Incidence of Fracture and Dislocation Patterns in Patients with Extremity Injuries Reporting to a Tertiary Care Hospital

Abstract

Background: 

Trauma is globally associated with significant mortality with developing countries bearing a disproportionately high burden. It represents a major epidemic of non – communicable disease. The aim of this study is to evaluate the incidence of various fracture and dislocation patterns in patients with extremity injuries and their 1- year mortality rate.

Materials and Methods: 

An observational, prospective study was undertaken to analyse the incidence of fracture and dislocation patterns in patients coming to the Orthopaedics OPD and emergency medicine department in a tertiary hospital during a period of two years from 1^st, October 2017 to 30^th, September 2019. Overall, 1182 patients were enrolled for the study with a mean age of 43 yrs.

Results: 

Age group 21 – 30 years was most common (17.1%) age to suffer injuries with a male preponderance (67.5%). The most common mode of injury was by road traffic accident (43%). 97.9% of the injuries had unilateral involvement with the lower extremity (57.2%) and the femur (21.2%) being most frequently fractured. Dislocations/fracture-dislocations constituted only 5.5% cases with shoulder dislocation being the most frequently involved joint. Plain radiographs were used in 96.9% cases for final diagnosis. Forty cases (3.4%) were found to not survive in the 1-year follow up after fracture.

Conclusion: 

The present study shows that most of the causes of trauma are preventable. This study could assist in raising the profile of RTI as a public health problem which needs to be addressed as a preventable cause of mortality and morbidity, and planning appropriate interventions for this major challenge.

INTRODUCTION

Injury is a major, preventable public health problem in terms of morbidity, premature mortality, or disability causing the death of over five million people around the world each year.[¹] Trauma has its own natural history and it follows the same epidemic pattern as any other disease, that is, the agent, host, and environment interacting together to produce injury or damage.[²]

According to a recent WHO report, the trauma would be the third-largest killer in developing countries by 2020.[³⁴] Worldwide, the projections for 2020 show that 8.4 million deaths are expected annually.[⁵] Trauma accounts for about 12% of all causes of death worldwide.[⁶]

Patterns and causes of trauma differ from place to place. Road traffic accidents (RTAs), falls, assaults, firearm injuries, burns, sports injuries, animal bites, and industrial accidents are some causes of trauma.[⁷⁸] Countries are passing through significant urbanization, motorization, industrialization, and a change in socioeconomic values. We human beings have to pay a heavy price due to altered fast life as a result of the rapid advent of progress in technology. Although the rates have noticeably decreased in developed countries, it is still a burning problem in developing countries.[⁹]

Accidents account for the fifth-leading cause of mortality, which accounts for 5.2% of all mortality, according to the 1996 WHO report.[¹⁰] India is the leading country in the number of deaths due to RTA.[¹¹] Maharashtra is one of the fastest developing states in India. With the advent of new technology, architecture, and modes of transportation, the pattern of trauma has changed dramatically. Among the developed states of India, Maharashtra is the third largest province area-wise and ironically happens to be the second most populous state. As a leading industrial region, it has witnessed a 45-fold rise in the number of vehicles on the road in the last three decades. However, the length of road has not grown at the same proportion and saw a meager five-fold rise. This has directly resulted in an over-burdening of these roads by up to four to five times their original capacity.[¹²]

Domestic fall incidents represent a major public health problem, because approximately one-third of all community-dwelling people aged 65 years or older fall once a year, and this goes up to 50% in persons aged 80 years or older.[¹³] Fall-related injuries are also accompanied by short-and long-term functional impairment and consequent reduction of quality of life among the elderly.[¹⁴]

The injury pattern in patients sustaining multiple injuries highly influences mortality, posttraumatic course, physical and psychosocial outcome, and posttraumatic quality of life. Mortality is mainly determined by the severity of head injury while exsanguination represents the second leading cause of death.[¹⁵¹⁶]

Injury and its consequences, as a research problem, have also been largely ignored in developing countries. Trauma care in most developing nations is at the infancy level even though about 90% of injury deaths occur in these nations.[¹⁷] The dearth of trauma centers, nonexistent ambulance services, and prehospital care, and unavailability of data on trauma are some of the impediments to trauma management in India. There are few studies from developing countries discussing the epidemiology of trauma.[^18192021] In developing countries like India, a majority of such injuries occur in the poor strata of society. Many of them are laborers, commercial workers, and people living on daily wages.

