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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 60-65

A retrospective study on the profile of long bone injuries in trauma patients presenting to emergency department


Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission11-Aug-2019
Date of Acceptance07-Sep-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Darpanarayan Hazra
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_35_19

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  Abstract 

Background: Trauma is one of the major causes of long bone injuries in India. This study was done to improve the understanding of the mode of trauma, type of injury and severity and outcome of trauma victims with long bone injuries in our hospital. Materials and Methods: This was a retrospective observational study of all trauma patients aged 18 years or more with long bone injuries presenting to our emergency department. Details of the incident, injuries, management, and outcome were noted. Results: We received a total of 2207 trauma patients during the 4-month study period with 14.31% (316/2207) being adult patients with long bone injuries. Male (71.8%) predominance were noted. The mean age was 45.7 (±17.9) years. Road traffic accident (68.35%) was the most common mechanism of the incident followed by slip and fall (20.56%). Majority of patients (43.98%) came during 15.00–22.00 h. The most common long bone injured was the tibia in the young (51.68%)- and middle-aged (58%) patients. In the elderly, femur (58.19%) was the most common bone involved. Head injury accounted for 13% of the associated injuries. Among these 316 trauma patients 186 were admitted, 105 (57.37%) patients had to undergo an emergency operation on the same day of arrival, whereas 78 (42.62%) patients were managed conservatively in the wards or had an elective surgery done at a later date. Conclusions: The tibia is the most common long bone injured in young adults, whereas the femur is the most common in the elderly. Prevention, education, legislative enforcement, and prehospital management and transportation of trauma-inflicted patients would impact immensely on the health of the people.

Keywords: Both bone fracture, femur fracture, long bone injuries, profile of trauma patients, road traffic accidents, tibia fracture


How to cite this article:
Dkhar I, Hazra D, Madhiyazhagan M, Joseph JV, Abhilash KP. A retrospective study on the profile of long bone injuries in trauma patients presenting to emergency department. Curr Med Issues 2019;17:60-5

How to cite this URL:
Dkhar I, Hazra D, Madhiyazhagan M, Joseph JV, Abhilash KP. A retrospective study on the profile of long bone injuries in trauma patients presenting to emergency department. Curr Med Issues [serial online] 2019 [cited 2019 Nov 17];17:60-5. Available from: http://www.cmijournal.org/text.asp?2019/17/3/60/267912


  Introduction Top


In the olden days, gunshot wounds and explosions were the most common causes of long bone injuries,[1] but now in the 21st century, trauma mostly because of road traffic accidents (RTAs) are the most common cause of long bone injuries. The World Health Organization reports that the number of global deaths due to RTAs has plateaued at 1.25 million a year.[2] In India, they have accounted for more than a third of the country's unnatural causes of death [3] and annually the country loses 2%–3% of its gross domestic product, i.e, 55,000 crore rupees due to RTAs.[4] Majority of the deaths occur on the site of the trauma or in the time period when the patient is being brought to a health-care facility. In India especially in the rural parts where roads and ways of commuting are difficult that so called “golden hour” of trauma is lost, even though there is a potential mortality and morbidity reduction if first aid was administered to trauma victims.[5],[6] Trauma victims with long bone injuries, whether open or closed, needs urgent assessment and treatment to reduce the risk of acute or chronic complications.[7] It, therefore, becomes important to assess the patients quickly and manage them in time. The purpose of this study was to better understand the mode of injury, the severity, the involvement of the different long bones, and to come up with ideas on how to better prevent and manage such types of trauma.


  Materials and Methods Top


Methodology

Design

The study was a retrospective cohort study conducted in the Emergency Department (ED) of Christian Medical College Hospital, Vellore.

Setting

The study was conducted in the ED of Christian Medical College Hospital, Vellore, which is a tertiary medical care center. The ED is a 45-bed department and tends to about 300 patients per day, including trauma and nontrauma patients.

Participants

All trauma patients who presented to the ED from November 2016 to February 2017 aged 18 and above who had sustained any type of trauma and had a long bone injury, e.g. fracture of the humerus, radius, ulna, femur, tibia, and fibula. Children and adolescents presenting with trauma and adult patients who were dead on arrival were excluded from the study.

Variables

Data of the patients were obtained from the electronic hospital records and the details of history and physical examination findings of all patients were recorded on a standard data collection sheet. The following were extracted: demographics, mode of injury, time of injury and time of arrival, triage priority, Revised Trauma Score (RTS) and Injury Severity Score (ISS), individual long bones involved, proportion of patients undergoing operative intervention, and the ED and hospital outcome in terms of mortality.

