spreader (Fig. 11.4B) or stout scissors, spread apart the split plaster edges
some 5 - 10 mm (Fig. 11.4D). Split the underlying cotton wool with a pair of blunt, angled
scissors (Fig. 11.4C) until the skin can be felt through the gap in the plaster along the entire
length (Fig. 11.4E). Secure the split plaster in place with a firmly applied, 7.5 cm-wide,
elastic bandage (Fig. 11.4F).
11.4. Splitting a plaster cast. Splitting a newly applied plaster cast with a scalpel (A); a
plaster spreader (B) or stout scissors (D) are used to open up the gap in the plaster cast;
dividing the underlying cotton wool with a pair of blunt, angled scissors (C, E) and then
holding the split plaster with an elastic bandage (F).
Partially padded plaster
When a plaster is changed some weeks after the initial trauma or operation, further swelling
of the limb is unlikely to occur and it is safe to apply the new cast over a single layer of
stockinet, with padding only over the bony prominences.
Instructions to be given to the patient
Give the patient (or his/her relatives) clear oral and written instructions to report back to the
hospital if there is any impairment of the circulation. Issue the patient with a standard
instruction card in a language that he/she can understand. The instructions should be as
follows:
1. Do not cover the plaster, but let it dry in the sun or hot air (a wet plaster tends to break). Do not
walk on a walking-plaster until it is fully dry.
2. Keep the limb in plaster elevated when you are at rest.
3. Exercise all free joints of the affected limb, especially those of the fingers (including the
knuckles) and toes, shoulder, elbow, and knee. Move each joint (with assistance, if necessary)
regularly and frequently during the day, until normal movements are possible without pain.
4. Sleep on a mattress placed on a hard bed or floor.
5. Report to hospital as soon as possible if the plaster is damaged in any way or if it is loose.
Report to hospital immediately if pain from the plaster interferes with sleep.
6. If symptoms of poor circulation develop (such as fingers or toes becoming swollen, blue,
painful, or stiff) raise the limb and exercise the affected part. If after half an hour there is no
improvement and if it is not possible to return immediately to hospital, ask someone to split
the plaster along its entire length. First soak the limb in water to soften the plaster and then
cut it with a knife, or saw through the plaster, including the cotton wool. Temporarily hold
the split cast in place by wrapping it with a length of cloth about 8 - 10 cm wide and 1 m
long. Make arrangements to return to hospital as soon as possible.
Complications associated with immobilization in plaster
Most of the problems related to POP plasters are in fact caused by improper initial
application of the cast.
Pressure sores
Sores can result from localized pressure on bony prominences, from ridge formation on the
inner surface of the cast, or from forcing foreign bodies between the plaster and the limb.
They may occur anywhere, but common sites are over the anterior superior iliac spine,
sacrum, malleoli, and the dorsum of the foot or ankle. Frequently the sequence of events is as
follows: for several days the patient complains of persistent localized discomfort; the
complaint is ignored and the symptoms pass off; by this time the tissues under pressure have
become anesthetic and sloughing has already commenced; soon the overlying cast becomes
stained, and the accumulated discharge and secretions become offensive. Never neglect the
signs suggestive of a sore - always cut a window in the plaster.
Treat pressure sores by cutting a hinged window in the plaster at the suspected site using a
small, angled plaster saw (Fig. 11.5A - C). If there is ulceration, clean and dress it, but if no
serious lesion is detected, just fill the window with a uniform pad of cotton wool. In all cases,
replace the piece of plaster and apply a firm bandage over it to prevent oedema of the
unsupported soft tissues presenting through the window (Fig. 11.5D, E).
Fig. 11.5. Cutting a window in a plaster cast. Cutting with a small, angled plaster saw (A
- C); the ulcer is cleaned and dressed, the plaster window piece is replaced, and the area
is bandaged(D, E).
Oedema distal to the plaster cast
Some degree of distal oedema is inevitable around injuries to the ankle or wrist. Oedema as a
result of injury disappears within 2 - 3 days with elevation of the limb and repeated active
exercise of the joints not in plaster. If oedema does not disappear in 2 - 3 days, the probable
cause is a tight plaster. In such cases, split the plaster along its full length and cut the padding
or stockinet down to the surface of the skin. Prise the plaster open 1 - 2 cm along its entire
length. Elevate the limb and continue active exercises.
Skin blistering and dermatitis
The skin under a plaster inevitably becomes dry and scaly because the discarded epithelium is
not washed off. Rarely the skin is susceptible to plaster allergy and dermatitis develops. In
hot weather, particularly when there is eruption of prickly heat (miliaria), staphylococcal
infection of hair follicles and sweat glands may supervene and, if ignored, can lead to a
severe painful and purulent dermatitis. Antihistamines, systemic antibiotics, and elevation of
the limb should relieve most of the symptoms within 48 hours. In severe cases, or if there is
no improvement, adopt an alternative method of treatment or apply a new plaster with extra
padding.
Gangrene
Gangrene after a fracture is usually the result of damage to the vascular supply of the injured
limb, but careful recording of capillary circulation (and pulse whenever possible) both before
and after the application of plaster should avoid the tragic occurrence of gangrene or
Volkmann’s contracture from a tight or unpadded splint.
Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology

Printable version
Basic techniques
10. Traction
Export document as HTML 11. Plaster technique

file Help
Removal of tight rings and bangles

Complications associated with immobilization

in plaster
Plaster removal

procedures

Back Cover
Plaster removal
Equipment
See equipment for Removing plaster, Annex 1.
Technique
The best place to cut a plaster is along its weakest or thinnest border (Fig. 11.6A). Avoid
cutting through the plaster slab where it overlies the subcutaneous border of a bone. Use
shears to cut through the plaster, starting at the edge, and then loosen the cast with a plaster
spreader (Fig. 11.6A - C). Complete the division of the plaster and padding with plaster
scissors. Under difficult conditions or if your patient is a frightened child, soften the plaster
by soaking it in water for 10 - 15 minutes and then remove it like a bandage (Fig. 11.6D, E),
or cut it with a sharp scalpel or knife.
Fig. 11.6. Removing a plaster. Cutting and spreading the plaster using plaster shears
and a spreader (A - C); soaking a plaster before removing it (D, E).
Open fractures
Classification
Open fractures are classified into three grades, with chances of infection being the highest in
Grade III:
• Grade I fractures involve a clean wound of less than 1 cm in size.
• Grade II fractures involve laceration of skin and subcutaneous tissue and a wound of more
than 1 cm.
• Grade III fractures involve extensive lacerations, avulsion of soft tissues, damaged muscles,
nerves, and vessels, and comminution of bone fragments.
Treatment
Wounds associated with Grade I fractures should be covered with a sterile dressing after
débridement, treatment thereafter being the same as for a closed fracture, though it may be
prudent during wound healing to provide cover with antibiotics for 5 - 10 days. Patients with
Grade II or Grade III fractures should be started on antibiotics immediately to cover a careful
débridement to remove all dead and suspect tissue. A large wound may require a longer
course of antibiotics. Always administer tetanus toxoid to patients with open fractures.
Treat concomitant joint injuries by wound toilet, closure of the synovium and capsule with
catgut, postoperative suction drainage, and preferably postoperative traction, with frequent,
intermittent exercise of the joint above and below the fracture.
Wound closure
Do not carry out primary closure in any cases of open fracture. On completion of wound
débridement, take a swab for bacteriological examination. Take additional swabs on the first
and second inspections during follow-up. Inspect and dress the wound daily or as indicated
depending on the discharge.
Assess the condition of the wound 5 - 7 days after the initial operation. Close the wound at
that time only if it is healthy. If the wound is not healthy, wait a further 2 - 4 weeks and then
close it by loose suture or by split-skin grafting. Wound closure under tension with
inadequate drainage is the commonest cause of ischaemia of the limb, and predisposes to
uncontrollable anaerobic infection and extensive chronic osteomyelitis.
Stabilization of the fracture
After wound débridement, stabilize the fracture by one of the following methods.
• Apply a well-padded, strong posterior plaster slab or a complete plaster cast (split to prevent
constriction) (Fig. 12.1A).
• For the lower extremity, apply a Thomas splint of suitable size (Fig. 12.1B-F), and skeletal
or skin traction (Fig. 12.1G, H); if transporting the patient to another hospital, further
reinforce the splint with POP bandages applied around it and the limb (Tobruk plaster) (Fig.
12.11).
• Insert one, or preferably two, Steinmann’s pins in the proximal and distal fragments of the
fractured bone and incorporate the limb as well as the pins in a padded plaster (Fig. 12.1J, K).
Before application of the plaster, make sure that there is no dressing or bandage encircling the
limb that might act as a tourniquet.
Fig. 12.1. Stabilization (immobilization) of fractures. A padded plaster slab (A); Thomas
splints with and without slings (B, C); measuring the limb for selecting a splint of
suitable size (D-F); fixed skin traction in a Thomas splint (G); fixed skeletal traction in a
Thomas splint (H); fixed skin traction in a Thomas splint reinforced with a plaster cast
(Tobruk plaster) (I); stabilization with Steinmann’s pins and a plaster cast (J, K).
Tendon injuries
Sudden, excessive, unaccustomed, or uncoordinated strain can rupture apparently normal

tendons, for example the Achilles tendon (which can rupture during jumping), the plantaris
tendon, and the extensor attachment into the terminal phalanx of the finger (whose rupture
causes mallet finger). Some of these closed injuries may be complications of epileptic fits.
Direct, blunt injuries over the Achilles tendon while in plantar flexion or over the rectus
femoris tendon while the knee joint is extended can also cause rupture.
Closed tendon injuries in the middle-aged or elderly patient occur in degenerated tendons.
Any undue strain or even normal activity may rupture a tendon partially or completely.
Common sites are the tendons of the rotator cuff in the shoulder, the long head of the biceps,
the rectus femoris tendon, and the extensor tendons at the wrist in rheumatoid disease.
Any tendon can be cut or torn in an open wound, but common sites are at or above the wrist
and in the palm and fingers. Tendons are most commonly severed in deep, incised wounds,
and less commonly by laceration.
Diagnosis
Partial rupture causes tenderness over the injured tendon, and movements that are still
possible are painful. After complete rupture of larger tendons, a gap can be felt when
movement is attempted, and the belly of the muscle bunches up into an abnormal lump or
“ball” above the rupture. The absence of specific movements in healed wounds of the finger
and wrist also suggests tendon injury. If the joints become stiff, tendons that are still intact
can be felt tensing under the palpating fingers during movement.
In all cases of open injuries over tendon sites, test each tendon individually for its specific
action. For example, absence of flexion of the terminal phalanx indicates injury to the
profundus tendon, while inability to produce plantar flexion at the ankle suggests injury to the
Achilles tendon. Identify cut tendons during wound débridement.
Treatment
Partial rupture
Partial rupture of tendons, whether degenerated or normal, requires no active surgery. Rest
the tendon in a relaxed position until the initial pain has subsided; then start rehabilitative
exercises. Infiltration of the site with a few millilitres of local anaesthetic is occasionally
indicated to relieve pain and give the patient the confidence to start these movements.
Complete, closed rupture
Complete, closed rupture of tendons, especially in the young, usually requires surgical repair
at a higher level hospital. In the middle-aged or elderly patient, decisions must be made as to
whether referral for further treatment is indicated or whether the loss of function is
compatible with the patient’s daily activities. In cases of acute rupture of the Achilles tendon,
extreme plantar flexion for 6 weeks followed by a lesser degree of equinus for another 6
weeks will lead to a union sufficient for normal activities in most patients. Shoulder-cuff
ruptures in the elderly should be treated conservatively by rehabilitative exercises. Rupture of
the long head of the biceps may usually be left alone since it rarely causes significant
disability, but fresh cases of mallet finger should be treated by straight splintage for 4 - 6
weeks.
Open injuries
Open tendon injuries require surgical treatment, starting with wound débridement. Tendon
repair then depends upon the site of the tendon injury and the type of wound (contaminated or
clean). Refer any patient with: a cut tendon associated with a contaminated, lacerated wound;
a cut flexor tendon on the anterior aspect of the wrist, palm, or fingers; or a cut tendon that
cannot be clearly identified and sutured. Pending referral, keep the related joints mobile by
passive assisted exercises.
Repair of cut tendons
Immediate repair of cut tendons by primary suture is appropriate at the district hospital only
in cases of open injuries to: the flexor tendons in the forearm; the extensor tendons of the
forearm, wrist, and fingers; the extensor tendons on the dorsum of the ankle and foot; and the
Achilles tendon. Repair of divided finger flexors within the synovial sheath requires
meticulous surgery and should never be attempted at the district hospital.
Equipment
See tray for Minor operations, Annex 1. Equipment for Application of plaster, Annex 1, may
also be required.
Technique
The patient should be given a general anaesthetic with a muscle relaxant.
After wound débridement, pass a loop suture (3/0 silk or nylon) on a straight needle into the
tendon through the cut surface close to the edge so that it emerges 0.5 cm beyond, and
construct a figure-of-eight suture, finally bringing the needle out again through the cut
surface (Fig. 12.2A - C). Pull the two ends of the suture to take up the slack, but do not bunch
the tendon (Fig. 12.2D). Deal similarly with the other end of the tendon (Fig. 12.2E), and
then tie the corresponding suture ends to each other, closely approximating the cut ends of the
tendon and burying the knots deep between them (Fig. 12.2F). Cut the sutures short (Fig.
12.2G).
Fig. 12.2. Primary suture of a cut tendon. Inserting figure-of-eight suture (A - C);
pulling the two ends of the suture (D); inserting a similar suture in the other end of the
tendon (E); tying the sutures and burying the knots (F); suture is completed (G).
After-care
Hold the repaired tendons in a relaxed position with suitable splintage for 3 - 4 weeks.
For details of the treatment of abdominal injuries, ruptured bladder, wounds of the face, and
ocular trauma, see Cook, J. et al., ed. General surgery at the district hospital (Geneva, World
Health Organization, 1988).

Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology

Printable version Basic techniques
10. Traction
Export document as HTML 11. Plaster technique

file Help

Vascular trauma
Volkmann’s ischaemia
Split-skin grafting
Hand injuries

procedures

Back Cover
Vascular trauma
Injury to the main limb arteries and veins may be open or closed. Open injuries are easier to
diagnose because of profuse bleeding from the wound in the vessel. If a vessel is completely
divided, however, its ends retract and there is little bleeding, although the circulation to the
distal limb is usually compromised. Closed injuries are usually associated with fractures of
the long bones and should be suspected if there is distal ischaemia of an injured limb. The
important clinical features of such ischaemia are pallor or discoloration of the foot or hand,
severe pain, and absent or diminished distal pulses.
Closed injury of the main vessels can also manifest itself by marked swelling of the limb in
the region of the fracture, with or without a pulsating haematoma (“false aneurysm”). The
distal circulation is usually not compromised. Venous injuries are generally less serious and
rarely result in circulatory problems, though local swelling from the haematoma and distal
swelling of the limb from impaired venous return often occur.
In all cases of limb injury, be alert for any clinical features of injury to the main vessels.
Explore any suspect wounds near or overlying the main vessels, and identify the vessels. Also
explore closed limb injuries when there is distal ischaemia or marked swelling in the region
of the fracture, again identifying the major vessels to check for injury.
Equipment
See tray for Minor operations, Annex 1 and add four bulldog clamps, a set of three Satinsky’s
clamps, and some fine rubber tubing.
Technique
For vascular injuries, general anaesthesia is preferred. Make a long incision over the wound
or fracture site to allow a wide exposure of the main artery and vein. Profuse haemorrhage
will indicate the location of the damaged vessel, unless it is completely divided. Both ends of
a completely transected vessel should be ligated. An incompletely divided vessel should be
controlled above and below the injury by light arterial clamps (for example, Satinsky’s or
bulldog) (Fig. 13.1C) or by lifting on ligatures or rubber tubing (Fig. 13.1A, B, D), and repair
may be attempted by direct suture (Fig. 13.1E, F) or a vein patch. A bruised, but intact artery
that no longer pulsates may have suffered a rupture of the lining with occlusion of the lumen.
If referral to expert care is easy, close the wound loosely and transfer the patient for
consideration of vascular grafting. If not, excise the damaged segment of vessel between
ligatures. If in doubt in cases of vascular injury, arrest bleeding by direct ligature, close the
skin loosely, and refer the patient.
Fig. 13.1. Vascular trauma. Controlling bleeding with rubber tubing (A, B, D);
controlling bleeding with light arterial clamps (C); suturing an arterial wound (E, F).
Severe swelling of a limb, after crushing injuries or fracture, can compromise the circulation,
leading to ischaemic damage to the muscles and to Volkmann’s ischaemic contracture (see
below). If the limb is markedly swollen, perform an adequate decompression fasciotomy as a
matter of urgency. Make a long incision down the anterolateral surface of the limb, through
the deep fascia, allowing the tense muscle to bulge into the wound. Leave the wound open
under dressings, and close it later by secondary suture or eventually by skin grafting.
Volkmann’s ischaemia
Volkmann’s ischaemia can occur as a complication of any fracture of the leg or arm
involving a major artery. Its main features, as in any other acute ischaemia, are pain chat is
severe and agonizing on passive stretching (extension) of the fingers or roes; pallor of the
digits with poor capillary circulation (sometimes resulting in a cyanosis or blotchy
appearance of the skin) and an abnormally cold limb; pulselessness, an important feature of
vascular complication; paralysis, with muscle weakness and sensory deficit distal to the site
of vascular damage; and tense and tender muscles as revealed by palpation.
Treatment
Immediately remove all encircling bandages, leaving the posterior splint, which should not
cover more than half of the circumference of the limb. The skin of the front of the limb
should be entirely visible. Carefully reduce any gross displacement of the fracture fragments,
and then moderately elevate the swollen limb to encourage venous and lymphatic return.
Straighten any acute flexion of the joint to prevent mechanical kinking of the artery. For the
arm, a position of 20 - 70° of flexion is advised. Do not warm or hear the limb but keep it
cool, especially in a hot environment, to reduce local tissue metabolic requirements. (See also
section on vascular trauma)
Split-skin grafting
Skin is the best cover for a raw surface caused by trauma or burns. The recipient area for the
graft should have healthy granulation tissue with no evidence of infection.
Equipment
See tray for Skin grafting, Annex 1.
Technique
The patient should be given a general anaesthetic.
The most commonly used donor site is the anterolateral or posterolateral surface of the thigh.
First clean the selected donor site with antiseptic and isolate it with drapes. Apply petrolatum
or liquid paraffin (mineral oil) to lubricate the area. Hold the assembled skin-grafting knife
(Humby) (Fig. 13.2A) in one hand and press the grafting board against the patient’s thigh (or
alternative donor site) with the other hand. Instruct an assistant to apply counter-traction to
keep the skin taut by holding a second board in the same manner. Cut the skin with regular
back-and-forth movements while progressively withdrawing the first board ahead of the knife
(Fig. 13.2B).
After cutting a length of about 2 cm of skin, inspect the donor area: homogeneous bleeding
confirms that the graft is of split-skin thickness; exposed far indicates that the graft is of full
thickness, i.e., too deep, in which case you should check the adjustment of the blade. As the
cut skin appears over the blade, instruct an assistant to hold it gently out of the way with non-
toothed dissecting forceps. Place the newly cut skin in saline and cover the donor area with a
warm wet pack before dressing it with petrolatum gauze. Spread out the cut skin, with the
raw surface upwards, on petrolatum gauze (Fig. 13.2C).
If a skin-grafting knife is not available, the graft can be taken with a razor blade held with
straight artery forceps. Start by applying the cutting edge of the blade at an angle to the skin
but after the first incision lay the blade flat.
Before applying the skin graft, clean the recipient area with saline. Wet the graft frequently
with saline to prevent it from drying out. Do not pinch it with instruments. To graft a large
piece of skin, first suture it in place at a few points and then continue to place sutures around
the edges of the wound. Sutures are not necessary for a small piece of skin.
Haematoma formation under the graft is the most common reason for graft failure. It can be
prevented by applying a “bolster” dressing made of moist cotton wool moulded in the shape
of the graft and tied over the graft with sutures. As an alternative, make several small
perforations in the graft (Fig. 13.2D), or cut the graft into small pieces (postage-stamp grafts)
and place them a few millimetres from each other to leave space for bridging during the re-
epithelization process.
Fig. 13.2. Skin grafting. A skin-grafting knife (Humby type) (A); cutting skin (B);
spreading out the cut skin (C); making perforations in the graft (D).
After-care
Hold the graft in place with petrolatum gauze, unless you have already sutured it and applied
a bolster dressing. Then apply additional layers of gauze and cotton wool, and finally a firm,
even bandage. Leave the graft undisturbed for 2 - 3 days unless infection or haematoma is
suspected. Change the dressing daily or every other day thereafter (a bolster dressing will no
longer be needed by this Stage), but never leave the grafted area uninspected for more than
48 hours. If the graft is raised, puncture it to release any serum underneath. Otherwise
interfere as little as possible. It may be possible to expose the graft to the air at this early
stage if the area can be protected by splints or mosquito netting, but only if there is adequate
nursing supervision. After 7 to 10 days, remove any sutures, wash the grafted area, and
lubricate it with liquid paraffin (mineral oil) or petrolatum.
The second week after grafting, instruct the patient in regular massage and exercise of the
grafted area, especially if it is located on the hand, the neck, or one of the limbs. These
exercises should be continued for at least 9 months. To prevent burn contractures, apply
simple splints for flexure surfaces and keep the grafts under tension using whatever means is
available. For example, simple tongue depressors can serve as finger splints and plaster of
Paris can be used for extremities.
Hand injuries
Open injuries of the hand must receive prompt attention to prevent infection and disability.
Assessment
Take the patient’s history and make a general assessment. Perform a local examination:
always check the circulation and sensory and motor functions in the part distal to the wound.
General or conduction anaesthesia may be required for an adequate examination of the
wound. Use aseptic technique and handle the tissues gently. Identify nerve, vascular, and
other soft-tissue injuries. Examine for fractures by palpation.
Determine whether the wound is clean or contaminated. A clean wound does not have foreign
matter or devitalized tissue. It is caused by sharp objects such as broken glass, knives, or
blades. A contaminated (dirty) wound contains more or less foreign matter and dead tissue,
and should be considered susceptible to infection. Such wounds are caused by crushing or
avulsion of tissue as in crushing or degloving injuries, lacerations and injuries from threshing
machines.
Investigations
Obtain radiographs of the underlying bones and joints.
Treatment
Treatment consists of wound débridement and repair. Administer antibiotics and tetanus
toxoid.
Equipment
See tray for Minor operations, Annex 1 and include a tourniquet and sutures of 4/0, 5/0, and
6/0 thread.
Technique
Use general or local anaesthesia as indicated by the extent of injury. Local anesthesia consists
of infiltration with 1% lidocaine without epinephrine. Ring-block anaesthesia is convenient
for finger injuries. Clean the wound thoroughly with toilet soap and water, and then with 1%
cetrimide or other antiseptic. Dry the wound and stop any oozing of blood by compression
with sterile gauze. For adequate exposure, extend the wound in line with the creases of the
digit and palm (Fig. 13.3A, B). Remove all remaining debris, foreign material including grass
and grease, and detached or dead tissue. Do not excise any skin unless it is dead.
Do not attempt to repair flexor tendons; refer the patient instead. Extensor tendons (Fig.
13.3C) may be repaired, unless there is gross contamination. Trim the frayed, cut ends of the
tendon minimally, and suture the two ends together with 4/0 thread using the figure-of-eight
technique (Fig. 13.3D - I). Once the two knots have been tied they become buried in the
anastomotic line (Fig. 13.3J, K).
As a rule, nerve repair is an elective procedure requiring referral. However, if the cut ends of
a digital nerve can be easily apposed, approximate them by a single 5/0 or 6/0 thread stitch
(Fig. 13.3L-O).
Fig. 13.3. Repair of extensor tendon and digital nerve of the hand. Normal hand
showing skin creases (A); extension of the wound (B); cut extensor tendon (C);
trimming the cut end of tendon (D); repairing the tendon using figure-of-eight
technique (E-K); cut digital nerve (L); apposing cut ends of the nerve with a single
stitch (M - O).
Wound coverage
Ensure meticulous haemostasis. Close a clean wound without tension by direct interrupted
sutures. Always insert a corrugated or glove drain (Fig. 13.4A). The wound may require
coverage by a split-skin graft, especially if there has been extensive skin loss.
When there has been a degloving injury with amputation of the finger, the skin from the
amputated part can be used (provided that it is not crushed and not obviously necrotic) as a
temporary cover for the stump once it has been trimmed (Fig. 13.4B-D). If the wound is
grossly contaminated or if there is exposure of deeper structures such as flexor tendons or the
neurovascular bundle, delay closure of the wound for a few days (delayed primary suture).
When there is skin loss of less than 1 cm2, the wound is best left to granulate spontaneously,
to produce a small acceptable scar. Skin loss of more than 1 cm2 at the finger tip or pulp is
best covered with a split-skin graft, which will give a satisfactory cosmetic appearance, with
partial sensation (Fig. 13.4E - G).
Fig. 13.4. Wound coverage for hand injuries. Closing a clean wound with interrupted
sutures and inserting a drain (A); degloving injury with amputation of finger (B);
trimming of the amputation stump and coverage with a split-skin graft (C, D); injury
with skin loss from pulp of finger (E); applying split-skin graft (F, G).
An amputated fingertip can simply be stitched back to its bed, but not if the line of
amputation is proximal to the distal phalanx.
Dressing
Cover the injured hand or finger with several layers of sterile, dry gauze (Fig. 13.5A - D).
Apply a compression dressing and a light plaster slab to hold the hand and wrist in about 20°
of dorsiflexion, and the metacarpophalangeal and interphalangeal joints in position of
function. Leave the fingertips and nails exposed (Fig. 13.5E - G).
After-care
For the first 3 - 4 days elevate the limb, either by attachment to an overhead beam if the
patient is in bed (Fig. 13.5H) or by use of a triangular sling (Fig. 13.5I), to reduce post-
traumatic oedema; also encourage active exercises and continue antibiotic treatment. Inspect
the wound, hand, and fingers 72 hours after the operation. Clean the wound, remove the
drainage tube, and dress and splint the area. Refer the patient if indicated.
Fig. 13.5. Dressing and elevation of hand injuries. Applying several layers of sterile, dry
gauze (A - D); applying a compression bandage and a plaster slab, leaving the fingertips
exposed (E - G); elevating the limb (H, I).
Complications
Possible complications include infection, stiffness, and pain, or loss of sensation (in cases of
nerve injury). Contracture is a possible late complication.
Subungual haematoma
Subungual haematoma causes severe pain due to the collection of blood deep under the nail.
The blood is liable to become infected. To relieve pain, sedate the patient and allow the blood
to escape through one or two small holes made in the overlying nail with the red-hot tip of a
5-cm safety pin. The procedure is painless.
14. Fractures of the upper limb
Shoulder and humerus
Clavicle
Diagnosis
In adults, the clinical diagnosis of a fractured clavicle is usually obvious. Deformity,

