Study of the severity of musculoskeletal injuries and triage during the 2005 Pakistan earthquake

Purpose

On 8 October 2005 a massive earthquake hit the northern mountainous areas of Pakistan and Kashmir causing 73,338 deaths and leaving over 125,000 severely injured. In a region which was less prepared for such an enormous disaster, mobilising rescue, relief and rehabilitation posed great challenges. The first author (SMA) established two level 1 orthopaedic trauma and rehabilitation units in each of two severely hit major cities through private philanthropy. According to the severity of injuries, the patients were triaged and treated. The aim of this study is to improve the future strategies in similar scenarios.

Methods

This is a retrospective review of medical records of patients suffering from musculoskeletal injuries in the aftermath of the 2005 earthquake who were managed in these centres in the order of triage priority. The patients were received, categorised, worked up and provided definitive surgical procedures. All patients were provided assistance for the fitting of a prosthesis and rehabilitation.

Results

Of 128,304 (total of injured patients), 19,700 were managed in two centres established by SMA during the first months after the earthquake. Of these, 112 patients underwent amputations of upper and lower limbs.

Conclusions

In a massive calamity over a wide geographical area away from big university hospitals, such as the 2005 Pakistan earthquake, the level 1 operating theatre facilities must be established within the area to meet the immediate needs of the patients nearest to their homes and families, and run forever so that patients can have excellent follow-up and can use the same facilities regularly. In the aftermath of this earthquake the need to practise triage in the first 72 hours was thoroughly realised and effectively practised in our centres     

What Is the Magnitude and Long-term Economic Cost of Care of the British Military Afghanistan Amputee Cohort?

Background

Personal protection equipment, improved early medical care, and rapid extraction of the casualty have resulted in more injured service members who served in Afghanistan surviving after severe military trauma. Many of those who survive the initial trauma are faced with complex wounds such as multiple amputations. Although costs of care can be high, they have not been well quantified before. This is required to budget for the needs of the injured beyond their service in the armed forces.

Question/purposes

The purposes of this study were (1) to quantify and describe the extent and nature of traumatic amputations of British service personnel from Afghanistan; and (2) to calculate an estimate of the projected long-term cost of this cohort.

Methods

A four-stage methodology was used: (1) systematic literature search of previous studies of amputee care cost; (2) retrospective analysis of the UK Joint Theatre Trauma and prosthetic database; (3) Markov economic algorithm for healthcare cost and sensitivity analysis of results; and (4) statistical cost comparison between our cohort and the identified literature.

Results

From 2003 to 2014, 265 casualties sustained 416 amputations. The average number of limbs lost per casualty was 1.6. The most common type of amputation was a transfemoral amputation (153 patients); the next most common amputation type was unilateral transtibial (143 patients). Using a Markov model of healthcare economics, it is estimated that the total 40-year cost of the UK Afghanistan lower limb amputee cohort is £288 million (USD 444 million); this figure estimates cost of trauma care, rehabilitation, and prosthetic costs. A sensitivity analysis on our model demonstrated a potential ± 6.19% variation in costs.

Conclusions

The conflict in Afghanistan resulted in high numbers of complex injuries. Our findings suggest that a long-term facility to budget for veterans’ health care is necessary.

Clinical Relevance

Estimates here should be taken as the start of a challenge to develop sustained rehabilitation and recovery funding and provision.     

Complete digital amputations undergoing replantation surgery: a 10-year retrospective study

Background

As a result of growing expertise and skill, replantation surgery has evolved to more than the technical reattachment of an amputated part.

Methods

A retrospective study of complete digital amputations undergoing replantation surgery was conducted for the purpose of assessing trends in these complex cases. All incomplete and partial amputations were excluded.

Results

A total of 171 patients who had replantation surgery between January 1, 1994 and December 31, 2003 for 278 completely amputated digits were reviewed. Of the 171 patients, 91 (53 %) had work-related injuries. The main mechanism of injury was saw injury (95 patients) for both occupational- and non-occupational-related injuries. The proximal phalanx was the most common level of amputation and the thumb was most frequently involved. The injuries happened more commonly in the summer months. Microvascular failure occurred in 29 % of the replanted digits and was most commonly associated with avulsion-type injuries.