Outcome variable

Prevalence of long bone injuries, commonly involved extremity fracture in trauma and mortality rate.

Bias

This is a retrospective study, and therefore, we could not control exposure or outcome assessment and instead relied on others for accurate recordkeeping.

Study size

Based on pilot data done in the ED, the prevalence of long bone injuries in trauma patients in the month of October was found to be 28.7%. Using that prevalence with 5% precision and 95% confidence interval, the required sample of the study was calculated to be 316 trauma patients.

Laboratory test

The associated injuries of the patients along with the long bone injuries were noted. All patients had routine blood investigations and relevant radiological tests based on the initial primary and secondary surveys.

Statistical analysis

All categorical variables were expressed as frequencies and percentages. The data were entered in Epidata software EpiData (Classic) Analysis v2.2.3 and analyzed using Statistical analysis was performed using SPSS software (SPSS Inc., Released 2007. SPSS for Windows, version 16.0, Chicago, IL, USA). Data were summarized using mean along with standard deviation for continuous variables and frequencies along with percentages were calculated and given.

Ethical considerations

This study was approved by the Institutional Review Board prior to the commencement of the study, approval from the Institutional Review Board Ethical Committee was obtained (IRB Min no: 10622 dated June 12, 2017). Patient confidentiality was maintained using unique identifiers and by password protected data entry software with restricted users.


  Results Top


The ED received and attended to a total of 23,950 patients during the study period of 4 months, of which 9.21% (2207/23950) were trauma cases [Figure 1]. More than two-thirds, 73% (1613/2207) were patients without long bone injuries. Patients who presented with long bones comprised 27% (594) which included pediatric as well as adult patients. More than half of these patients were adults and comprised 53.1% (316). Males predominance (72%) was noted. The mean age was 45.7 (±17.9) years [Table 1].
Figure 1: Strobe diagram.

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Table 1: Baseline characteristics

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Diabetes and hypertension were the major comorbidities [Table 1]. Among the patients with long bone injury, 30% (97/316) came directly to the ED after the trauma and 70% (219/316) presented following primary care from elsewhere.

RTA (68.35%) was the most common mechanism of incident followed by slip and fall (20.56%). Among the patients with RTAs, 43.35% (137) of them were driving motorized two-wheeler vehicles and 6.96% (22) were pillion riders, Those involved in four wheeler accidents accounted to 6.96 %(22) patients. Incidence of pedestrians getting hit by vehicles were 6.64% (21) patients. Injuries involved with a three wheeler (auto-rickshaw) were 3.16% (10) and finally those riding a bicycle accounted to1.26% (4) patients [Table 2]. Thirty (9.4%) patients had positive blood and histories of alcohol intake at the time of trauma and 100% of the patients were male. Majority of the patients had received initial treatment elsewhere in other hospitals or peripheral centers [Table 2].
Table 2: Severity of injury and mode of incident

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{Table 2}

The cumulative average of RTS [Figure 2] among all patients was 7.64. The cumulative average of ISS [Figure 3] among all patients was 13.066. Among patients who were triaged into priority 1, the average mean was 21.588; average mean was 11.48 in priority 2 patients and those in Priority 3 the average mean was 10.53.
Figure 2: Revised Trauma Score.

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Figure 3: Injury Severity Score.

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On an average day, 104 (32.91%) patients had the trauma during 12.00 hours to 17.00 hours, 101 (31.96%) patients had trauma during 17.00 hours to 00.00 hours, 32 (10.12%) patients had the trauma during 0.00 hours to 06.00 hours and 79 (25%) patients had the trauma during 0600 hours to 1200hrs.

There were a total of 466 fractures among all the patients; two-thirds of the patients 309 (66.3%) sustained closed fractures and rest 157 (33.69%) sustained open fractures. Majority of the patients, 246 (77.84%), had no associated injuries. [Table 2], and finally patients with other injuries 1 (0.31%). The patients were classified into three age groups: young (18–30 years), middle age (31–50 years), and elderly (above 50 years). Among these patients, 89 (28%) represented young patients, 105 (33.2%) represented middle-age patients, and 122 (38.6%) represented elderly patients. The most common lower limb bone fractured was tibia - 46 (51.68%) patients between 18 and 30 years of age, followed by fibula - 32 (35.95%) patients and femur - 28 (31.46%) patients. In the upper limbs, the most common bone fractured was the radius - 20 (22.47%) patients, followed by the ulna - 13 (14.60%) patients and humerus -11 (3.48%) patients [Table 3].
Table 3: Age-wise distribution of fractures

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Majority of the patients 183 (57.9%), were admitted, remaining 93 (29.40%) patients were discharged stable from the ED. Discharges against medical advice accounted to 38(11.9%) patients and 1 (0.31%) patient died in the ED.

