Open fractures: prospective and epidemiological study

Abstracts

OBJETIVO: Traçar o perfil epidemiológico dos pacientes atendidos em uma unidade de urgência com diagnóstico de fratura exposta. MATERIAIS E MÉTODOS: O trabalho é do tipo epidemiológico, prospectivo, descritivo, observacional, das fraturas expostas atendidas por amostra de conveniência na instituição, no período de 1 setembro de 2005 a 31 de março de 2007. A coleta dos dados foi através de questionário com diversas variáveis. RESULTADOS: Obtivemos 342 pacientes portadores de 346 fraturas, sendo a maioria do sexo masculino (86,84%), com idade média de 30,41 anos e tempo médio de internação de 6,87 dias. As profissões encontradas foram os estudantes (21,92%), seguido dos "motoboys" (11,40%). Os acidentes ocorreram em vias públicas (57,30%), acometendo os ossos da perna (37,86%) e classificadas como grau III (45,36%). Lesões associadas ocorreram em 27,19%, apresentando 11,11% de complicações. Houve consumo de bebida alcoólica (12,86%) e drogas (1,46%) nas 6 horas que antecederam o trauma. CONCLUSÃO: Houve o predomínio do paciente jovem do sexo masculino, com ensino fundamental incompleto, acidentes de trânsito, no período das 19hs às 0hs, acometendo os ossos da perna e classificadas como grau III. As lesões associadas e complicações precoces estão mais relacionadas às lesões de maior gravidade.

Fraturas expostas; Epidemiologia; Estudos prospectivos

ORIGINAL ARTICLE

Department of Orthopedics and Traumatology of Hospital Santa Marcelina

Mailing Address

ABSTRACT

OBJECTIVE: To delineate the epidemiological profile of patients attended by an emergency unit, diagnosed with open fractures.

MATERIALS AND METHODS: This is an epidemiological, prospective, descriptive, observational study of open fractures attended at the institution, selected by convenience sampling, in the period September 1, 2005 to March 31, 2007. The data were collected from patients using a questionnaire with multiple variables.

RESULTS: we obtained 342 patients with 346 open fractures. The majority of the patients were male (86.84%), with an average age of 30.41 years and average hospitalization time of 6.87 days. The main professions were students (21.92%), followed by motorcycle couriers (11.40%). The accidents occurred on public roads (57.30%), affecting mainly the leg bones (37.86%) and classified as level III (45.36%). Associated injuries occurred in 27.19%, with 11.11% complications. There was evidence of alcohol consumption (12.86%) and drug use (1.46%) in the six hours prior to the trauma.

CONCLUSION: The patients were mainly young, male, with incomplete school education. The main cause of the traumas was road accidents, occurring at night (between 7 pm and midnight), with leg bone injuries classified as level III. The associated injuries and early complications were predominantly related to injuries of greater severity.

Keywords: Open Fractures. Epidemiology. Prospective study.

INTRODUCTION

Open fractures remain a challenge for orthopedists as far as stabilization, alignment and skin coverage besides infection pro-phylaxis are concerned. They represent severe injuries with high socioeconomic impact.

The Hippocratic treatment of patients severely injured in wars was amputation of the affected limb or cauterization of the wound, evolving in the 15^th and 16^th centuries with Brunschwig and followers who postulated that the removal of the devitalized tissue was necessary for wounds that did not heal. After World War I, extensive debridement was consolidated as one of the principles of treatment to prevent infection.¹

Open fractures treated in the orthopedic trauma unit in Edinburgh were seen in 11.5 of every 100,000 inhabitants per year.² In the United States, the annual cost is estimated at around U$ 230,600 million.³ In Brazil, in an epidemiological study, the authors observed that traffic accidents were the main cause of occurrence of these injuries.⁴

Epidemiological studies are of vital importance to the centers of reference of health care services for the population; this information can be used to plan the treatment, define priorities and enhance the understanding of this complex group of traumas.^5,6

The aim of the project was to define the epidemiological profile of patients attended in the Orthopedics and Traumatology service of Hospital Saint Marcelina, in the period from September 1, 2005 to March 31, 2007, with a diagnosis of open fracture, and to establish the frequency of fractures in terms of the main variables: gender, age, occupation, school education, type of trauma, classification of the lesion, location of the lesion, seasonality (month, day of the week and time of incidents), mode of transport to the hospital, associated lesions, immediate complications, hospitalization time and others.