Conclusions

Complete amputations represent a more complex injury than incomplete amputations, with a higher failure rate.     

Chronic unilateral locked facet joint with spinal cord injury in a 26-month-old child: A case report

Objectives

This study presents the successful posterior surgical reduction and fusion on a 26-month-old child with chronic unilateral locked facet joint and spinal cord injury (SCI).

Methods

A 26-month-old child with chronic unilateral locked facet joint and SCI treated by posterior surgical reduction and fusion. Plaster external fixation was applied and rehabilitation exercise was trained post-operatively.

Results

Chronic unilateral locked facet joint was reduced successfully and bone fusion of C4/5 was achieved 3 months after surgery. The function of both lower limbs was improved 1 year after surgery, aided with physical rehabilitation.

Conclusion

Unilateral locked facet joint in pediatric population is rare. Few clinical experiences were found in the literature. Non-surgical treatment has advantages of not being invasive and is preferred for acute patients; however, it may not be suitable for chronic unilateral locked facet joint with SCI, in which surgical intervention is needed.     

Functional electrical stimulation as a component of activity-based restorative therapy may preserve function in persons with multiple sclerosis

Objective

To examine the effect of functional electrical stimulation (FES) cycling on disability progression in persons with multiple sclerosis (MS).

Design

Retrospective cohort, 40 participants with mean follow-up of 15 months.

Setting

International Center for Spinal Cord Injury at Kennedy Krieger Institute in Baltimore, a rehabilitation referral center.

Participants

Forty consecutive persons with MS undergoing rehabilitation from 2007 to 2011, with at least two evaluations based on the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI).

Interventions

FES cycling as part of activity-based restorative therapy interventions.

Outcome measures

Change in Expanded Disability Status Scale (EDSS) and ISNCSCI motor, light touch, and pin prick scores from baseline to latest evaluation.

Results

In 71% of patients, activity-based rehabilitation included FES cycling. There was no disability progression on the EDSS. Lower extremity motor scores improved or stabilized in 75% of patients with primary progressive MS (PPMS), 71.4% with secondary progressive MS (SPMS), and 54.5% with relapsing remitting MS (RRMS). Among patients with improved or stabilized lower extremity motor function, PPMS recorded a mean 9% improvement, SPMS 3% and RRMS 6%. In PPMS, use of FES showed trend towards improvement in motor scores (P = 0.070).

Conclusions

FES as part of activity-based rehabilitation may help preserve or improve neurological function in patients with MS.     

Critically assessing the haiti earthquake response and the barriers to quality orthopaedic care

Background

Although numerous authors have described surgical experiences following major disasters, little is known regarding the needs of and barriers to care faced by surgeons during such disasters.

Questions/purposes

We therefore (1) identified and compared recurrent interview themes essential to the disaster response following the 2010 Haiti earthquake; (2) determined the difference in reported disaster equipment management task difficulty between disaster-trained and untrained volunteers; and (3) approximated the quantity of various procedures performed.

Methods

We conducted 14 interviews with selected orthopaedic surgeon volunteers. We also invited the 504 members of the American Academy of Orthopaedic Surgeons (AAOS), who registered as Haiti earthquake volunteers, to complete an online survey; 174 (35%) completed the survey and 131 (26%) were present in Haiti during the 30 days after the earthquake. Recurrent interview themes were identified, quantified, and compared using Poisson regression analysis. The difference in disaster equipment management difficulty scores was determined with a Wilcoxon rank-sum test.

Results

Of 10 recurrent interview themes, group organization (31 occurrences) was mentioned much more often than all but two of the remaining nine themes. Compared with disaster-untrained respondents, equipment management tended to be less challenging for disaster-trained respondents. Transporting to the treatment site and security during storage at the site were less challenging (19.5% and 16.5% decreases, respectively). Revision surgeries, guillotine amputations, fasciotomies, and internal fixations, suggestive of inappropriate disaster care, were frequently reported.

