Injury, Int. J. Care Injured 43 (2012) 219–222

Fracture stabilisation in a polytraumatised African population—A comparisonwith international management practice

Ben Grey a,*, Reitze N. Rodseth b,c, David J.J. Muckart d,e

a Department of Orthopaedics, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Private Bag 7, Congella 4013, South Africab Perioperative Research Unit, Department of Anaesthetics, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, South Africac Department of Anaesthetics, Inkosi Albert Luthuli Central Hospital, Durban, South Africad Level 1 Trauma Unit and Trauma Intensive Care, Inkosi Albert Luthuli Central Hospital, Durban, South Africae Department of Surgery, University of KwaZulu-Natal, South Africa

A R T I C L E I N F O

Article history:

Accepted 17 August 2011

Keywords:

Timing of fracture fixation

Polytrauma

A B S T R A C T

Introduction: Fracture management in polytrauma patients has favoured early definitive fracture fixation

with some authors advocating a staged management approach in these potentially unstable patients. We

aimed to investigate the timing of surgical fracture stabilisation in polytrauma patients with significant

orthopaedic injuries in a Level 1 trauma unit in South Africa (RSA) and to compare its performance with

Level 1 trauma units in the USA and Europe.

Materials and methods: A retrospective review was performed extracting polytrauma patients with a

New Injury Severity Score (NISS) � 15, with significant pelvic or long bone fractures managed surgically.

We compared these data with recently published data from the USA and Europe.

Results: Over a 3 year period pedestrian (46.3%) and motor vehicle or motorcycle accidents (40.7%) were

the predominant mechanisms of injury in the 123 eligible patients. Compared to international data,

patients were significantly younger (32.41 years (SD 13.4) vs. USA 44.1 years (SD 16.39) and Germany

41.2 years (SD 15.35), p < 0.001); and had a higher NISS score (RSA 31.93 (10.3), USA 27.4 (8.65),

Germany 29.4 (6.88), p = 0.007). Less definitive fixation took place in the first 24 h (RSA 37.4%, USA 57.1%,

Germany 65.6%, p < 0.001), but overall definitive fixation took place earlier (RSA 3.6 days (SD 4.39), USA

5.5 days (SD 4.2), Germany 6.6 days (SD 8.7), p = 0.001).

Conclusion: In a developing country when compared to international trauma centres, less primary

definitive fixation was performed in the first 24 h.

� 2011 Elsevier Ltd. All rights reserved.

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Injury

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Introduction

Fracture management in polytrauma patients has beenextensively researched over the last few decades. Studies duringthe 1980s showed that early fracture fixation (<24 h post injury) inpolytrauma patients (Injury Severity Score (ISS) > 18) decreasedthe incidence of fat embolism syndrome, acute respiratory distresssyndrome (ARDS), pneumonia, and days spent in ICU.1–4

As more emphasis was placed on early fracture fixationsubsequent publications showed that a staged approach to fixingmajor fractures in polytrauma patients with significant (AcuteInjury Score (AIS) > 2) chest, abdominal or head injuries resulted inimproved clinical outcomes.5–8

A recent study compared current treatment strategies at Level1 trauma centres in the USA and Germany.9 Early (<24 h)

* Corresponding author. Tel.: +27 312604293.

E-mail address: bcgrey@gmail.com (B. Grey).

0020–1383/$ – see front matter � 2011 Elsevier Ltd. All rights reserved.

doi:10.1016/j.injury.2011.08.023

definitive fracture stabilisation took place in 65.6% of patientsin the German group and 57.1% of American patients (p-value notsignificant). Both groups had similar time periods to definitivefixation (5.5 days in the American group and 6.6 days in theGerman group, p-value not significant).

In the developing world trauma carries a significant health careand economic burden. Males between the ages of 21 and 30 aremost often injured,10,11 with most injuries and related mortalitybeing caused by road accidents11 and interpersonal violence.12

Patient extraction from rural areas is often delayed due to the poorcondition of roads, and lack of available ambulances. A prospectivestudy in Dakar showed that 77.8% of polytrauma patients wereextracted without pre-hospital care and the mean time from injuryto arrival at the emergency department was 8 h.11

In South Africa the average pre-hospital time ranges from 51to 84 min in urban areas and may double in rural areas.13,14

Secondary hospitals treat most trauma patients, but due to lackof specialists and intensive care beds polytrauma patients areoften transferred to tertiary hospitals for specialist and intensive

B. Grey et al. / Injury, Int. J. Care Injured 43 (2012) 219–222220

care. Based on these factors it would seem inevitable that timingto fracture fixation in a South African Level 1 trauma unit wouldbe delayed when compared to international first world traumaunits.

We wished to compare the performance of the newlyestablished Inkosi Albert Luthuli Central Hospital (IALCH) Level1 trauma unit with the current published international standardof care. IALCH is a quaternary hospital based in KwaZulu-Natal,South Africa. This study aimed to investigate the demographicsand current treatment strategies of polytrauma patients withsignificant orthopaedic injuries with specific attention to thetiming of surgical fracture fixation and to compare theirmanagement to current international practice. Ethics approvalwas obtained from the Biomedical Research Ethics Committee,University of KwaZulu-Natal (BE 207/09).