swelling, and tenderness are evident at the site of injury, and the affected shoulder tends to
sag. A radiograph is not essential for isolated fractures of the clavicle (Fig. 14.1A). If a
pneumothorax is suspected, take a chest radiograph showing both clavicles and both shoulder
joints.
Equipment
See equipment for Application of plaster, Annex 1 and add a crepe bandage and a triangular
sling.
Treatment
Classical treatment is the application of a well-padded figure-of-eight bandage, but this may
be uncomfortable, especially in the axillae, if not properly applied. For some patients a
triangular sling is more suitable.
A figure-of-eight bandage is applied to alleviate pain, but is not essential to healing. First
ensure that the shoulders are braced back (Fig. 14.1.B). Use a broad stockinet as a bandage,
secured by a few turns of plaster, and pad the axillae well with cotton wool. The patient
should sit, hands on hips, as the bandage is applied (Fig. 14.1C, D). Anaesthesia is
unnecessary.
A triangular sling can also give satisfactory results, and may be more acceptable to the patient
(Fig. 14.1E - G).
Fig. 14.1. Fracture of the clavicle. Fracture (A); applying a figure-of-eight bandage (B -
D); applying a triangular sling (E - G).
After-care
After-care consists of frequent, active elevation and retraction of the shoulder, as well as
exercises for the elbow and hand. Check the bandage or sling frequently and remove it after 3
weeks for children or 6 weeks for adults.
Complications
Complications of this injury are rare, but can include non-union, malunion, and temporary
stiffness of the shoulder.
Scapula
Scapular fractures are usually associated with rib fractures; look for such associated injuries.
Diagnosis
Confirm the diagnosis by taking a chest radiograph.
Equipment
A triangular sling.
Treatment
Reduction of the fracture is impossible and unnecessary, even if it is communicated. Hold the
upper limb in a triangular sling on the same side as the fractured scapula. The patient should
wear the sling for 5 - 4 weeks and perform graduated pendulum exercises daily (Fig. 14.2A,
B), so that full activity is restored by the fourth week.
Fig. 14.2. Pendulum exercises for fracture of the scapula (A, B).
Proximal humerus
Diagnosis
Suspect a fracture of the proximal humerus if there is a history of shoulder pain following
trauma and a tender swelling of the shoulder with loss of, or restricted, function. Confirm the
injury by obtaining a radiograph of the humerus.
The sites that may be fractured are the greater and lesser tuberosities and the surgical neck,
with or without anterior dislocation.
Equipment
A crêpe bandage and a triangular sling.
Treatment
Treat isolated fractures of the greater or lesser tuberosity or undisplaced fractures of the
surgical neck of the humerus (i.e., fractures without a complete transverse fracture-line across
the full width of the humeral shaft) by holding in a triangular sling, with early mobilization of
the shoulder joint (Fig. 14.3A - C). Treat displaced fractures (having a complete transverse
line across the bone) and fractures associated with dislocation by reduction to the best
possible position with the patient under anaesthesia, followed by application of an axillary
pad and an arm-to-chest bandage (Fig. 14.3D - F). In cases of fracture dislocation, try to
reduce the dislocation as described for uncomplicated dislocation. If closed reduction fails or
if there is any evidence of neurovascular injury, refer the patient.
Fig. 14.3. Fractures of the proximal humerus. Fracture of greater tuberosity (A);
incomplete fracture of the surgical neck of the humerus (B); triangular sling (C) applied
to treat (A) or (B); complete fracture of the surgical neck of the humerus (D); fracture
dislocation of the shoulder joint (E); arm-to-chest bandage (F) applied after reduction
of (D) or (E).
As soon as the pain subsides, usually in 10 - 15 days, initiate pendulum exercises in a sling
and graduated activity, aiming at full activity within 8 - 12 weeks after the injury.
Complications
Possible complications include delayed union, malunion, non-union, and joint stiffness.
Humeral diaphysis
Diagnosis
The diagnosis is made from a history of injury followed by pain and weakness in the arm.
There is usually obvious deformity and abnormal mobility at the site of injury. Take a
radiograph to confirm the diagnosis (Fig. 14.4A, B). Check for radial nerve palsy by testing
dorsiflexion of the wrist (Fig. 14.4G - I).
Equipment
See equipment for Application of plaster, Annex 1 and add a triangular sling and a crepe
bandage.
Treatment
Treat the patient conservatively by closed reduction (with appropriate anesthesia) and
immobilization. Perfect bony apposition is not essential. Minimal overriding is acceptable
(Fig. 14.4A), but distraction of the humeral fragments is not (Fig. 14.4B). Immobilize the
fractured humerus for 4 - 6 weeks in an arm-to-chest bandage (sling and swathe) or in a U-
shaped plaster slab (Fig. 14.4C - F) with a triangular sling. The patient should begin daily
shoulder exercises, continuing until the fracture is consolidated.
If the fracture shows no evidence of union after 8 weeks, or if there is distraction of the bone
ends, refer the patient.
Complications
The commonest complication of humeral shaft fracture is radial nerve palsy. Protect the
affected wrist with a cock-up splint (Fig. 14.4J, K) or in a POP bandage. Vascular damage at
the diaphyseal level is rare unless there is an open fracture, for example as a result of a
shooting injury. Refer patients with either of these complications.
Fig. 14.4. Humeral diaphyseal fractures. Fractures (A, B); determining the required
length of plaster bandage for making a U-slab (C); applying a padded U-slab, which is
then secured with a wet cotton bandage (D, E); final position of the arm in plaster (F);
relationship of the radial nerve to the shaft of the humerus (G); testing for radial nerve
palsy (H - I); splint for wrist drop caused by radial nerve palsy (J, K).
Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology

Printable version
Basic techniques
Export document as HTML 14. Fractures of the upper limb

file Help
Elbow region
Forearm
Wrist and hand
15. Fractures of the pelvis and lower limb
16. Fractures in children
17. Dislocations of the upper limb
18. Dislocations of the lower limb
19. Spinal injuries
20. Head injuries
21. Amputations
22. Burns

procedures

Back Cover
Elbow region
Intercondylar fractures in adults
Diagnosis
Usually there is marked swelling of the arm, but confirm the diagnosis by radiography.
Intercondylar fractures are T- or Y-shaped and are intra-articular (Fig. 14.5A), so that
stiffness of the elbow is a frequent complication. For the diagnosis of supracondylar fractures
in children, see Supracondylar fracture of the humerus.
Equipment
Treatment
Treat these fractures by closed manipulative reduction (Fig. 14.5B), with the patient under
anaesthesia, and a posterior plaster splint. Three to four days after reduction, the patient
should begin pronation and supination exercises within the splint. After 2 - 3 weeks, remove
the splint temporarily to allow active exercises four to six times a day. Replace the splint with
a sling 4 - 6 weeks from the time of injury. Conservative management and early mobilization
can give results that are as good as those obtained by open reduction, despite incomplete
anatomical reduction. If the results of closed reduction are unsatisfactory, refer the patient,
especially the young adult who requires a better functional result.
Fig. 14.5. Intercondylar fracture in adults. Fracture (A); reduction by pressure over the
fragments while traction is applied (B).
Olecranon
Olecranon fracture may result from direct trauma or from an upward pull by the triceps
muscle.
Diagnosis
Skin damage is evident if the fracture is the result of direct trauma. The point of the elbow is
swollen and tender. A radiograph will show a comminuted fracture (often from direct trauma)
or a transverse fracture (from muscle pull, Fig. 14.6A, B). The radial and ulnar nerves lie
close to the elbow (Fig. 14.6C, D) and may be damaged.
Fig. 14.6. Fractures of the olecranon. Transverse fractures from muscle pull with
minimal (A) and wide (B) separation; relationship of the radial and ulnar nerves to the
elbow region (C, D); suturing the torn triceps tendon (E, F); inserting Kirschner wires
and holding the ends with rubber bands (G - J); position of elbow in plaster at 30° of
flexion (K).
Equipment
See equipment for Application of plaster. Annex 1 and for open fractures add a sterile tray for
wound débridement, No. 1 chromic catgut, and Kirschner wires with equipment for inserting
them.
Treatment
Treat undisplaced fractures (with intact triceps expansion) by a posterior plaster slab applied
with the elbow flexed to 90° - not in full extension. After 3 - 4 days, start the patient on
pronation and supination exercises within the splint, and after 2 - 3 weeks on intermittent
flexion - extension. Remove the protective splint at 3 - 4 weeks; for the following 6 weeks the
patient should not undertake exercise against resistance.
In cases of open fracture with comminution, perform wound débridement and approximate
the torn triceps tendon with No. 1 chromic catgut (Fig. 14.6E, P). Alternatively, insert
Kirschner wires percutaneously, one each in the proximal and distal fragments (Fig. 14.6G -
I). Twist the protruding ends of the wires and hold them in apposition with a small
compression device or strong rubber bands (Fig. 14.6J). Do not close the skin after fixation.
Place the elbow in a plaster slab at 30° of flexion (Fig. 14.6K), and refer the patient.
Refer all cases of closed fractures with wide separation of the fragments (ruptured triceps
expansion).
Head and neck of the radius
These fractures are caused by falls on the outstretched hand with the elbow in a slight valgus
position.
Diagnosis
There is tenderness over the head of the radius and rotation is painful; a radiograph of the
elbow will confirm the diagnosis (Fig. 14.7A - D).
Fig. 14.7. Fractures of the head and neck of the radius; different forms of injury of
increasing severity (A-D).
Equipment
See equipment for Application of plaster, Annex 1.
Treatment
Treat minimally displaced fractures by application of a removable posterior splint, with the
patient anaesthetized as appropriate. Start the patient on active exercises of pronation -
supination and flexion - extension as early as possible during the first week. Remove the
splint as soon as the pain has subsided. Most patients achieve very good functional results
from such treatment and are free of pain. Refer the patient if gross displacement of the
fragments suggests future limitation of movement.
Complications
Possible complications include joint stiffness and, occasionally, myositis ossificans.
Neglected or maltreated injuries around the elbow
Refer patients with such injuries after splinting the elbow. Deal with fracture dislocations
around the elbow in the same manner.
Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology

Printable version
Basic techniques

file Help
Elbow region
Forearm
Wrist and hand
19. Spinal injuries
20. Head injuries
21. Amputations
22. Burns

procedures

Back Cover
Forearm
Fracture dislocation in the upper forearm (Monteggia)
Fracture of the upper third of the ulna with dislocation of the radial head is caused by a fall
on the outstretched hand, combined with pronation of the forearm. The common
displacement is anterior, the fractured ulna projects forwards, and the radial head is
dislocated anteriorly.
Diagnosis
The elbow region is swollen and the ulna is obviously deformed. Radiography will confirm a
fracture of the ulna and a dislocation of the radial head (Fig. 14.8A, C, D).
Equipment
Treatment
Closed reduction, with appropriate anaesthesia, is the first step in the treatment of children
(Fig. 14.8A, B), but failure to achieve or maintain a satisfactory position, despite supination
of the forearm beyond the normal range, is an indication for referral. Refer adult patients, as a
stable reduction is rarely achieved by closed methods (Fig. 14.8E).
In all cases, a plaster cast should be applied to maintain the forearm in supination and the
elbow flexed to 90° (Fig. 14.8F).
Fig. 14.8. Fracture dislocation in the upper forearm (Monteggia). Fracture in a child
(A); reduction of fracture in a child, arrows showing the direction of pressure applied to
the forearm (B); fracture in an adult (C, D); reduction of fracture in an adult (E); final
position with POP applied in either child or adult (F).
Diaphyseal fractures of the radius and ulna
Diagnosis
Examine and obtain radiographs of the fracture sites and also of the elbow and wrist joints to
check for associated dislocations.
Equipment
Treatment
Undisplaced, single fractures of either the ulna or the radius alone generally do well in an
above-elbow plaster cast with the elbow held at 90° and the forearm in the mid-prone
position (Fig. 14.9A). Initially treat fractures of both bones or displaced fractures of a single
bone by closed reduction and by application of an above-elbow plaster cast. After the patient
has been given a general anaesthetic, achieve reduction by traction on the fingers and
appropriate manipulation while bending the elbow to 90° as an assistant applies counter-
traction on the upper arm (Fig. 14.9B - D). Refer the patient if it is not possible to obtain a
satisfactory position or if anatomical reduction cannot be maintained.
Fig. 14.9. Diaphyseal fractures of the radius and ulna. Above-elbow plaster cast with
elbow at 90° and forearm in midprone position (A); method of reduction of displaced
fractures (B-D).
Fracture dislocation in the lower forearm (Galeazzi)
This injury is a combination of fracture of the junction of the middle and distal thirds of the
radius with subluxation of the distal radio-ulnar joint, but with the ulna intact (Fig. 14.10A,
B). The principles of treatment are the same as those for displaced fractures of forearm bones
(initial closed reduction and plaster application). Open reduction is often required, so it is
advisable to refer the patient.
Fig. 14.10. Fracture dislocation in the lower forearm (Galeazzi). Anteroposterior (A)
and lateral (B) views; above-elbow plaster cast with elbow at 90° and forearm in
midprone position (C).
Wrist and hand
Colles’ fracture
Diagnosis
Colles’ fracture usually results from a fall on the outstretched hand. It occurs through the
distal cancellous region of the radius and is often accompanied by a fracture of the distal end
of the ulna or by a rupture of the ulnar collateral ligament of the wrist. The injury is easily
recognized clinically by the “dinner-fork” deformity appearance of the wrist (Fig. 14.11A). A
radiograph of the wrist will confirm a transverse fracture of the radius at about 2.5 cm from
the distal end (Fig. 14.11B, C) and, commonly, a fracture of the ulnar styloid process. The
distal radial fragment is impacted, and also shifted and tilted backwards and radially (Fig.
14.11C, D).
Equipment
Treatment
Treatment aims at achieving an acceptable functional and cosmetic result and at maintaining
full function of shoulder, elbow, and hand.
Fig. 14.11. Colles’ fracture. “Dinner-fork” deformity (A); lateral (B) and
anteroposterior (C) radiographic views; backward and radial tilt of the distal radial
segment (C, D); injecting local anaesthetic into the fracture haematoma (E - G).
Disimpacting the fracture (H, I); correcting radial deviation (J - M); checking for
satisfactory reduction (N, O).
Reduce Colles’ fractures with the patient under general anaesthesia whenever possible. For
the reduction of fresh (within 10 days after injury) displaced fractures, however, an
intravenous injection of diazepam and pethidine will suffice, and can be given irrespective of
food intake. When there is a preference for conduction anaesthesia, most of these fractures
can be safely reduced after injection of 5 - 10 ml of 2% lidocaine, under strict aseptic
conditions, directly into the fracture haematoma (Fig. 14.11E - G).
Disimpact the fracture by traction on the hand; palmar-flex the wrist and pronate the forearm
(Fig. 14.11H, I). While traction is maintained by an assistant, apply pressure over the distal
radial fragment in an ulnar direction to correct the radial deviation (Fig. 14.11J - M). Check
that reduction is satisfactory (Fig. 14.11N, O). Immobilize the wrist and forearm in a well-
padded, below-elbow plaster cast for 3 weeks. The wrist should be in 15° palmar flexion and
full ulnar deviation, the forearm in full pronation.
After-care
Take postreduction radiographs. Further manipulation may be necessary if reduction is not

satisfactory, but do not repeat the procedure more than once. Examine the fingers the next
day for swelling and cyanosis; if either is present, split the plaster immediately and cover it
with a crepe bandage. Complete the POP bandage only once any swelling has subsided. Take
a further radiograph 7 - 10 days after reduction; if the position of the bones is unacceptable,
refer the patient. Otherwise, encourage the patient to start shoulder, elbow, and finger
exercises as soon as possible.
After 3 weeks, apply a closely moulded plaster over a stockinet to maintain the bones in
correct alignment, with the wrist in neutral position. Keep this on for a further 3 weeks.
Complications
In the first day or two after reduction, a tight plaster may need to be split to relieve the
circulation (see above and pages 87 - 88). Possible later complications include stiffness of the
shoulder, wrist, and even finger joints; Sudeck’s atrophy; and rupture of the tendon of the
extensor pollicis longus.
Smith’s fracture
This is a fracture of the distal radius with displacements that are the reverse of those found in
Colles’ fracture, i.e., anterior displacement and anterior tilt of the distal fragment (Fig.
14.12A). Unlike Barton’s fracture (see below), the articular surface of the radius is usually
not involved. The distal fragment and the carpus are both displaced anteriorly.
Equipment