Among the admitted patients, 18 (9.83%) patients required ICU admission and remaining 165 (90.16%) were admitted in hospital wards. Emergency surgical intervention on the same day was required by 105 (57.37%) patients, whereas 78 (42.62%) patients were managed conservatively in the wards or had an elective surgery done at a later date.

Hospital stay for these patients varied from 2 days to more than 2 weeks. Majority of the patients 139 (43.98%) stayed in the hospital for upto 2 days, 55 (17.40%) patients stayed between 3 to 7 days, 86 (27.21%) patients stayed between 7 to 14 days and 36 (4.43%) patients stayed for more than 14 days. There were 2 (0.63%) mortalities from the admitted patients whereas the remaining 314 (99.63%) patients were discharged in a stable condition.


  Discussion Top


Trauma is one of the major causes of death and disability worldwide, knowing how to tackle and dealing with the causes and managing the patients inflicted with trauma can greatly reduce the morbidity and mortality that it carries with it. Trauma is inevitable in our times, but it can be prevented, and even if it has occurred, it can still be managed and treated. In India, trauma is a major problem with vast complications and consequences. Owing to the developing nature of our country and the growth in urbanization, motorization, and industrialization, there is a rapid surge in the number of automobiles and industries all over the country and therefore an increase in the number of trauma cases.[8],[9] In our study, we found a male predominance for trauma which is consistent with other studies.[8] This can be because males are more employed in tackling heavy machinery, driving automobiles, and high construction projects which makes them more at risk of having trauma. The mean age among our patients was found to be 45.7 (±17.9) which is consistent with other studies.[8]

RTA victims constitute a large chunk of our trauma patient load and is one of the leading causes of trauma mortality both nationally and globally.[8] A large proportion of the patients who were involved in RTAs were two-wheeler drivers (43.35%) and were consistent with the studies done by Rastogi et al. and Mishra et al.[8],[10] Most pillion riders were victims of their driving counterparts. Pedestrians, four-wheeler accidents, and even bicycle accidents formed a significant proportion of the victims. This points out to the recklessness of the drivers to ride motorized vehicles at higher speeds and the disregard for traffic rules and regulations in the driving scene. Alcohol is another evil regularly documented to be one of the main causes for trauma. Our study reported that 9.4% of the patients were allegedly under the influence of alcohol, but in other studies, the numbers are much higher.[9] Intoxicated drivers pose a health hazard not only to themselves but also put the people around them at risk of trauma. Strict measures and penalties should be enforced for anyone caught driving under the influence of alcohol, then only can the damage caused by this evil be checked.

Lay people or bystanders are usually the first people to come into contact with a victim of trauma and trained or untrained; they would have had tried their best to offer first aid to the victim. Studies have shown that there is a potential mortality and morbidity reduction if correct first aid was administered to trauma victims.[6] One study, however, reported that in 83% of the cases incorrect first aid was given to the trauma victim.[11]

Falls on level ground or slip and falls are the second most common cause of trauma in the elderly; our study recorded a 44.26% of slip and falls in the elderly age group. A study in Egypt, however, recorded a 63% prevalence of falls among the elderly.[12] In this part of the country, most of the elderly walkabout on the streets unattended or are without any relatives or bystander to look after them, this coupled with the rashful and erratic behavior of motor vehicle drivers usually leave the elderly in a painful heap on the floor. Proper care and attention to our elderly citizens will prevent such terrible consequences and promote a safer environment for them.

Limb injuries are common after a trauma, especially traumas such as RTAs, fall from height, and fall on level ground and many studies have recorded that lower limb injuries are the predominant injuries of the extremities.[13] Our study has also recorded the predominance of lower limb injuries in trauma and the most common bone affected was the tibia in the young age group and the femur in the elderly age group. This could be attributed to the mechanism of injury and the frailty of the human bones at the different age groups. A young man who slipped and fell on level ground would have a lower risk of having a femur neck fracture or intertrochanteric fracture as compared to an old, elderly frail person.