MATERIAL AND METHODS

The proposed study was epidemiological, prospective, descriptive and observational, involving open fractures attended by convenience sampling at the institution.

The study group consisted of patients admitted to the service with a diagnosis of open fracture, in the period from September 1, 2005 to March 31, 2007.

A questionnaire was formulated for the gathering of patient data, with variables to be analyzed subsequently. This questionnaire was completed after the signing of the consent term by the patient or legal guardian, maintaining assurance in its methodology of the right to confidentiality and to the freedom of non-inclusion in the study at the beginning as well as at any time.

Inclusion criteria: All the patients hospitalized with a diagnosis of open fracture, with no restrictions as regards gender, age, fracture location or associated lesions.

Exclusion criteria: Patients attended previously in other services; admitted in the emergency room with more than 6 hours of evolution; death before performance of orthopedic procedure; evasion before hospital discharge and those that refused to sign the informed consent term.

We considered lesions associated with the presence of other non-open fractures, vascular lesions besides peripheral nerve, abdominal, thoracic, cranioencephalic, buccomaxillofacial and cutaneous lesions.

Complications occurring in up to seven days after the injury were defined as early-onset complications.

For the classification of fractures we used the method of Gustillo and Anderson⁷, modified by Gustillo et al.⁸ and widely disseminated in medical literature, which describes the morphology of the fracture and lesions of associated soft parts.

Four 6-hour periods were established for analysis of the accident time (from 1 a.m. to 6 a.m., from 7 a.m. to noon, from 1 p.m. to 6 p.m. and from 7 p.m. to midnight).

The information obtained was processed in a record bank of the Microsoft ACCESS program, version 2003 for data preparation and analysis. Pearson's chi-square test was used for verification of homogeneity among categories of the qualitative variables (distribution by months, day of the week, time, age bracket, school education, type of accident, type of casualty rescue transportation, region affected and severity of the fracture), and to verify the existence of association among variables. A significance level of 5% (alpha = 0.05) was used in all the tests, while tests with p < 0.05 were statistically significant.

The research project was duly approved by the committee of ethics of the Hospital, under registration number 37/2005.

RESULTS

The study group consisted of 342 patients with 346 open fractures, attended between September 1, 2005 and March 31, 2007, with an average 0.59 cases per day.

Most of the patients - 297 (86.84%) were male while 45 (13.16%) were female. As regards ethnic distribution, 194 patients (56.72%) described themselves as not white, 142 (41.52%) as white and 6 (1.75%) as yellow.

The average age was 30.41 years (ranging from 1 to 88 years) and standard deviation was 16.8 years. The mode was 21 years, corresponding to 17 cases. The age bracket with the highest rate of cases ranged between 21 and 30 years (Figure 1), with statistical significance (p < 0.001). The percentage of children victims of fractures with bone exposure draws attention (11.69%).

There was a predominance of patients with incomplete primary education in 142 (41.52%) cases, followed by incomplete secondary education with 71 (20.76%) and complete secondary education with 58 (16.95%), p < 0.001. (Figure 2)

The statistical comparison of the proportions of open fractures per month and per week, performed by means of the study of percentages, did not show a significant difference, with p = 0.932 and p = 0.878. Even comparing the percentages of the weekend with the others, there was no statistical difference, p = 0.163. (Figures 3 and 4) There was a predominance of medical care in the period from 7 p.m. to midnight, with 142 (41.52%) incidents. This difference proved statistically significant, with p < 0.001. (Figure 5)

The average hospitalization time was 6.87 days (ranging from 1 to 75 days) and standard deviation of 9.36 days. The mode was 7 days, corresponding to 34 cases.