Treatment
The choice of anaesthesia is the same as that for Colles’ fracture (see above). Disimpact the
fracture as for Colles’ fracture and then reduce it by applying direct pressure posteriorly and
pushing the distal fragment in a radial direction. After reduction, apply an above-elbow
plaster with the wrist in dorsiflexion and the forearm in full supination. Subsequent
management and complications are similar to those of Colles’ fracture.
Barton’s fracture
This is a fracture dislocation with the osteochondral fracture involving the distal articular
surface of the radius (Fig. 14.12B). A wedge-shaped fragment of the anterior surface of the
distal radius is sheared off and it and the carpus are both displaced anteriorly and upwards.
Maintenance of the fragments after closed reduction may be difficult, so refer the patient after
application of a below-elbow POP cast, to maintain the wrist in dorsiflexion and the forearm
in full supination. The choice of anaesthesia is the same as that for Colles’ fracture.
Fig. 14.12. Smith’s fracture (A); Barton’s fracture (B). Anterior to posterior direction is
shown left to right.
Scaphoid
Apart from fractures of the scaphoid, injuries of carpal bones are rare, as are dislocations of
carpometacarpal joints.
Diagnosis
Diagnosis of fracture of the scaphoid depends on a careful physical examination of the wrist
and on examination of good quality radiographs taken in the anteroposterior (Fig. 14.13A),
oblique (ulnar deviation), and lateral projections. Typically, the clinical features of a
fractured scaphoid are fullness and tenderness in the anatomical snuffbox.
Some fractures are not apparent on the initial radiographs, so treat a “sprained wrist” with
tenderness over the waist of the scaphoid as a fractured scaphoid until this possibility has
been ruled out by a second radiograph 2 weeks after injury. In diagnosing cases with
negligible displacement, it is useful to obtain radiographs of both the injured and the normal
wrist on the same plate for comparison, as hairline fractures through the waist of the scaphoid
can easily be missed.
Equipment
Treatment
A “scaphoid plaster” is moulded particularly carefully to the hand in the position of open
grasp; sedation may be needed. The cast extends from the upper forearm (radial tuberosity) to
just short of the metacarpophalangeal joints of the fingers, but the thumb is included up to the
interphalangeal joint (Fig. 14.13B, C). Immobilization is maintained for 12 weeks.
Fig. 14.13. Fracture of the scaphoid. Fracture (A); “scaphoid plaster” (B, C).
Complications
Important complications are delayed union and non-union, for which the patient should be
referred.
Metacarpals
Metacarpal fractures can be stable or unstable, intra-articular or extra-articular, and closed or

open.
Equipment
Treatment
Most metacarpal fractures (Fig. 14.14A) can be treated satisfactorily by correcting gross
displacements with direct pressure (with the patient under anaesthesia) and by splinting with
a below-elbow, padded posterior plaster slab that extends up to the dorsum of the proximal
phalanx and holds the metacarpophalangeal joints in the position of function (Fig. 14.14B,
C). Instruct the patient to exercise free joints and fingers vigorously. Remove the splint after
2 - 3 weeks.
Fracture dislocation of the first carpometacarpal joint (Bennett’s fracture)
This injury is an oblique or vertical fracture of the base of the thumb metacarpal involving the
first carpometacarpal joint. Usually a smaller medial fragment of the base of the thumb
metacarpal maintains its relationship with the trapezium, while the remaining larger fragment
of the first metacarpal dislocates proximally and laterally (Fig. 14.14D).
Equipment
Treatment
With the patient under general or conduction anaesthesia, reduce the fracture dislocation by
applying traction on the thumb in abduction, with direct pressure on the lateral aspect of the
base of the rhumb metacarpal (Fig. 14.14E). Maintain traction and pressure while an assistant
applies a well-padded and moulded “scaphoid plaster” with the thumb in the open grasp
position (Fig. 14.14F).
Fig. 14.14. Fracture of metacarpals. Metacarpal fracture (A); applying a padded

posterior plaster slab with metacarpophalangeal joints in the position of function (B,
C); fracture dislocation of the first carpometacarpal joint (Bennett’s fracture) (D);
reducing the fracture dislocation (E); applying a “scaphoid plaster” (F);
Phalanges
After 2-3 weeks, apply a new plaster directly over stockinet. Discontinue immobilization in
plaster after a total of 6 weeks. A satisfactory functional result can usually be obtained by
such non-operative treatment.
Diagnosis
Suspect a broken finger if there is a history of trauma, pain, swelling, angulation and loss of
function. Confirm the diagnosis by radiography (Fig. 14.15A)
Equipment
See equipment for Application of plaster, Annex 1 or, for undisplaced fractures, use a garter,
adhesive rape, or a broad rubber band.
Treatment
Undisplaced fractures are relatively easy to manage. For adequate support and a good
functional result, strap the injured finger to the adjacent healthy finger with the garter,
adhesive tape, or broad rubber band (Fig. 14.15B) for 2 - 3 weeks. Start the patient on active
exercises. If pain and swelling are marked, splint the finger with a narrow dorsal or anterior
slab, or bandage the hand while the patient holds a tennis ball or an equivalent-sized roll of
bandage, so as to maintain a moderate degree of flexion of all the interphalangeal joints.
In displaced fractures of the proximal and middle phalanges there is usually angulation with
anterior convexity. Correct the deformity by direct pressure and traction, with the patient
under anaesthesia. Maintain correction by splinting the finger (flexed at the interphalangeal
joints) for 2 - 3 weeks in a dorsal, padded plaster slab extending from above the wrist to the
base of the finger-nail (Fig. 14.15C, D).
Fig. 14.15. Fracture of the phalanges. Fracture (A); an injured finger strapped to an
adjacent healthy finger (B); splinting an injured index finger with a dorsal plaster slab
(C, D).
Mallet finger
Mallet finger (Fig. 14.16A) results from a tear of the distal insertion of the long extensor
tendon. It may be associated with an avulsion fracture from the dorsum of the base of the
distal phalanx (Fig. 14.16B).
Equipment
See equipment for Application of plaster, Annex 1 or use a malleable splint.
Treatment
Provide analgesia as necessary. Hold the finger in a padded plaster (or other malleable
material) with flexion of the proximal interphalangeal joint and extension of the distal
interphalangeal joint (Fig. 14.16C), for 4 - 6 weeks. Full, active extension of the distal
interphalangeal joint may rake many months to recover.
Fig. 14.16. Mallet finger. Appearance of the finger (A); fracture (B); plaster cast (C).
Open fractures of the hand
In general, manage open fractures and accompanying soft-tissue injuries as described on

pages 92 - 94 and 97 - 105, but bear in mind the following specific points:
1. Always try to reduce swelling by elevating the hand, using compression dressings, and
encouraging the patient to exercise the whole of the upper limb as much as possible.
2. The position of function for immobilizing the hand is with flexion of the
metacarpophalangeal joints and almost straight interphalangeal joints.
3. Take care to avoid rotational malalignment when splinting a finger; check the alignment by
comparison with the finger of the uninjured hand held in an identical position. It is worth
noting that if each finger is flexed individually the fingertip always points towards the base of
the thenar eminence.
Pelvis
Fractures of the pelvic ring can be classified as (1) those of a single part (stable fractures)
(Fig. 15.1A, B) and (2) those that break the ring at two sites or are associated with disruption
of the symphysis pubis or sacroiliac articulation (unstable fractures) (Fig. 15.1C - E).
Sometimes a second break is not visible on routine radiographs. A fracture or disruption that
is obviously displaced must be the result of two or more breaks.
Treatment
Stable fractures
Stable fractures of the pelvis are generally not associated with visceral damage, but the
patient has pain. Treatment is symptomatic and consists of bed rest on a hard bed and
administration of analgesics for 2 - 6 weeks. As the discomfort sub-sides, the patient may be
permitted to walk with a stick.
Unstable fractures
Unstable fractures of the pelvic ring are serious injuries that are often complicated by damage
to the urethra, bladder, and other viscera. There is usually hypovolaemic shock from massive
internal blood loss. Treat the shock immediately; once it has been controlled, try to stabilize
the fracture and then attend to the other complications, for example by suprapubic drainage of
the bladder.
The preferred way to reduce and stabilize a fractured pelvic ring is to support it with a firm
sling and to apply skeletal traction to one or both lower limbs as appropriate, the hip(s) and
the knee(s) being maintained in 20° of flexion (Fig. 15.1F). This is comfortable for the
patient, and makes nursing and observation easier. Alternatively, gross displacements can be
reduced with the patient under general or spinal anaesthesia and a hip spica plaster applied to
maintain the hips in 30° of abduction and 20° of internal rotation, and the knees in 10° of
flexion (Fig. 15.1G, H). In 6 - 8 weeks the pelvis should be sufficiently firm to allow
replacement of the plaster with a pelvic corset; weight-bearing can start after 12 weeks.
Fig. 15.1. Fractures of the pelvis. Stable fractures (A, B); unstable fractures (C-E);
skeletal traction (F); hip spica (G, H).
Femur
Intracapsular fractures of the femoral neck
Diagnosis
Intracapsular fracture of the femoral neck is suspected from a history of trauma followed by
inability to stand or bear weight on the affected leg. The hip is painful and there is external
rotation of the leg, which may appear shortened. Confirm the diagnosis by radiography.
Equipment
See tray and equipment for Skin traction, Annex 1 or, for transportation, use a Thomas splint
or pillows and tying tapes.
Treatment
Ideally, all patients with intracapsular fractures of the femoral neck (Fig. 15.2A) should be
referred. During transportation, hold the limb in a Thomas bed knee splint (Fig. 15.2D). If a
Thomas bed knee splint is not available, immobilize the fractured limb after pulling it
straight, by tying it to the uninjured limb over padding or pillows (Fig. 15.2B, C). Another
safe position for transportation is with the limb held with pillows and rapes in a moderate
degree of flexion of the hip and knee.
Fig. 15.2. Intracapsular fracture of the femoral neck. Fracture (A); immobilizing the
injured limb by tying it to the normal limb over pillows (B, C); the injured limb
immobilized in a Thomas splint (D).
If referral is difficult, treat undisplaced stress fractures or impacted fractures by mild skin
traction with 1 kg in 20° of abduction and a neutral position for 10-12 weeks. Follow-up the
patient closely for the first 3 weeks. If disimpaction is suspected, arrange for referral. In the
elderly patient with limited activity, apply skin traction and initiate active and assisted hip
exercises to be continued for 2-4 weeks. Most elderly patients are then sufficiently mobile,
with the aid of a raised shoe and a crutch.
Complications
Complications include avascular necrosis of the femoral head, delayed union, non-union, and
joint stiffness.
Intertrochanteric fractures
Diagnosis
The patient is unable to stand after a fall, and the affected leg is shorter and externally
rotated. Obtain radiographs of the limb and pelvis. Typically, the fracture occurs between the
greater and the lesser trochanters (Fig. 15.3A), but can extend into the subtrochanteric part of
the femur.
Equipment
See tray and equipment for Skeletal traction, Annex 1.

Treatment
Conservative treatment, by balanced skeletal traction in a suspension frame (Fig. 15.3B),

produces fracture union in most cases within about 12 weeks. Older patients in traction may
be difficult to nurse, however, and complications such as pressure sores and bladder infection
may result. Varus deformity often follows, especially in patients with unstable or
comminuted fractures of the proximal femur, so referral for operation should be considered.
Fig. 15.3. Intertrochanteric fractures. Fracture (A); balanced skeletal traction (B).
Apply traction with 4 - 5 kg in 20 - 30° of abduction and neutral rotation. Begin active
exercises for both the fractured and normal limbs. After 12 weeks, when radiographs show
fracture union, allow the patient to walk without weight-bearing or with protected partial
weight-bearing. Elderly patients should use crutches at first and, subsequently, a stick held in
the opposite hand to minimize the risk of further falls.
Fractures of the upper-third and shaft of the femur
Diagnosis
The diagnosis of a fracture of the femoral shaft usually presents no difficulty. After trauma,
weight-bearing is not possible and there is abnormal mobility at the level of the fracture.
There is external rotation of the leg and abduction with shortening. Obtain a radiograph to
confirm the diagnosis and to exclude dislocation of the hip, fracture of the pelvis, or knee
injury.
Equipment
Treatment
Fracture of the femoral shaft can cause considerable internal bleeding (up to 3 litres in an
adult), so blood transfusion should be considered. If a satisfactory position of the fragments
of an upper-third femoral fracture can be maintained by traction with abduction and flexion
of the thigh, with the patient under anaesthesia, treat the fracture by such conservative means
until it has united. If the fracture is irreducible, refer the patient for open reduction and
internal fixation.
Generally treat all fractures from 4 cm distal to the lesser trochanter to the distal part of the
diaphysis by continuous skeletal traction applied through the upper end of the tibia, with the
limb supported on pillows to avoid posterior sagging. Maintain the length of the femur,
general alignment, and anterior convexity. When the fracture becomes “sticky” (deformable
without being displaceable) and is stable (about 6 - 8 weeks after fracture), apply a 1½ hip
spica if the fracture is above the mid-shaft or a single hip spica if the fracture is at a lower
level. The hip and the knee should be in 20 - 30° of flexion. Send the patient home with
crutches. Unprotected weight-bearing is possible after 6 months.
An alternative treatment of fresh fractures is Küntscher nailing, but this procedure requires
referral.
Knee region
Patella
Diagnosis
Diagnosis is based on a history of injury, usually with direct trauma to the knee, followed by
painful swelling. Obtain radiographs of both patellae.
Equipment
See equipment for Application of plaster. Annex 1 and, for open patellar fractures, tray for
Minor operations. Annex 1 with the addition of 0 catgut.
Treatment
Rest undisplaced fractures of the patella or fractures without a break in the continuity of the
quadriceps mechanism in a plaster cylinder for 3 - 4 weeks (Fig. 15.4A, B). Initiate
quadriceps exercises. In the early stages, a tense, painful haematoma may require aspiration.
The patient should begin knee-bending exercises when the plaster is removed, and
unprotected weight-bearing 8 - 12 weeks later.
Refer cases of closed, displaced fracture of the patella with rupture of the quadriceps
mechanism.
Open fractures
After wound débridement, approximate the synovium and quadriceps expansion with 0 catgut
(Fig. 15.4D, E). It the patellar fragments are grossly comminuted, remove small free
fragments and, if necessary, the whole patella (Fig. 15.4F). Leave the wound open and splint
the knee with a strong posterior plaster slab in 10 - 20° of flexion (Fig. 15.4C). Close the
wound at a later date, when there is no risk of infection, by delayed primary suture or by skin
grafting. The patient can begin guarded, intermittent, active knee-bending with assistance and
quadriceps exercises about 6 weeks after the repair. Remove the posterior splint at 12 weeks
and allow guarded weight-bearing, initially with the help of crutches.
Fig. 15.4. Fractures of the patella. Undisplaced fracture (A); undisplaced fracture
immobilized in a plaster cylinder (B); posterior plaster slab for splinting the knee after
an open fracture (C); suturing the synovium and quadriceps expansion after wound
débridement (D, E); removing small free fragments of the patella when there is gross
comminution (F).
Supracondylar fracture of the femur
Diagnosis
Suspect supracondylar fracture of the femur from a history of injury, followed by deformity
and inability to bear weight. The distal fragment of the femur points backwards. Confirm the
diagnosis by radiography.
Equipment
See tray and equipment for Skeletal traction. Annex 1.
Treatment
Treat all cases of Supracondylar fracture of the femur by skeletal traction through an upper
tibial pin (Fig. 15.5A, B). Hold the knee in 10° of flexion with the help of splints or pillows,
and maintain the anterior convexity of the femur at the site of fracture. Undisplaced or
minimally displaced fractures do not require reduction, but all displaced fractures, especially
those with osteochondral extension (intercondylar or condylar), should be accurately reduced,
with the patient anaesthetized as appropriate. Maintain reduction by traction, and begin early
quadriceps exercises and passive movements of the patella. When the fracture becomes sticky
(at 4 - 6 weeks), begin guarded knee-bending exercises, with a cast brace.
Fig. 15.5. Supracondylar fracture of the femur. Fracture (A); skeletal traction (B).
If satisfactory reduction is not possible by closed methods or in the rare event of failure of the
fracture to unite, refer the patient.
Fractures of the upper end of the tibia
Diagnosis
There is usually a history of direct injury to the knee, followed by pain, swelling, and
inability to bear weight. Confirm the diagnosis by radiography.
Equipment
Treatment
Apply traction through the tibia, 6 - 10 cm distal to the site of fracture. Using closed methods,
reduce displaced fractures to the best possible position, with the patient under anaesthesia.
Initiate early, repetitive quadriceps and knee-bending exercises while the limb is in traction.
The functional results of such treatment are often better than the radiographic appearance
would indicate. In cases of grossly displaced (but not grossly comminuted) fracture, when it
has not been possible to obtain reasonable apposition, refer the patient for open reduction. All
patients with grossly comminuted fractures should be referred.
Tibial diaphysis
Diagnosis
The diagnosis is usually obvious. The patient presents with a history of injury, pain, swelling
and clear deformity with bruising or an open wound. Confirm the diagnosis by radiography.
Equipment
Treatment
Many tibial fractures (with or without fracture of the fibula) can be reduced to a satisfactory
position by letting the fractured lower leg hang over the edge of a table with the knee at a
right-angle (Fig. 15.6A, B); the patient should be anaesthetized as appropriate. Apply a well-
moulded, padded plaster cast extending up to the groin, with 10° of flexion of the knee joint
(Fig. 15.6B, C). After 6 - 8 weeks, change the plaster to a well-moulded, patellar, tendon-
bearing plaster over stockinet (Fig. 15.6D).
Fig. 15.6. Diaphyseal fracture of the tibia. Fracture (A); applying a long-leg plaster cast
(B, C); a patellar, tendon-bearing plaster cast (D).
If reduction by closed technique is not satisfactory or there are concomitant injuries, refer the
patient for open reduction and internal fixation.
After-care
Encourage ambulation on crutches from the very beginning, gradually increasing weight on
the fractured limb. Encourage knee-bending exercises as soon as the plaster is removed and
allow full weight-bearing soon after. This treatment gives the highest incidence of union in
the shortest time, though the time necessary for this may be up to 18 weeks.
Ankle and foot
Fracture dislocation of the ankle
Ankle fractures are intra-articular injuries. Essentially, accurate reduction and immobilization
are based on performing movements that will reverse those that produced the fracture.
Almost all such injuries involve damage to the structures on the medial, as well as the lateral,
side of the ankle. Fracture dislocations of the ankle are classified according to the major
deforming force that has produced the injury, as summarized below.
External rotation
The main components of an external rotation fracture dislocation are a spiral fracture of the
lateral malleolus (Fig. 15.7A) with or without rupture of the deltoid ligament, or avulsion
fracture of the medial malleolus with or without fracture of the posterior malleolus of the
tibia. Mild cases have no subluxation, moderately severe cases have lateral subluxation, while
severe cases have an additional posterior subluxation.
Abduction
An abduction fracture dislocation consists of an almost transverse fracture of the fibula about
5 cm proximal to the joint line, with or without rupture of the deltoid ligament, or an avulsion
fracture of the medial malleolus, with or without fracture of the posterior malleolus, or both
(Fig. 15.7B). Mild cases have no subluxation, moderate cases have lateral subluxation, and
severe cases have additional posterior subluxation.
Adduction
An adduction fracture dislocation results from forceful inversion of the talus, causing a nearly
vertical fracture of the medial malleolus starting from its base (Fig. 15.7C). On the lateral
side there is an avulsion fracture of the lateral malleolus or rupture of the lateral ligament of
the ankle joint. The injury may be associated with medial subluxation.
Vertical thrust
Vertical thrust fractures (due to falling from a height) produce vertical splitting of the distal
end of tibia with or without comminution, and fracture of the medial or lateral malleolus (Fig.
15.7D), with or without fracture of the posterior malleolus. There may be diastasis of the
inferior tibiofibular mortise and fracture of the dome of the body of the talus.
Fig. 15.7. Fracture dislocation of the ankle. External rotation fracture dislocation (A);
abduction fracture dislocation (B); adduction fracture dislocation (C); vertical thrust
fracture (D).
Equipment
Treatment
Closed methods can succeed in the reduction of minimally displaced fractures, and are worth
trying even in cases of gross displacement. With the patient under anaesthesia, apply traction
and then accurately reverse the forces that caused the displacements. Apply a padded plaster
from below the knee to the toes with the foot at 90° to the leg. If there is a wide separation of
fracture fragments, however, the initial plaster should extend to the groin. Elevate the limb
and start the patient on active exercises. Change the plaster after 3 - 4 weeks to a well-
moulded cast applied over a stockinet. Allow weight-bearing, in plaster, 8 weeks after
reduction, and guarded weight-bearing, free of plaster, at 12 weeks.
Refer patients with fractures that cannot be reduced by closed methods or that become
displaced while in plaster. In patients with open fracture dislocations, an acceptable result
may be obtained by skeletal traction through the calcaneum.
Calcaneum
Diagnosis
The patient usually reports falling from a height, and landing on the affected foot. There is
pain with swelling and inability to use the foot. Confirm the diagnosis by radiography and
check the hip and knee for associated injury.
Equipment
Treatment
Isolated avulsion fractures of the calcaneum do not involve the subtalar joint. Treat small
fractures, or those with minimal displacement, by a short leg plaster in the neutral position
(Fig. 15.8A, B), with the patient anaesthetized as appropriate. Refer patients with a large
avulsion of bone bearing the insertion of the Achilles tendon (Fig. 15.8C), but first splint the
ankle in an equinus position.
Treat crushed and comminuted fractures (Fig. 15.8D) conservatively; elevate the leg to
reduce swelling, later supplementing this by elastic bandaging of the foot and ankle.
Encourage early ambulation using crutches from about 4 days after injury, and gradually
increase to full weight-bearing over several weeks.
Fig. 15.8. Fractures of the calcaneum. Small fracture (A); short leg plaster for treating a
small fracture, with the foot in a neutral position (B); large avulsion (C); crushed
fracture (D).
In children, a fracture will unite in an acceptable position as long as the general longitudinal
alignment of the fractured bones is maintained. Non-union of a tubular bone, such as the
tibia, may indicate congenital pseudoarthrosis; it may also be due to extensive soft-tissue
damage at the site of the fracture or to damage to the bone from infection.
The younger the child, the more the growth potential of the involved bone; the nearer the
growing area of bone, the greater the chances of spontaneous correction. Greater defects of
overriding, rotation, and angulation are therefore acceptable in younger children. Growth will
remould up to 30° of angulation in the direction of movement of the neighbouring joint (for
example anteroposterior angulation in the lower third of the femoral shaft), 20° of rotation,
and 2-5 cm of overriding in children. In a patient younger than 5 years, shortening or over-
riding of the femur of up to 5 cm is acceptable, as is a “bone block” in front of the elbow
from a malunited supracondylar fracture. The block does not need to be removed, as it
remoulds itself with time and growth, and the elbow eventually regains movement. Children
do not usually develop stiffness of joints as a result of a neighbouring fracture unless the
joint, especially the elbow, has been repeatedly manipulated and massaged. However,
osteochondral fractures (such as lateral condylar fracture of the humerus, medial condylar
fracture displaced into the elbow joint, and fracture of the tibial spine with restriction of knee
movement) require accurate reduction with or without internal fixation, for which, of course,
the patient should be referred.
Epiphyseal plate injuries
Epiphyseal plate injuries are common in children. Most of them occur through the weakest
part of the plate that is situated at the junction of the zones of hypertrophic cells and
provisional calcification. In general, growth disturbances do not result unless the germinal
layer of the epiphyseal cartilage plate is damaged. In injuries associated with displacement,
the germinal layer is displaced with the epiphysis. The Salter - Harris classification is a good
working guide:
• In Type I injuries, slipping occurs through the junctional zone, as described above, without any
fracture of the bone (Fig. 16.1A). After reduction, no growth disturbance results.
• In Type II injuries, a triangular segment of metaphyseal bone slips along with epiphyseal
plate (Fig. 16.1B). Common examples are fracture separations of the distal radius or the
femur. After accurate reduction, no growth disturbance results.
• In Type III injuries, an osteochondral fracture extends vertically through the full height of
the epiphysis and, as in Type I, through the junctional area (Fig. 16.1C). The fractured
epiphyseal plate is displaced along with the fractured epiphysis. Accurate reduction is
essential to prevent subsequent growth disturbance.
• In Type IV injuries, a vertical fracture involves the epiphysis and metaphysis (Fig. 16.1D).
Accurate reduction is essential, and even if it is successful, the degree of growth disturbance
cannot be predicted.
• Type V injuries involve “crushing” or “smashing” of the growth plate and result in growth
arrest (Fig. 16.1E). The usual cause is vertical impaction.
Fig. 16.1. Epiphyseal plate injuries. Slipping of the epiphyseal plate with the epiphysis at
the junctional zone - Type I (A); slipping of a triangular segment of bone along with the
epiphyseal plate - Type II (B); a vertical fracture through the epiphyseal plate and the
epiphysis - Type III (C); a vertical fracture through the epiphysis and metaphysis -
Type IV (D); crushing injury of the epiphyseal plate - Type V(E).
In patients with Types I and II injuries, make only one attempt at closed reduction, with the
patient under anaesthesia; minor residual deformities will correct themselves. Open reduction
itself may cause more trauma to growth potential. The epiphyseal injury that most often
needs open reduction (and therefore referral) is fracture of the lateral condyle of the humerus
with rotation of the fragments. Refer patients with Types III, IV, or V injuries after suitable
splintage.
Supracondylar fracture of the humerus
Supracondylar fracture of the humerus is a common injury in children. It results from a fall
on the outstretched hand with the elbow in slight flexion. The distal fragment is usually
displaced posteriorly (Fig. 16.2A).
Diagnosis
The elbow is painful, deformed, and swollen, especially a little above the epicondyles.
Examine carefully and record the circulation and motor and sensory function in the distal part
of the limb, as this fracture is apt to be associated with vascular or nerve damage. Obtain a
radiograph of the elbow region.
Equipment
Treatment
Reduce a displaced Supracondylar fracture as early as possible, with the patient under general
anaesthesia. As a guide to the degree of displacement, compare the injured and uninjured
elbows. With the patient supine and near the edge of the table, apply traction on the forearm
with the elbow held at about 20° of flexion while an assistant applies counter-traction (Fig.
1.6.2B). The overriding of the fractured ends will be corrected by sustained traction for a few
minutes. Without releasing traction, grasp the distal fragment of the humerus at the level of
the epicondyles and correct the side-to-side displacement, tilt, and axial rotation (Fig. 16.2C).
Then push the distal fragment forward to normal alignment, replacing it in position, and
gently flex the elbow (Fig. 16.2D). The intact triceps expansion holds the fracture in the
reduced position and prevents over-reduction. Maintain the reduction with a padded posterior
plaster slab in nearly 120° of flexion and full supination (Fig. 16.2E). If a satisfactory radial
pulse cannot be palpated at acute flexion, extend the elbow until the pulse returns. If there is
any doubt about the circulation to the hand after reduction, keep the elbow in 20° of flexion
in a posterior splint and observe the patient closely.
After reduction, obtain anteroposterior and lateral radiographs to confirm the reduction (Fig.
16.2F). If an acceptable position cannot be obtained by closed manipulation (do not attempt
more than two manipulations), apply a posterior slab and refer the patient. Moderate degrees
of anteroposterior and side-to-side displacements are acceptable, as these remodel with time
and growth. Appreciable tilt or axial rotation is not acceptable, as remodelling does not
correct these displacements and varus or valgus deformity at the elbow may result.
Fig. 16.2. Supracondylar fracture of the humerus in children. Fracture (A); applying
traction with the elbow in about 20° of flexion (B); correcting the side-to-side tilt and
rotation of the distal segment (C); flexing the elbow after aligning the distal segment
(D); applying a posterior plaster slab with the elbow in about 120° of flexion (E);
radiographic confirmation of reduction (F).
After-care
Encourage finger and shoulder movements from the very beginning and closely monitor the
patient’s circulation for the first 24 hours, in hospital.
The fracture usually unites within 3 - 5 weeks, at which time the posterior splint should be
discarded. Start the patient on active exercises and encourage use of the elbow, but allow no
passive movements, such as pushing, pulling, weight-carrying, or massage. Good function
can be expected within 3 - 6 months.
Complications
The most serious complication is Volkmann’s ischaemia.
Anterior displacement
Rarely, supracondylar fracture in children is caused by a fall on the hand with the elbow
extended, resulting in the distal fragment being displaced and tilted forward. Achieve
reduction by traction and repositioning of the displaced bone with the elbow extended. After
reduction, apply a posterior plaster slab with the elbow in 10 - 20° of flexion. After 2 - 3
weeks, remove the slab, bring the position of the elbow to 90° with the forearm in the mid-
prone position, and hold it in a fresh plaster slab for another 10 - 14 days.

Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology

Printable version
Basic techniques

file Help

Shoulder
Elbow
Hand
19. Spinal injuries
20. Head injuries
21. Amputations
22. Burns

procedures

Back Cover
Shoulder
Anterior dislocation
Diagnosis
Of all the major dislocations of joints, more than 50% occur in the shoulder. About 95% of
shoulder dislocations are of the anterior type. As a result of injury (a combination of
abduction, external rotation, and extension), the head of the humerus dislocates out of the
glenoid cavity, and passes forward and down to lie in the subcoracoid region. The contour of
the shoulder is thus altered from the usual curved appearance to one that is much more
angular, with no movement possible (Fig. 17.1A). Anteroposterior (and axial, if possible)
radiographs will reveal anterior dislocation of the humeral head, and any associated fracture
around the shoulder (Fig. 17.1B, C).
Equipment
A triangular sling and a swathe bandage.
Treatment
Reduce a fresh dislocation or a recurrent dislocation after administering intravenous

diazepam and an analgesic. General anaesthesia is occasionally needed.
The Kocher method of reduction is most suitable for fresh dislocations without fracture of the
humerus or glenoid. Pull on the flexed elbow, rotate the head of the humerus laterally, and
then adduct the humerus across the body while rotating the humerus internally (Fig. 17.1D -
G).
Carry out dependent reduction with the patient under deep sedation with muscle relaxation.
Place the patient prone on the edge of a table with the dislocated shoulder and arm hanging
down vertically, and attach a weight to the arm or apply traction for a few minutes (Fig.
17.1H). Reduction may occur spontaneously with minimal manipulation by the surgeon.
Dependent reduction is especially useful in patients with osteoporosis or with fracture of the
neck or shaft of the humerus, and in cases of recurrent dislocation of the shoulder.
The Hippocratic method (Fig. 17.1I) is an alternative method of reduction that remains
popular with some clinicians. The patient should be supine. Apply traction to the arm by a
hold on the hand. Exert counter-traction by placing the stockinged heel of your foot on the
medial wall of the axilla. The right foot is most convenient for the right shoulder and the left
foot for the left shoulder. Avoid excessive pressure on the ribs as they could fracture. While
maintaining traction, employ the lateral border of the foot on the axilla to lever the dislocated
humeral head back into position.
The reduction is clinically complete if the hand and elbow can rest comfortably on the
opposite shoulder and chest, respectively. Confirm the reduction by radiography. Keep the
arm in position with the help of a sling-and-swathe bandage (Fig. 17.1J) for 2 weeks in
elderly patients and otherwise 4 weeks. Encourage the patient in deep breathing and isometric
exercises for all the muscles of the shoulder. After the period of immobilization, begin
pendulum and circumduction exercises, progressing finally to full abduction and external
rotation.
Fig. 17.1. Anterior dislocation of the shoulder. Clinical appearance (A); anteroposterior
(B) and axial-lateral (C) radiographic appearance; reduction by the Kocher method:
lateral rotation with traction, adduction, and internal rotation (D - G). Reduction by the
dependent method (H); reduction by the Hippocratic method (I); sling-and-swathe
bandage (J).
Posterior dislocation
Posterior dislocation of the shoulder is extremely rare. It may result from a fall on the
outstretched hand with the limb internally rotated, or a direct blow to the front of the
shoulder. The humeral head is dislocated posteriorly. An anteroposterior radiograph may
show only that the head of the humerus overlaps the margin of the glenoid (Fig. 17.2A). An
axial view, however, will show the posterior dislocation (Fig. 17.2B). Reduce a fresh
dislocation after administering intravenous diazepam and an analgesic; general anaesthesia is
occasionally needed. Apply traction with the shoulder in 90° of abduction and externally
rotate the limb (Fig. 17.2C, D). Postreduction care is the same as that for anterior dislocation.
Fig. 17.2. Posterior dislocation of the shoulder. Anteroposterior and axial radiographs
(A, B); applying traction with the shoulder in 90° of abduction (C); rotating the limb
externally (D).
Fracture dislocation
Dislocation of the shoulder can be associated with an avulsion fracture of the greater
tuberosity which generally reduces satisfactorily during the reduction of the dislocated
shoulder. As a result of more severe violence, the dislocation may be associated with a
fracture through the surgical neck of the humerus or with a fracture of the surgical neck and a
fracture of the greater tuberosity. When the injury is fresh, always try closed reduction (with
the patient under general anaesthesia) by applying strong traction in moderate abduction and
by directly manipulating the head of the humerus through the axilla. If this method is
successful, postreduction treatment is the same as that for a dislocated shoulder. Always
check blood circulation and nerve function in the limb after such manipulation.
If closed reduction of a dislocation or fracture dislocation fails, or if the injury is more than
10 days old, apply a sling and refer the patient. In general, encourage early mobilization,
especially in elderly patients.
Elbow
Diagnosis
Suspect a dislocated elbow from the history of a fall on the outstretched hand. Clinically, the
triangular relationship between the olecranon and the two epicondyles in 90° of flexion is
disturbed. Assess and record ulnar nerve function. Confirm the diagnosis by anteroposterior
and lateral radiographs (Fig. 17.3A). In young children, obtain radiographs of both elbows in
an identical position to compare the injured and normal medial epicondyles. The medial
epicondyle may have fractured and be trapped in the joint.
Equipment
Treatment
Treatment is immediate closed reduction with the patient under anaesthesia with muscle
relaxation. To reduce the dislocation, apply traction with the elbow in slight flexion and
direct pressure on the tip of the olecranon to lift it distally, anteriorly, and medially (in
posterolateral dislocation) or laterally (in posteromedial dislocation) (Fig. 17.3B). Clinically
test for full reduction by checking for a complete range of motion (Fig. 17.3C) and the
absence of valgus deformity, particularly on full extension. Always take postreduction
radiographs. If closed reduction fails or if reduction is incomplete, the likely cause is soft-
tissue interposition or a trapped, fractured medial epicondyle, and the patient should be
referred.
After-care
Postreduction treatment consists of application of a padded posterior plaster splint with the
elbow at 90° of flexion in the mid-prone position (Fig. 17.3D, E); elevation of the limb; and
active, frequent exercising of the fingers and shoulder, which should be started immediately.
After 2 - 3 weeks, the patient should begin intermittent, active, flexion - extension and
pronation - supination exercises. Remove the plaster splint after 4 weeks when the patient has
gained good muscle control. Restoration of the full range of elbow movements may take 8 -
12 weeks. Passive stretching or massage of the elbow is strictly prohibited.
Fig. 17.3. Elbow dislocation. Dislocation (A); reducing the dislocation by traction and
pressure (B); flexing the elbow fully as a test of reduction (C); immobilizing the limb in
an above-elbow plaster slab (margin shown by dotted line) and a sling (D, E).
Hand
Lunate or perilunar dislocation
Diagnosis
Lunate dislocation is a serious injury causing limitation of wrist motion, fullness of the
palmar aspect of the wrist, local tenderness, and often signs of median nerve involvement
(reduced sensation) over the median nerve distribution in the fingers and the palm of the
hand. Always obtain radiographs of both wrists for comparison (Fig. 17.4A-D). The lateral
radiograph of the injured wrist will reveal an anteriorly displaced lunate bone with its
concavity facing forward (Fig. 17.4D). In the anteroposterior view, a dislocated lunate
appears triangular (Fig. 17.4B), rather than quadrangular. The dislocation may also be
associated with a fracture of the scaphoid. In perilunar dislocation, the carpal bones are
displaced posteriorly, but the lunate maintains its normal appearance and relation-ship to the
inferior articular surface of the radius.
Fig. 17.4. Dislocated lunate bone. Radiograph of features of both wrists in
anteroposterior and lateral views for comparison (A-D); the injured wrist (B, D).
Equipment
Treatment
With the patient under general or conduction anaesthesia, reduce the dislocation by prolonged
traction and counter-traction, and reposition the displaced bones by direct pressure.
Following reduction, apply a posterior slab with the wrist in a neutral position. Refer patients
in whom reduction has failed and those reporting more than 48 hours after the injury.
Other dislocations
Equipment
Treatment
The treatment of Bennett’s fracture dislocation of the first carpometacarpal joint is described
on pages 121 - 122. In most cases, dislocations of metacarpophalangeal and interphalangeal
joints result from hyperextension injuries and are almost always posterior. When the injury is
fresh, closed reduction (with the patient anaesthetized as appropriate) is usually successful:
pull at the phalanx and push the base of the dislocated phalanx anteriorly into position. After
reduction, apply a light plaster splint with a moderate degree of flexion of the joint. Remove
the splint after 2 - 3 weeks. If reduction by closed methods fails, which is usually the result of
a “button-holing” of the anterior capsule, refer the patient.
Hip
General
Diagnosis
Dislocation of the hip joint is a major injury. It may be posterior, central, or anterior.
Carefully examine the patient to detect and evaluate associated injuries, including fractures in
the same limb, particularly fracture of the shaft of the femur. Obtain radiographs of the hip
joint, the entire pelvis, and other areas where injury is suspected.
Treatment
An uncomplicated dislocation can be reduced under anaesthesia as soon as the patient’s

general condition is stable. In general, refer patients with dislocations associated with major
fractures of the acetabulum (for example Fig. 18.1) or fractures of the femoral neck or shaft,
and those with dislocations that are older than 7 days or that cannot be reduced anatomically.
Sciatic nerve palsy is also an indication for referral; it occurs in about 10% of patients, yet
most recover after successful reduction.
Fig. 18.1. Posterior and central dislocation of the hip. Dislocation with fracture of the
posterior lip of the acetabulum (A); central dislocation of the hip with fracture of the
acetabular floor (B).
Pending the referral of a patient with a dislocation associated with a major fracture, apply
skeletal traction to the injured limb. The treatment of patients with uncomplicated posterior or
anterior dislocations is outlined below.
Posterior dislocation without fracture
Diagnosis
This is the most common type of hip dislocation (Fig. 18.2A). The deformity is typical and
comprises flexion, adduction, and internal rotation of the hip. The patient presents with the
knee of the affected limb overlying the lower-third of the opposite thigh, but beware of the
possibility of a dislocated hip associated with a fracture of the shaft of the femur, where the
classical deformity is masked by the fracture. Always suspect a dislocated hip if a fractured
shaft (upper fragment) remains adducted.
Equipment
See tray and equipment for Skin traction, Annex 1.
Treatment
Reduce the dislocation with the patient under spinal or general anaesthesia with good muscle
relaxation. Lay the patient on the floor and flex the hip to bring the leg into neutral position
while an assistant presses down on the pelvis to steady it (Fig. 18.2B). Then bring the hip to
90° of flexion and gently rotate it while applying pressure over the femoral head to restore
the latter to its normal position (Fig. 18.2C - E).
An alternative method is dependent reduction, which is especially useful when dislocation is

associated with fracture of the femur of the same side. With the patient prone, and under
anaesthesia, flex the dislocated hip over the edge of the table and apply traction downwards
on the flexed hip. Replace the femoral head in its normal position by gentle rotation and
direct pressure on the femoral head in the gluteal region (Fig. 18.2F).
Fig. 18.2. Posterior dislocation of the hip. Dislocation (A); applying traction while an
assistant steadies the pelvis (B); maintaining traction as the hip is flexed to 90° and then
rotated, and applying pressure over the femoral head (C-E); reduction by the
dependent method (applying traction to the limb and pressure over the femoral head)
(F).
Failure to achieve closed reduction is an indication for referral, after applying an adequate
splint.
After-care
Apply postreduction skin traction for about 3 weeks or until the hip is no longer painful.
From the beginning, allow gentle hip exercises and sitting up in bed, except if there is a
fracture of the posterior rim of the acetabulum. The patient may begin non-weight-bearing
ambulation after 6 weeks and weight-bearing after 12 weeks, and discard the crutches when
satisfactory function has been obtained, generally after 16 weeks.
An alternative method of treatment, if the patient must return home, is with a postreduction
POP hip spica bandage in about 30° of abduction, 20° of flexion, and neutral rotation, for the
first 6 weeks. Then encourage active exercises and crutch-walking, as above.
Anterior dislocation (obturator dislocation)
Diagnosis
This is a rare condition in which the dislocation is the result of an accident that occurs while
the thighs are held wide apart. Clinically, the limb lies externally rotated, abducted, and
slightly flexed. The femoral head is palpable in front, or on the medial side, of the base of the
thigh. Radiographs will confirm the diagnosis.
Treatment
Reduction techniques and maintenance are similar to those for posterior dislocation.
Ankle and foot
For the treatment of fracture dislocation of the ankle.
Talar and subtalar dislocations
Dislocation may occur at the subtalar level or at the talonavicular joint, or the talus itself may
dislocate. These dislocations are the result of very severe and progressive inversion forces
applied to the foot. The extreme degree of inversion may rupture all ligaments completely,
dislocate the talus, and even extrude it out of the foot through an open wound. There may be
an associated fracture of the neck of the talus.
Equipment
See tray for Minor operations, Annex 1 and add three Kirschner wires with equipment for
inserting them. See also equipment for Application of plaster, Annex 1.
Treatment
With the patient under anaesthesia, attempt closed reduction, which, because of the extensive
damage to ligaments, is usually not difficult, and apply a plaster cast. It may be possible to fix
major bone fragments with percutaneous Kirschner. If closed reduction is unsuccessful, refer
the patient.
19. Spinal injuries
Without cord damage
Cervical
Equipment
See tray and equipment for Skull traction, Annex 1.
Treatment
Fractures of vertebra C1 or C2 are best managed by skull traction for the first 3 weeks, to
provide rest to the injured part and permit assessment of the extent of damage. After the acute
stage, treat by immobilization of the spine in a Minerva jacket (Fig. 19.1A, B) or in a four-
post collar. The patient should remain mobile with the jacket or in the four-post collar for 3
months, by which time stability should be achieved.
Treat all cases of fractures, dislocations, and fracture dislocations of C3-7 without cord
damage (Fig. 19.1C) by recumbency and skull traction during the acute stage. If traction is
maintained, appropriate positioning of the neck will reduce gross displacements unless the
dislocation has resulted in locked facets. After 3 - 6 weeks of traction, mobilize the patient in
a wheelchair with a Minerva jacket (Fig. 19.1A, B) or in a four-post collar for 3 - 4 months.
Spontaneous stabilization occurs in the presence of a fracture. Pure dislocations may not
stabilize in 3 - 4 months, so should then be referred.
Fig. 19.1. Cervical spinal injuries. Minerva jacket (A, B); fracture of C2 and fracture
dislocation of C6 (C).
Thoracolumbar
Treatment
Thoracolumbar fractures or fracture dislocations without neurological deficit are classified as

being either stable or unstable and are treated accordingly.
Stable fractures include compression fractures of the vertebral body with less than 50% loss
of vertical height, most burst fractures, minor fractures, shearing fractures, and rare laminar
fractures (Fig. 19.2A, B). Treatment consists of rest in a hard bed for 10 - 20 days, frequent
turning of the patient in a log-rolling fashion (Fig. 19.2D, E), mild analgesics, and active
exercises; back extension should be begun as soon as local pain permits. Allow the patient
with a stable fracture to get up without external support once good muscle power has
returned. Patients in severe pain may require a plaster jacket (Fig. 19.2C) for 6-12 weeks.
Fig. 19.2. Thoracolumbar fractures or fracture dislocations. Compression fracture of

the vertebral body (A); shearing fracture of the anterior superior corner of the
vertebral body (B); plaster jacket (C); turning the patient using the log-rolling method
(D, E).
Unstable fractures are usually caused by a severe flexion and rotation injury and are
commonly associated with a neurological deficit in the form of partial or complete paraplegia
(for which a referral is required). In the absence of paraplegia, nurse the patient in the
recumbent position on a hard bed or in a plaster bed for about 3 months. Most fractures heal
in this time with spontaneous osseous stabilization.
In patients with thoracolumbar injuries, retroperitoneal haematoma may induce a paralytic

ileus, in which case oral feeding may need to be replaced temporarily by intravenous fluids
With cord damage
If possible, refer all patients with cord damage for specialized treatment and rehabilitation.
Transfer the patient carefully on a firm board. While awaiting transfer, keep in mind the
following points.
Displaced structures in the cervical spine may cause quadriplegia, in the thoracic region
paraplegia, and in the lumbar region a cauda equina lesion (lower motoneuron type). The
neurological injuries fall into three clear groups: cord concussion, cord transection, or root
transection, but sometimes there is a mixture of all three.
In cord concussion, recovery from paralysis starts within 24 - 48 hours of rest to the spine and
is generally complete within 3 - 4 weeks. If the cord is transected, paralysis will be
permanent. A return of anal and penile reflexes within 24 - 48 hours of rest to the spine
without recovery of sensation or motor power indicates complete cord transection. Within 3 -
4 weeks, the patient with complete cord transection starts to develop an extensor plantar
response, spastic paralysis, increased tone, exaggerated reflexes, and clonus, without return of
skin sensation. Sometimes there is deep muscle sensation and an appreciation of bladder
fullness.
Care
Skin
Skin care of the patient with neurological deficit should begin immediately. Nurse the patient
on a hard bed with a firm mattress; the mattress, bed sheets, and patient’s clothing must not
be creased. Ideally, every 2 hours, log-roll the patient (rolling the entire body from side to
side at the same time) with the help of at least three other people (Fig. 19.2D, E). Wash the
skin of the back and the flanks frequently, rub it gently, and dry it with methylated spirit.
Never apply heat locally. After 3 - 4 weeks the anaesthetic skin becomes slightly more
tolerant to pressure, at which time the patient can learn to turn using an overhead bar. Train
the patient’s relatives to help with the turning, nursing, and simple physiotherapy, which they
may eventually take over entirely when the patient is released from hospital.
Bladder and bowel
During the first 24 - 48 hours the patient may have a distended bladder with overflow
incontinence. Insert an indwelling bladder catheter and drain the urine into a closed bag.
Clamp the catheter and release it intermittently every 4 - 6 hours. Usually, after about 3
weeks, partial control of bladder function results in an automatic (reflex) bladder or in a
bladder that can be emptied by suprapubic pressure.
Bowel training can be provided by enemas, laxatives, and abdominal exercises at regular
hours, but this is possible only if the anal reflex is present and if an anal sphincter tone can be
elicited on rectal examination.
Paralysed limbs
Exercise paralysed limbs three times daily, gently aiding each joint through its full range of
movement. Excessive force in moving the joints can cause pathological fracture of an
osteoporotic limb or myositis ossificans, resulting in total immobility. If referral has not been
possible, encourage ambulation 3 months after injury with suitable braces and appliances,
depending upon the level of transection.
20. Head injuries
Wounds of the scalp
Scalp wounds bleed considerably, but after débridement and suture, for which a field block
usually provides satisfactory anaesthesia, they heal rapidly.
Avulsion of the scalp is associated with a larger blood loss than other types of scalp wound.
Clean and replace the avulsed tissue, suturing it loosely layer by layer to provide temporary
cover.
Prophylactic antibiotics should be given to all patients with scalp wounds.
Skull fractures
Closed fractures
Closed fractures of the skull, without any neurological symptoms, do not require active
intervention. Depressed fractures (Fig. 20.1A, B) may require elevation of the depressed
fragment (see Fig. 20.3), but usually this is not urgent. In young children with depressed
fractures of the parietal region, elevation is sometimes required as an elective procedure, and
such patients should be referred.
Fig. 20.1. Depressed skull fracture (A, B).
For the treatment of patients with associated intracranial injury, see Fractures of the base of
the skull below.
Compound fractures of the vault
Diagnosis
Always look for evidence of associated damage to the skull and brain. Skull fracture may be
suggested by the nature of the injury, by local examination, or by signs of severe damage to
the brain. Confirm a skull fracture by radiography. A scalp haematoma in an infant or child
can be mistaken for a depressed fracture of the skull. There is no need to aspirate or incise
such a haematoma.
Equipment
See trays for Craniotomy and for Minor operations. Annex 1 and add bone wax and
absorbable gelatin sponge.
Treatment
Treat compound fractures of the vault of the skull on the general principles of compound
fracture, unless accompanied by intracranial injuries and intracranial bleeding (see below).
Carry out débridement of the open fracture, removing all small, loose pieces of bone,
elevating larger fragments after making burr holes as necessary (see Fig. 20.2), and then
closing the wound without tension over a drain. Do not elevate any depressed fragment over
the midline, as this can tear the sagittal sinus, causing profuse, uncontrollable, and fatal
bleeding.
Always give prophylactic antibiotics.
Fractures of the base of the skull
Diagnosis
Fractures of the base of the skull are difficult to diagnose on radiographs, but their presence is
indicated by bleeding from the nose, throat, or ears and, if the dura is also torn, by escape of
cerebrospinal fluid. Possible injury to cranial nerves can usually be detected by clinical
examination.
Treatment
Treatment of basal fractures is directed mainly to the prevention of intracranial infection.