Unlike Western countries, where majority of health conditions are catered by insurance, these individuals neither have insurance nor the means to avail high-class medical care.

Trauma epidemiology is essential to describe the morbidity, disability, and dependency as well as define the most important target for prevention regarding the severity of the injury. The mortality and economic losses imposed by morbidity which results from injuries are largely preventable. Analysis of fracture epidemiology from the study will help clinicians to determine definable and preventable characteristics that predispose to skeletal fracture and planning of appropriate treatment strategies.

The aim of this study is to evaluate the incidence of various fracture and dislocation patterns in patients with extremity injuries reporting to a tertiary care hospital and their 1-year mortality rate.

MATERIALS AND METHODS

This study is an observational, prospective, hospital-based study undertaken to analyze the incidence of fracture and dislocation patterns. All patients with Orthopaedic extremity injuries coming to the Orthopaedics outpatient department (OPD) and emergency medicine department of a tertiary hospital in Pune during a period of 2 years from October 2017 to September 2019 were enrolled in this study.

Inclusion criteria

• All adolescents/young adults and adult patients (above 10 years of age)
• Orthopedic trauma extremity injuries.

Exclusion criteria

• Age <10 years
• Old fractures (nonunion and malunion) and pathological fractures (infection or tumor)
• Isolated head, chest, or abdomen injury
• Spinal and rib fractures
• Isolated soft-tissue injuries-incised and lacerated wounds, tendon and ligament injuries, and muscle injuries.

Tool for data collection

• Pro forma was filled for every person who met all inclusion and exclusion criteria
• Detailed history and examination were undertaken as per department protocol for patients coming to the hospital
• Fractures of the upper extremity and lower extremity were grouped separately
• Particular age groups affected were noted. Mortality rates as per varying age groups were noted
• The cause of mortality was determined
• Radiological investigations for confirming the clinical diagnosis of fractures and dislocations-X-RAY, computed-tomography (CT) scan, magnetic resonance imaging (MRI).

Statistical data analysis

• The data on categorical variables are shown as n (% of cases) and the data on continuous variables is presented as mean and standard deviation (SD). The inter-group statistical comparison of the distribution of categorical variables is done using the Chi-Square test or Fisher's exact probability test. All results are shown in tabular as well as graphical format to visualize the statistically significant difference more clearly
• In the entire study, the P < 0.05 are considered statistically significant. All the hypotheses were formulated using two-tailed alternatives against each null hypothesis (hypothesis of no difference). The entire data is statistically analyzed using the Statistical Package for the Social Sciences (SPSS version 22.0, IBM Corporation, USA) for MS Windows.

RESULTS

The present study included 1182 patients reported to a tertiary care hospital in Pune with extremity injuries during October 1, 2017–September 30, 2019.

Age distribution

In our study, we found that most patients were in the age group of 21–30 (19.3%) followed by 31–40 (15.5%). The mean ± SD of the age of cases studied in the entire study group was 43.0 ± 21.1 years and the minimum– maximum age range was 11–100 years [Table 1].

Table 1: Age distribution of the cases

Gender distribution

There were 798 (67.5%) males and 384 (32.5%) females with a male-to-female ratio of 2.08:1.00.

Mode of injury

RTA was the most common mode of injury accounting for 43% which included skid and fall from two-wheelers, hit by vehicle to pedestrians, the collision of one vehicle with another or a stationary object and overturning of the vehicle. This was followed by domestic fall (31.4%) and fall from height (11.3%) [Figure 1].

Figure 1: Distribution of mode of injury

Associated injuries

Of 580 cases studied, 108 (9.1%) had an external wound, 39 (3.3%) had abrasion, 34 (2.9%) had head injury, 6 (0.5%) had ENT injury, 4 (0.3%) had injury related to the respiratory system and 8 (0.7%) had other associated injury in the study group [Figure 2].

Figure 2: Distribution of associated injuries

Distribution of fractures or dislocations

1117 (94.5%) had fracture, 31 (2.6%) had dislocation and 34 (2.9%) had fracture + dislocation in the study group.

Side involved

1157 (97.9%) had unilateral side involvement and 25 (2.1%) had bilateral involvement in the study group.

Type of fracture

505 (87.1%) had closed type of fracture and 22 (12.9%) had compound fractures graded as per Gustilo and Anderson's classification for open fractures [Table 2].

