In general extremity injuries should be immobilised by appropriate early surgical procedures – plating, nailing etc. As far as possible external fixation of extremity fractures should be avoided since they often contribute to significant nursing problems.
Informed judgement on the need for bony realignment of extremity fractures should be made, taking into consideration the patient’s neurological deficit. Thus in general there is a greater need for expert reconstruction of upper extremity fractures; soft tissue injuries compared to lower extremity injuries.
Surgical intervention to spinal column injuries is very unlikely to contribute to neurological recovery.
Most spinal column injuries, associated with spinal cord injury can be treated conservatively in a DGH, if the hospital has adequate and reliable nursing expertise.
Patients with cervical spinal column/cord injuries will usually need skull traction with appropriate tongs. Patients with hyperextension injuries of the cervical spine with a resultant tetraparesis can often be treated without skull traction and the neck supported on a pillow to avoid extension, provided such an individual does not have head injury/cerebral irritation.
Attempts should be made to reduce dislocations of the cervical spine at the earliest opportunity by gradually increasing skull traction with or without gentle manipulation of the cervical spine using appropriate radiological control . By avoiding a general anaesthetic the neurology can be assessed and monitored during the process.
Inexpert application of either traction or manipulation is potentially dangerous. Please liaise with your local Spinal Injuries Unit.
Surgical stabilisation of cervical spinal column injuries in the presence of neurological deficit should be attempted only by surgeons with adequate expertise supported by informed anaesthetists. Inexpert and extensive anterior and/or posterior stabilisation not uncommonly results in the need for extended period of postoperative ventilation and other respiratory complications. Such procedures do not necessarily contribute to neurological recovery nor reduction in hospital stay but can add significantly to the cost of care and the development of multiple complications.
Thoracic spinal column injuries, associated with complete paraplegia can often be managed conservatively.
Thoraco-lumbar spinal column injuries without neurological deficit can benefit from segmental instrumentation carried out by an orthopaedic team familiar with such procedures. Opinion is divided about the benefits of surgery in patients with neurological damage.
Spinal canal clearance by surgical decompression does not necessarily contribute to neurological recovery in the majority of patients with SCI. Please liaise with your local spinal cord injuries centre.