Keep the oropharynx clear by suction until bleeding has stopped, clean the external auditory
meatus, and cover (not pack) the ear to soak up the blood. It is important to treat the patient
with a sulfonamide or antibiotic as long as there is a leak of blood or cerebrospinal fluid.
Sulfamethoxazole plus trimethoprim (co-trimoxazole) is probably the most useful agent, and
chloramphenicol the best of the antibiotics likely to be available.
In patients with basal fractures, radiographs may show the presence of intra-cranial air.
Radiographs taken after 24 hours should show a reduction in the amount of air shadow from
absorption, but if the amount of air is increasing, refer the patient for repair of the anterior
cranial fossa. In very severe basal fractures, avoid the use of a nasogastric tube as it can enter
the cranial cavity, with fatal results
Intracranial injuries
Generally, the term “head injury” denotes an injury to the skull that has caused intracranial
injury, mainly to the brain but also to the blood vessels (the middle meningeal arteries and
venous sinuses, including the intracerebral vessels). Intracranial bleeding from the diploë of
the skull can also be considerable.
Diagnosis
Significant brain damage results in unconsciousness, which may last for only a short time.
The patient may have no recollection of the episode. If a conscious patient has a history of
unconsciousness following an accident or other injury, brain injury has probably occurred.
The patient may be in the “lucid interval” preceding a further loss of consciousness and
deterioration in condition, and should be carefully observed for at least 24 hours. Most
patients with head injury, however, recover and retain consciousness.
Table 2. Glasgow Coma Scale a
Response Score
Eye-opening response Spontaneous 4

(opening of eyes in response to stimulation)
To speech 3
To pain 2
None 1
Best verbal response Oriented 5

(response to command or request)
Confused 4
In appropriate 3
Incomprehensible 2
sound
None 1
Best motor response Obeys commands 6

(response by voluntary movement of limb to instruction or
stimulation)
Localizes pain 5
Flexion withdrawal 4
Abnormal flexion 3
Extension 2
None 1
a
For an objective analysis of the patient’s state, add up the score under the three headings The best
prognosis is indicated by a score of 15 the worst by a score of 3. The size and reaction of the pupils
indicate the state of intracranial tension and may help to localize the side of injury, Increasing
tension first gives a contracted pupil that still reacts to light; later the pupil starts to dilate and loses
its light reflex.
A patient who is brought to hospital unconscious after an accident should be treated as having
suffered intracranial injury. Initial management aims to prevent further “insult” to the brain
by establishing a clear airway, administering oxygen, and restoring the blood volume.
Examine the patient for concomitant injuries that require urgent care and resuscitation, for
example penetrating wounds of the chest or abdomen. Also examine the patient for injuries to
the spine and the spinal cord, and for fractures of the limbs. In patients with multiple injuries,
the priority is to establish a clear airway and treat hypovolaemic shock.
Next, assess the extent of brain injury, for example using the “Glasgow Coma Scale” (Table
2).
Increasing intracranial tension will cause secondary brain injury and may be due to: cerebral
swelling from accumulation of carbon dioxide in the blood, hypoxia, and hypotension;
haematomas that can be extradural, subdural, or intracerebral; or acute obstructive
hydrocephalus due to posterior cranial haematomas and associated intraventricular
haematomas.
Increasing intracerebral tension will cause herniation of the brain, the clinical features of
which are: a deteriorating level of consciousness; slowing of the pulse rate (bradycardia) with
rising blood pressure; inequality of the pupils; dilating, sluggishly reacting pupils and ptosis;
focal seizures or hemiparesis; and extensor posturing of the limbs (terminal event).
Monitor the patient’s blood pressure, pulse rate, and respiration every 15 minutes. A slow,
full pulse and raised blood pressure suggest an increase in intra-cranial tension. Hypotension,
however, is not a sign of head injury, and its cause must be sought elsewhere.
Radiography of the skull can await control of the airway and initial stabilization of other
injuries. Simple anteroposterior and right and left lateral views will give all the necessary
information about the skull. In addition, always obtain radiographs of the cervical spine of
deeply unconscious patients to exclude an otherwise unrecognized fracture.
Diagnosis of a head injury does not stop once the existence of brain damage has been
established; it is a process of continually observing the improvement or deterioration of the
patient’s brain function and the response to treatment, and watching for signs that may
indicate the need for emergency operation.
In a patient who has had an injury to the skull, unconsciousness rarely has any other cause.
Examine the patient, however, to exclude: epileptic fit; cerebrovascular accident;
hypoglycaemic and diabetic coma; alcohol or drug abuse; or fat embolism, which can lead to
unconsciousness 2 - 3 days after a limb fracture. Take a history of the patient’s previous
illnesses from relatives and inquire of witnesses about the mode of injury and whether
unconsciousness occurred beforehand.
If unconsciousness appears to be due to a specific disease or condition, treat the patient

accordingly, but do not assume that there has been no brain injury, and keep the patient under
close observation for signs of intracranial haematoma.
Investigations
Radiographic examination is necessary, but angiography and other specialized investigations

will not be possible at this level of care. After radiography, measure the patient’s
haemoglobin level, proceed with grouping and cross-matching of blood, and test the urine for
sugar and protein.
Treatment
The aim of immediate care of an unconscious patient with an intracranial injury is to maintain
the vital functions.
Ensure a clear airway 1. Prevent the tongue from falling back by the use of an oropharyngeal
airway. Clear the mouth and throat of blood, froth, or any loose teeth by suction. If necessary,
insert an endotracheal tube which can be kept in position for as long as 3 days. If it is difficult
to pass an endotracheal tube, repeated suction through an oropharyngeal airway can help
avoid airway obstruction. Tracheostomy is occasionally necessary, particularly if secretions
are excessive or if there are extensive fractures of the facial bones, mandible, or the base of
the skull with bleeding into the nasopharynx.
1
For further information, including details of the technique for endotracheal intubation, see Dobson,
M. B., Anaesthesia at the district hospital (Geneva, World Health Organization, 1988).
A patient who is vomiting or unable to swallow will require intravenous fluids.

Overhydration will aggravate cerebral oedema, so pass an indwelling bladder catheter,
monitor the urinary output, and limit intravenous fluids to 1.5 - 2 litres a day. Pass a
nasogastric tube and aspirate the stomach contents if there is vomiting or reflex abdominal
distension (but remember the danger of introducing infection by intubating through the nose
in the presence of severe basal skull fractures). The tube can be left in place and later used for
intragastric feeding.
In general, avoid giving analgesics or sedatives to a restless patient with a head injury, as
restlessness may be the only indication of stripping of dura from the skull by extradural
haematoma. For the conscious patient with a mild head injury, the safest analgesic is
acetylsalicylic acid by mouth. Seizures may be controlled by 12-hourly intramuscular
injections of phenytoin sodium - 200 mg for an adult, 100 mg for a child. Prophylactic
antibiotics are indicated for compound fractures and to cover the making of burr holes.
For the operative treatment of open head injuries Open head injuries, below.
The aim of treatment of closed injuries is to prevent the further deterioration that would result
from increasing intracranial pressure and eventual tentorial herniation. Increasing intracranial
pressure may be caused either by cerebral oedema or by extracerebral compression. It may be
possible to distinguish between the two on clinical grounds, and the former may be suspected
because of the severity of the injuries and of known damage to the brain substance. However,
the only safe way for the surgeon to exclude extracerebral compression is to make
exploratory burr holes (see below). Exploration is indicated in only some 10% of cases, but in
the presence of signs of increasing intracranial pressure it must not be delayed.
Once extracerebral compression has been ruled out by burr holes, continued deterioration,
presumably due to oedema, can be treated by an intravenous infusion of 20% mannitol (200
g/litre), 1 g/kg of body weight over about 30 minutes. A smaller dose, 0.25 g/kg of body
weight, may be repeated at 3-hourly intervals over the next 24 hours, to a maximum total
dose of 250 g for an adult. Mannitol treatment should not be continued thereafter. Steroids
should be avoided.
Making burr holes
Equipment
See trays for Craniotomy and for Minor operations, Annex 1 and add bone wax and
Technique
The operation can be carried out under conduction anaesthesia.
Make a curved incision over the temporal region between the ear and external limit of the
orbit, on the side of the fracture or on the side of clinical compression (Fig. 20.2A, B). Cut
both the skin and the temporal fascia, controlling bleeding with pressure over gauze and with
artery forceps, and separate the temporalis muscle fibres to expose the skull subpericranially
(Fig. 20.2C, D). Coagulate bleeding points, if possible, by diathermy, but do not waste time
on this, as a self-retaining retractor will often control superficial bleeding sufficiently (Fig.
20.2E).
Make a burr hole 2 cm above and behind the orbital process of the frontal bone; start with a
drill cutter and then burr down to the dura, which will be less resistant than bone (Fig. 20.2E).
Enlarge the opening as needed by nibbling the edge of the burr hole towards the
infratemporal fossa (Fig. 20.2F). Bleeding from the anterior branch of the middle meningeal
artery, which may be encountered here, can be controlled by diathermy or ligature. Control
venous bleeding with a piece of crushed muscle or absorbable gelatin sponge and bleeding
from bone with bone wax. Wash our an extradural haematoma with a hand syringe. Close the
wound over a drain, which can be removed after 24 hours (Fig. 20.2G).
Fig. 20.2. Making burr holes. Site of incision (A); making an incision (B); controlling
bleeding with pressure over gauze (B) and with artery forceps (C); separating fibres of
the temporalis muscle (D); burr hole made down to the dura (E); nibbling the edge of
the burr hole (F); wound closed over a drain (G); brace and bits (H).
If a haematoma cannot be found on the side of the fracture, expose the opposite side to
exclude contra coup bleeding.
Once an extradural haematoma is evacuated, the patient’s level of consciousness should

improve rapidly. If there is subdural haemorrhage, however, no improvement can be expected
and the patient should be transferred to a higher level hospital.
Open head injuries
A patient presenting with an open head injury may well be suffering from intra-cranial injury
and should be assessed and managed accordingly.
Initial management consists of first aid, with particular attention to the airway; resuscitation
may be needed. Assess the patient for intracranial injury as described in Intracranial
injuries, but do not probe or disturb the head wound in any way.
Prepare for operative treatment of the open injury and provide antibiotic cover. The scalp
should not be shaved until the patient is ready for surgery.
Equipment
See trays for Craniotomy and for Minor operations, Annex 1 and add bone wax and
Treatment
General anaesthesia is usually preferable, but infiltration anaesthesia may be used

additionally.
Linear fractures do not require specific treatment, but they can lead to intracranial oozing of
blood followed by sepsis, so monitor the patient carefully after repair of the scalp wound.
If there is a comminuted fracture of the skull, remove any small, loose fragments to leave a
clear passage down to the dura. Carefully elevate large, depressed fragments after making a
burr hole (Fig. 20.3), but avoid damage to or elevation in the region of the venous sinuses.
Remove blood clots and gently wash away damaged, protruding brain substance with spurts
of saline from a hand syringe. Achieve haemostasis by diathermy or fine ligatures, meningeal
vessels being underrun with a stitch, and control bleeding from bone by plugging the raw
edge with bone wax. Bleeding from venous sinuses is more difficult to control; apply direct
pressure as a temporary measure and then fix a muscle parch (prepared from a piece of
muscle cut from the temporalis and hammered flat) in place, if necessary by Stitches, over the
bleeding point, or use absorbable gelatin sponge. Close dural tears loosely, though it may not
be possible to close the dura completely. Close the scalp wound in two layers and try to
ensure that the deeper parts of the wound are covered, even if this means extending the
original wound so as to obtain some rotation of skin for this purpose. Areas remaining
without skin cover should be covered with petrolatum gauze and a firm dressing.
Fig. 20.3. Comminuted skull fracture; elevation of depressed fracture fragments.

Instructions for the care of the patient after discharge
Even if there is no evidence of serious injury, an individual who has received a blow or injury
to the head may develop symptoms hours or days later. The patient should be instructed not
to take alcohol for 2 - 3 weeks, nor analgesics stronger than aspirin or metamizole unless
prescribed by a doctor.
A patient who has been treated for head injury should be discharged from the hospital in the
care of a responsible adult. Instruct the carer to observe the patient carefully during the first
week and to call a doctor or take the patient back to hospital should drowsiness, vomiting,
severe headache, or fits develop.
21. Amputations
The object of amputation is the removal of a limb or part of a limb on account of irreparable
injury or of disease that has failed to respond to treatment. In the district hospital, it is wise to
restrict amputation to cases where there is an immediate threat to life, for example established
gangrene or a severely crushed limb with vascular damage. Amputation is irreversible; no
artificial limb has true sensory perception, so that an extremity with sensation intact (but no
unbearable pain) should not be removed, even in the absence of motor function. When in
doubt, err on the side of conservation and always obtain another opinion before
amputating.

Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology

Printable version
Basic techniques

file Help
Export document as PDF file 16. Fractures in children
19. Spinal injuries
20. Head injuries
21. Amputations
Guillotine amputation
Definitive amputation
Specific sites
22. Burns

procedures

Back Cover
Guillotine amputation
This amputation is used in emergency, when primary healing of the wound is unlikely
because of gross contamination or infection.
Equipment
See tray for Minor operations, Annex 1 and add an amputation saw, an amputation knife, a
bone file, and a rubber Esmarch bandage or a pneumatic tourniquet.
Technique
With the patient under general anaesthesia, lift the affected limb and apply a tourniquet,
unless there is underlying arterial disease or gross infection. Divide all structures of the limb
as far distally as is required to eradicate the disease (Fig. 21.1A). If viable skin flaps are
available, hold them over a large gauze pack with a few stitches (Fig. 21.1C, D), and close
the stump only when infection is under control. If no viable skin flaps are available, cut all
structures at the same level (Fig. 21.1B). Apply traction to the skin margins to prevent them
from retracting from the edge of the stump (Fig. 21.1E). Definitive amputation will be
necessary in 2 - 4 weeks time, when the local condition of the limb and general condition of
the patient are more favourable, so as to achieve a weight-bearing stump at the site of
election.
Fig. 21.1. Guillotine amputation. Site of amputation (A); when viable skin flaps are
available they are held together with a few stitches over a gauze pack (C, D); when no
viable skin flaps are available, all tissues are divided at the same level (B); and skin
traction is applied (E).
Occasionally a patient with a destroyed or gangrenous limb may present in such poor general
condition that delay and anaesthesia are equally dangerous. The limb should then be
amputated without anaesthesia through the most proximal part of the dead area, to relieve the
patient of the cumbersome, toxic limb and to make nursing and subsequent referral easier.
Definitive amputation
In most cases, the patient should be referred for definitive amputation. This form of
amputation has limited application at the district hospital, but can nevertheless be useful if the
limb is grossly mangled.
In all definitive amputations of the upper limb, plan to preserve as much of the limb as
possible. The ideal levels for lower-limb amputation are 12 cm proximal to the knee joint
(through the femur) and 14 cm distal to the knee joint (through the tibia). Many factors can,
however, modify the choice of level for definitive amputation; for example, in a patient with
an ischaemic condition, the amputation should be made just distal to the palpable pulse or
through the distal part of “warm” skin.
Skin flaps
In a definitive amputation, in most cases the anterior and posterior flaps should be equal,
consisting of skin, subcutaneous tissue, and deep fascia. Local skin conditions may
necessitate unequal or even irregular skin flaps, but however they are fashioned, the sum of
the lengths of the two flaps (from the base/site of bone section) should be one and a half
rimes the diameter of the limb at the level of bone section.
Equipment
See tray for Minor operations, Annex 1 and include a pneumatic or an Esmarch rubber
tourniquet, an amputation saw, an amputation knife, a Farabeuf’s rugine, 2 osteotomes, a
bone nibbler, a pair of bone-cutting forceps, and a bone file.
Technique
The patient should be given a general anaesthetic.
After applying a tourniquet with the limb temporarily elevated, cut skin flaps 5 - 6 cm and
muscles 2 - 4 cm distal to the proposed level of bone section (Fig. 21.2A - C). Cut major
nerves 2 cm proximal to the proposed bone end. In below-the-knee amputations, bevel the
anterior border of the tibia (Fig. 21.2F) and cut the fibula 3 cm proximal to the tibia. Doubly
ligate the main vessels (Fig. 21.2D, E), remove the tourniquet, and tie all bleeding points.
Stitch the opposing muscles over the cut end of the bone (Fig. 21.2G). Suture the skin flaps
loosely in two layers of interrupted stitches - one for the deep fascia and one for the skin -
over a corrugated drain (Fig. 21.2H), which can be removed in 48 - 72 hours. Apply a firm
bandage and splint the stump to prevent flexion.
Fig. 21.2. Below-knee amputation. Tourniquet applied to the thigh (A); from left to
right, levels of division of skin, muscle, and bone (B); division of tissues completed (C);
doubly ligating the main vessels (D, E); bevelling the anterior border of the tibia (F);
stitching muscles over the cut end of the bone (G); closing skin over a drain (H).
After-care
Within a few days the patient should be ambulatory on crutches or on a temporary pylon.
Start active exercise of all adjacent joints to prevent stiffness and muscle wasting. Refer the
patient for the fitting of a prosthesis.
Specific sites
Finger
Amputate a finger only if repair is impossible. Cover whatever is saved of the finger,
preferably with a liberal palmar skin flap. The thumb is functionally more important than all
the fingers put together, so make every effort to save as much of it as possible, even if it is
stiff. When amputating fingers, save the proximal phalanx if there is mobility at the
metacarpophalangeal joint, as this will preserve a better grip. Otherwise, amputate through
the distal third of the metacarpal for better cosmesis.
Around the wrist
Save as much of the carpus as possible to give flexion - extension movements to the stump
and prosthesis. Saving the inferior radio-ulnar articulation will preserve pronation and
supination. Cover the end of the stump with a long palmar skin flap to maintain better tactile
sensation.
Through-the-foot amputations
Save as much of the foot as possible, provided that the remnant can be held in a neutral
position, i.e., at right angles to the leg, and that there is enough plantar skin (with intact
sensation) to cover the weight-bearing area. The Achilles tendon may pull the foot into an
equinus deformity, and unopposed action of other muscles may also cause deformities of the
stump, but these can be easily avoided by splintage and later tendon transfers, if necessary. A
satisfactory amputation can be carried out through the shafts of the metatarsals, the
tarsometatarsal joints, or the midtarsal joint.
Syme amputation
This is an amputation through the cancellous part of the distal end of tibia just above the
ankle joint. Because the end of the stump is designed to be weight-bearing, the posterior flap
must be composed of the skin of the heel.
Equipment
See tray for Minor operations, Annex 1 and include a pneumatic or an Esmarch rubber
tourniquet, an amputation saw, an amputation knife, a Farabeuf’s rugine, 2 osteotomes, a
bone nibbler, a bone lever, a pair of bone-cutting forceps, and a bone file.
Technique
The patient should be given a general anaesthetic. After applying a thigh tourniquet (Fig.
21.3A), carry an incision from the tip of the lateral malleolus, across the dorsum of the foot,
to a point 1 cm below the medial malleolus (Fig. 21.3B, C). Complete the incision across the
sole of the foot, cutting right down to the calcaneum. Divide all the structures at the level of
skin incision until bone is exposed in the wound. On the medial side, divide the two terminal
branches (but not the trunk) of the posterior tibial artery and the medial and lateral plantar
arteries. This will preserve the medial calcaneal branches of the posterior tibial artery and
ensure a supply of blood to the heel flap.
With the foot maintained in full equinus position throughout, the talus and calcaneum can
now be excised: (a) identify the level of the ankle joint, insert a knife into the joint space
between the talus and tibiofibular mortise, and section the capsule and all ligaments on the
anterior, medial, and lateral sides (Fig. 21.3D); (b) insert a bone lever into the posterior part
of the body of the talus and pull it further down; (c) cut the posterior capsule of the ankle
joint; the Achilles tendon should now be visible; (d) continue sectioning the insertion of the
Achilles tendon from the calcaneum as close to the bone as possible, and then insert the bone
lever into the posterior aspect of the calcaneum and pull it down forcefully; (e) continue
dissection subperiosteally on the plantar aspect of the calcaneum to reach the skin and soft
tissues of the sole. The entire foot can now be removed by dividing any remaining tissues
close to the bone (Fig. 21.3E).
Retract the heel-flap and anterior skin flap proximally, and cut the tibia and fibula at right
angles to their long axis just (0.5 cm) proximal to the articular cartilage (Fig. 21.3 F, G).
Identify the medial and lateral plantar nerves, pull them distally, and divide them with a sharp
knife 1 cm proximal to the bone ends. Also shorten any cut tendon that is protruding distal to
the bone ends and allow it to retract proximally. Identify and cut the anterior tibial artery, the
medial and lateral plantar arteries (terminal branches of the posterior tibial artery), and the
accompanying veins between clamps, and ligate them. Approximate the heel-flap to the
anterior flap, excising excess tissue on the heel-flap if necessary. Now stitch the heel-flap to
the anterior flap using interrupted sutures over a corrugated drain (Fig. 21.3H). Stabilize the
flap with straight needles inserted into the cancellous bone of the tibia. Remove the drain
after 48-72 hours.
Fig. 21.3. Syme amputation. Tourniquet applied to the thigh (A); site of skin incision (B,
C); dividing all ligaments and the capsule at the level between the talus and tibiofibular
joint, with the foot in full plantar flexion (D); division is completed (E); retracting the
skin flap and cutting the ends of the tibia and fibula (F, G); closing the wound by
stitching skin flaps over a drain (H).
After-care
Encourage walking on crutches immediately, until the wound has healed. Wrap the stump
with an elastic bandage for 3 - 4 weeks.
Through-elbow and through-knee amputations
It is preferable to perform these amputations through the cancellous, distal end of the bone
(humerus or femur). They are of particular value in children, as they preserve the growth
plate.
22. Burns
A burn causes a coagulation of tissue protein that leads to tissue death. Around the dead
tissue is a zone of damage that results in leaky capillaries and oedema. Whether the damaged
tissue survives or dies may depend upon treatment.
Most burns occur at home and the patient rarely requires hospitalization. Serious burns are
uncommon, and their treatment is best left to the specialist. Nevertheless, in an emergency or
if referral is not possible, any doctor should be able to care for a burned patient.
Classification of burn depth
The depth of a burn depends upon the temperature of the heat source and the duration of its
application. Burns are best described as superficial, dermal, or full-thickness. The older
system of classification of burns as first-, second-, or third-degree is roughly equivalent.
Superficial burns
In superficial burns, the damage is restricted to the epidermis and upper dermis. The nerve
endings of the dermis are hypersensitive to painful stimulation. Blister formation is common
unless the injury is minimal and results in erythema only. Provided that the burn remains free
from contamination, healing without scarring usually takes place in 7 - 10 days.
Dermal burns
The germinal layer of the epidermis rests upon and derives support and nourishment from the
vascularized collagen framework of the dermis. The interface between the layers is not
smooth, but is formed of interdigitating projections. During fetal life, rods of epidermal cells
grow down into the dermis and later become canalized to form the sweat glands, sebaceous
glands, and hair follicles. Even when heat damage from a superficial burn breaches the
germinal layer of the epidermis, numerous epidermal cellular elements still remain that are
able to re-epithelialize the raw surface. When the damage penetrates deeper into the dermis,
fewer epidermal elements survive. The time necessary for healing, generally from 10 to 21
days, and the amount of scarring that results correspond with the density of surviving
epidermal elements. Healing of “deep dermal” burns may take longer than 21 days and
usually occurs with such severe scarring that skin grafting is generally recommended.
Because the vessels and nerve endings of the dermis are damaged, dermal burns appear paler
and are less sensitive and painful than superficial burns.
Full-thickness burns
In full-thickness burns, all epidermal and dermal components have been destroyed. The
coagulated protein gives the burn a white appearance, and neither circulation nor sensation
can be detected. After separation of the dead eschar, healing proceeds very slowly from the
wound edges. Skin grafting is always required, unless the area is very small. Severe scarring
is inevitable.
Estimating burn depth