Conclusions

Organizational and training barriers obstructed orthopaedic care delivery immediately after the Haiti earthquake. Disaster training and outcomes require further study to improve care in future catastrophes.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-012-2333-4) contains supplementary material, which is available to authorized users.     

Rehabilitation after lower limb injury: development of a predictive score (RALLI score)

Background

The purpose of our study was to identify the risk factors associated with the need for inpatient rehabilitation after lower limb injury to develop a predictive scoring tool for early identification of such patients.

Methods

We followed a prospective cohort of patients admitted to a level 1 trauma centre. Data were collected through chart review and a self-administered questionnaire on sociodemographics, patient living environment, pretrauma status, injury and treatment received. We compared patients who were discharged home with those going to rehabilitation after acute care. Analysis consisted of bivariate comparisons and logistic regression.

Results

Our study included 160 patients with a mean age of 56 years. A total of 40% were discharged to an inpatient rehabilitation centre. Factors associated with inpatient rehabilitation were low preinjury physical health status, concomitant injury of the upper limbs, bilateral lower limb injury, the use of a walking aid before injury, head injury and femur or pelvic fractures. We created a predictive score using the top 3 risk factors: upper limb injury, bilateral lower limb injury and presence of femoral or pelvic fractures. The chance of needing inpatient rehabilitation rose from 14% with 0 factors to 47% with 1 factor and 96% with 2 factors.

Conclusion

Rehabilitation planning should begin for patients exhibiting at least of 3 risk factors at the time of admission to acute care. Prospective validation of the tool is needed, but it has the potential to orient the multidisciplinary team’s decision on rehabilitation needs postdischarge.     

Long-term outcomes after upper limb arterial injuries

Objective

To assess long-term outcomes in multisystem trauma victims who have arterial injuries to upper limbs.

Design

A retrospective case series.

Setting

Tertiary care regional trauma centre in a university hospital.

Patients

All consecutive severely injured patients (Injury Severity Score greater than 15) with an upper limb arterial injury treated between January 1986 and January 1995. Demographic data and the nature and management of the arterial and associated injuries were determined from the trauma registry and the hospital records.

Outcome measures

Death rate, discharge disposition, residual disabilities and functional outcomes as measured by the Glasgow Outcome Scale.

Results

Twenty-five (0.6%) of 4538 trauma patients assessed during the study period suffered upper extremity arterial injuries. Nineteen of them were victims of blunt trauma. The death rate was 24%. There were 10 primary and no secondary amputations. An autogenous vein interposition graft was placed in 10 patients. Concomitant fractures or nerve injuries in the upper limb were present in 80% and 86% of the patients, respectively. Long-term follow-up data (mean 2 years) were obtained in 16 of the 19 who survived to hospital discharge. The residual disability rate was high. It included upper limb joint contractures, pain and persistent neural deficits (69%). Associated injuries in other body areas also contributed to overall disability. Only 21% of the patients recovered completely or had only minor disabilities.

Conclusions

Associated injuries, rather than the vascular injury, cause long-term disability in the multi-system trauma victim who has upper extremity involvement. Persistent neural deficits, joint contractures and pain are the principal reasons for long-term impairment of function.     

Epidemiology and impact of early rehabilitation of spinal trauma after the 2005 earthquake in Kashmir,India

Purpose

The Kashmir earthquake, also known as the South Asia earthquake, hit Jammu and Kashmir (India) on 8th October 2005 (registered as 7.6 on Richter scale) and was quite devastating, with the official toll being 1,360 (some estimates being around 1,800). The injured registered around 6,300. In such an enormous disaster, rescue operations, relief and rehabilitation is a great challenge. One week after the Kashmir earthquake (2005), a multidisciplinary rehabilitation team headed by the corresponding author went to Srinagar (Kashmir). The purpose was to tackle the medical rehabilitation issues of the victims of the earthquake and later study the epidemiology of various injuries, especially the spinal injuries, so as to improve the future rehabilitation strategies in similar scenarios.