Table 2: Distribution of type of fracture

Involvement of extremity

659 (42.8%) had upper extremities and 881 (57.2%) had lower extremities involvement in the study group.

Pattern of involvement of various bones involved

The right side (51.6%) was most frequently injured by trauma. Of all the bones, the femur was the most commonly fractured bone with a total of 327 cases (21.2%) followed by radius (n = 263, 17.1%) and tibia (n = 256, 16.6%) [Table 3].

Table 3: Distribution and pattern of involvement of various bones involved

Radiological investigations

Of 1182 cases studied, 1146 (96.9%) had only an X-Ray done, 33 (2.8%) had X-Ray + CT Scan done and 6 (0.3%) had X-Ray + MRI done in the study group.

Incidence of 1-year mortality

Forty (3.4%) expired at the end of 1-year follow-up in the study group. The incidence of mortality (1 year) is significantly higher in the older age groups 61–70 years, 71–80 years, 81–90 years, and 91–100 years compared to other age groups in the study group (P < 0.05). The incidence of mortality (1 year) did not differ significantly in the age groups 10–20 years, 21–30 years, 31–40 years, 41–50 years, and 51–60 years compared to other age groups in the study group (P > 0.05 for all) [Figure 3].

Figure 3: Distribution of incidence of 1-year mortality by age

DISCUSSION

India is rapidly developing and is currently one of the countries with the fastest-growing economy in the world.[²²] Due to the rapid economic transition, there is an increase in the number of automobiles on the road and a rapid increase in RTA.

The main challenge for public health in the coming century is to decrease the burden of injuries.

In the present study conducted over 2 years, there were a total of 1182 trauma admissions with extremity injuries to the patients. Most of the injuries were seen in the 21–30 years (17.1%) and 31–40 years (16.9%) age groups [Table 1].

Dsouza et al.,[⁵] in their study, found that the annual incidence of trauma admissions in the hospital was 15.96% with most of the injuries seen in the 21–40 years age group (39.67%). Similar findings were noted in a study which was done by Swarnkar et al. in a hospital in central India.[²³] Similar studies conducted by Meena et al.[²⁴] found that most patients were in the age group of 31–40 years (24%) followed by 21–30 years (20%). The two age groups accounted for 44% of all trauma victims. Jha, et al.[²⁵] in their study of injury patterns among RTA cases in a tertiary hospital in South India found that more than 53% of the victims were in the age group between 20 and 40 years. Akinpelu et al.[²⁶] in their study of RTAs in a Nigerian tertiary hospital observed that a total of 47.3% of trauma admissions were in the third and fourth decades of life, with mean age as 32 years.

This age group is the most productive, and trauma and its morbidity result in a huge economic setback for the country. Furthermore, these age groups were highly stressful and mobile leading to increased incidence of injuries.

Males far outnumbered females, with a ratio of 2.08:1. Similarly, male predominance was seen in other studies which were done in India,[^5232728] which could have occurred because in India, males are still the main working community and are hence more exposed to work-related stress and workplace injuries.

Meena et al.[²⁴] in their study found that male-to-female ratio was 2.5: 1. Swarnkar et al.[²³] in their study of trauma in Central India observed that the male-to-female ratio was 3.9:1. Okaro and Ohadugha[²⁹] in their study of anatomic patterns of fractures and dislocations among accident victims observed that the male-to-female ratio was 1.8:1.

An unprecedented increase in the number of vehicles has outpaced the development of adequate roads and highways. India has 1% of the motor vehicles in the world, but it bears the burden of 6% of the global vehicular accidents. We had 508 cases [Table 2] of RTAs. Interestingly, at 43%, our hospital sees a higher rate of RTA-related trauma, which is much higher than the Western world (33% for the United Kingdom and 35% for the United States). Probable reasons for such an observation could be the close proximity of our hospital to the national highway and the increased incidents of sports-related injuries in the western world. RTAs accounted for the most common mode of trauma seen, followed by domestic falls in our study, which was similar to those seen in other studies, where RTAs were the most common mode of injury.[²³²⁸] Road traffic injuries are a major cause of death and disability globally, with a disproportionate number occurring in developing countries. They were the leading cause of injury in this study in a similar manner to a number of studies[²³] and accounted for over 70% of the mortality.