Burns are frequently of mixed depth, but estimating the average depth will help you to
calculate the time necessary for healing. The appearance of the burn, which varies with the
cause, is one indication of its depth. Further assessment can be made by pricking different
parts of the burn with a sharp, sterile needle. The resulting range of response, from
hypersensitivity to complete absence of sensation, will allow you to map the burn depth of
the damaged areas.
The cause and circumstances of the injury are also indicative of the burn depth. Flash burns
are generally superficial; carbon deposits from smoke may give such burns a charred
appearance. House fires, burning clothing, burning cooking oil, scalds, and chemicals usually
produce mixed full- and partial-thickness burns; whereas molten metal, electric current, and
hot-press machines normally cause full-thickness burns.
Assessment of the patient
A burn is a severe form of trauma. The patient’s prognosis and progress depend upon several
factors, which you should take into consideration when assessing each case.
Age of the patient
Extremes of age influence the outcome of a burn injury; the very young and the very old do
not tolerate burns well.
Burn area
If the sum of the patient’s age plus the percentage of surface area burned exceeds 90, the
chances of survival will not be more than about 50% (and less in the case of the very young
or the very old). Burns involving the respiratory passages further lower this figure.
The size of a burn wound is difficult to estimate, but in cases of external burns the so-called
“rule of nines” is helpful in making the calculation. For an adult, each of the following areas
can be taken as 9% of the total surface area: front of thorax, back of thorax, front of
abdomen, back of abdomen, each arm, front of each leg, back of each leg, head plus neck
(Fig. 22.1A, B). The area of the perineum is about 1% of the total surface area, as is the front
of the patient’s hand. For a child, the area of the head is proportionately much greater, for
example 15% for a 5-year-old and 20% for a 1-year-old. Do not count areas of erythema.
Fig. 22.1. Rule of nines. Areas of the body as percentages of the total surface area of an
adult (A, B).
Burn depth
Although the depth of a burn affects the prognosis, it is not relevant to initial resuscitation,
except as a possible indication for analgesics.
Respiratory involvement
Burns of the oral mucosa and the nasal vibrissae, or the presence of stridor, may indicate
smoke or heat damage to the respiratory system, which will also affect the prognosis.
Associated injuries
The circumstances of a burn injury will indicate any possible associated injuries. For
example, if the burn is the result of an explosion, suspect blast damage to the ears and lungs.
First aid
First aid can be given at home or at the district hospital.
Drench the burn thoroughly with cool water to prevent further damage. Remove all burnt
clothing from the patient, since garments retain heat and can even smoulder unnoticed. In
cases of scalding, hot water may be trapped in clothing next to the skin. If the burn area is
limited, immerse the site in cold water for 30 min to reduce pain and oedema and to minimize
tissue damage.
The area of a large burn, especially after it has been doused with cool water, is a major source
of heat loss and hypothermia, particularly in young children. Keep the patient warm and wrap
the burned area (or the entire patient) in a clean material, such as linen.
The first 6 hours following injury are critical. If first aid has been administered at home, the
patient should subsequently be transported as soon as possible to the nearest health facility.
Initial resuscitation
Resuscitation is particularly important for patients who are seriously burned. In other cases, if
resuscitation is not necessary, proceed with treatment of the burn wound.
Begin resuscitating the patient in the emergency room; insert a wide-bore intra-venous
cannula before peripheral vasoconstriction occurs and give an appropriate fluid at a rate
established with the help of the formula given on Large burns. Administer analgesics.
Morphine is best for this purpose and should be given intravenously in small, incremental
doses until pain relief is achieved, though large doses may be required. Catheterize the
patient’s bladder to monitor urinary output.
For patients with burns of the respiratory tract, oxygen administration by mask or nasal
catheter and even endotracheal intubation may be necessary, but tracheostomy should be
avoided if possible.
Early treatment of the burn wound
Burns, by nature, are usually initially sterile. The aim of treatment should be to speed healing
while minimizing the risk of infection.
After administering first aid, gently cleanse the area with 0.25% (2.5 g/litre) chlorhexidine
solution or 0.1% (1 g/litre) cetrimide solution, or another mild water-based antiseptic. Never
use alcohol-based solutions. Apply a thin layer of silver sulfadiazine.
Dress the burn with petrolatum gauze and then dry gauze. The bandage should be thick
enough to prevent seepage through to the outer layers. Change the dressing on the burn after
2 - 3 days, and as frequently as necessary thereafter. A full-thickness burn will require skin
grafting.
In all cases administer tetanus prophylaxis.
Burned hands
Burned hands require special treatment that takes precedence over the treatment of other burn
areas. Cover the hands with silver sulfadiazine and place them in loose polythene gloves or
bags secured at the wrist with a crepe bandage. Elevate the hands for the first 48 hours, and
then start the patient on hand exercises. At least once a day, remove the gloves, bathe the
hands, inspect the burn, and then reapply silver sulfadiazine and the gloves. Any necessary
skin grafting should be carried out as soon as healthy granulation tissue appears in the raw
area.
Large burns
Burns of 10% or more of the body area in infants or of 15% or more in adults call for
experienced assessment and special care (see below).

Preface
Acknowledgements
Contributors
Introductory notes
Obstetrics
Gynaecology

Printable version
Basic techniques

file Help

19. Spinal injuries
20. Head injuries
21. Amputations
22. Burns
Classification of burn depth
Assessment of the patient
First aid
Initial resuscitation
Early treatment of the burn wound
Large burns
Burn healing
Escharotomy

procedures

Back Cover
Large burns
The magnitude of the large burn injury is often underestimated. In addition to superficial skin
damage, the patient suffers profound physiological and metabolic changes that require
treatment.
Hypovolaemic shock phase
Intravenous resuscitation is indicated if the burn is 10% or more of the body area of an infant,
or 15% or more of that of an adult, excluding erythema and regardless of burn depth. Blood
transfusion may be indicated, but is usually unnecessary in the first few days.
The burn-injured patient with a large area of moist, damaged skin has lost the ability to
conserve body heat. The capillary walls leak not only adjacent to the burn but also throughout
the body. If the patient’s intravascular volume is allowed to decrease, hypovolaemic
hypotension develops with renal shut-down, rapidly followed by tubular necrosis. Expanding
and maintaining the circulation is of utmost importance at this point.
Monitor the patient’s pulse, peripheral circulation, and urinary output. Infusions of large
volumes of plasma or other colloid will be required in the first 36 - 48 hours. When you have
assessed the area of the burn, use your estimate to determine the “unit of fluid replacement”
from the formula:
1 unit of replacement (ml) = total area of burns × body weight in kg × 0.5
For example, for a 30% burn in a 60-kg adult the unit of replacement would be 30 × 60 × 0.5
= 900 ml. Give the replacement fluid as colloid (dextran, polygeline, hydroxyethyl starch,
plasma, or blood) according to the following schedule:
1 unit every 4 hours for the first 12 hours

1 unit every 6 hours for the next 12 hours
1 unit during the next 12 hours
(total 6 units of replacement in 36 hours)
In addition, give the daily water requirement of the patient orally, or intravenously as a 5%
(50 g/litre) glucose solution (at least 35 ml/kg of body weight per day for adults and 150
ml/kg of body weight per day for children weighing less than 10 kg).
Assess fluid requirements regularly. A rising pulse rate, cool, pale extremities, and a
decreased urinary output all suggest a drop in plasma volume that requires urgent correction.
In cases of non-respiratory burns, crepitations in the lungs indicate fluid overload. The
erythrocyte volume fraction, initially estimated every 4 hours, will reflect the adequacy of the
fluid replacement until a stable pattern of resuscitation has been established.
Try to maintain a urinary output of at least 0.5 ml/kg of body weight per hour.
Haemoglobinuria, due to haemolysis, is a sign of severe burn and may indicate renal failure.
When fluid replacement is adequate but urinary output is poor, employ mannitol to stimulate
a diuresis.
Anaemia can develop quickly in a patient with a large burn since there has been direct
damage to the red cells in the region of the burn, resulting in increased red-cell fragility. Care
should be taken to avoid fluid overload in such patient’s. Intravenous administration of fluids
may nevertheless be necessary, even after 36 hours, if the patient cannot tolerate fluids given
orally. In the patient with a moderately large burn, the fluid required can be given orally or
through a nasogastric tube. The preparation should contain electrolytes and glucose; a
solution of oral rehydration salts (ORS) is ideal. For a more detailed discussion of fluid and
electrolyte therapy, see Anaesthesia at the district hospital and General surgery at the district
hospital.
After 48 hours, the patient may still be oedematous, but with a reduced demand for fluid.
This is an indication that the hypovolaemic phase is over.
Burn-illness phase
Once past the hypovolaemic phase, the patient undergoes a metabolic response to injury that
usually corrects spontaneously, but requires monitoring.
Bone-marrow depression, anaemia, platelet deficiency, and some reduction of immunity

leave the patient vulnerable to infection. This risk can be reduced by the application of topical
antibacterial agents such as silver sulfadiazine. Give systemic antibiotics only in cases of
haemolytic streptococcal wound infection or septicaemia. Pseudomonas aeruginosa infection
is common in burns and often results in septicaemia and death. The presence of bacteria on
the burn surface, however, does not necessarily mean clinical infection; cellulitis in the
surrounding tissue is a better indicator. Fever, which may persist until after skin grafting,
occurs in most patients with burns, but fever alone is not an indication for anti-biotic therapy.
The patient’s energy and protein requirements will be extremely high due to the catabolism of
trauma, heat loss, infection, and tissue regeneration. It may even be necessary during this
phase to feed the patient though a nasogastric tube to ensure an adequate energy intake - up to
25.1 MJ/day (6000 kcalth/day).
Further treatment of the burn wound
Carry out débridement of deep dermal and full-thickness burn wounds as soon as is practical,
and apply a split-skin graft once healthy granulation tissue appears. If competent personnel
for wound excision and grafting are not available, refer the patient taking care to keep him or
her warm in transit. A patient who has sustained disfigurement as a result of burns should
always be considered for referral for specialized treatment.
Escharotomy may be indicated in certain patients with full-thickness burns.
Burn healing
Once the catabolic phase is over, healing begins. The depth of the burn and its area influence
the duration of this phase. Provided that infection does not intervene, superficial burns heal
rapidly and without complications.
Like all scars, burn scars undergo maturation. At first they are red, raised, and uncomfortable.
Frequently, they become hypertrophic. The scars improve with time as they flatten, soften,
and fade, but the process is unpredictable and can take up to two years.
Burn scars require long-term follow-up, particularly in children. The scars cannot expand to
keep pace with the growth of the child, and so lead to contractures. Where contractures
develop, provide immediate surgical release before they can interfere with growth.
Burn scars of the face require special and early attention. Ectropion can lead to exposure
keratitis and blindness. Contractures involving the lips can restrict eating and care of the
mouth. Skin grafting alone may not be enough. Such patients should be referred.
Escharotomy
Circumferential, full-thickness burns on the limbs can cause constriction, particularly during
the hypovolaemic phase. To prevent ischaemia distally or in underlying muscles, provide
release by surgical incision of the eschar (escharotomy). If necessary, carry out escharotomy
over the thorax to allow full respiratory movement.
Equipment
See tray for Skin grafting, Annex 1.

Technique
Administer a sedative (anaesthesia is usually unnecessary, since the eschar is insensitive).

After preparing the skin, make a longitudinal incision through the eschar, avoiding the sites
of major nerves (Fig. 22.2). Control any oozing of blood with pressure over gauze, though
bleeding in these cases is minimal. Check for improvement in distal blood flow and, if in
doubt, make a second longitudinal incision.
Fig. 22.2. Escharotomy. A longitudinal incision has been made through the eschar.
Dress the area with topical silver sulfadiazine. As appropriate, elevate the affected limb or, if
escharotomy has been carried out over the thorax, ensure that the patient sits up in bed.
23. Infections
Pyogenic arthritis of infancy and childhood
The hip and knee are the joints most commonly involved in suppurative arthritis of infancy
and childhood. Timely intervention at the district hospital can prevent the development of
serious complications, such as pyaemia, joint distraction and deformity, and spread of
infection to other sites.
Diagnosis
The child presents with fever and with pain, swelling, and tenderness of the affected joint.
Treatment
Treat the child by aspirating fluid from the joint, administering appropriate antibiotics, and
improving his or her general condition. If the hip or the knee is affected, follow aspiration by
skin traction to reduce or prevent deformity. After aspirating pus from any joint of the upper
limb, apply a removable splint, such as a posterior plaster slab, to hold the joint in the
position of function. Aspiration can be repeated and followed by local instillation of a broad-
spectrum anti-biotic, such as chloramphenicol.
Effective evacuation of pus should lead to rapid improvement in the general and local
condition of the patient. Each time pus is obtained, take swabs for direct smear and culture,
and for testing drug sensitivity if possible. Refer the patient if there is no improvement.
Aspiration of pus
Equipment
See tray for Incision and drainage of abscess, Annex 1.
Technique
Sedation and conduction anaesthesia should be provided.
Hip
The best site for aspiration is that of maximum swelling, but the joint can be approached from
any aspect. The patient should be supine.
In the lateral approach, the needle is inserted just below and anterior to the greater trochanter,
at an angle of about 45° to the surface of the thigh. Advance the needle in an inward and
upward direction, aspirating at the same time (Fig. 23.1A, B).
Knee
Aspirate pus from a septic knee joint through a needle inserted laterally at the level of the
medial or lateral, upper or lower border of the patella (Fig. 23.1C, D).
Elbow
To aspirate pus from the elbow, insert the needle between the head of the radius and the
olecranon (Fig. 23.1E).
Fig. 23.1. Pyogenic arthritis in infancy and childhood. Aspirating pus from the hip joint
with the needle introduced laterally and pointed medially and upwards (A, B);
aspirating pus from the knee joint with the needle inserted from the side at the level of
the lower pole of the patella (C), or at the level of the upper pole of the patella (for
effusion mainly in the suprapatellar bursa) (D); aspirating pus from the elbow joint by
introducing the needle posterolaterally just above the head of the radius; the bony
landmark is shown (E).
Acute osteomyelitis
Diagnosis
Acute osteomyelitis is most common in children and is characterized by pain, high fever,
malaise, local swelling, and pseudoparalysis. Staphylococcus aureus is the usual causative
organism. The condition is usually preceded by trauma, a history of sore throat, or
intercurrent infection. Tenderness is greatest in the affected bone, and localized in the
metaphyseal region. The mobility of the neighbouring joints is usually reduced, but some
painless movement may still be possible.
The differential diagnosis of osteomyelitis should include acute suppurative arthritis, acute
rheumatic “arthritis”, early paralytic poliomyelitis, acute subperiosteal haematoma in scurvy,
acute sickle-cell crisis, and cellulitis.
In acute suppurative arthritis, tenderness is greatest at the joint line, with loss of joint
function. In acute rheumatic “arthritis”, the involvement tends to flit from one joint to
another, and there may be associated carditis and skin rash; this condition responds
dramatically to aspirin. Careful history-taking and examination should exclude acute
paralytic poliomyelitis and bleeding disorders (such as scurvy and sickle-cell crisis).
Suspected cellulitis should always be considered as acute osteomyelitis until proved
otherwise, as radiographs are of little or no diagnostic value for up to 2 - 4 weeks.
Radiographs can, however, exclude scurvy, in which a subperiosteal haematoma will be
evident and which is frequently associated with an epiphyseal separation.
Treatment
Begin treatment with appropriate antibiotics as soon as the diagnosis is suspected, and
observe the patient closely. If blood-culture facilities are available, take a blood sample
before administering antibiotics.
Except for acute haematogenous osteomyelitis of the maxilla in the newborn (which should
be treated conservatively), drain the affected bone in all cases of acute osteomyelitis as soon
as a firm diagnosis is made. Delay in drainage beyond 48 hours results in continued pyrexia
and slow devitalization of the cortex of the bone, from the metaphysis to the middle or even
distal end of the bone, finally resulting in massive sequestra (Fig. 23.2D). Take a sample of
any infected material or pus for bacteriological examination.
Antibiotic treatment must be continued for a further 3 - 4 weeks after the subsidence of local
and systemic signs of active infection. The effective antibiotics include penicillin,
erythromycin, meticillin, ampicillin, and gentamicin. The usual recommendation is two
antibiotics at a time for a total of at least 6 weeks, with a change of combination according to
the results of blood and pus culture (if available), or after a few weeks.
Splint the affected area with a posterior plaster cast or, for the leg, a Thomas splint with knee-
flexion piece. Pathological fracture through the infected bone is not uncommon, so the limb
must be protected. If antibiotic treatment has been started early and is effective, there should
be significant resolution of pain and pyrexia within 24 hours.
Drainage of the bone
Equipment
See tray for Incision and drainage of abscess, Annex 1 and include two Volkmann spoons, a
hand drill (Zimmer type) (Fig. 23.2B), and drill bits. The equipment for Application of
plaster, Annex 1 should also be available.
Technique
The patient should be given a general anaesthetic. Make an incision directly over the
metaphyseal region of the involved bone. Carry the incision through the skin, subcutaneous
tissues, muscles, and periosteum, down to bone. If pus is not evident, even in the
subperiosteal layer, make multiple drillings through the cortex into the medullary canal to
allow the trapped pus to escape (Fig. 23.2A). Repair the skin wound only, with loose stitches
over a corrugated drain (Fig. 23.2C). Remove the drain in 24 - 72 hours. Take a sample of the
infected material for bacteriological examination.
Complications
If treatment is delayed or inadequate, osteomyelitis becomes chronic. Areas of dead bone