The most frequent occupation was student, with 75 (21.92%) patients and 39 (11.40%) motorcycle couriers. (Table 1)

Accidents on public roads were the most common with 196 (57.30%) cases (run-over cases, car, motorcycle and bicycle accidents). Compared with the other causes the difference of these proportions was significant, with p < 0.001. (Table 2)

The Fire Brigade was responsible for transporting 194 (56.72%) victims to the emergency room, followed by own modes of transport: 110 cases (32.16%), SAMU (Urgent Mobile Health Care Service): 27 (7.89%) and military police air rescue on 11 (3.21%) occasions. The comparisons of the type of transportation and the severity of the fracture are shown in Figure 6.

There was a predominance on the left side in 202 (59.06%) patients, 132 (38.15%) on the right and 8 (2.31%) bilateral. The segments that presented the highest percentages of open fractures were the leg bones with 131 (37.86%) lesions and the hand bones with 57 (16.47%), whereas the difference among open fractures of the leg compared with the others were statistically representative, with p < 0.001. (Table 3) When we evaluated only open fractures of the leg, we noticed a higher incidence of the left side with 84 (64.12%) cases. Thirty-eight (11.11%) patients had a record of open fracture and in the group of patients identified as motorcycle couriers, this percentage rose to 18 (17.4%).

Lesions classified as type III, according to Gustillo, were more abundantly present in 157 (45.36%) fractures, followed by type II 101 (29.19%) and type I 88 (25.54%) with this difference also having statistical significance p < 0.001. (Figure 7)

A total 93 (27.19%) patients were found with associated lesions, of which the most frequent were: other closed fractures 36 (38.7%), followed by vascular lesions 15 (16.12%). (Table 4) Early-onset complications occurred in 38 (11.11%) patients. The most common were amputations with 23 (6.67%) cases .(Table 5) The frequency of alcohol consumption and illegal drug use and both in the 6 hours that preceded the trauma were respectively 44 (12.86%), 5 (1.46%) and 11 (3.21%) patients.

DISCUSSION

The incidence of open fractures, their consequent complications and the shortage of other prospective epidemic articles in Brazilian literature motivated the performance of this study.

The goals proposed initially were attained, there was no loss of data or non-completion of the questionnaires. The bias described by several retrospective studies was resolved with this approach, making the data more trustworthy.

A total 344 patients were attended in the period from September 1, 2005 to March 1, 2007 with 348 open fractures. Two of these patients were excluded, one due to evasion and the other due to intra-operative death in the urgent care center, totaling 342 patients and 346 fractures. No patient refused to sign the term of informed consent or withdrew during the execution of the work.

Most of the patients were male, in the proportion of 6.6 men to every woman and the majority was in the economically active age bracket (from 21 to 30 years), in conformity with the literature.^4,8-11 One fact that concerned us was the large number of children that we encountered in the survey, particularly during the school holiday months.

There was a small predominance of non-white patients, contradicting the results observed from the bibliography,⁴ a fact that is directly related to the population of this region that differs from other epidemiological and population studies.

A wide variety of occupations was found, with significant participation of those that called themselves motorcycle couriers with no similarity between our findings and literature,⁴ a fact related to the geopolitical and economic differences of the region of each study. Most of the sample group called themselves students, a result that is due to the large number of patients in the student age bracket. The majority of the patients had a level of education below that expected for their age, reflecting a sample of the regional population.¹² The most common level of education was incomplete primary education, while only one Brazilian reference to this variable was found, with its predomination as well.⁴ Illiteracy was found in 6.43% of the cases, similar to the mean value of inhabitants of the State of São Paulo (4.7%).¹²

The data obtained in this study evidenced the high demand for this orthopedic emergency service in a reference hospital for trauma. Contradicting the results of Cunha et al.^13,14, there was no statistical difference in the distribution of accidents when we evaluated months or days of the week, which surprised us. We observed a certain level of seasonality in the school holiday months (December, January, June and July) and in the nighttime period, although there was no significance.

