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Abstract

Objective: To study the etiology, various mechanisms of injury and outcome of orthopedic trauma in elderly patients presenting to the Emergency Department of a tertiary care hospital. Methods: The data was prospectively collected over a period of 1 year (Jan 2015-Dec 2015) at the Jinnah Postgraduate Medical Centre's orthopaedic bay in the Emergency Department. 692 elderly trauma-patients above 65 years were included. The doctors on duty filled out a simple questionnaire for every patient that presented with orthopedic injury. Statistical analysis was done using SPSS version 20. Results: Falls on the same plane were the most common cause of injury at 67.1% (n=464), while road traffic accidents were the second most common accounting for 22.55% (n= 156), and alarmingly third came gunshot injuries at 2.3 % (n=16). The most common site of injury due to falls was the lower limb at 43.9% (n=304) while the upper limb was 23.1% (n =160). Of the fall injuries, 81.9% (n=464) had a fall on the same plane while 18.1% (n=84) had a fall from 10 feet or higher. Conclusion: The percentage of elderly patients amongst the general population is increasing day by day and so is the risk for trauma. Aggressive management to counteract this increase in geriatric trauma is required, along with sensitivity to issues such as elder abuse. An emphasis on nationwide policies and state-run programs for elder citizens regarding healthcare and primary disease prevention as well as their rehabilitation will serve to reduce the burden on an already poverty-stricken nation.
ORIGINAL ARTICLE
JPOA 16
Epidemiology of Orthopedic Trauma in The Geriatric Population of
Karachi, Pakistan
Mansoor Kanaan1, Saba Shahnawaz2, Ranjeet Kumar3, Ali Ahmad3, Anisuddin Bhatti3
ABSTRACT
Objective: To study the etiology, various mechanisms of injury and outcome of orthopedic trauma
in elderly patients presenting to the Emergency Department of a tertiary care hospital.
Methods: The data was prospectively collected over a period of 1 year (Jan 2015-Dec 2015) at the
Jinnah Postgraduate Medical Centre’s orthopaedic bay in the Emergency Department. 692 elderly
trauma-patients above 65 years were included. The doctors on duty filled out a simple
questionnaire for every patient that presented with orthopedic injury. Statistical analysis was done
using SPSS version 20.
Results: Falls on the same plane were the most common cause of injury at 67.1% (n=464), while
road traffic accidents were the second most common accounting for 22.55% (n= 156), and
alarmingly third came gunshot injuries at 2.3 % ( n=16). The most common site of injury due to falls
was the lower limb at 43.9% (n=304) while the upper limb was 23.1% (n =160). Of the fall injuries,
81.9% (n=464) had a fall on the same plane while 18.1% (n=84) had a fall from 10 feet or higher.
Conclusion: The percentage of elderly patients amongst the general population is increasing day by
day and so is the risk for trauma. Aggressive management to counteract this increase in geriatric
trauma is required, along with sensitivity to issues such as elder abuse. An emphasis on nationwide
policies and state run programs for elder citizens regarding healthcare and primary disease
prevention as well as their rehabilitation will serve to reduce the burden on an already poverty
stricken nation.
INTRODUCTION
Pakistan is a developing nation with limited resources
at hand and an ever-expanding population, due to
which there is a scarcity of proper medical
management. Orthopedic injuries in Pakistan are as
common as in any other part of the world. The burden
of orthopedic injuries is prevalent in all age groups of
the population but the geriatric age group has been
claimed to have a poor outcome regarding traumatic
injuries. This is postulated to be due to a decrease in
physiological reserve and an increase in the number of
co-morbid factors [1,2].
Ranging from adolescents to adults, a large
portion of trauma patients can be attributed to the
aforementioned age groups, but the fastest growing
age band for trauma centers is patients above the age
1Emergency Department, Dr. Ziauddin University Hospital,
Karachi, Pakistan
2Dialysis Unit, The Kidney Centre, Karachi, Pakistan
3Orthopaedics Department, Jinnah Postgraduate Medical
Centre, Karachi, Pakistan.