(sequestra) become surrounded by infected, thickened bone (involucrum) (Fig. 23.2D). The
destroyed areas appear as cavities surrounded by dense, sclerosed bone. Pathological fracture
through the infected bone may occur if the bone is not adequately protected during healing,
until the formation of a sufficiently strong involucrum.
Fig. 23.2. Acute osteomyelitis. Making multiple drillings through the cortex into the
medullary canal of the affected bone (A); a hand drill (Zimmer type) (B); closing the
wound by stitching the skin over a drain (C); bone with a large sequestrum (D).
Treatment of chronic infection is essentially conservative: keep the area over the bone clean,
elevate the limb at night, avoid local trauma, provide adequate nutrition, and give occasional
short courses of antibiotics to control any flare-up of infection. Drain any abscess that
develops.
Sequestrectomy is indicated if a large sequestrum, which on radiographs seems to have

separated from the involucrum, is causing sinuses, recurrent abscesses, or attacks of pain and
swelling in the limb, with fever. However, patients with especially large or extensive
sequestra should be referred. Do not remove a sequestrum unless there is a strong
involucrum, and approach the sequestrum carefully so as not to fracture the rest of the bone.
All patients with abscesses that require extensive deroofing or with extensive scarring of the
overlying skin should be referred.
Hand infections
Staphylococci are the organisms commonly responsible for acute infections of the hand.
Streptococcal hand infections are rare. Pus is often present when the patient is first seen.
Although, rarely, an early infection may resolve with the administration of antibiotics alone,
incision and drainage are usually needed. Penicillin or another appropriate antibiotic should
be given until healing is complete.
Diagnosis
Suspect the presence of pus if the patient has a history of throbbing pain and if there is a hot,
tender, indurated swelling with flexion deformity of the finger and pain on movement.
Investigations
Obtain a radiograph of the hand. If there is discharge of pus, investigate by Gram staining.
Equipment
See tray for Incision and drainage of abscess, Annex 1.
Technique
The patient should be given a general or conduction anaesthetic. Confirm the diagnosis by
preliminary needle aspiration.
Proceed with incision and drainage, modifying the procedure, as indicated, for special sites.
In general, make an adequate, but not extensive incision along a skin crease at the site of
maximum tenderness and swelling. Aspirate or mop away all pus. Open up deeper loculi with
a pair of sinus forceps and insert a drain. Take a specimen of pus for bacteriological
examination. Dress the wound loosely with dry gauze, and administer appropriate antibiotics.
It is important to remember that in all infections of fingers and the hand there is marked
swelling in the dorsum. This is due to lymphoedema and does not require drainage.
Paronychia
Infection of the nail bed (Fig. 23.3A) may necessitate excision of a portion of the nail for
effective drainage of pus, but in most early cases a small incision of the inflamed skin is
adequate (Fig. 23.3B). Excise part of the nail overlying the abscess only if skin incision has
not permitted the free escape of pus (Fig. 23.5C, D).
Whitlow
Drain a fingertip pulp infection or abscess by incision along the medial or lateral border of
the terminal digit (Fig. 23.3E - H). Place the incision over the point of maximal swelling
and/or tenderness.
Fig. 23.3. Treatment of hand infections. Paronychia of the middle finger (A); site of
incision (B); site of incision for excision of the nail (C); excising part of the nail (D); site
of incision and drainage of an early whitlow (E, F); hockey-stick incision for draining a
late whitlow (G, H); sites for incisions to drain abscesses of flexor tendon sheaths (I, J);
location of the tendon sheaths (K); sites of incision for draining pus from the radial and
ulnar bursae (L); sites of incision for drainage when infection has spread to the forearm
(M).
Suppurative tenosynovitis
Suppurative tenosynovitis of the flexor tendons is an uncommon, but important infection. The
involved finger is swollen, extremely tender, and held in flexion. Administer antibiotics and
promptly drain the abscess through long incisions along the lateral or medial borders of the
fingers (preferably the junctional area between the palmar and dorsal skin) (Fig. 23.3I, J).
Infection of the tendon sheaths of the thumb or little finger may spread to the radial or ulnar
bursa, respectively (Fig. 23.3K), necessitating drainage by short, transverse incisions in the
distal palmar crease and/or at the base of the palm (Fig. 23.3L). Rarely a neglected infection
may spread from either bursa up to the fascial space in the forearm beneath the flexor
digitorum profundus and require drainage there through longitudinal incisions proximal to the
wrist, along the medial or lateral borders of the forearm (Fig. 23.3M).
Fascial palmar space infection
Infections of fascial palmar spaces result from extensions of infections of a web-space or a

tendon sheath. Drain the affected fascial space by skin incision directly through the area of
maximum swelling and tenderness. Open deeper parts of the abscess with sinus forceps. In
general, place incisions for drainage along creases of the palm, along the lateral or medial
borders of the fingers, or along the ulnar or radial borders of the forearm. Avoid transverse
incisions on digital creases or transverse incisions in the anterior aspect of the wrist because
of the danger of cutting the underlying vital structures.
After-care
Rest the hand in position of function. Encourage active exercises as soon as possible.
Continue to give appropriate antibiotic therapy and analgesics. The drain can be removed in
24 - 48 hours.
Complications
Possible complications include stiffness and the extension of infection to bones and joints of
the hand
Chronic infections
If any of the following chronic infections of bones and joints are suspected, or if the
diagnosis is in doubt, the patient should be referred:
• Tuberculosis, including cold abscess, joint effusion, and disease of the spine.
• Chronic osteomyelitis, including subacute haematogenous osteomyelitis (Brodie’s abscess)

and osteomyelitis due to tuberculosis, spirochaete infections, maduramycosis, salmonellosis,
and brucellosis.
24. Miscellaneous bone and joint disorders
Congenital and childhood disorders of the foot and hip
Patients with congenital deformities should in general be referred. With the exception of
idiopathic congenital talipes equinovarus, for which it is important that corrective treatment is
started immediately after birth, the treatment of these conditions is best not attempted at the
district hospital.
Children suffering from conditions such as Perthes’ disease (osteochondritis of the hip) or
“painful hip”, due for example to tuberculous or transient synovitis or a slipped upper
femoral epiphysis, should also be referred.
Idiopathic congenital talipes equinovarus
Idiopathic congenital talipes equinovarus (CTEV) (Fig. 24.1A) is a common and important
congenital deformity of the foot that must be differentiated from similar deformities caused
by myelomeningocele, arthrogryposis, and poliomyelitis. For prognostic reasons, CTEV is
classified as mild, moderate, or severe.
Treatment
Mild forms of CTEV respond to repeated stretching and splinting, and moderate cases to
corrective plaster and corrective manipulations repeated at weekly intervals. Severe cases,
and all cases presenting late, should be referred for specialist attention (indeed it is usually
helpful to have some specialist guidance on the management of CTEV). A start may,
however, be made on stretching the foot and applying a corrective plaster, pending referral.
Correction of the deformity should start soon after the child is born.
Equipment
Technique
Place the child supine on a firm table. Ask an attendant or the child’s mother to help by
holding the child and the limb.
The correction is always carried out in three stages: first correct the forefoot adduction, then
the inversion of the heel and foot, and finally the equinus of the ankle. Mould the foot with
the flat and heel of your palm. The expression of the child’s face will be a reliable guide to
the safe amount of pressure to apply.
In the first stage, while permitting the foot to stay in equinus, exert pressure on the medial
aspect of the foot to stretch the medial border and to push it into some degree of abduction
(Fig. 24.1B). This manoeuvre should correct forefoot adduction. In the second stage, correct
inversion of the heel by everting it, and then correct forefoot inversion (Fig. 24.1C, D).
Abduction and eversion of the heel and forefoot indicate complete correction of hindfoot and
forefoot deformities. Only if the lateral border of the foot can be made straight should you
proceed to step 3 - correction of the equinus of the ankle. Correct the equinus by exerting
firm pressure upwards on the entire sole of the foot, moulding the foot into dorsiflexion (Fig.
24.1D).
Hold the foot in the corrected position with adhesive strapping about 5 cm wide (Fig. 24.1E)
or with a plaster cast. If plaster is to be applied, clean the limb and wrap the foot and leg with
1-cm thick, cotton padding, placing extra on the medial side of the heel and foot. Soak the
plaster well before application and apply it quickly. Mould the plaster without wrinkling or
cracking. While applying the plaster, hold the patient’s knee in flexion, and with each turn of
the plaster bandage mould the plaster on the foot so as to correct the deformity (see above).
Pass the plaster from the medial to the lateral side over the dorsum of the foot and ankle.
During moulding, place a “spacer” such as a pencil along the lateral border of the foot and
heel, to leave an empty space in the cast. As an alternative, after the cast has set, split it along
the lateral border of the foot and heel. For extra strength, incorporate a wet plaster slab on the
medial aspect of the foot and ankle. Generally, the cast should extend from the tibial tubercle
to the tip of the great toe, but the tips of all the other toes should be visible. In babies with
excessive fat and severe equinus, an above-knee cast will be necessary for a few weeks since
a below-knee plaster cast is liable to slip off.
Fig. 24.1. Idiopathic congenital talipes equinovarus. Clinical appearance of the

deformity (A); exerting pressure on the medial aspect of the foot (B); everting the foot
(and heel) after correcting forefoot adduction (C, D); holding the foot in the corrected
position with adhesive strapping (E).
After-care
Within 3 - 6 months it will become apparent whether or not the patient requires surgery.
Continue applications of corrective, moulded plasters until the child starts walking, thereafter
maintaining correction by using Denis Browne’s night splints and club-foot shoes. Continue
with corrective exercises and shoes until puberty.
In all cases of neglected, recurrent or resistant CTEV, the patient should be referred for
specialist attention.
Congenital dislocation of the hip
Diagnosis
The diagnosis is suggested by clinical findings. In unilateral cases, skin creases at the back of
the hip appear asymmetrical, the limb is short, abduction of the dislocated hip in flexion is
limited, and forward pressure in this position produces a click as the dislocated femoral head
enters the acetabulum. This sign (Ortolani’s) is particularly valuable in examinations during
the first week of life, but its absence does not rule out congenital dislocation. In the same
position of flexion with abduction, the femoral head can be made to slip in and out of the
acetabulum by holding the upper part of the femur between the thumb and fingers. Confirm
the diagnosis by obtaining a radiograph of the whole pelvis, including both hips.
Treatment
Do not attempt treatment at the district hospital, but refer the patient for specialist attention.
Deformities due to poliomyelitis
Diagnosis
Immunization in developed countries has been very successful in eliminating poliomyelitis.

However, even in immunized children, rare attacks of acute poliomyelitis may occur, but
with mild and mostly transient paralysis. In developing countries, new cases of poliomyelitis
are not uncommon.
Usually the child presents with paralysis of the limbs, with or without involvement of the
trunk muscles, following a minor illness such as a sore throat, diarrhoea, or pyrexia. The
affected limb is painful and tender, the skin looks bluish or flushed, and the limb feels cold
(rarely warm in the very early stage). The paralysed part feels floppy. The diagnosis in an
established case is not difficult, as the paralysis typically comes suddenly and reaches its
maximum within the first 2 - 3 days. As a rule, the distribution of paralysis is asymmetrical; it
is of lower motoneuron type, with no sensory deficit. Very rarely, in addition to the
involvement of anterior horn cells, the poliomyelitis virus may cause meningoencephalitis.
Treatment
As soon as the paralysis is detected, apply a padded splint to the limb in the position of
maximum function. It is important during this acute stage to keep the child at rest, as
excessive activity may spread the paralysis. Paralysis of the trunk muscles requires
recumbency. Once the muscle tenderness has subsided, usually 2 weeks after the onset, the
convalescent stage has been reached. During this stage, gently exercise the joints and their
muscles by assisting the patient in exercises through a full range of movement. This will
minimize wasting, stiffness, contractures, and deformities. Gradually increase physiotherapy
to include assisted and active exercises, 4 times a day for about 6 months. Give centripetal
massage twice a day for about 3 months in an attempt to improve circulation in the paralysed
limb.
The management of established or residual paralysis will be described in detail in a separate

publication. 1
1
Rehabilitation surgery for deformities in poliomyelitis at the district hospital. Geneva, World Health
Organization, in preparation.
Deformities due to leprosy
Peripheral deformity and disability in leprosy result from chronic inflammation of mixed
peripheral nerves, which interferes with all three modalities of nerve function - motor,
sensory, and autonomic - resulting in deformities, trophic ulcers, and nerve paralysis due to
compression.
Deformities
Deformities arise mainly as the result of muscle imbalance after selective muscle paralyses.
They can be minimized by a combination of active and passive exercises to mobilize
distorted joints and by suitable splints and callipers to prevent overstretching of paralysed
muscles. Orthopaedic specialists may be able to restore some muscle balance by the transfer
and sharing of tendons of intact muscles.
Trophic ulcers
Trophic ulcers occur in areas of sensory loss, from untended wounds, burns, or pressure
necrosis. They heal readily if the part is rested and protected in a padded plaster cast. Ulcers
of the feet can be prevented by keeping the feet clean and dry, and by wearing clean cotton
socks. The patient should also wear shoes with a special insole to spread the weight evenly
over the whole foot while walking. Clean, padded cotton gloves will protect anaesthetic
fingers from sharp objects. Wooden spoons and appliances should be used to avoid the risk of
thermal injury when handling very hot or cold materials. The patient should be advised how
to use his/her hands and feet in ways that protect them from injury.
Nerve damage
Loss of nerve function is particularly evident in certain peripheral nerves, usually several
centimetres proximal to a point of potential compression of the nerve by some anatomical
structure. The ulnar nerve is affected above the elbow, the median nerve above its entry to the
carpal tunnel at the wrist, the lateral popliteal nerve at the neck of the fibula, and the posterior
tibial nerve behind the medial malleolus of the ankle. Although the inflammatory changes are
steadily progressive, damage may be aggravated by abscess formation in the nerve and acute
swelling during lepra reactions, and as a result of actual compression at these points.
Severe pain in the affected nerve, or a sudden deterioration in nerve function, may be an
indication for surgical decompression of the nerve, but this should be undertaken only when
medical treatment fails. The surgical procedures are not especially difficult and can be
undertaken at the district hospital, but the techniques should first be learned from specialists.
Surgical treatment, to be successful, must be accompanied by sustained multidrug therapy
and attempts to improve the patient’s nutritional status and general standard of living.
Annex 1. Surgical trays and equipment for specific procedures
This annex lists the instruments, equipment, and materials that should be included, as a
minimum, on the surgical trays used for the procedures described in this handbook; these
items must be sterilized before use. Items of orthopaedic equipment that do not need to be
sterilized are listed separately. For most procedures, dressings and drugs, apart from local
anaesthetics, are not included.
Non-sterile equipment
Plaster bandage
Tape measure, 1
Cotton wool
Gauze bandage
Bucket filled with water
Bandage scissors, 1 pair
Plaster scissors, 1 pair
Plaster spreader, 1
Scalpel handle with blade, 1
Plaster saw, 1
Artificial rupture of membranes
Amniohook or long-toothed dissecting forceps or tissue forceps (Allis), 1 pair

Antiseptic solution
Sterile drapes
Sterile gloves, 1 pair
Caesarean section
Add the following to the tray for Laparotomy

Uterine haemostasis forceps (Green-Armytage), 8 pairs
Obstetric forceps, 2 pairs (1 low, 1 midcavity)
Vaginal speculum, 1 Suction catheters
Cervical cauterization
Diathermy electrode
Vaginal speculum, 1
Retractor for anterior vaginal wall, 1
Vulsellum forceps, 1 pair
Antiseptic solution
Gauze swabs
Kidney dish, 1
Gallipot, 1
Sterile drapes
Craniotomy (orthopaedics)
Self-retaining rake retractors (West), 2

Periosteal elevator (Farabeuf), 1
Dissector (Macdonald), 1
Brace (Hudson), with 3 sizes of bit (burrs, perforators), 1 set
Bone forceps (De Vilbis), 1
Compound-action bone nibbler, 1
Diathermy electrode, 1
Dilatation and curettage
Vaginal speculum, 1
Uterine sound, 1
Uterine dilators, 6 (one set)
Uterine curette, 1 (at least)
Sponge forceps, 2 pairs
Retractor for anterior vaginal wall, 1 (at least)
Gauze swabs
Vaginal pad
Antiseptic solution
Kidney dish, 1
Gallipot, 1
Sterile drapes
Drainage of pelvic abscess
Add the following to the tray for Incision and drainage of abscess
Vaginal speculum, 1
Retractor for anterior vaginal wall, 1
Episiotomy
Episiotomy scissors, 1 pair

Small artery forceps, 4 pairs
Dissecting forceps, toothed, 1 pair
Dissecting forceps, non-toothed, 1 pair
Needle holder, 1
Syringe, 5 ml with needle, 1
Local anaesthetic agent, e.g., lidocaine 1%
Sutures and ligatures, 0 chromic catgut, ties and with needles
Antiseptic solution
Gauze swabs
Sterile pad
Suction catheters
Kidney dish, 1
Gallipot, 1
Sterile drapes
Incision and drainage of abscess

Lidocaine 1%
Dissecting scissors, 1 pair
Stitch scissors, 1 pair
Needle holder, 1
Small, curved artery forceps, 3 pairs
Large, curved artery forceps, 2 pairs
Large, straight artery forceps, 2 pairs
Sinus forceps, 1 pair
Grooved director, 1
Flexible probe, 1
Corrugated drain
Safety pins, 2
Petrolatum gauze
Syringe, 10 ml with wide-bore needle, 1
Gallipot, 1
Kidney dish, 1
Antiseptic solution
Gauze swabs
Cotton wool
Specimen bottles, 2 (1 containing formaldehyde in saline)
Sutures, 2/0 chromic catgut, ties and with needles
Sutures, 2/0 thread, ties and with needles
Sterile drapes
Sterile gloves, 2 pairs
Laparotomy
Curved dissecting scissors, 1 pair

Scalpel handle and blade, 1
Short dissecting scissors, 1 pair
Long dissecting scissors, 1 pair
Small, straight artery forceps, 6 pairs
Needle holder, long, 1
Needle holder, short, 1
Retractors (Langenbeck), medium, 1; narrow, 1
Retractors (Deaver), medium, 1; narrow, 1
Self-retaining retractor, 1
Long dissecting forceps, non-toothed, 1 pair
Tissue forceps (Allis), 2 pairs
Tissue forceps (Duval), 2 pairs
Tissue forceps (Babcock), 2 pairs
Malleable copper retractors (spatulae), 2
Occlusion clamps, straight, 2; curved, 2
Crushing clamps, large, 2; small, 2
Sutures, No. 1, 0, and 2/0 chromic catgut and 2/0 plain catgut, ties and with needles
Sutures, No. 1, 0, 2/0, and 3/0 thread, ties and with needles
Sutures, No. 1, 0, and 2/0 nylon, ties and with needles
Suction nozzle, 1
Flexible probe, with round point, 1
Grooved director, 1
Nasogastric tube, 1
Towel clips, 6
Stainless-steel bowls, 2
Kidney dishes, 2
Gallipots, 2
Linen tape
Gauze swabs
Abdominal packs, 5
Dissecting gauze rolls, 10
Antiseptic solution
Adhesive tape
Tubing for tension sutures
Drainage tubes
Safety pin, 1
Colostomy bags (optional)
Sterile drapes
Sterile gloves, at least 3 pairs
Making plaster bandage
Gauze bandage, 500 cm long and 15 cm wide
Plaster of Paris powder
Gloves, 1 pair
Minor operations

Tissue forceps
Scalpel handle and blade, 1
Small dissecting scissors, 1 pair
Sutures, 2/0, 3/0, and 4/0 chromic catgut, ties and with atraumatic needles
Sutures, 2/0 and 3/0 thread, ties and with cutting needles
Needle holder, 1
Rake self-retaining retractor, 1
Lidocaine 1%
Gallipot, 1
Kidney dish, 1
Skin hooks, 2
Towel clips, 4
Corrugated drain
Petrolatum gauze
Gauze swabs
Antiseptic solution
Adhesive tape
Sterile drapes
Removing plaster
Plaster saw (Tenon), 1
Plaster saw (Engel), 1
Shears, 1 pair
Plaster scissors (Böhler), 1 pair
Plaster spreader, 1
Skeletal traction
Steinmann’s pin, 1 (with covers for ends)

T-handle or hand drill (introducer and chuck), 1
Stirrup, 1
Mallet, 1
Lidocaine 1%
Petrolatum jelly
Antiseptic solution
Gauze swabs
Cotton wool
Sterile drapes
Thomas splint, 1
Weights, cord, and pulley
Skin grafting
Skin-grafting knife, Humby, with blade, 1
Scalpel handle with No. 10 blade, 1
Razor blade, 1
Towel clips, 4
Dissecting forceps, non-toothed, 2 pairs
Dissecting forceps, toothed, 2 pairs
Dissecting scissors, straight, 1 pair
Dissecting scissors, curved, 1 pair
Dissecting scissors (Metzenbaum), 1 pair
Hook retractors, small, 2 pairs
Skin hooks, 4
Gallipots, 2
Ruler, 1
Petrolatum gauze
Wooden boards with bevelled edges, 4
Antiseptic solution
Gauze swabs
Gauze packs (abdominal packs)
Cotton wool
Sterile drapes
Skin traction
Antiseptic solution
Adhesive strapping (7.5-cm wide for an adult patient)
Tape measure
Wooden spreader, 1
Cotton wool or felt
Crêpe or gauze bandage
Thomas splint (appropriate size), 1
Skull traction
Skull callipers (tongs), complete with spanner, 1 set

Hand drill with bits, 1 set
Lidocaine 1%
Antiseptic solution
Gauze swabs
Cotton wool
Sterile drapes
Tubectomy (or appendicectomy)

Dissecting scissors, 1 pair
Needle holder, 1
Retractors (Langenbeck), narrow, 2
Suction nozzle, 1
Sutures, 0 and 2/0 thread, ties and with needles
Sutures, 0 and 2/0 chromic catgut, ties and with needles
Sutures, No. 1 nylon, ties and with needles
Kidney dishes, 2
Gallipots, 2
Linen tape, 1 piece, 20 - 30 cm long
Gauze swabs
Antiseptic solution
Sterile drapes
Vulval biopsy
Small artery forceps, 4 pairs
Needle holder, 1
Small dissecting forceps, toothed, 1 pair
Small dissecting forceps, non-toothed, 1 pair
Sutures, 2/0 chromic catgut, ties and with needles
Sutures, 2/0 thread, ties and with needles
Lidocaine 1%
Antiseptic solution
Gauze swabs
Gallipot, 1
Kidney dish, 1
Sterile drapes
Sterile gloves, at least 1 pair
Annex 2. Essential surgical instruments, equipment, and materials for the

district hospital
This annex lists the instruments, equipment, and materials needed, as a minimum, for the
practice of surgery in the district hospital. It contains all the items listed in Annex 1, with the
exception of local anaesthetics, containers for laboratory specimens, and chemical products
such as antiseptics and lubricants. It also includes operating-room and anaesthetic equipment,
and instruments required for the surgical procedures described in General surgery at the
district hospital (Geneva, World Health Organization, 1988).
Surgical instruments
Quantity Size
General instruments Sponge forceps (Rampley) 4 25 cm

Instrument pins (Mayo) 4
Towel clips (Backhaus) 6 11 cm
Artery forceps (Crile):
straight 6 16 cm
curved 6 16 cm
Artery forceps (mosquito):
straight 6 13 cm
curved 6 13 cm
Curved artery forceps (Mayo or 6 20 cm

