Introduction and an overview of the global burden of injuries
Physical trauma or injuries remain a serious problem for human health globally. As we struggle to support our nations in achieving sustainable development goals and other ambitions, we put our lives at risk of getting injuries on different roads. No single human is 100% protected from getting traumatic injuries. This is because we all use cars, motorcycles, and bicycles; across different roads we move with our feet; our children do jump; and some do climb trees while playing. We cannot escape the risks of sustaining injuries. However, trauma remains a neglected epidemic worldwide because it is still a major public health problem and a leading cause of death and disability. Starting in 2000 numerous authors referenced the estimates of the World Health Organization that, injuries claim the lives of 16,000 people per day, and several thousand more suffer injuries that result in long-term morbidity(1). By 2014, it was postulated that “every day the lives of more than 14 000 people are cut short as a result of an injury”(2). Moreover, it was asserted that “every six seconds someone in the world dies as a result of an injury”(2). Reports from middle-class and lower-class countries indicate a higher trauma load. In low- and middle-income nations, almost 88% of injury-related deaths occur(3). This is a sad fact because available data indicates that 2,117,500 lives could be saved annually if injury mortality rates in low- and middle-income nations were lowered to those in high-income countries. This is a painful fact because there has been a claim made in the Sustainable Development Goals that by 2020, we should have halved the number of global deaths and injuries from road traffic accidents. The World Health Organization Reports that:
· “Injuries—both unintentional and violence-related—take the lives of 4.4 million people around the world each year and constitute nearly 8% of all deaths.”.
· “For people age 5-29 years, 3 of the top 5 causes of death are injury-related, namely road traffic injuries, homicide, and suicide.”.
· “Injuries and violence are responsible for an estimated 10% of all years lived with disability.”
· “Injuries and violence place a massive burden on national economies, costing countries billions of dollars each year in health care, lost productivity, and law enforcement.”
· “Preventing injuries and violence will facilitate the achievement of several Sustainable Development Goal (SDG) targets.”
Studies have shown that physical trauma is mainly caused by road crashes. Road crashes annually result in the deaths of nearly 1.3 million people, with an additional 20 million to 50 million individuals suffering injuries(4). More than 90 percent of these deaths occur in low- and middle-income countries, which have less than half of the world’s vehicles(5,6). As the WHO indicates for people aged 5–29, 3 of the top 5 causes of death are injury-related. The majority of these people are married motorcycle riders or car drivers whose families depend on them. When road traffic-related deaths occur, they leave behind a tragic struggle for their wives and children to endure. At this point, there is a need to pause and ask questions. Is it right to call all road-related deaths accidents? Typically, the answer is no. Why not? The bad behaviors of road users, especially drivers, motorcyclists, and bicycle riders, lead to the majority of road deaths and disabilities. For example, drivers who talk on the phone, drive after consuming excessive alcohol, ignore standard road and car rules, or speed excessively cause the majority of road-related deaths and disabilities. All deaths and disabilities caused by the bad behaviors of all road users, car users, motorcycle users, and bicycle users should not be considered road traffic accidents. Pedestrians and passengers are always innocently harmed and killed by drivers, motorcycle riders, and bicycle riders displaying bad behaviors. “Pedestrian deaths have increased 83% since reaching their low point in 2009 and account for 18% of crash fatalities”.The remaining family members of these pedestrians and passengers also face a tragic struggle in life. One of the major life-saving approaches to preventing road-related traumatic deaths is to remind all those who drive cars, motorcycles, bicycles, and others that the lives of other people, including the lives of their families, should take the first priority than any other interests or personal preferences. It is an obligation that all people actively participate to support their nations in attaining sustainable development. Thus, people must move by whatever means to enable them to pursue activities that have the potential to ensure sustainable development. While trying to ensure sustainable development, in any country, no single person should be killed or disabled by cars, motorcycles, or any other things.
Globally, all countries have opted to reform their healthcare systems in order to support achieving millennium development goals, sustainable development goals (SDGs), universal health care, and others. However, despite all those reforms, it has been frequently and still nowadays reported that numerous countries still have weak healthcare systems. This weakness hinders the provision of the standard of care for both primary healthcare and various specialty services supposed to be given to patients in many healthy facilities. Orthopedics is among the top-affected specialties, especially in developing nations. Thus, many patients who suffer from musculoskeletal disorders, including injuries, face more challenges in terms of getting the standard of care they deserve. Safe mobility and protecting all people from injuries should be two of the most respected human rights.