Correspondence: Kanaan Mansoor
E-mail: kanaanm@gmail.com
of 65 years [3]. A Census done in the United States in
2010 stated that there were roughly 40.3 million
people aged 65 years or older comprising 13 percent of
the total population as compared to an older census in
2000 which showed 35 million people in this age
bracket, amounting to 12.4 percent of the total
population [4]. Trauma is considered to be the fifth
leading cause of death and it is approximated that
roughly 1/3 of the health care resources are spent on
patients above 65 years of age [4-7]. The National
Trauma Database of the United States highlighted that
elderly patients comprised 25 % of the patients
presenting to trauma centers in the United States
during 1990 [8]. A major etiology of orthopedic trauma
is shown to be injuries related to falls in the elderly
while in young patients the major cause of injuries was
due to penetrating injuries and road traffic accidents or
motor vehicle accidents [9-10]. The global burden of
injuries is already substantial and in the years to come,
the leading cause of death and disabilities would be
injuries [11]. A major chunk of this burden would be
borne by countries, which have a high population of
low or middle-income people [12], and thus Pakistan is
amongst the front-runners of such nations. In the
Mansoor Kanaan, Saba Shahnawaz, Ranjeet Kumar, Ali Ahmad, Anisuddin Bhatti
JPOA 17
census of 1998 there were 7.3 million elderly persons
which was 5.6% of the total population, and this
population of elderly persons is expected to rise to as
high as 26.84 million, or 11% of the total population of
Pakistan soon [13]. This shows that healthcare and
rehabilitation issues regarding senior citizens will be on
the rise in the future and appropriate measures should
be taken to combat them, as this is one section of the
population which usually does not contribute to the
economy and therefore a rise in their issues means an
increased burden on the country.
Pakistan is a developing nation with high crime
rates, a negligible following of traffic laws and poor
health care. This study was done in the most populated
city of Pakistan, Karachi, to study the pattern of injuries
amongst the geriatric population of the study. Jinnah
Post Graduate Medical Center is the busiest tertiary
care hospital in the city and has one of the highest
inflows of patients in the city.
METHODS
This was a cross sectional study conducted at, Karachi,
Pakistan. The survey included analysis of all injured
patients greater than 65 years of age who presented at
the orthopaedic unit of the Accident and Emergency
Department for a period of 1 year starting from
January 2015. Ethical committee of the hospital
approved the study protocol before initiation.
Informed consent was obtained from all patients. The
doctors on duty filled out a questionnaire for every
geriatric patient that presented with an orthopedic
injury. The information recorded included the victim’s
age, gender, date, nature of injury, place of injury,
cause of injury, approximate time of injury, mode of
treatment, time of treatment and outcome. The total
sample size was 692 that were collected over the
period of a year. Statistical analysis was done using
SPSS version 20.
RESULTS
A total of 692 patients above the age of 65 presented
to the ER during the time frame of the study. The most
common cause of injury was noted to be a fall which
accounted for 67.1% (n=464), while road traffic
accidents were the second most common cause of
injury which accounted for 22.5% (n= 156) and the
third most common cause and the most alarming
finding was orthopedic trauma due to gunshot injuries
which accounted for 2.3 % ( n=16). The most common
site of injury in the case of a fall was the lower limb,
accounting for 43.9% (n=304) while upper limb injuries
due to fall came to 23.1% (n =160).
Table 1: Cause of trauma
Frequency (n)
Percent %
RTA-Pedestrian
116
16.8
RTA- Bike
38
5.5
RTA- Car
20
2.9
RTA- commercial
2
.3
Fall-same level
380
54.9
Fall- height
84
12.1
Gun shot
16
2.3
Assault- blunt
4
.6
Assualt -penetrating
4
.6
Occupational machine
2
.3
Sports
2
.3
Other
24
3.5
Total
692
100.0
As highlighted in Table 1, author divided fall
related injuries into two different categories, which
included fall from the same plane and fall from a height
of more than 10 feet. Out of the 464 patients who
presented with fall related injuries, 81.9% (n=464) had
a fall on the same plane level while 18.1% (n=84) had a
fall from 10 feet or more.