Method

This is a single-phase, hospital-based study of spinal injury patients of the Kashmir earthquake (October 2005) admitted in various hospitals of Srinagar (the capital city of Kashmir, India) and around it. This was conducted one week after the Kashmir earthquake (October 2005). Detailed history of patients, clinical and radiological evaluation was done. In consultation with neurosurgeons and spine surgeons, issues of rehabilitation were noted, and need based on early rehabilitation care was provided by means of rehabilitation orthoses (aids/appliances), physiotherapy, psychotherapy, etc.

Results

Out of 2,621 cases who received various injuries (as per records of different hospitals and health institutions), 1,366 (52.11 %) were referred to different health institutions of Kashmir valley, of which 429 (31.40 %) cases were admitted for orthopaedic intervention at different referral hospitals of Srinagar and Baramula. Out of 429 admitted patients of different hospitals, we covered 266 patients of four major hospitals, of which 38 (12.33 %) cases were spinal injuries, 20 cases (52.7 %) had dorsolumber segment involvement with 12 cases (31.5 %) having cervical and six cases (15.8 %) sacrococcigeal injury.

Conclusion

In a massive natural calamity like the Kashmir (India) earthquake of 2005, a collective effort by a rehabilitation team for providing supportive/assistive devices along with physiotherapy and psychotherapy has significantly helped in recovery of functional and psychological status of the spinal trauma victims. No doubt that the life saving operations and definitive surgery are important to combat major catastrophe in such disasters but early medical rehabilitation is equally important to reduce injury-related disability.     

Senior Managed Care System for Hip Fracture in the United States

Background

It is debatable whether a managed care model would affect the quality of care and length of hospital stay in the treatment of hip fractures in elderly patients.

Methods

This prospective study was undertaken to determine whether or not a managed care critical pathway tool shortened hospital stay in a group of 102 senior patients with fractures of the hip during follow-up. We compared our study findings with two equivalent populations of senior hip fracture patients not treated using a critical care pathway concerning specific markers of quality.

Results

The managed care group had a 9% mortality rate, 95% return to prefracture living and 63% return to ambulatory status. The rates compared favorably with previous studies. The quality of care provided before and after the critical pathway was equivalent, while the post-pathway length of stay dropped 30%.

Conclusions

The proposed care protocol is recommended to shorten hospital stay in elderly patients with hip fractures.     

The benefit of modified rehabilitation and minimally invasive techniques in total hip replacement

INTRODUCTION

We wished to assess if an intensive rehabilitation regimen alone, or one combined with modified anaesthetic and surgical techniques, can change the speed of rehabilitation or the length of hospital stay after total hip replacement.

PATIENTS AND METHODS

We compared 44 patients who had followed a traditional care pathway, with 38 patients who had rehabilitated under a new rehabilitation protocol, with 40 patients who had also received modified, minimally invasive techniques. The speed of rehabilitation was measured in terms of three specific milestones accomplished on the day after surgery.

RESULTS

We found a statistically significant improvement in the day after surgery each activity was possible. The length of hospital stay was reduced from 6.5 days to 5.4 days to 4.1 days, a difference which was also statistically significant.

CONCLUSIONS

The data support the view that a new rehabilitation protocol alone can reduce the length of hospital stay and hasten rehabilitation. The combination of modified anaesthetic and minimally invasive surgical techniques with the new rehabilitation regimen can further improve short-term outcome after total hip replacement.     

A Canadian population-based description of the indications for lower-extremity amputations and outcomes

Background

To our knowledge, there have been no previously published reports characterizing lower-extremity amputations in Canada. The objective of this study was to describe the indications and outcomes of lower-extremity amputations in the Canadian population.

Methods

We performed a retrospective cohort study of all adult patients who underwent lower-extremity amputation in Canada between 2006 and 2009. Patients were identified from the Canadian Institute for Health Information’s Discharge Abstract Database, which includes all hospital admissions across Canada with the exception of the province of Quebec. Pediatric, trauma, and outpatients were excluded.