Many studies have been done to find out the best scoring system to grade the severity of injuries, yet no perfect system exists. Trying to summarize the severity of injury in a patient into one single number is difficult and then trying to develop a system to predict the various outcomes in that trauma patient seems impossible.[14] The RTS is a physiological scoring system and the ISS is an anatomical scoring system developed to grade the injuries of trauma patients and predict mortality. Our study shows that the ISS and RTS are correct predictors of mortality as in concordance with other studies.[9],[15]

In our institution, a patient coming to the ED will first be resuscitated by the ED team, and subsequently, the different units will be called according to the injuries. According to the injuries sustained will the patient be treated and admitted. A bulk of our patients was admitted and the others discharged. Most of the admitted patients would have to undergo surgery either on emergency basis or elective basis. Our institution being a tertiary referral center does not have enough slots in the operation theater even for emergency surgeries because of the sheer load of the patients. Most of the patients in the ward would have to wait at least a day for the required operation to be done. Ways and means must be developed to decongest the operation theater and rules and education to the public must be given.

Our study reveals that the impact trauma has in the lives of people, whether they are young or elderly. It reveals the burden and consequences that comes with trauma. Our study was done in a tertiary health center where state of the art and specialized facilities are available. Most of the trauma occurs in the rural areas, on the highways, in the fields or at home. These places can be near to a well-equipped health facility, but most of the time, they are not. Patients get treated first at a local health center and then sent to the higher centers for further management, a bulk of our patients were referred or had already received some sort of treatment elsewhere and then came to our ED. Some of them were delayed, whether this can be attributed to our failed emergency services or a lack of clear-cut protocol among the primary health centers for early referral of patients is yet to be answered.


  Conclusions Top


Our study shows that RTA and falls are the predominant causes of trauma with the most common long bone affected being the tibia in the young and femur in the elderly. A proactive attitude with intensive research on the prevention, education, legislative enforcement, and prehospital management and transportation of trauma-inflicted patients would impact immensely on the health of the people.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research Quality and Ethics Statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board / Ethics Committee review, and the corresponding protocol / approval number is IRB Min no: 10622 dated June 12, 2017. We also certify that we have not plagiarized the contents in this submission and have done a Plagiarism Check.

 
  References Top

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2.
World Health Organization | Global Status Report on Road Safety 2015. World Health Organization. Available from: http://www.who.int/violence_injury_prevention/road_safety_status/2015/en/. [Last accessed on 2017 May 01].  Back to cited text no. 2
    
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Government of India Accidental Deaths and Suicides in India National Crime Records Bureau. New Delhi: Ministry of Home Affairs; 2013.  Back to cited text no. 3
    
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World Health Organization. World Report on Road Traffic Injury Prevention: Summary. Geneva: World Health Organization; 2004. p. 1-52.  Back to cited text no. 4
    
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Carr BG, Caplan JM, Pryor JP, Branas CC. A meta-analysis of prehospital care times for trauma. Prehosp Emerg Care 2006;10:198-206.  Back to cited text no. 5
    
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Tannvik TD, Bakke HK, Wisborg T. A systematic literature review on first aid provided by laypeople to trauma victims. Acta Anaesthesiol Scand 2012;56:1222-7.  Back to cited text no. 6
    
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Brundage SI, McGhan R, Jurkovich GJ, Mack CD, Maier RV. Timing of femur fracture fixation: Effect on outcome in patients with thoracic and head injuries. J Trauma 2002;52:299-307.  Back to cited text no. 7
    
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Rastogi D, Meena S, Sharma V, Singh GK. Epidemiology of patients admitted to a major trauma centre in Northern India. Chin J Traumatol 2014;17:103-7.  Back to cited text no. 8
    
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Abhilash KP, Chakraborthy N, Pandian GR, Dhanawade VS, Bhanu TK, Priya K. Profile of trauma patients in the emergency department of a tertiary care hospital in South India. J Family Med Prim Care 2016;5:558-63.  Back to cited text no. 9
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Mishra B, Sinha Mishra ND, Sukhla S, Sinha A. Epidemiological study of road traffic accident cases from Western Nepal. Indian J Community Med 2010;35:115-21.  Back to cited text no. 10
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Ertl L, Christ F. Significant improvement of the quality of bystander first aid using an expert system with a mobile multimedia device. Resuscitation 2007;74:286-95.  Back to cited text no. 11
    
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Kamel MH, Abdulmajeed AA, Ismail Sel-S. Risk factors of falls among elderly living in urban Suez – Egypt. Pan Afr Med J 2013;14:26.  Back to cited text no. 12
    
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Chawda MN, Hildebrand F, Pape HC, Giannoudis PV. Predicting outcome after multiple trauma: Which scoring system? Injury 2004;35:347-58.  Back to cited text no. 14
    
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    Figures

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    Tables

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