The public rescue service proved to be more important in providing assistance to the more severely injured victims. The representative portion of patients with other associated lesions reflects the clear relationship of open fractures with traumas of high kinetic energy and also the importance of a multidisciplinary team trained to provide adequate emergency care.

Accidents on public roads continue the chief causes of these kinds of lesions.^{2,10,11,15-20} Previous studies already indicated this type of accident as the main cause of open fractures, particularly at the expense of motorcycle accidents.^4,11 The occurrences of run-over cases on pedestrian crossings denotes disrespect for traffic laws. We believe that the creation of educational campaigns, specific lanes for motorbikes and other measures can change this statistic.

Approximately one third of injuries resulted from motorcycle accidents, and in almost all of these, open fractures were located in the lower limbs.^19,20 We believe that the use of motorcycles both as a work tool and as a means of locomotion and the greater exposure of the lower limbs in this mode of transport contributed toward these results.

Hand injuries ranked second in frequency, Howard and Court-Bronw⁶, Cunha et al.¹³ and Larsen et al.²¹, however, presented hand injuries as the most important in their series. This difference is based on the large number of civil construction worker patients encountered in those studies and on the fact that our services is a reference to the most critical situations.

Type III open fractures formed the majority, in conformity with literature,^2,4,8,11,17 except for Gustillo¹⁵ who presented only 25.5% of lesions classified as type III. The difference between the incidences of these studies and the data found by Gustillo draws attention. This discrepancy occurs due to the effect of variables such as location of services, degree of urbanization, risk factors and research performance time, requiring new comparative studies of these variables to better correlate them. In this study, the most severe fractures (type III) occurred mostly in the leg bones, probably on account of the most common trauma mechanism, fall from motorcycle. The associated lesions, including other closed fractures, and early complications were more frequently encountered at degree III open fracture, when compared with those of type I and II. The associations verified are also a result of the high energy involved in these traumas.^17,19

Amputations occurred in 6.67% of the total, a lower percentage than that described in literature.^{8,16,19,22,23} Amputations were indicated for the most critical lesions. We believe that the lower frequency observed is related to the availability of a first aid vascular surgery team and the conduct of the service in always attempting to preserve the limb, considering the difficulties faced by patients in acquiring prostheses and in signing up for rehabilitation programs.

The average hospitalization time of these patients was 7 days, similar to literature. This period corresponds to the time necessary for intravenous antibiotic therapy, damage control, treatment of associated lesions, surgical re-approaches and dressings. In an analysis of our sample, we can observe an association of infection in patients with more extensive injuries and with greater implication of soft parts.

A considerable part of the sample declared alcohol consumption or illegal drug use before the accident. We observed that in the period where accidents are more frequent, 7 p.m. to midnight, they coincide with a greater number of patients under the effect of alcohol or other narcotics, showing an association of these substances with accidents involving open fractures. However, no toxicological tests were conducted for investigation.

It is obviously important for the orthopedic surgeon to be familiar with the epidemiological behavior of this pathology. We believe that the short data gathering time was a limitation for probable other conclusions in this study. New surveys with a longer gathering time or multicentric surveys could add new concepts on a vast array of variables of these traumas.

CONCLUSION

In the results obtained there was a predomination of male youths with incomplete primary education, traffic accidents, in the night-time period from 6:01 p.m. to 11:59 p.m., involving the leg bones and classified as degree III (high-energy trauma), in conformity with literature. The associated lesions and early complications are more closely related to the lesions of greater severity. Due to its type of medical care the public rescue service has objectified a more adequate treatment when in relation to the accident time and the final treatment. These patients remained in hospital for a week on average.

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Open fractures: prospective and epidemiological study

Luciano Rodrigo Peres Arruda; Marco Aurélio de Campos Silva; Frederico Galves Malerba; Miguel de Castro Fernandes; Flávio Moral Turíbio; Marcelo Hide Matsumoto

Publication Dates

• Publication in this collection
  03 Mar 2010
• Date of issue
  2009

History

• Received
  25 Aug 2008
• Accepted
  12 June 2009