Results

During the study period, 5342 patients underwent lower-extremity amputations in 207 Canadian hospitals. The mean age was 67 ± 13 years, and 68% were men. Amputations were most frequently indicated after admission for diabetic complications (81%), cardiovascular disease (6%), or cancer (3%). In total, 65% of patients were discharged to another inpatient or long-term care facility, and 26% were discharged home with or without extra support. Most patients were diabetic (96%) and most (65%) required a below-knee amputation. Predictors of prolonged (> 7 d) hospital stay included amputation performed by a general surgeon; cardiovascular risk factors, such as diabetes, hypertension, ischemic heart disease, congestive heart failure, or hyperlipidemia; and undergoing the amputation in the provinces of Newfoundland and Labrador, New Brunswick, or British Columbia.

Conclusion

There is variability in the delivery of lower-extremity amputations and postoperative hospital discharges among surgical specialists and regions across Canada. Future work is needed to investigate the reasons for this variability and to develop initiatives to shorten postoperative hospital stays.     

Current practice of aneurysm management in the UK

INTRODUCTION

The aim of this study is to establish the current practice of aneurysm management, to assess the introduction of fenestrated endovascular aneurysm repair (FEVAR) and to establish the criteria for its use and its role in the UK.

METHODS

All UK centres performing FEVAR and centres with an established interest in infra-renal endovascular aneurysm repair (EVAR) were invited to respond to an open-ended questionnaire about abdominal aortic aneurysm (AAA) management.

RESULTS

A response was obtained from over 90% of UK FEVAR centres. Results showed marked regional differences in aneurysm management, in particular with regard to indications for complex aneurysm management.

CONCLUSION

The trend in the UK is towards endovascular repair. However, there are still variations in unit policies, indicating regional differences in patient management.     

Acetabular fractures before and after the introduction of seatbelt legislation

Objectives

To compare the incidence and severity of acetabular fractures and associated injuries before and after seatbelt legislation.

Design

A retrospective study.

Setting

Two major trauma centres, which are teaching hospitals.

Patients

Three hundred and ninety-three patients who sustained acetabular fractures during the 5 years before and 5 years after seatbelt legislation was enacted. Of these, the fractures in 198 patients (50.4%) resulted from a motor vehicle accident.

Main Outcome Measures

The number and severity of acetabular fractures and associated injuries.

Results

There has been a significant reduction in the number of acetabular fractures (p = 0.005) since seatbelt use became mandatory, and the complexity of the fractures has decreased. There has also been a marked reduction in associated injuries, such as fractures of other bones, and head, chest and abdominal injuries (p < 0.001).

Conclusion

The seatbelt law has been a useful preventive measure, resulting in a reduction in the incidence of acetabular fractures and associated injuries.     

Changes in sleep architecture after burn injury: ‘Waking up’ to this unaddressed aspect of postburn rehabilitation in the developing world

BACKGROUND:

Changes in sleep architecture are common phenomena observed in post-traumatic patients; such altered sleeping patterns have negative implications on various phases of rehabilitation. Sleep is an essential process, without which one cannot function effectively and, hence, any aberrations in the quality of sleep in such patients need to be critically analyzed.

OBJECTIVE:

To probe the quality of sleep in postburn patients at one year compared with a group of adequately matched controls.

METHODS:

Quality of sleep in postburn patients at one year was measured using the Pittsburg Sleep Quality Index questionnaire and compared with a group of adequately matched controls. Data were tabulated and subjected to statistical analysis using Pearson’s χ² test.

RESULTS:

The relationship between the postburn state and sleep disturbances was found to be statistically significant. Other relevant parameters are also highlighted and discussed.

DISCUSSION:

Sleep is one of aspect of functioning that may be least taken into account by professionals during the phase of postburn rehabilitation because more obvious threats receive preferred treatment. Unless these problems are dealt with in the postburn period, rehabilitation can never be complete.

CONCLUSION:

Postburn patients experience significant changes in sleep architecture, which need to be taken into account to enable complete rehabilitation of the patient.     

Fever During Rehabilitation in Patients With Traumatic Spinal Cord Injury: Analysis of 392 Cases From a National Rehabilitation Hospital in Turkey

Objective:

To determine the incidence and etiology of fever and the risk factors related to fever in adults with spinal cord injury (SCI) at the rehabilitation stage.

