Characteristics of open fractures during armed conflicts in Libya.

Authors:

Eman Elzwai1, Asera Eljalaly2, Wafa Alelwani2, Hanin Elmariamy2, Dona Eljalaly2, Salem Langhi1.

Affiliations:

1 Department of orthopedic surgery, Benghazi Medical Center, Benghazi, Libya
2 Faculty of medicine, Benghazi Medical University, Benghazi, Libya

Corresponding author:

Dr. Salem Langhi,
Consultant Orthopedic Surgeon and Trauma,
Department of orthopedic surgery, Benghazi Medical Center, Benghazi, Libya
Tel.: 00218916416197 – 00218923264889
e-mail: shamana67@yahoo.com

Abstract
Background: combat injuries usually result in open contaminated wounds, and open fractures. Extremities are the most commonly injured parts of the body.
Objective: the aim of study is to describe the pattern of open fractures among injured patients during a period of 6 years of Libyan conflict in single trauma center.
Patients and Methods: a retrospective descriptive study to review patients with open fractures at a period of 6 years of Libyan conflict. Patient data were collected from single trauma center in Benghazi (Benghazi Medical Center).
Results:  a total of 1091 patients were recorded in files of Benghazi Medical Center (BMC) as orthopedic war injuries. 71.6% of the patients were young males between age of 21 – 40 years, 52.5% were diagnosed with open fractures types IIIB and IIIC Gustilo-Anderson classification, lower limb injuries 62.5% were common than upper limb injuries 22.8%, surgical treatment with external fixation 24% vs. Internal fixation 25% in upper limbs and external fixation 63% vs. internal fixation 62% lower limbs, post-operative infection rate within the first two weeks 2.8%.
Conclusion: We have observed that the lower limbs injuries more frequently than the upper limbs, probably due to using of antipersonnel land mines, internal and external fixation as primary fixation equally.

Key words: Libya, war injuries, open fractures, Libyan conflict

During Libyan conflict which start at 2011 weapons become widespread in the society and used by untrained civilian that result in recurrent attacks of random shooting and lead  to lacerated wounds and foreign bodies (bullet or fragments)injuries to civilians.  The situation of the conflict inside the cities, make more destructive effects of many explosive projectiles in the wider city area, and large population of civilian people get injured, combined with the predominantly unprepared population. Pre-hospital care was unachievable.

Extremities are the most commonly injured parts of the body, it has been estimated that (40-70%) of all combat wounds affect extremities (1). Open fractures are a challenge to manage in war field and should manage as part of Advance Trauma Life Support Protocol( ATLS) were resuscitation and physiological stabilization of the patient and treat the life threating injuries take priority first . Surgical debridement and wound exploration is the cornerstone of war injuries management alone with fixation of fracture (damage control orthopedic protocol) (2).

 In this study we describe the pattern of open fractures among injured patients during Libyan conflict. There no publish reports from this country regarding to this injury.

MATERIALS AND METHODS

This is a retrospective descriptive study.  A Chart of all  patients who were admitted from February 2011 and December 2016 to an orthopedic department of Benghazi medical center (BMC), where are retrieved from medical records , including demographic properties such as age, sex, mechanisms of injuries, types of injuries and treatment. Files of 1091 patients was examined, the questioner was fielded. We exclude the patients had spinal, pelvic and hands injuries because it treated by other specialty (plastic and neurosurgery). Data were analysis by using SPSS version 18.

RESULTS

97.5% of patients were males and 71.6% were young between age of 21 and 40 years-old (Fig. 1).

Fig. 1.  Age distribution.

52.5 % were diagnosed with open fractures types IIIB (80%) and IIIC (5%) (Fig. 2,  3).

Fig. 2. Diagnosis

Fig. 3. Gustilo- Anderson classification of open fracture

Direct gunshots were most common cause of injury, 73.7%, followed by explosions, 26.3%. (Table I).

Table I: Mechanism of injury

42.6% of wounds were managed with debridement and remove foreign bodies (bullet or explosion fragment) and External fixation was needed by 19.7% (Table II).

Table II. Type of management interventions required.