Materials and methods

A retrospective database review was performed at the Level 1Trauma Unit of Inkosi Albert Luthuli Central Hospital (IALCH),Durban, South Africa. All polytrauma patients treated in theTrauma Unit since its opening in March 2007 until October 2010were reviewed. Data were extracted using the hospital datamanagement system Medicom.

The New Injury Severity Score (NISS) was used to grade injuryseverity.15 Polytrauma patients were defined as those with aNISS > 15. Within this group we selected patients with significantpelvic or long bone fractures (extremity NISS � 9). We excludedchildren younger than 13 years, those that underwent their initialsurgery at another hospital and those who did not undergosurgical fracture stabilisation. We compared our findings to arecent matched-pair analysis study which compared currenttreatment strategies at Level 1 trauma centres in the USA andGermany.9

Statistical analysis

Standard descriptive statistics were used to describe patientcharacteristics, including means, standard deviations and inter-quartile ranges for continuous variables. All data analyses wereperformed using SPSS 15.0 for Windows (SPSS, Chicago, IL), usingthe x2 test for categorical data and Student’s t-test and one-wayANOVA where appropriate for normally distributed continuous

Table 1Demographic comparison between the three Level 1 trauma centres.

RSA (n = 123) U

Age (SD) 32.41 (13.4) 4

Male sex (%) 80 (65) 3

Mean NISS points (SD) 31.93 (10.3) 2

Mean ICU stay in days (SD) 14.73 (13.82) 1

RSA, Republic of South Africa; USA, United States of America; SD, standard deviation;

* Statistically significant.

Table 2Fracture management in the first 24 h.

Orthopaedic management RSA (n = 123)

Primary definitive fixation (%) 46 (37.4)

Non-invasive: traction or backslab (%) 34 (27.6)

Temporising external fixation (%) 12 (9.8)

Definitive external fixation (%) 36 (29.3)

RSA, Republic of South Africa; USA, United States of America.* Statistically significant.

data. Statistical significance was defined as a two-sided p-value<0.05.

Results

During this period 396 trauma patients with orthopaedicinjuries were treated at this facility. After exclusion 123 patientswere considered eligible. The mechanism of injury was viapedestrian vehicle accident (PVA) in 57 (46.3%), motor vehicle(MVA) or motorcycle (MCA) accident in 50 patients (40.7%), gun-shot wound in 11 (8.9%) and fall from height in 5 (4.1%) patients.Forty patients (32.5%) were admitted from scene, with the restbeing referred from other hospitals.

We grouped patients according to time to surgical fracturestabilisation with 88 patients (71.5%) undergoing fracture stabi-lisation within 48 h, 17 (13.8%) between 48 and 96 h and 18(14.6%) after 96 h. In the subgroup of 40 patients who werereceived directly from scene 60% underwent surgery at <12 h, and70% at 24 h.

We subsequently compared the demographics (Table 1) and thetiming of our surgical fracture fixation (Table 2) with those fromrecently published German and US data. The mean time todefinitive fixation in our group was 3.6 (standard deviation (SD)4.39) days compared with 5.5 days (SD 4.2) in the USA and 6.6 (SD8.7) in Germany (p = 0.001).

Discussion

We performed a retrospective database review of polytraumapatients with significant orthopaedic injuries presenting to theLevel 1 Trauma Unit, Inkosi Albert Luthuli Central Hospital inDurban, South Africa, in which we investigated the demographics,primary treatment during the first 24 h, and the time to definitivefixation. Additionally we compared our results with a recentretrospective review comparing treatment strategies of majorfractures in polytrauma patients presenting to comparable Level 1trauma centres in the USA and Germany.9

Although a similar male predominance existed between thestudies, the average age of our patient group was significantlylower than the international patient groups. Two recent prospec-tive studies of polytrauma patients presenting to other Africanteaching hospitals in Lagos10 and Dakar11 also reported a similaryounger average age, 31.2 years and 30 years respectively. As

SA (n = 57) Germany (n = 57) p value

4.1 (16.49) 41.2 (15.35) <0.001*

7 (64.9) 36 (63.2) 0.968

7.4 (8.65) 29.4 (6.88) 0.007*

0 (7.49) 15.6 (18.25) 0.06

NISS, New Injury Severity Score; ICU, intensive care unit.

USA (n = 77) Germany (n = 93) p value

44 (57.1) 61 (65.6) <0.001*

7 (9.1%) 1 (1.1%) <0.001*

19 (24.8) 21 (22.6) 0.005*

7 (9.1) 10 (10.8) <0.001*

B. Grey et al. / Injury, Int. J. Care Injured 43 (2012) 219–222 221

young adult males make up the majority of the potential workforce these findings highlight the additional economic cost of thetrauma burden in Africa.