Design/Subjects:

A retrospective examination of records of 392 consecutive adult patients with traumatic SCI who received inpatient rehabilitation program.

Setting:

A national rehabilitation center in Turkey.

Outcome Measures:

Incidence and etiology of fever, period of hospitalization (days).

Results:

A total of 187 patients (47.7%) had fever at least once during their rehabilitation program. The most common etiology was urinary tract infection. The rate of fever occurrence was significantly higher in patients with complete SCI (P  =  0.001). In patients with fever, the use of an indwelling catheter was significantly higher compared with clean intermittent catheterization and spontaneous voiding (P  =  0.001). The hospitalization period of patients with fever was significantly longer than that of patients without fever (P  =  0.006).

Conclusions:

A high rate of fever was seen in patients with SCI during rehabilitation. Fever was caused by various infections, of which urinary tract infection was the most common. Patients with motor complete injuries and those with permanent catheters constituted higher risk groups. Fever prolonged the length of rehabilitation stay and hindered active participation in the rehabilitation program.     

The SCIRehab project: treatment time spent in SCI rehabilitation. Psychology treatment time during inpatient spinal cord injury rehabilitation

Background

Rehabilitation psychologists are integral members of spinal cord injury (SCI) rehabilitation teams.

Objective

To describe specific information regarding types and intensity of treatments delivered by rehabilitation psychologists to patients with various levels of SCI.

Methods

Utilizing a taxonomy of psychological interventions as a framework, rehabilitation psychologists documented time spent on specific psychology interventions for each interaction they had with 600 patients with traumatic SCI at 6 inpatient SCI rehabilitation centers. Associations of patient and injury characteristics with time spent on various psychological interventions were examined using ordinary least squares stepwise regression models.

Results

Psychologists focus the majority of the time they spend with patients with SCI on psychotherapeutic interventions of processing emotions, emotional adjustment, and family coping, while educational efforts focus mostly on coping and adjusting to the new injury. There was wide variation in the amount of time spent on psychotherapeutic and psychoeducational interventions; patient, injury, and clinician characteristics explained little of the variation in time spent.

Conclusions

Variations observed in psychological treatment delivery mirror real-world human complexity and clinical experience; they are not explained well by patient and injury characteristics and set the stage for future analyses to associate treatments with outcomes.     

Relationship of psychology inpatient rehabilitation services and patient characteristics to outcomes following spinal cord injury: The SCIRehab Project

Context and objective

To evaluate the effects of psychological interventions on rehabilitation outcomes, including residence and functional status at discharge, and residence, school attendance, or employment, and physical, social, occupational, and mobility aspects of participation 1 year after spinal cord injury (SCI).

Design

Prospective observational cohort study.

Setting

Six inpatient rehabilitation facilities in the United States.

Participants

Inpatients with SCI 12 years of age and older.

Interventions

Usual rehabilitation care.

Outcome measures

Functional Independence Measure at rehabilitation discharge and 1-year injury anniversary; discharge destination and residence at 1-year anniversary; Craig Handicap Assessment and Reporting Technique, Diener Satisfaction with Life Scale, Patient Health Questionnaire, employment or school attendance, rehospitalization, and occurrence of a pressure ulcer at 1-year anniversary.

Results

More time in psycho-educational interventions was associated with better function, discharge to home, home residence at 1 year, and the absence of pressure ulcers at 1 year. More psychotherapeutic sessions focusing on processing emotions and/or locus of control were associated with poorer function at discharge and 1 year, less physical independence and community mobility, lower satisfaction with life, and the presence of pressure sores at 1 year.

Conclusions

Psychological services are an important component of comprehensive medical rehabilitation and tailored to patient needs and readiness to benefit from rehabilitation. Services focused on remediating deficits tend to be associated with negative outcomes, while services intended to foster adjustment and growth tend to be associated with favorable outcomes. Further research is needed to determine the optimal type and timing of psychological services during inpatient rehabilitation based on individuals'' strengths and vulnerabilities.

Note

This is the sixth in this third series of SCIRehab articles.