Kelly)
Straight artery forceps (Spencer 6 20 cm
Wells)
Tissue forceps (Allis) 4 15 cm
Standard dissecting forceps:
toothed 2 14.5 cm
non-toothed 2 14.5 cm
Long dissecting forceps, 1 25 cm

toothed
Long dissecting forceps, non- 1 25 cm
toothed
Straight dissecting scissors 2 17 cm
(Mayo)
Curved dissecting scissors 1 23 cm
(Mayo)
Dissecting scissors 1 18 cm
(Metzenbaum)
Stitch scissors, with blunt ends 2 15 cm
Rake retractors (Volkmann), 4- 2 22 cm

toothed
Rake self-retaining retractors 2 21 cm
Retractors (Langenbeck):
narrow 2 6.0 mm wide
medium 2 9.5 mm wide
Retractors (Deaver):
medium 1 25 mm blade
large 1 75 mm blade
Hook retractors 2 15 cm
Needle holders (Mayo):

medium 9 15 cm
large 2 17.5 cm
Scalpel handles No. 3 (Bard- 12

Parker)
Parker)
Parker)
Suction nozzle (Yankauer) 1 28.5 cm
Nozzle (Poole-Wheeler) 1
Diathermy electrodes, 2
coagulating and fulgurating
Flexible probe, with round 1 20 cm
point
Grooved director (Kocher) 1 20 cm
Stainless-steel sponge bowls:
small 6
medium 6
large 6
Stainless-steel kidney dishes:
small 4
medium 4
large 4
Stainless-steel gallipots 2
Sinus forceps 2
Abdominal instruments Self-retaining retractor with 3 1

blades (Balfour)
Proctoscope (anal speculum,
Goligher):
child-size 1 6 cm
adult-size 1 7.5 cm
Sigmoidoscope, complete with
pump:
child-size 1
adult-size 1
Light source with cable, to fit 1

sigmoidoscope
Biopsy forceps 2
Clamps (Moynihan), box-joint 6 23 cm
Gallbladder trocar and cannula 1

(Ochsner)
Gallstone forceps (Desjardin) 1
Malleable probe and scoop 1

(Moynihan)
Lacrimal probes, set of 3 1
Tissue forceps (Duval):
medium 2 15.5 cm
large 2 19 cm
Crushing clamps (Payr):
small 2 21 cm
large 2 36 cm
Crushing clamps
(Schoemaker):
small 2 17 cm
large 2 20 cm
Malleable copper retractors 2

(spatulae)
Occlusion clamps (Doyen):
straight 2 22.5 cm
curved 2 22.5 cm
Twin occlusion clamps (Lane) 1 31.8 cm

Intestinal tissue-holding forceps 4 24.0 cm
(Babcock)
Glass rods 2
Chest instruments Chest-drainage set, including 1

tube and calibrated bottle
Craniotomy instruments Self-retaining rake retractors 2
(West)
Periosteal elevator (Farabeuf) 1
Dissector (Macdonald) 1
Brace (Hudson), burrs and 1 set

perforators with 3 sizes of bits
Bone forceps (De Vilbis) 1
Dental, plastic surgery, and Standard skin-grafting knife 1

maxillo-facial instruments (Humby), with spare blades
Electric dermatome 1
Wooden skin-grafting boards 4
Pin-cutting forceps 1
Straight bone-awl (Kelsey Fry) 1
Straight elevator (Warwick 1

James or modified Kelsey Fry)
Curved elevators:
right 1
left 1
Dental mirror 1
Dental forceps:
universal upper 1
universal lower 1
Wire cutters 1
Skin hooks (Gillies) 4
Small hook retractors 2

Fine dissecting forceps:
toothed 1
non-toothed 1
Curved artery forceps (Crile) 6 14 cm
Handle holder (Mayo-Hegar) or 1 15 cm

needle holder (Gillies)
Dental probes/spoons 2
Gynaecology instruments Vaginal specula (Sims):
small 1 1
large 1 3
Weighted vaginal speculum 1 38 × 75 mm

(Auvard)
Vulsellum forceps (Teale or 2 28 cm
Duplay)
Episiotomy scissors 2
Vacuum extraction apparatus 1
Amniohook 1
Uterine sound (Simpson) 1 30 cm
Double-ended uterine dilators, 1

set of 6
Uterine curettes (Sims) 1 set 26 × 7 mm to 26
×14 mm (various
sizes)
Ovum forceps (de Lee) 1 24 cm
Cranial perforator 1
Straight hysterectomy forceps 6 22.5 cm

(Péan)
Craniotomy forceps 2
Uterine haemostasis forceps 8 20 cm

(Green-Armyrage)
Obstetric forceps:
low 1
midcavity 1
Retractor (Doyen) 1
Anterior vaginal-wall retractors 2
Punch biopsy forceps 1
Endometrial biopsy cannula 1
Suction cannulas, set of 4 1
Colposcope 1
Ophthalmic instruments Eyelid speculum (dark) 1
Eyelid retractors (Desmarres) 2
Small rake retractors 2
Pterygium knife 1
Dissecting forceps, toothed 1 0.5 mm
1 0.9 mm
Dissecting forceps, non-toothed 1 0.5 mm
1 0.9 mm
Conjunctival scissors 1
Conjunctival forceps 2
Extracapsular forceps 1
Chalazion clamp 1
Chalazion curettes, set of 3 1

sizes
Enucleation scissors 1
Straight ring scissors 1
Spring scissors (Westcott) 1

Corneal scissors (Castroviejo):
right 1
left 1
Iris scissors 1
Iris forceps 2
Needle holder, curved with lock 1

(Castroviejo)
Operating loupe (or similar 1
magnifying device)
Capsule forceps, non-toothed 1
Simple ball-type cautery 1
Muscle hooks 2
Strabismus hooks 2
Cystotome 1
Vectis 1
Periosteal elevator 1
Iris retractor 1
Iris spatula (repositor) 1
Irrigating cannula 1
Meibomian curette 1
Eyelid clamp (and/or Trabut 1

plate)
Flat cataract curette 1
Knife needle 1
Spirit lamp with hot-point 1

cautery
Punctum dilator 1
Tear-duct probes 1 set 4/0-4

Irrigating cannula 1
Air cannula 1
Eye spud (Walton) 1
Orthopaedic instruments Plaster instruments:
plaster saw (Tenon) 1
plaster saw (Engel) 1
shears (Stille) 1 46 cm
scissors (Böhler) 1 25 cm
opening shears (Daw) 1
bandage scissors (Lister) 1
plaster spreader 1
Pneumatic tourniquet 1
Rubber bandages (Esmarch) 2
Pins (Steinmann), with covers

for ends
Hand chuck for introducing 1
pins (T-handle)
Stirrups (Böhler)
Wires (Kirschner)
Wire stirrups (Kirschner) 6
Hand drill and drill bits 1 set

(Zimmer)
Mallet (Heath) 1 38 mm head
Small mallet 1
Straight osteotomes (Stille):
broad 2 18 × 160 mm
narrow 2 6 × 160 mm
Straight chisels (Stille) 2
Straight gouges 2
Orthopaedic self-retaining 1
retractor
Tissue forceps (Lane) 2
Spoons (Volkmann):
small 1 17 cm
medium 1 21 cm
Amputation knife 1 20 cm
Amputation saw (Satterlee) 1
Finger saw 1
Bone-holding forceps 2
(Fergusson or Lane)
Bone levers (Lane) 2
Rugine (Farabeuf) 1
Compound-action bone nibbler 1

(rongeur)
Compound-action bone-cutting 1 19 cm
forceps
Bone file 1
Skull callipers (Crutchfield) 1
Skull callipers (Cone), with 1

spanner
Auriscope and aural specula 1 set
Otolaryngology instruments Ear syringe 1
Head mirror 1
Nasal specula (Thudicum), set 1

of 4 sizes
Angled dressing forceps 2
(Tilley)
Self-retaining retractor (West) 1
Aural probe, hook, and curette 1 set
Myringotome 1
Mouth gag (Boyle - Davis):
child-size 9
adult-size 9
Angled tongue depressors 2
Small suction tubes 9
Small catspaw retractors 9

(Kilner)
Tracheal dilator (Bowlby) 1
Assorted tracheostomy tubes or

tracheostomy sets
(Chevalier Jackson):
child-size
adult-size
Urogenital instruments Curved urethral bougies 2 sets 10-24 Ch.

(Clutton)
Straight bougies (Powell) 2 sets 10-24 Ch.
Filiform bougies 2 sets 33 cm long

2-6 Ch.
Bougies (Guyon), for use as 9 12 Ch.
filiform guide
Bougies, 5/8 of a circle, olive- 1
tipped (Hey Grove), set of 3
Soft penile clamps 9
Suprapubic trocars and 1 25 Ch.

cannulas
1 30 Ch.
Catheter introducer (Malecot) 1
Catheter introducer (Foley) 1
Vascular instruments Bulldog clamps 4 22 mm

Clamps (Satinsky), with 3 1 set
different blade shapes
Narrow-jaw needle holders 1 17.5 cm
(Hegar)
Operating-room equipment
Quantity
Fixed Fixed operating-room light 1

equipment
Ultraviolet light source 1
Scrub basins with hot and cold running water
Exhaust fans
Electric autoclave with horizontal drum 1
Electric or kerosene sterilizer for boiling instruments 1
Other Operating table, universal frame-type with headpiece 1

equipment
Plaster, orthopaedic fracture table (modified Watson- 1
Jones)
Utensil sterilizer for bowls, boiling-type 1
Electric or kerosene hot-air sterilizer 1
Forceps sterilizers (Cheatle), heavy-duty 2
Forceps sterilizers (Harrison) 2
Instrument trolleys 4
Anaesthetic trolleys 2
Instrument stands with trays (Mayo) 4
Instrument stands with bowls:
single 2
double 2
Stands for swabs 2
Portable aspirating surgical suckers, electric 2

Portable aspirating surgical suckers, foot-operated 2
Cylindrical sterilizing drums:
24 cm diameter 4
29 cm diameter 4
34 cm diameter 4
Stainless-steel buckets with covers 4
“Kick-about” receptacles, on frames with roller 4

casters
Revolving operating stools of adjustable height 4
(enamel finish)
Footstools 2
Dressing trays:
small 4
medium 4
large 4
Portable operating-room lights, with stands 2
Diathermy machine 1
Radiograph viewing boxes 2
Dispensers for hot and cold sterile distilled water (4 2

litres/hour)
Stretchers with combination wheel and adjustable 4
sides
Labour and delivery beds, with two-piece mattresses 2
Folding stretchers 4
Covered instrument trays 4
Covered instrument/dressing trays 4
Instrument trays with handles 4
Instrument and catheter trays 4

Stainless-steel jugs:
3 litre 2
4 litre 2
Stainless-steel funnels, 200 ml 2
Stainless-steel graduated measures with handles, 1 2

litre
Utility basins, 3 litre 2
Self-retaining 4-wing catheters (de Pezzer), sizes 8,

14, 16, and 18 Ch.
Self-retaining balloon catheters (Foley), sizes 8, 14,
16, 18, and 22 Ch.
Urethral catheters (Nelaton), solid-tip, sizes 8, 10,
12, and 14 Ch.
Urethral catheters, coudé, sizes 8, 10, 12, 14, and 16
Ch.
Urinary bags
Graduated drainage (collecting) bottles, glass, 1.5

litre
Surgeon’s latex gloves, sizes 6, 6.5,7, 7.5,8
Rubber rectal tubes, funnel-end, 20 Ch., 50 cm long
Rubber rectal tubes, funnel-end, 28 Ch., 50 cm long
Colostomy bags
Nasogastric tubes (Levin), 12 Ch.
Polythene nasal feeding tubes:
infant-size, 8 Ch., 38 cm long
adult-size, 16 Ch., 80 cm long
Metal irrigating syringe (Kramer), 90 ml 1
Glass irrigating syringes, 100 ml 2
Syringes:
insulin, 1 ml
tuberculin, 1 ml
hypodermic, 2, 5, 10, 20, and 50 ml
Hypodermic needles, gauges 18 - 25, 27, and 28
Stomach tubes, 24 Ch., 150 cm long
Face masks and caps
Washable footwear, antistatic
Drapes
Gowns
Surgeon’s handbrushes with nylon bristles
Sutures/ligatures:
chromic catgut and plain 6/0,4/0, 3/0, 2/0, 0,

catgut, with and without No. 1 0,
needles
nylon and silk, with and 8/0,6/0,5/0,4/0, 3/0,
without needles 2/0, 0, No. 1
soft, stainless-steel wire, 0.55 mm chick (about size
0)
Regular-eye needles, assortment of different types
and sizes
Scalpel blades, No. 10, 11,17, 15,21, 22, 23 100 of each size
Aneurysm needles:
right 3
left 3
Stitch removal scissors 2
Heavy-duty “counter” scissors 2
Cannulas: stainless-steel 2
curved intravenous (Webster Luer) 2
transfusion (Luer), 1.25×41 mm (gauge 18) 2

Disposable scalp-vein infusion sets
Polythene tubing, 0.86 mm inner diameter, 1.27 mm

outer diameter
outer diameter
outer diameter
Latex tubing:
3.2 mm inner diameter
Soft rubber tubing, 2.0 mm inner diameter
Connectors for tubing, assorted, including T-shape

and Y-shape
Utility apron, opaque plastic 90 cm × 100 cm
Plastic sheeting, clear vinyl, 91 cm wide
Rubber sheeting, double-coated, 91 cm wide
Foam rubber
Corrugated latex drain
Gauze bandage:
25 mm × 9 m
50 mm × 9m
75 mm × 9m
Absorbent gauze (for dressings, swabs, abdominal

packs, petrolatum gauze, etc.):
20 cm × 6 m
1 m × 100m
Linen tape:
5 mm wide
10 mm wide
Surgical adhesive tape, 25 mm ×10 m
Adhesive zinc oxide tape, 75 mm ×5 m
Non-adhesive elastic bandage, 7 5 mm × 5m
Absorbent cotton wool
Eye pads
Eye shields
Umbilical tape, 3 mm wide
Indelible pencils
Safety pins, medium size
Rubber bands, assorted
Garters, elasticated
Manually operated hair clippers, narrow 2
Clipboards, 23 ×32 cm 2
All-metal safety razors, 3-piece
Double-edged safety-razor blades
Battery-operated wall clock, with hands showing 1

time in seconds, minutes, and hours
Laboratory balance, 2 kg capacity 1
Sandbags
Stainless-steel rulers 2
Aneroid sphygmomanometer, range 0 - 300 mmHg, 1

with cuff
Stethoscopes, binaural (bell and diaphragm) 3
Oesophageal stethoscope 1
Fetal stethoscope 1
Tape measure, 1.5m 1
Clinical thermometers
oral 1
rectal 1
Shiötz tonometer 1
Torch, battery-operated 1
Clothes-pegs
Wooden spatulae
Orthopaedic equipment
Gauze bandages, 10 cm and 15 cm wide
Crepe bandages
Stockinet, assorted sizes
Plaster of Paris powder (anhydrous calcium sulfate)
Triangular cloth bandages (for arm slings)
Thomas splints:
child-size 8
medium-size 8
adult-size 8
Pearson attachments for Thomas splints:
child-size 4
medium-size 4
adult-size 4
Half-ring Thomas splints:
right side 4
left side 4
Multi-purpose board splints, 3 sizes 1 set
Cramer wire splints: narrow, medium, and wide
Frames with pulleys (Böhler-Braun) 3
Pulley systems:
free 6
in frames 6
Wooden spreader bars, square:
7 × 7m 10
10 × 10m 10
Non-elastic traction cord
Blocks (for elevating bed), 22 cm and 30 cm high
Overhead traction suspension frames 4
Weights for traction
Anaesthetic equipment
Anaesthetic face masks, infant-size to large adult- 2 of each size, total 14

size
Oropharyngeal airways, sizes 00 to 5 2 of each size, total 12
Laryngoscopes 2 handles + 3 pairs of

blades, or 4 plastic
laryngoscopes (2 adult + 2
paediatric)
Spare bulbs for laryngoscopes 12
Batteries for laryngoscopes 30 (or 8 rechargeable

batteries + charger)
Endotracheal tubes, sizes 2.5 - 10 mm (internal
diameter) in 0.5 mm steps, Oxford or Magill or
similar, with cuffs only on sizes >6 mm
Urethral bougies, for use as intubating stylets
Magill’s intubating forceps (in an emergency, ovum 2 pairs

forceps can be used instead)
Endotracheal tube connectors, 15 mm plastic (can be 3 for each tube size
connected directly to the breathing valve)
Catheter mounts (sometimes also called endotracheal 4
tube connectors), antistatic rubber
Breathing hose and connectors:
lengths of 1 metre antistatic tubing 2
lengths of 30 cm tubing for connection of 4

vaporizers
T-piece for oxygen enrichment 1
Breathing valves (universal non-rebreathing type):
child-size 2
adult-size 6
Breathing systems (for continuous-flow anaesthesia):
Ayre’s T-piece system 2
Magill breathing system 2
Self-inflating bellows or bags:
child-size 1
adult-size 1
Anaesthetic vaporizers, for ether, halothane, and

trichloroethylene (draw-over type)
Needles and cannulas for intravenous use, including
paediatric sizes and an umbilical vein catheter
Intravenous infusion sets
Spinal needles, range of sizes, 18-gauge to 25-gauge

Price (Sw.
fr.)*
Cook, J. et al. Ed. General surgery at the district hospital 30 - (21.-)
1988 (230 pages)
Dobson, M, B. Anaesthesia at the district hospital 20 - (14 -)
1988 (143 pages)
Palmer. P. E. S. Et al. Manual of radiographic interpretation for general 28 - (19.60)
practitioners (WHO Basic Radiological System)
1985 (216 pages)
Effective choices for diagnostic imaging in clinical practice 16 - (11.20)
Report of a WHO Scientific Group
WHO Technical Report Series. No, 795, 1990 (131 pages)
Levy-Lambert. E. ed. Manual of basic techniques for a health laboratory 30 - (21-)
1980 (487 pages)
The use of essential drugs 15 - (10.50)
Seventh report of the WHO Expert Committee
WHO Technical Report Series. No. 867, 1997 (80 pages)
Vaughan, J. P. & Morrow. R. H., ed. Manual of epidemiology for district 35 - (24.50)
health management
1989 (vii + 198 pages)
WHO model prescribing information: drugs used in anaesthesia 11 - (7.70)
1989 (53 pages)
Essential elements of obstetric care at first referral level 14 - (9.80)
1991 (vii + 72 pages)
Female sterilization: a guide to provision of services 41 - (28.70)
1992 (x + 197 pages)
* Prices in parentheses apply in developing countries
Further information on these and other World Health Organization publications can be
obtained from Distribution and Sales, World Health Organization, 1211 Geneva 27,
Switzerland
Back Cover
This handbook is one of three published by the World Health Organization for the
guidance of doctors providing surgical and anaesthetic services in small hospitals that
are subject to constraints on personnel, equipment, and drugs and where access to
specialist services is limited. It has been prepared for the medical officer who does not
necessarily have a formal surgical training, but nevertheless has experience, gained
under supervision, of all the relevant techniques.
The text, complemented by numerous detailed illustrations, is split into two main parts -
obstetrics and gynaecology, and orthopaedics and traumatology. The first of these
describes obstetric procedures considered essential for treating the major complications
of pregnancy and childbirth and for preventing maternal death, as well as various
gynaecological procedures appropriate to the district hospital. The second part covers
both basic orthopaedic techniques, such as traction and plaster application, and the
management of specific fractures, dislocations, and other injuries, including burns.
Simple but standard surgical techniques have been selected wherever possible, and
procedures that require specialist skills or that could add unnecessarily to the doctor’s
workload have been avoided. Essential surgical instruments, equipment, and materials
for the district hospital are listed in the annexes.
Also available:
Dobson, M.B. Anaesthesia at the district hospital (1988)

“...an excellent, accurate, basic manual...” - Anaesthesia
Cook, J. et al., ed. General surgery at the district hospital (1988)

“...an invaluable practical guide for doctors working in remote areas...” - British journal
of clinical practice
Price: Sw. fr. 25.-

Price in developing countries: Sw. fr. 17.50
ISBN 92 4 154413 9

Surgery at The District Hospital

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Surgery at The District Hospital

Hochgeladen von

Copyright:

Verfügbare Formate

Surgery at the District Hospital: Obstetrics,

Gynaecology, Orthopaedics and

World Health Organization

Reprinted 1993, 1998

WHO Library Cataloguing in Publication Data

Surgery at the district hospital: obstetrics, gynaecology, orthopaedics and traumatology /

© World Health Organization 1991

Christian Medical Commission

Professor R. Baveja, Professor and Head, Department of Obstetrics and Gynaecology,

Mr J. Cook, formerly Consultant Surgeon, Department of Surgery, Eastern General Hospital,

Professor K.G. Gürsu-Hazarli, Director, Department of Plastic and Reconstructive Surgery,

Dr B. Sankaran, formerly Director, Division of Diagnostic, Therapeutic and Rehabilitative

Dr A.E.O. Wasunna, Medical Officer, Clinical Technology, World Health Organization,

Obstetrics and gynaecology

Orthopaedics and traumatology

Surgery at the District Hospital: Obstetrics, Gynaecology,

Export document as HTML 3. General obstetric procedures

Export document as PDF file

Orthopaedics and traumatology

Annex 1. Surgical trays and equipment for specific

Annex 2. Essential surgical instruments, equipment, and

Selected WHO publications of related interest

Haemorrhage in the last trimester of pregnancy should be taken particularly seriously.

Immediately administer 15 mg of morphine by intramuscular injection, if this was not already

Accidental haemorrhage (abruptio placentae)

Possible complications include postpartum haemorrhage, disseminated intravascular

Export document as HTML 3. General obstetric procedures

Orthopaedics and traumatology

Annex 1. Surgical trays and equipment for specific

Annex 2. Essential surgical instruments, equipment, and

Selected WHO publications of related interest

Impending eclampsia is characterized by generalized or localized headache, visual

Differential diagnosis should include epilepsy, meningitis, cerebrovascular accident,

As an alternative, give 50 mg of chlorpromazine and 25 mg of promethazine intramuscularly

Possible complications include inhalation pneumonia, accidental haemorrhage, vasomotor

Export document as HTML Low forceps delivery

Lower-segment caesarean section

3. General obstetric procedures

Orthopaedics and traumatology

Annex 1. Surgical trays and equipment for specific

Annex 2. Essential surgical instruments, equipment, and

Selected WHO publications of related interest

See tray for Episiotomy, Annex 1.

Surgery at the District Hospital: Obstetrics, Gynaecology,

Export document as HTML Low forceps delivery

Lower-segment caesarean section

Orthopaedics and traumatology

Annex 1. Surgical trays and equipment for specific

Annex 2. Essential surgical instruments, equipment, and

Selected WHO publications of related interest

The diagnosis is confirmed by a history of regular uterine contractions, by abdominal

First calm the patient by giving 10 mg of diazepam intramuscularly every 8 hours.

Low forceps delivery

Fetal indications include:

Possible complications include fetal asphyxia and intracranial haemorrhage; maternal

Vacuum extraction is an alternative to forceps delivery. It is indicated mainly in cases of

Vacuum extraction is contraindicated in acute fetal distress or prematurity.

Assess the patient as for forceps delivery.

Possible complications include cephalhaematoma, intracranial haemorrhage, and sloughing of

Lower-segment caesarean section

See tray for Caesarean section, Annex 1.

The recommended procedure is transperitoneal, lower-segment caesarean section with a

Breech presentation occurs when vertex presentation is affected by conditions such as