The most common mechanism of injury in our study waspedestrian vehicle accidents, followed by motor vehicle andmotorcycle accidents. As reflected in this paper, road accidents arethe leading cause of injury-related mortality worldwide, withmore than 90% of accidents occurring in low- and middle incomecountries.16 In developed countries such as the United States themajority of road accident fatalities are motor vehicle drivers. Incontrast pedestrian vehicle accidents predominate in the devel-oping world as shown in our data was well as data from Kenya,17

Ghana,18 Uganda,19 Cameroon,20 and Mozambique21 wherepedestrians make up 45–70% of road accident fatalities.

The NISS has been shown to be an accurate predictor of traumarelated mortality.15 Despite our use of a NISS > 15 as our inclusioncriteria, our mean NISS was significantly higher than theinternational trauma centres who used a NISS > 16 as theirinclusion criteria. This may be explained partly by the internationalpaper excluding patients who died during their hospital stay whilstwe only excluded patients who died preoperatively. Our meanNISS was not statistically significantly different when comparedindividually to the Germany population (p = 0.09) but wassignificantly different when compared to the US population(p = 0.004). This may reflect differences in referral patterns inthe USA.

Early definitive fixation (<24 h) of fractures has been shown tobe the preferred treatment in polytrauma patients resulting in thereduction of acute respiratory distress syndrome (ARDS), fatembolism syndrome and time spent in ICU.1–4 A large population-based database review of patients with femur fractures found thatin severely injured patients (ISS � 15) early femur fracture fixation(<24 h) decreased mortality significantly when compared to non-surgical management (3.8% vs. 24%, p < 0.0001).22 The additionalbenefits of ‘‘early total care’’ include improved pain relief, ease ofnursing, earlier patient mobilisation with a reduction in complica-tions associated with immobilisation and shorter hospital stays.

We performed less primary (early) definitive fracture fixation(<24 h) than the international trauma centres with 37.4% of ourpatients undergoing primary definitive fixation compared with57.1% of the American patients and 65.6% of the German patients(p < 0.001) but by 48 h 59.3% of our patients had undergonedefinitive fixation. This delay may reflect the higher NISS scores inour population or the manner in which the unit is run. Full 24 hcover is provided by a team of surgical, orthopaedic andanaesthetic registrars supervised by a trauma surgeon. In additionthere is a dedicated trauma theatre available solely for use by thetrauma unit. This availability of both the theatre and themanagement team removes the pressure created by limitedtheatre access. Definitive fracture fixation can be delayed untilthe patient is fully resuscitated rather than the team beingpressurised into attempting definitive fixation during a surgicalprocedure when the patient may not be optimally resuscitated.

Certain studies have shown that a delayed or staged approachto fracture fixation is preferable in polytrauma patients withsignificant (AIS > 2) head, chest or abdominal injuries.5–8 Theconcept of damage control orthopaedic surgery has emerged as astrategy to deal with fractures in unstable or potentially unstablepolytrauma patients.23,24 The strategy consists of early (<24 h)temporary external fixation of femur fractures, continued resusci-tation in the intensive care unit and delayed conversion to anintramedullary nail.23,24 Primary external fixation with secondarydelayed definitive fixation decreased the incidence of ARDS whencompared to primary (<8 h) intramedullary femoral nailing (7.8%vs. 15.1%, p = 0.003) and decreased the incidence of multiple organfailure (11.5% vs. 16.2%, p = 0.03).24

We treated significantly more patients with a non-invasiveapproach during the first 24 h post arrival to the unit (RSA 27.6%,USA 9.1%, Germany 1.1%, p < 0.001). This approach includedtraction of femur fractures and temporary back slabs for other longbone fractures to provide temporary immobilisation until resusci-tation was complete and patients were stable enough for surgicalfracture stabilisation.

In contrast to the international groups, most of our patientswith external fixation did not have secondary conversion to anintramedullary nail and were referred back to their base hospitalsupon discharge from ICU. Data regarding further fracturemanagement at these hospitals were not available for this review.This may explain why the average time to definitive fixation in ourgroup was significantly shorter than the international groups (RSA3.6 days, USA 5.5 days, Germany 6.6 days, p = 0.001).

There are a few limitations to our study. This retrospectivelycollected data was compared to a matched-pair patient cohortpopulation which may not accurately reflect the average patientpopulations in Germany and the USA. In addition the comparisonpaper examined individual fracture management whilst ourstudy examined individual patient rather than specific fracturemanagement.

Conclusion

As a dedicated Level 1 trauma unit in Africa our traumapopulation consists predominantly of young males involved inpedestrian motor vehicle accidents. In comparison to other Level 1international trauma centres we performed less primary definitivefixation and managed more patients non-invasively during thefirst 24 h, with subsequent staged definitive fixation after a periodof further resuscitation in ICU.

Financial support

This study was funded by departmental funds only. Dr Rodseth issupported by a CIHR Scholarship (the Canada-HOPE Scholarship).

Conflict of interest statement

We declare that we have no conflicts of interest.

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