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Ifeanyi C Nwagbara
Imo State University
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Original Article
Abstract
Background: The management of open fractures has been of great challenge to surgeons over the years, and these fractures are often associated
with considerable patient morbidity and high socioeconomic consequences. Epidemiological studies are of great importance in the management of
these conditions as the information obtained will be used to define priorities and enhance the understanding of this challenging subgroup of traumas.
Objective: The aim of this study was to define the epidemiological profile of patients who were managed for open fractures of the long bones
at a teaching hospital in South East Nigeria. Materials and Methods: This was a retrospective and descriptive epidemiological study involving
open fractures of the long bones managed at a teaching hospital in the southeastern part of Nigeria over a period of 3 years, from January 2014 to
December 2016. Data which were collected from patients’ case notes were subjected to descriptive analysis, and the results were presented with simple
frequency tables, percentages and charts. Results: Seventy patients with 73 fractures were treated for open fractures within the period of the study.
The male to female ratio was 4.3:1, and the peak age incidence was 20–29 years (30%). The most common cause of the injury was motor vehicle
accidents (82.9%), of which 64.3% of cases were as a result of motorbike accidents. The leg bones were the most affected site (63%) while the Gustilo
type III fractures were the most common injuries (67.1%). The average time interval from injury to presentation was 10 h. Wound infections were
the most frequent complications observed, followed by delayed union. Conclusion: Open fractures are challenging conditions which affect mainly
the young and active males in our society. The victims often present late which affects the management outcome. The burden of open fractures can
be minimised in our society by efforts aimed at reducing the menace of motorbike operators, the latter being the most common cause of the injury.
48 © 2020 Nigerian Journal of Orthopaedics and Trauma | Published by Wolters Kluwer - Medknow
[Downloaded free from http://www.njotonline.org on Thursday, January 21, 2021, IP: 10.232.74.27]
Materials and Methods followed by the 30–39 years’ age group (n = 13 [18.6%])
while the least number of cases were seen in the 80–89 years’
This was a retrospective and descriptive epidemiological
age group (n = 1 [1.4%]) [Table 1]. The male to female ratio
study involving open fractures of the long bones managed
was 4.3:1.
at a teaching hospital in the southeastern part of Nigeria. It
involved patients admitted and managed over a period of The most common cause of injury was road traffic accident
3 years, from January 2014 to December 2016. For the purpose which accounted for 82.9% of cases (n = 58), followed by
of this study, long bones refer to the following bones: the gunshot injuries (n = 6 [8.6%]), assault (n = 3 [4.3%]) and
humerus, radius/ulna, femur and tibia/fibula. Ethical approval fall (n = 2 [2.8%]) [Figure 1]. Majority of the road traffic
was obtained from the ethical committee of the institution to accident cases were motorbike related (n = 45 [64.3%]) while
carry out the study. the rest were due to car crashes (13 [18.6%]).
A pro forma was formulated for the collection of data from There was a remarkable seasonal variation in the incidence
patients’ case notes. The variables considered were gender, age, of open fractures. Most of the injuries happened in the
type of trauma, classification of the lesion, location of the lesion, months of December to March (n = 39 [56%]) [Figure 2].
seasonality, mode of treatment and complications. We classified The leg bones presented the highest proportion of open
open fractures using the Gustilo and Anderson classification[8] as fractures (n = 46 [63%]) [Table 2]. The thigh was involved in
modified by Gustilo et al.[9] The class of each fracture as recorded 19.2% of cases, followed by the forearm (11%) and arm (6.8%).
in the case notes at presentation was used for the analysis. The The average time interval from injury to presentation was 10 h,
fractures were managed based on the hospital management with a range of 30 min to 2 weeks.