Table 2: Severity of Injuries in Patients with Fall
Frequency
Percent
Fracture of upper limb
128
27.6
Fracture of lower limb
264
56.9
Fracture of pelvis
14
3.0
Fracture of clavicle
8
1.7
STI upper limb
10
2.2
STI lower limb
24
5.2
Dislocation upper limb
14
3.0
Dislocation lower limb
2
.4
Total
464
100.0
Patients who had a fall on the same plane were
mostly women 54%(n=208) while men constituted
45.2% ( n=172) , and these falls mostly occurred at
home. Our data has included the sub categories of
patient presentation, time and the time of injury.
Patients who had an injury due to a fall and presented
on the same day were 59.1% of the total (n=274) out of
which 63.5% (n=174) had a fall during the day while
36%(n=100) had a fall at night. Another aspect that is
interesting is that 40% (n=190) out of the 464 patients,
Epidemiology of Orthopedic Trauma in The Geriatric Population of Karachi, Pakistan
18 Vol. 29 (2) July, 2017
who had a fall, had their medical management delayed
by their caretakers
Patients, who had a fall, had different degrees of
injury, ranging from fractures to dislocations and soft
tissue injuries, as shown in Table 2.
Patients with upper limb fractures had 8.4%(n=58)
combined Radius and Ulna fractures while isolated
fractures of the Radius were 4.6% (n=32), Humerus
were 3.75% (n=26) and Ulna were 0.3%(2). Patients
with lower limb fractures had 24.3% (n= 168) neck of
femur fractures, 6.9% (n=48) shaft of femur fractures
and combined fractures of the Tibia and Fibula
accounted for 2.3% (n =16). Isolated fractures of the
Tibia were (8), Fibula were (4) and patellar fractures
were (4). Out of the patients with fractures of the
upper limb, 4 were admitted, while 134 patients with
lower limb fractures were admitted and 8 were
referred. Rest of the patients were managed
conservatively and asked to follow up in the OPD.
The second most common cause of injury was
shown to be road traffic accidents, which we divided
into four categories; (1) patients who were pedestrians,
(2) patients who were in a car, (3) a commercial vehicle
or (4) whether the patient was riding a bike. Out of the
total sample size of 692, the percentage of road traffic
accidents involving elderly patients was 25.4% (n=176).
Majority of the patients involved in RTAs were males
20.2% (140) while females constituted 5.2% (n=36).
Most of the patients were pedestrians, accounting for
16.7% (n=116), patients riding bikes were 5.49
%(n=38), patients were either passengers or driving the
cars were 2.9% (n=20) while patients who were either
passengers or drivers of commercial vehicles were .3%
(n=2).
Table 3: Most common site of injury according to the type of RTA
Cause of trauma
Total
RTA-Pedestrian
RTA- Bike
RTA- Car
RTA- commercial
Fracture of upper limb
28
12
4
0
44
Fracture of lower limb
72
14
8
2
96
Fracture of pelvis
0
2
0
0
2
Fracture of clavicle
2
2
2
0
6
STI upper limb
4
2
6
0
12
STI lower limb
6
2
0
0
8
Dislocation upper limb
0
2
0
0
2
Dislocation lower limb
0
2
0
0
2
Diabetic limb/ gangrene
2
0
0
0
2
Infection, wound, cut, vascular,
amputation, foreign body
2
0
0
0
2
116
38
20
2
176
The most common bone affected in pedestrians
was the combined fracture of Tibia and Fibula which
accounted for 3.5%(n=24) while the second most
fractured region was the neck of femur 2.3%(n=16),
followed by the shaft of femur 1.4%(n=10). The most
common bone affected in patients involved in RTA-
Bike was the combined fracture of Radius Ulna which
accounted for (n=12) while the second most fractured
bones were Tibia and Fibula combined (n=6), followed
by the Humerus (n=4). Patients involved in RTA Car
sustained fractures to the Humerus (n=4), followed by
fractures of the Tibia and Fibula combined (n=6).