Long bone fractures
The human skeleton consists of 206 bones (osseous tissue). Bones are hard, dense connective tissue. They provide structural support to the body and serve numerous physiological and social functions in the daily lives of human beings. The bones support and protect soft tissues. They store minerals and are involved in mineral homeostasis, such as calcium and phosphate. Blood cell production occurs in red bone marrow (hemopoiesis), and energy storage occurs in yellow bone marrow. They provide muscle attachment sites, thus making movement possible mainly with the support of long bones. Long bones refer to bones that are cylindrical and whose length is longer than their width. In the human body, there are about 90 long bones assigned to move different parts of the body. Figure 1 shows different types of Long Bones. Fracture refers to the clinical state in which there is a loss of continuity in the substance of a bone. Fracture of any long bone leads to impaired movement and other functions of human beings. Thus, timely intervention should be given to such a patient in order to restore those functions as quickly as possible. Fractures of long bones are the most common type of injury sustained during a trauma event. Traumatic long bone fracture occurs as a result of excessive application of forces to the long bone. A long bone fracture can be open or closed. An open long bone fracture occurs as a result of a penetrating injury or when fracture fragments have protruded through the skin. While closed long bone fractures (simple fractures) are injuries in which the overlying skin is intact.
Figure 1: Showing examples of long bones
A vast amount of literature indicates that, during a trauma event, trauma victims can sustain various types of injuries, but for the most part, long bone fractures have been reported to be the most common. A long bone fracture predisposes a patient to numerous complications. Studies have shown that these complications can be reduced if a traumatic long bone fracture patient timely presents to the health facilities and receives the proper care. In spite of the best evidence that complications associated with long bone fractures would be reduced if patients were present at the proper time, there is a painful fact indicating that most of the patients who sustain traumatic long bone fractures delay presenting to the health facility. Such delay has been identified as one of the major drivers leading to both short-term and long-term complications associated with traumatic long bone fractures.
When should patients arrive at the medical facilities after a traumatic occurrence, and what generally happens during that time?
Immediately after the fracture of any bone, the healing process starts. In order to optimize and ensure the healing processes of the bones happen in the right manner, a timely intervention should be offered to the patient. Like all other patients with physical injuries, those who sustain traumatic long bone fractures should present to the health facility and receive proper care as soon as possible. This fact is crucial because, like all other injuries, following traumatic long bone fractures, the patient exhibits biologic responses that are valuable for survival, healing, and the ultimate return to social usefulness. Studies have shown that these biological responses can be optimized and ensured to happen in the right manner if a traumatic long bone fracture patient presents to the health facilities at the proper time and receives definitive care. However, as stated above, most of the patients with traumatic long bone fractures delay presenting to the health facility. Such delay leads to significant challenges in terms of providing the standard of care they deserve. Short-term and long-term complications associated with traumatic long bone fractures may occur as a result of the delayed presentation. Delayed presentation for long bone fracture patients may be defined as the presentation to the hospital more than 24 hours after injury for the patients who sustained closed fractures or presentation to the hospital more than 2 hours after injury for those who sustained open fractures, as well as spending more than 30 minutes without being attended to after reaching the hospital for any patient with either a closed or open long bone fracture. The delayed presentation of traumatic long bone fracture patients typically happens in developing countries. In these countries, these are common and serious problems that deserve optimal attention.
In principle, any kind of fracture is managed by following the accident and trauma life support (ATLS) protocols. These protocols are also of first priority when managing traumatic long bone fractures. In reality, it is apparent that patients who delay presenting to the health facility miss an opportunity to receive the care they deserve. These protocols contain all interventions aimed at preventing deaths. However, these interventions also influence all other steps of traumatic long bone fracture management. For instance, long-term bone healing is influenced by enough blood supply to the bones. Thus, if a patient suffers from traumatic long bone fractures associated with either external or internal hemorrhage and delays presenting to a health facility, more bleeding will continue to occur, which may lead to impaired bone healing. In fact, sometimes poor outcomes happen due to delays in presentation, no matter how good the care is given at the arrival.
Timely intervention supports mechanical and biological factors as well as the apposition of fragments. But also, sometimes there is interposition of the soft tissues and muscles between the bone fragments, which needs quick correction. Further evidence indicates that failure to provide these timely interventions increases the risk of fracture healing failure. Following the stabilization of the patient, definitive treatment should be instituted. The definitive care is accomplished either by closed reduction or by open reduction and fixation. The main purpose of these interventions is the attainment of sound bony union without deformity and the restoration of function so that the patient is able to resume the usual activity or social activity as quickly as possible.
Other possible benefits from the timely presentation of traumatic long bone fracture patients include:
I) Early initiation of the evaluation and management of long bone fractures, which leads to accurately assessing the fracture environment. These may include assessments of: 1) vascular supply; 2) muscle tendon damage; 3) skin coverage; and 4) the degree of soft tissue damage.
II) Endurance of proper timing for the provision of Lambotte’s principles of surgical treatment to traumatic long bone fracture patients. Four Lambotte’s principles are: 1) anatomical reduction of the fracture segment; 2) stable internal fixation to fulfill the local biomechanical demands; 3) preservation of blood supply to the injured areas of the extremity; and 4) active pain-free mobilization of the adjacent muscles and joints in order to prevent the development of fracture diseases.