protocol for open fractures. Type I fractures were treated as Open fractures classified as type III, according to Gustilo et al.,
closed fractures as soon as soft tissue healing was achieved. The were the most common variety (n = 49 [67.1%]), followed by
treatment options were casting or open reduction and internal
fixation. Type II, IIIA and IIIB fractures were managed by wound
debridement, open reduction and external fixation. Each case of Table 1: Age distribution in years
internal fixation was done with distraction compression plate Age range (years) Frequency (%)
and screws while external fixation was done with linear rail
10‑19 3 (4.3)
external fixator frame. Soft tissue cover in the form of split skin 20‑29 21 (30)
graft or muscle flap was additionally provided for the type IIIB 30‑39 13 (18.6)
fractures. Therapeutic antibiotic administration is carried out 40‑49 11 (15.7)
for all case of open fractures in our centre, and this was done 50‑59 10 (14.3)
for all the cases in this study. The choice is usually between the 60‑69 8 (11.4)
quinolones and third‑generation cephalosporins combined with 70‑79 3 (4.3)
metronidazole and an aminoglycoside. In addition, each patient 80‑89 1 (1.4)
received antitetanus prophylaxis. Total 70 (100)
type I (16 [21.9%]) and type II (8 [11%]) [Figure 3]. Table 3 of non‑union were recorded in the type IIIB fractures
shows the severity of injury to the various long bones of the (union rate: 82%). All the four cases of type IIIC fractures
body. The leg bones were the most predominantly affected in required amputations. The average time for fracture union in
all the classes of injury. the upper limb was 8 weeks (range: 5–14 weeks); in the tibia,
it was 22 weeks (range 10–36 weeks) while in the femur, it
Table 4 shows the mode of fracture treatment for the
was 19 weeks (range: 7–30 weeks). Figures 4-9 show the x-ray
various classes of fractures based on Gustilo classification.
images of an index case of Type IIIA open fracture of the tibia/
Fracture union was recorded in all cases of type I and
fibula managed within the study period.
type II fractures. One case of non‑union was recorded in
the type IIIA fractures (union rate: 91.6%) while five cases Fifty‑three complications were observed. The most common
were wound infection with 20 cases (37.7%), followed
by delayed union, i.e., 10 cases (18.9%) and non‑union, variety. Our findings also showed that the leg bones were the
i.e., 6 cases (11.3%) [Table 5]. most common site for open fractures.
The male to female ratio in this study was 4.3:1. The
Discussion male preponderance is in keeping with the findings of a
Open fractures accounted for 14% of the fracture cases number of other authors.[10‑12] The male prevalence of open
managed at our centre and affects mainly young males, with fractures is reported to be due to their higher activity and
most of the cases presenting more than 6 h after the injury. thus higher risk of exposure to trauma. [13,14] Majority of
Majority of the cases were due to road traffic crashes while the victims were in the economically active age groups
the severe forms of open fractures were the most common (20–29 and 30–39 years’ age groups). In our study, these
two age groups constituted 34.3% of the patients. The high
incidence of trauma cases in the younger age groups has
Table 5: Frequencies of complications been widely reported in the literature and further highlights
Complications Frequency (%) the degree of economic burden posed by the condition in our
Wound infection 20 (37.7) society.[13,15]
Delayed union 10 (18.9)
The finding that a large proportion of the injuries were as
Nerve injury 1 (1.9)
a result of motor vehicle accidents is in keeping with the
Nonunion 6 (11.3)
reports of other authors in Nigeria and elsewhere.[11,12,16,17]
Chronic osteomyelitis 4 (7.5)
Motorbike accidents accounted for the majority of the road
Malunion 1 (1.9)
Pin‑tract infection 8 (15.1)
traffic accidents as previously reported in the literature.[10,12]
Joint stiffness 3 (5.7)
Total 53 (100)
from motorbike accidents affected the lower limbs and were of review. Injury 2012;43:891‑7.
higher grade injuries. We therefore advocate efforts at training 5. Ekere AU. Simple patterns and definitive treatment of open tibia
fractures: A private practice experience in Port Harcourt, Nigeria. Niger
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Acknowledgements emergencies. The experience of Imo State university teaching hospital,
Orlu. Niger J Surg Sci 2010;20:11‑6.
We wish to thank Dr. Raju Vaishya, Chief Consultant 14. World Health Organization. World Health Statistics. World Health
Orthopaedeic Surgeon at Indraprastha Apollo Hospital, Organization; 2010. Available from: http://www.who.int/whosia/
New Delhi, India for his invaluable support during the whostat/EN_WHS10_Full.pdf. [Last accessed on 2019 May 08].
preparation of the manuscript. 15. Ikem IC, Oginni LM, Bamgboye EA. Open fractures of the lower limb
in Nigeria. Int Orthop 2001;25:386‑8.
Financial support and sponsorship 16. Ekere AU, Yellowe BE, Umune S. Surgical mortality in the emergency
room. Int Orthop 2004;28:187‑90.
Nil. 17. C Onyemaechi NO, Nwankwo OE, Ezeadawi RA. Epidemiology
of injuries seen in a Nigerian tertiary hospital. Niger J Clin Pract
Conflicts of interest 2018;21:752‑7.
There are no conflicts of interest. 18. Nzegwu MA, Aligbe JU, Banjo AA, Akhiwui W, Nzegwu CO. Patterns of
morbidity and mortality amongst motorcycle riders and their passengers
in Benin‑city Nigeria: One‑year review. Ann Afr Med 2008;7:82‑5.
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