Commercial RTAs rarely occur and if so, the passenger
and drivers are mostly safe thus there were only two
fractures in that category, which were of the neck of
femur.
The third most common cause of fractures was
Fire Arm injuries. The group of people that presented
with fire arm injury and fractures were 2.3% (n=16) and
the most common site of injury was the upper limb at
1.2% ( n=8) followed by the lower limb at 1.2%(n=8).
The most common bones to be fractured were the
Humerus, Radius, Metacarpals and Scapula which were
evenly divided leading to 2 of each. The lower limb had
four fractures, which evenly divided into 2 fractures in
each category: the Fibula and the ankle joint. Majority
of the gunshot victims were males 1.7%(12) while there
were only 0.6%(n=4) females.
Mansoor Kanaan, Saba Shahnawaz, Ranjeet Kumar, Ali Ahmad, Anisuddin Bhatti
JPOA 19
DISCUSSION
The elderly population is slowly rising due to
advancements in the health sector. This population is
at a higher risk of orthopedic injuries due to the
increased number of co-morbids [14]. The most
reliable assessment of global mortality and morbidity is
provided by the Global Burden of Disease project [15]
and the first ever Global Burden of Disease study was
conducted in 1991 and published in 1996 [11]. This
study introduced DALY (disability-adjusted life year),
which drew attention to non-fatal outcomes of
diseases that prevail in the society and impact the
overall health status of a population. Unintentional
injuries accounted for 66% of injury related deaths and
70% of injury related DALYs in 2001 [16].
Amongst 692 patients, the three most common
causes of injury were noted to be a fall (67.1%), road
traffic accidents (22.5%) and most alarmingly,
orthopedic trauma due to gunshot injuries (2.3%),
respectively. These results, except for the gunshot
injuries, were similar to a study conducted at an urban
university hospital in the United States published in
2000 [17], and the results demonstrated previously in
Ontario, Canada, published in 2006 [17]. Another set of
results from 1999 showed that elderly patients are
more likely to be injured by falls [18].
In 2013 it was shown in Karachi, Pakistan that 59%
of the elderly who had a fall sustained an injury to their
lower limb and that a majority of the elderly who had a
fall was because of tripping or slipping on the same
plane as opposed to falling from a height and this fact
is reinforced in our study [14]. Out of the 464 patients
who presented with fall related injuries, 81.9% (n=464)
had a fall from the same plane level while 18.1% (n=84)
had a fall from 10 feet or more, similar to what was
deduced previously in the city of Rahim Yar khan,
Pakistan in 2011 [19].
Patients who had a fall on the same plane were
mostly women 54%(n=208) while men constituted
45.2% (n=172), and these falls mostly occurred at
home, which was in accordance with a study done by
the British Geriatric Society and other studies [20-24].
The British Geriatric Society’s research also stated that
a majority of the falls happened during the day, which
is also evident in our data. Another aspect that is
interesting is that 40% (n=190) out of the 464 patients,
who had a fall, had their medical management delayed
by their caretakers, which begs to take elderly abuse in
to account. This is an issue which has not been paid
much heed in a society like Pakistan where religious
beliefs already emphasize on the respect and care of
parents and elderly people.
The second most common cause of injury was
shown to be road traffic accidents, corroborated by a
study from 2012, showing that elderly patients were
are at an increased risk of RTAs and they respond
poorly to the sustained injuries [25]. Elderly patients
tend to sustain different types of injuries when
compared to younger patients and have a mortality of
more than 50% above that of the general population
[26-28]. Aggressive management is the most important
aspect in treating elderly patients involved in RTAs as it
leads to a better outcome [29].
