Open fractures: epidemiological pattern, initial management and challenges in a sub-urban teaching hospital in Nigeria

Introduction Management of open fractures poses a constant challenge to Orthopaedic surgeons in Nigeria. Our aim is to determine the epidemiological pattern of open fractures in our centre and share our experiences on the initial management and problems encountered. Methods This was an 18 month prospective study of patients that presented with open fractures at our emergency room. Already prepared data collection sheets were used to collect relevant data directly from patients and patients' files. Results There were 58 open fractures in 52 patients (31 males and 21 females). Mean age of patients was 36.4 ± 12.2 years. Most patients (82.7%) fell within the age group of 20-49 years. Traders (28.9%) and students (19.6%) were mostly affected. Most open fractures (88.5%) were due to road traffic accidents. The tibia and fibula were the most frequently affected (44.4%). Most injuries were Gustilo et al. types IIIA & IIIB (79.3%) open fractures. Patients had initial resuscitation followed by debridement in 42 cases (72%). Fractures were initially stabilized with external fixators in 23 cases (39.7%) and cast slabs in 19 cases (32.8%). The average time between presentation and debridement was 30 hours and average hospital stay was 36 days. Forty two point five per cent of wounds were infected. Conclusion Open fractures were mostly due to road traffic accidents and affected the tibia and fibula most frequently with Gustilo et al. types IIIA and IIIB forming the bulk of the injuries. Management was challenging with late presentations, scarcity of resources and consequent high rate of infections, prolonged morbidity and hospital stay. These problems were worsened by delay in antibiotic commencement and initial debridement, sub-optimal treatment at peripherial hospitals and mis-management by traditional bone setters.


Introduction
"An open fracture is one in which a break in the skin allows for direct communication of the fracture site or fracture haematoma with elements external to the usual protection of the skin" [1]. It is estimated that 1 in every 120 persons under the age of 65 years will have fracture and 3% of these fractures are open. Three to six million fractures occur yearly in the United States. Thus fractures are a major public health concern [2,3]. The degree of soft tissue and bony injuries vary with the amount of energy dissipated during the fracturing process and this eventually also affect the healing process

Methods
This was a prospective study that involved consecutive patients with open fractures that presented at our accident and emergency (A/E) department and were subsequently managed in our centre over a period of 18 months (1 st January 2016-30 th June 2017). Institutional ethical clearance was gotten after which details of study was explained to each patient and verbal consent obtained by patient agreeing to participate in the study. In addition privacy and confidentially was ensured as the data collection sheet did not provide for names of patients-this was also relayed to patients to reassure them. Already prepared data collection sheets were then used to collect data directly from patients and from records in patients' files by pre-trained registrars in our Orthopaedic unit. Bio-data and data on socio-demographic characteristics of patients were collected in addition to that related to the injuries sustained. Open fractures were classified according to Gustilo et al. [6,7] classification and managed accordingly. Data were analysed using SPSS version 20 and presented here as ratios, means, percentages, tables and charts.

Discussion
The management of open fractures has been a challenge since ancient times and remains so to the present day practicing orthopaedic and trauma surgeon and other Physicians who treat fractures [4,5,[8][9][10]. There is increased risk of contamination, infection, fracture non-union and mal-unions, delayed union, neurovascular complications, increased amputation rate, prolonged morbidity and mortalities etc, depending on the level of tissue damage [6,[9][10][11][12]. The aims of treatment are to prevent infection, ensure early treatment of associated injuries, early soft tissue cover, stabilization of the fracture, achievement of healing and return to work [4,6,13]. Open fractures have been reported in the literature to be commoner in males than females [2,5,9,10,14]. The observation in this study also agrees with this-about 60% of patients in the study being males. This finding is explained by the fact that males are generally more prone to injuries as a result of exposure to risky activities both at work-being largely the bread winners -and at leisure [5,15]. The average age of patients in this study was 36.4±12.2 years. This average age is much higher than 23±1.5 years reported by Arti et al [8], but lower than 38.08 years and 45.5 years

Another important challenge in the management of open fractures in
our centre is the delay in time between presentation and initial debridement. This ranged in this study from 1 hour to 7 days. The major cause of this delay is often patients' inability to pay for treatment. In Nigeria, health insurance coverage is very low and even in those patients that have health insurance, trauma is often not covered. Patients and relations have to pay from their pockets and ours being a poor nation with over 80% of the population leaving below the poverty line, it is often an uphill task to get patients to pay.
Our centre operates a "pay before service policy" and patients may not get any form of treatment until they pay. In fact some patients had to be discharged home without treatment or with suboptimal treatment because they could not pay. Those needing more than one

Conclusion
This study has exposed many peculiar

Competing interests
The author declares no competing interest.

Authors' contributions
The author has read and agreed to the final manuscript.

Acknowledgements
I am grateful to the resident doctors in the orthopaedic unit of my centre for their assistance in data collection in the course of this study and also to other consultant trauma surgeons in my centre whose patients were included in this study.