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Axilla and elbow 1

In the river islands of northern Bangladesh known as the Chars, the majority of households use clay stoves fueled by wood for cooking. In this challenging environment, even a small accident near a burning stove can result in severe burn injuries. The population residing in these areas faces limited access to healthcare, but organizations like Friendship are working diligently to bridge this gap. Friendship operates hospital ships that navigate from island to island, delivering essential medical care to those in need, including reconstructive surgical procedures like burn contracture release.

Medical history

In this particular case, a 9-year-old girl was brought to our attention. According to her father, she had accidentally fallen onto a burning stove—an unfortunate and common occurrence in the area. Initially, she received primary burn management at a nearby hospital. However, despite these initial efforts, her condition deteriorated over time. The burn site in her left arm developed a shrinkage and contracture, progressively impairing the arm's functionality. When the girl's family learned about the reconstructive surgeons visiting the Emirate Friendship Hospital ship, they immediately embarked on a boat in search of proper care. However, due to financial constraints, they were unable to pay the fare and had to disembark. Upon hearing of their predicament, the compassionate staff at Friendship promptly dispatched a boat to transport the girl and her mother to the hospital ship.

Physical examination

Upon arrival at the hospital ship, the girl underwent a thorough examination conducted by the local medical team, accompanied by visiting surgeons and an anesthetist. It became evident that she experienced significant difficulty in using her affected arm, and the scars caused her persistent pain. On closer examination and palpation, a severe narrow band contracture with a noticeable fold was observed, extending from her chest to her left forearm. The healthier side of the fold was positioned anteriorly at the axilla level, while the more medial side was observed at the elbow level. Despite her burn injury, the girl was in overall good health, and there were no indications of anemia.

Surgery

The surgical plan involved creating two jumping man designs that would mirror each other. This approach was chosen to effectively address the complex nature of the contracture and provide the best possible outcome for the patient. By carefully planning and executing these techniques, the surgical team aimed to alleviate the functional limitations and improve the overall quality of life for the patient.

The use of mirroring jumping man techniques allows for a comprehensive and tailored approach to address the unique challenges posed by this particular contracture.

Postoperative care

Postoperative care was crucial for supporting the patient's healing process and ensuring a successful outcome. The skin flaps were protected using tetracycline-coated Vaseline gauzes, covered with dry gauzes for added protection (Photo 9). Immobilization measures were implemented to maintain proper limb positioning and facilitate healing.

The elbow was secured in extension using a plaster cast, while the shoulder was kept in abduction with the help of a pillow (Photo 9). These measures provided stability to the surgical site, promoting tissue regeneration and reducing the risk of contracture recurrence.

The day after the surgery, the patient was transferred to the ward, located in a temporary barracks near the ship (Photo 10). Dedicated Friendship nurses conducted regular ward rounds to monitor the patient's progress and provide necessary care. The patient's family also played a vital role, following instructions to maintain the arm in a position that ensured 90 degrees of shoulder abduction (Photo 11).

After five days, the dressings were removed for wound inspection, assessing healing and identifying any potential complications. This allowed for timely intervention and adjustment of the treatment plan as needed, optimizing the patient's outcome.

Outcome

Following the postoperative care and diligent adherence to the recommended exercises, the patient showed remarkable progress in her recovery. After a few weeks, she was discharged from the hospital with instructions on specific exercises aimed at maintaining full extension and abduction of the elbow and shoulder. These exercises played a crucial role in restoring her arm's functionality.

Six months later, the Friendship team revisited the patient and were delighted to witness her using her left arm as normal (Photo 12). This significant improvement in her arm's mobility and functionality brought immense joy to both the patient and her parents. The gratitude expressed by the parents towards the dedicated Friendship team highlighted the profound impact their medical care and reconstructive surgical interventions had on the patient's life.

Lessons learned

This example showcases the successful integration of surgical care into global health strategies in low-resource settings, challenging previous assumptions about complexity and cost. Friendship, a local organization, demonstrated strong organizational skills by embedding team members within communities, overcoming barriers to provide essential surgical services in remote areas.

Despite operating in a basic facility, Friendship ensured safe and effective care by equipping their operating theater appropriately. They leveraged modern technology for follow-up and evaluation, prioritizing patients' quality of life and continuously improving their services.

While external expertise was still required for surgeries, Friendship's commitment to learning presents opportunities to train local specialists. This capacity-building approach aims to empower these specialists to perform surgeries independently, reducing reliance on external support and ensuring sustainable access to surgical care.

This example inspires and highlights the importance of determination, effective organization, and ongoing education for integrating surgical care in low-resource settings. By empowering local communities and strengthening healthcare systems, organizations like Friendship pave the way for expanded surgical care and improved health outcomes in underserved areas.

Case

Axilla and elbow 1