We divided road traffic accidents into four
categories; patients who were pedestrians, patients
who were in a car, a commercial vehicle or whether the
patient was riding a bike. Out of the total sample size
of 692, The percentage of road traffic accidents
involving elderly patients was 25.4% and a majority of
the patients involved in RTAs were males, similar to the
results previously obtained in 2011 [19] and a study
done in the UAE in 2008 [30]. These findings are in
accordance with those procured in 2005 which state
that the difference between the proportions of males
to females in a country like Pakistan is owing to the fact
that men spend a lot more time in motor vehicles as
compared to women and men are more likely to be
employed as drivers [31]. Most common bone affected
in pedestrians was the combined fracture of Tibia and
Fibula followed by the neck and shaft of femur
respectively. This shows that pedestrians were mostly
exposed to bumper fracture injuries.
The third most common cause of fractures was
Fire Arm injuries, highlighting an increase in street
violence in Pakistan and specifically in Karachi; there is
an increased incidence of firearm injuries amongst all
age groups. More than 25000 people die with gunshot
injuries in the USA alone. Pakistan has a high number
of firearm injuries because of the manufacturing of
weapons in tribal areas and its shared border with
Afghanistan [32]. In 2011 Lustenberger concluded that
firearm injuries are not uncommon and are primarily
self-inflicted and the site of injury is usually the head
[33], but as religious beliefs in Pakistan are primarily
against suicide, this is not seen often. The group of
people that presented with fire arm injury and
fractures were 2.3% (n=16) and the most common site
of injury was the upper limb at 1.2% ( n=8) followed by
the lower limb at 1.2%(n=8). The most common bones
to be fractured were the Humerus, Radius, Metacarpals
Epidemiology of Orthopedic Trauma in The Geriatric Population of Karachi, Pakistan
20 Vol. 29 (2) July, 2017
and Scapula, which was evenly, divided leading to 2 of
each. The lower limb had four fractures, which evenly
divided 2 fractures in each category: the Fibula and the
ankle joint. This shows that most of the injuries
inflicted on the upper limb were because of self-
defense while the lower limb is the common site for
ricochet bullets. Majority of the gunshot victims were
males 1.7%(12) while there were only 0.6%(n=4)
females.
Cases presenting with a gangrenous limb or an
infection leading to amputation constituted a miniscule
yet important chunk of the total. In previous studies,
although trauma (most commonly due to RTA) ranked
second as the cause for limb amputations [34], it was
found to be the most common indication for
amputation in young adults. Occupational and Sports
related injuries do not make a substantial contribution
the geriatric age group as most elders do not partake in
sports or occupational machinery work in our society.
CONCLUSION
The percentage of elderly patients amongst the general
population is increasing yearly and owing to their
decreased physiological reserve and lack of adaptation
to trauma, they are at a higher risk of traumatic
injuries. These patients require aggressive
management with a multidisciplinary approach that
encompasses not only general medical principles but
also keeps possibilities such as abuse in mind. In our
country, due to the lack of government aid for senior
citizens, most elders are financially dependent upon
their caregivers, which have a higher possibility of
negligence leading to malnutrition and thus an
increased risk of fractures due to nutritional
deficiencies. Further detailed studies are required to
visualize the nutritional as well as other pertinent
aspects of trauma amongst this age group and an
emphasis on Geriatric care policies in the country is the
need of the hour. A network of government employed
Social workers should be deployed to ensure regular
follow ups at the workplaces/ residences of elder
citizens who are suspected to be facing abuse and
neglect and nationwide campaigns focusing on diet and
nutrition with regard to senior citizens should be
launched. An emphasis on nationwide policies and
state run programs for elder citizens regarding
healthcare and primary disease prevention as well as
their rehabilitation will serve to reduce the burden on
an already poverty stricken nation.
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