III) Promotion of early initiation of monitoring of long bone fracture healing processes with the aid of: 1) use of different imaging modalities; 2) smart implants; 3) ultrasound wearable systems; and 4) the squat and smile challenge. Early and proper use of these strategies could help precisely determine the healing status and healing failure of traumatic long bone fractures.
It is of great significance at this point to pause and ask a question: between closed and open reduction and fixation, which one would ensure quick restoration of functions? Closed reduction is the most common approach used to treat long bone fractures in many health facilities of developing countries. This contrasts with the available evidence that, for adults, most of the time, they actually do not work or work after a prolonged period of time. Possibly the main reason for continuous use of closed reduction is due to a lack of instruments to use for open reduction and fixation. These happen because of non-availability or poor supplies of equipment to use for closed reduction. However, the patient spends prolonged time on this kind of treatment. Possibly, this will increase some fear for those who sustain fractures, leading to a failure to turn up or a delay in their presentation to the hospital.
What are the problems resulting from the delayed presentation for traumatic long bone fracture patients?
The problems resulting from the delayed presentation of traumatic long bone fracture patients include those that compromise the provision of standard comprehensive care and definitive treatment to traumatic long bone fracture patients.
The worst medical problems to associate with delayed presentation include:
· Increased incidence of certain complications
· Disruption of biomechanical healing processes for long bones
· Increase of mortality and morbidity linked to long bone fractures
The complications depend on the types and nature of fractures that the patient sustained. For instance, there is an ever-present risk of bacterial infections for open-traumatic long bone fracture patients. These patients need emergency care in order to ensure a good outcome. Despite the need for emergency treatment for long-term bone fracture patients, most of them delay presenting to the hospital. A study done in 2020 in Ethiopia, which enrolled 301 patients with lower extremity long bone fractures, demonstrated an 85% delay in presenting to the hospital, and 65% of them were not operated on within 24 hours of their presentation(7). In fact, evidence indicates that mortality is high for patients who suffer traumatic long bone fractures due to delays in accessing care.
John Hunter (1728–1793), a father of scientific surgery, clearly described those bones are dynamic tissues due to the equilibrium of bone deposition and resorption. With the support of such equilibrium, bone repair takes place properly without scar formation. Hunter demonstrated four classic stages of bone repair, namely: 1) inflammation; 2) soft callus formation. 3) Hard callus formation and 4) remodeling. Primary and secondary bone healing processes have been recognized. For primary long bone healing, long bone defects are directly restored via the formation of cortical bone. For secondary long-bone healing, there must be callus formation. Long bone fracture healing is accomplished via a complex biological process that involves four distinct responses, namely: 1) those that take place in the bone marrow; 2) those that take place in the cortex; 3) those that take place in the periosteum; and 4) those that take place in external soft tissues.
The main determinant for proper healing of any bone is stability at the fracture site. Such stability can be achieved via operative or non-operative methods. The likelihoods of success for the chosen method increase if such a method is instituted timely. Delayed presentation has negative impacts on the healing processes of long bone fractures because of the disruption of the healing processes of long bones. This may occur because of the compromises in providing proper fixation. Thus, the probability of the occurrence of complications such as non-union, malunion, delayed union, re-fracture, pseudoarthrosis, etc. increases.
Non-medical challenges that may be associated with delayed presentation for traumatic long bone fracture patients include compromise for the patient’s socioeconomic status and confrontation for the health systems of countries. The management of traumatic long bones is costly because of the increase in actual, hidden, and opportunity costs. The actual cost is the amount of money that the patients have to pay for the services they receive. Hidden costs refer to the unforeseen expenses that a traumatic long-bone fracture patient must clear in order to get care for their injuries. Such money may include transportation fees, the purchase of some drugs, and other instruments. Opportunity cost refers to the amount of money that traumatic long bone fracture patients do not generate as they miss various opportunities that would generate income for them. Delayed presentation is among the prominent factors contributing to all of these costs. Other factors include: 1) prolonged hospital stay; 2) higher incidence of complications such as infections, delayed union, malunion, and nonunion. All of these contribute to the compromises in the health systems of various countries manifested by the poor socioeconomic status of the population.
Conclusion
Long bones play an essential role as organs that provide muscle attachment sites, enabling movement. Fractures of long bones can hinder this function and increase the risk of complications for the patient. Delayed presentation of the patients who sustain long bone fractures can lead to higher mortality and burden, particularly in developing nations. To reduce physical trauma-related mortalities and morbidities, it is crucial for each individual to prioritize preventing trauma. Given the high prevalence of long bone fractures, it is recommended to ensure standard care for them. Therefore, the author advocates for and urges the implementation of standard management approaches to eliminate delayed presentation of patients with traumatic long bone fractures in developing nations.
References
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