Injury patterns due to falls were gender- and age-related and resulted mainly in fractures. Especially, women and the oldest old are at risk for fall-related injuries. This is not surprising because age, female gender, and medication use are well-known risk factors for fall incidents. The oldest old presented with a higher incidence of hip and pelvic fractures. There is most likely an association between fall techniques and comorbidity. “Younger” adults try to reduce the impact of a fall in a moment by stretching their arms, which endures high pressure on impact. This mechanism leads to fractures of the upper extremity. As the oldest old fail to do so, because of less muscle mass, muscle strength, and reflex reaction time, they cannot reduce the impact of their fall as younger adults can do. Furthermore, underlying diseases such as osteoporosis are more pronounced in females and the oldest old which could potentially explain the higher numbers of hip and wrist fractures in these groups compared with males and younger persons.

Of 1182 cases studied, 1080 (91.4%) had closed type of fracture, 35 (3.0%) had compound Grade 1 fracture, 47 (4.0%) had compound Grade 2 fracture, 19 (1.6%) had compound Grade 3A fracture, 8 (0.7%) had compound Grade 3B and 13 (1.1%) had compound Grade 3C in the study group.

97.9% of the extremity injuries had unilateral involvement with the upper extremity (57.2%) and right side (51.6%) most frequently injured by trauma.

Of all the bones, the femur was the most commonly fractured bone with a total of 327 cases (21.2%), especially in elderly patients who suffered domestic falls and had subsequent involvement of the proximal femur owing to direct impact over the hips after a fall. The radius was the second most commonly involved bone to be fractured with 263 (17.1%) cases. This can be correlated with the fall over outstretched hand acting as a protective mechanism to stop a fall and hence the higher incidence of the fracture. The tibia was also similarly seen to be involved in fractures (16.6%). This could be attributed to its subcutaneous location and hence increased vulnerability to trauma even of mild to moderate energy trauma.

Dislocations/fracture-dislocations constituted only 5.5% of all the total cases in the study with shoulder dislocation being the most frequently involved joint.

X-Rays were the favored modality of radiological investigation to come to a diagnosis of the involved extremity injury. It was used in 96.9% of the cases for aiding in the final diagnosis. Its relative economic affordability, quick and precise nature of investigation made it the gold standard for diagnosing fractures in our study. CT was used in 2.8% of cases to further elucidate the fracture pattern.

Finally, a total of 40 cases were found not to survive in the 1 year follow-up after the fracture incidence in the case. Of these, 10 were below the age of 60 years and the rest were above 60 years of age with maximum mortality in the age group of 91–100 years (29.4%). However, when the causes of death were ascertained through telephonic follow–up they were found to be unrelated to the fractures in all cases.

We came across certain limitations during and upon completion of the study. The study population was not representative of the entire population as most of the patients coming to the tertiary hospital were of the lower and middle socioeconomic strata with very few patients belonging to the higher socioeconomic status. Some patients who came to the Orthopedic OPD or Emergency department initially were not willing for further medical management at our hospital due to financial constraints or other reasons. Hence, investigation such as X-Ray which would help in the final diagnosis of the injury could not be performed in such patients. Furthermore, a few patients were lost to the 1–year mortality follow-up due to change in their telephone/mobile numbers.

CONCLUSION

The glaring reality that came forth from this study was:

• 1182 cases of limb trauma alone presented to this one hospital alone in a city in 2 years, indicating a huge incidence of trauma overall
• The most frequently affected population is between 20 and 40 years of age, which happens to be the most active workforce of society causing huge losses to the working man hours as well as income generation for the affected families
• RTAs are the most common mode of injury
• The 1–year mortality has shown that the incidence of mortality is significantly higher in the elderly though fractures were not found to be the cause of death in these patients.

There is also a need for improving the basic infrastructure at District level Hospitals so that number of referrals is decreased. There is an urgent need to set up a Trauma Center on the National Highway in and around Pune, seeing the magnitude of trauma, with fully equipped operation theater to deal with orthopedic emergencies which includes: External fixators, Inter-locking Nailing systems needless to say the routine plating and Nailing systems and last but not the least an Image intensifier.

Awareness campaign regarding strict traffic regulation and safe driving practices may be targeted at the high risk groups (Adult males and students). Multiple effective falls programs focusing on the high-risk groups, such as in women and the oldest old, should be implemented. Future studies should assess long-term quality of life, which has recently been suggested as an increasingly important alternative study endpoint for trauma research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.