However, other management procedures such as ORIF, cast, amputation, exploration and skeletal traction were 7.4%, 6.3%, 2%, 1.1% and 0.4% correspondingly. Long bones like Femur and tibia were the most common bones involved in fractures (Table III).

Table III. Bones involved in reducing frequency.

DISCUSSION

Open fractures due to high velocity missiles are common (40%-70%)¹. In open fractures;  bone  and surrounding soft tissues are exposed to the external environment, putting these patients of high risk for ischemia, wound infection, and delayed or nonunion. It may also be associated with neurovascular injuries.

In our study young patients were the most affected group during the war, 67.6% of the total injured were between (20 – 40 years) as it has been demonstrated in the other studies (3, 4). Children less than 16 years old constituted 2.5 % of the total patients; which is comparable to other study 10% (5).

73.7% of injuries were due to gunshots and 26.3% were explosions, this high percentage of gunshots injured due to widespread of light weapons in the society after the conflict. High velocity wounds have the greatest potential for devastating injury, largely because they have a higher percentage of kinetic energy transference, have a higher degree of wound contamination, and more often associated comminuted fractures with devitalized bony fragments.

71.6 % of patients were males between of 21-40 years, 52.5% were diagnosed with open fractures types IIIB (80%) and IIIC (5%) Gustilo-Anderson classification, which is less than the results of Brett et al, and they found 82% of all extremity injury was open fractures (6). Lower limb injuries 62.5% were more common than upper limb injuries 22.8%, due to use of anti-personal land mines in the city after they leaves and using it in assassination. Tibial fractures 18.2% of lower limb fractures, and Mody RM et al report more femoral fractures (57%) (7).The upper limb fractures were equal for humerus, radius and ulna 5.9% each.

Damage control surgery of multiple trauma patients has been used in abdominal surgery to save patient’s life (stop bleeding, restore tissue perfusion). After physiological stabilization, a second operation (definitive management) performed after general condition of the patient stabilization has been achieved (2). The Same principle can be applied in orthopedic trauma patients (damage orthopedic protocol), means stabilizing the fracture by external fixation, until the patients general condition improves and then definitive treatment could be performed.

 Treatment of patients started at emergency department with exploration of the wound and examine the surrounding tissue and vascular status then good wash with normal saline and start intravenous broad spectrum antibiotic, and anti-tetanus vaccine, immobilization of the fracture with slab then debridement in operative theater in first 24 hours of presentation and the open fractures managed with external fixation 19.3% and internal fixation 7.4%. External fixation was used as primary and definitive management in 93% of our patients with good healing results (24% of upper limb injuries and 63% of lower limb injuries). Out of all patients with fracture 7.7% were multiply injured and managed according to damage control orthopedic protocol, which include debridement and external fixation.

Wound and bone infections remain an important source of morbidity in combat casualties (2). In our study, intravenous broad spectrum antibiotic (cephalosporin family and Gentamicin) were started to all the patients from the first day of admission for 48 hours then changed to oral antibiotic for 5 days. Post-operative infection rates within the first two weeks was 2.8 %, which is lesser than the result of Mody RM et al (7), Dua AA et al (8) both were 40%, Lohr B et al (9) 60%, and more than L. Mathieu et al (10) they have no infection in their patients and Brett D. et al (6) results that the infection and complication rate in open fractures between 0% and 60%.

There are several limitations of this study that are noteworthy. Lack of electronic archiving system, surgical records and other important patients’ data were handwritten and such records can be lost easily and may not be cross-referenced. The large number of casualty patients at the time of explosion of the city and a shortage of medical staff because road blocked in conflict areas, may cause poor registration of patients’ data (cause of the nature of trauma, describe of patient condition or wound and fracture classification, anatomical site of injury or fracture, timing of injury or surgery and surgical procedure type and details). Some records missed as patients’ leaves the hospital and take their records with them. Follow up charts not available for the patients. Diagnosis of wound infection depends on culture and sensitivity results within two weeks of admission.

We found that the lower limbs are injured more often than the upper limbs because the use of landmines. Internal and external fixation was used as primary fixation equally.

 However, lack of electronic records even in armed conflicts impairs accurate documentation, cross referencing and future for long term sequels.

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