Follow up on Mr. Yagogo



Mr. Yagogo returned yesterday, reinforcing why it can be so challenging to work in a rural setting in a developing country. As a reminder, Mr. Yagogo suffered bilateral medial tibial plateau fractures after being involved in a mining accident around December 9. We referred him for orthopedic referral on December 16. Yesterday he returned to KRCH requesting an xray. He was told to follow up with the orthopedists in Kanchanaburi, but because that is 4 hours from his home, he came to KRCH instead. Great, so I have no idea what they did, what they want to do with the fractures (how long should he be casted, how long should he be non weight bearing?), or why they decided not to treat both fractures. After a prolonged conversation through the translator it becomes a little more clear. The patient had been placed in a long leg, straight cast on the left leg, with instructions to weight bear minimally on the right. No surgery was performed. He didn't know when he needed to take the cast off.


We did an xray of both knees. The left knee (the casted side) appeared to be healing well. The ride side looked more sclerotic, with medial joint space narrowing, suggesting poor healing.

I placed him in a shorter fiber glass cast on the left knee with his knee held in slight flexion. On removal of his clunky plaster cast, he had absolutely no cast padding between his skin and the cast. He fortunately had no skin breakdown or sores. He'll be non weight bearing on this side for at least one more month, and I instructed him to use his right leg only as needed. I considered sending him home with crutches, but did not want to encourage ambulation.

When I saw him yesterday I have to admit I was frustrated. I was concerned enough about this patient to refer him 3 hours away, where they didn't really do anything for him that I couldn't have done. AND he's still weight bearing on a broken tibia, that looks worse on xray. But I soon realized there probably wasn't anything else that could have been done. Casting both of his legs would mean that he would be bed ridden for months which would likely requiring staying in a facility, which is very expensive. So they opted for the lesser of two evils I suppose by just casting the "bad" knee, and limiting his weight bearing on the more stable side. He'll probably heal well on the casted side, and have chronic issues with the right, but at least he can kind of manage right now.

In short, his management is not ideal, but that's been par for the course here in rural Thailand, so I guess we'll take what we can get.






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