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Musculoskeletal injuries associated with earthquake
Injury, Int. J. Care Injured (2005) 36, 27—32
www.elsevier.com/locate/injury
Musculoskeletal injuries associated with earthquake A report of injuries of Iran’s December 26, 2003 Bam earthquake casualties managed in tertiary referral centers Tahmasebi Mohammad Naghi*, Kiani Kambiz, Jalali Mazlouman Shahriar, Taheri Afshin, Shahriar Kamrani Reza, Panjavi Behnam, Alami Harandi Bahador Department of Orthopedic and Trauma Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Accepted 28 June 2004
KEYWORDS Musculoskeletal injuries; Iran; Earthquake
Summary This is a descriptive analysis, performed on victims of Iran’s December 26, 2003 Bam earthquake that were referred to tertiary referral trauma management centre in Tehran. Two hundred and ten patients were included in this study. Associated musculoskeletal injuries and renal function of the patients were recorded. The mean time under rubble was 1.9 h in our patients with a mean rescue to first medical aid time of 13.5 h. We had 19 cases of compartment syndrome and 6.7% of patients had impaired renal function. The incidence of compartment syndrome had a direct relation to the time under rubble and the incidence of renal failure was directly related to rescue to first medical aid time. Axial skeleton fractures, amongst them the lateral compression type pelvic fractures, were particularly common. Fracture associated neural injuries were also common. Institution of renal protective protocols from the very first hours after injury more conservative approaches to treatment of fractures in these crush trauma patients are strongly recommended. # 2004 Elsevier Ltd. All rights reserved.
Introduction * Corresponding author. Tel.: +98 21 84902238; fax: +98 21 2521330. E-mail address: [email protected] (Tahmasebi Mohammad Naghi).
During severe seismic activities of earth, translated as more than 6—7 in Richter’s scale, cracks and fissures appear in the ground, trees and rocks are uprooted and buildings collapse. The amount of
0020–1383/$ — see front matter # 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2004.06.021
28
destruction is in direct relation with the quality of the structure of buildings and ‘‘preventing collapse’’ engineering standards, in the case of Bam, mudbrick buildings with the least tolerance of seismic waves. During the collapse of a single story building 80% of those trapped inside die.1 The immediate causes of death are head, chest and abdominal crush injuries, followed later by suffocation, exsanguinations and onset of acute renal failure.13 The speed and skill with which the rescue teams save the casualties and the quality of post-rescue care are the next important factors. Soft tissue crush injuries, fractures, compartment syndromes and renal failure due to crush syndromes are musculoskeletal complications that should be addressed from the very first hours or they will result in life-threatening or life-long consequences that could have been preventable. Every major disaster warrants retrospective studies so we can learn how to improve all levels of Emergency Medical Services. The problems, needs and challenges no longer differ between countries, and creating specialized search and rescue teams, including physicians and structural engineers, might be useful.2 Therefore, the report presented here gives a clear view on how to cope with future disasters with better experience and equipment.
Methods and materials On December 26, 2003, 5:30 a.m. local time, an earthquake measuring 6.8 on the Richter scale, shook the ancient city of Bam (Fig. 1) in southern east Iran and destroyed more than 20,000 homes. More than 40,000 of 90,000 residing population of the city perished and nearly 30,000 were injured. Up to 12,000 casualties were airlifted to other parts of country, including Tehran. The hospitals of Tehran University of Medical Sciences were among those who admitted some of the casualties. The first group of patients arrived at 10:30 p.m. the same day. These patients had not been screened before referral and trauma of every genre, from trivial to major, existed among them. Patients who were referred on later days were those with major soft tissue or skeletal injuries who had undergone primary management in local area care-giving centres. We recorded the musculoskeletal injuries of patients who were admitted in Shariati Hospital and some of the casualties whose records were available for follow-up in Imam and Sina hospitals of Tehran. Patients admitted into our hospital (Shariati), underwent a uniform protocol of initial management and apart from the trauma team, a nephrol-
T. Mohammad Naghi et al.
Figure 1 The ancient citadel of Bam, dating back to preIslamic Iran, before and after the earthquake.
ogist and a psychologist visited all patients. A total of 210 patients were included in the study. A questionnaire was used for gathering information pertaining to head and neck, urologic and abdominal injuries and information regarding the timing of care-giving and type of treatment given was also recorded on the same questionnaire. Finally, the data were analysed using descriptive statistics and regression logistic analysis by SPSS1 software.
Results The mean age of the patients was 30.2 years with a range of 7—70 years. 57.6% of patients were females and the mean time under rubble was 1.9 h (Fig. 2) The mean time from rescue to first medical aid was 13.5 h (with a range of 1—72 h) as stated by patients and the mean time from first aid to referral to Tehran was 3 days (with a range of 0.5—16 days). We had 7 patients with upper limb compartment syndrome and 12 patients with lower limb compartment syndromes. (The compartment syndrome was defined as intra-compartmental pressure of more than 30 mmHg.) Nine patients with crushing injuries
Musculoskeletal injuries associated with earthquake
29
Figure 3 The most common type of pelvic fracture was lateral compression (LC), followed by anteroposterior compression (APC) and vertical shearing (VS) types. Figure 2 The histogram of time being under rubble. The mean time under rubble was 1.5 h.
(including lacerations, contusions and pre-compartment status) in the upper limbs and 13 patients with crushing injuries in lower limbs were seen. Fourteen patients (6.7%) had major soft tissue loss. Six patients (2.9%) had acute renal failure and nine patients (3.8%) had elevated creatinine levels that responded to therapeutic measures. Three patients with acute renal failure had fasciotomies. The most common peripheral nerve injury was to the sciatic nerve (25 cases) and radial nerve (15 cases) and six (2.9%) patients had spinal injuries, which were all associated with vertebral fractures. 93.3% (14) of the radial nerve injuries were associated with fractures (11 with humeral shaft fractures). Sixty-eight percent (17) of the sciatic nerve injuries were associated with lower limb fractures or dislocations. Eighteen patients had compartment syndrome (8.6%) and 16.7% (35) had major soft tissue injury. 36.2% (76) of the patients had axial skeleton fractures (pelvic and vertebral) with 22 (10.5%) vertebral fractures and 63 (30%) pelvic fractures. The most common type of pelvic fracture was lateral compression. (Fig. 3) (32 cases) with isolated fractures (20) and anteroposterior compression fractures (5 cases) the next most common. 22.7% of vertebral fractures were associated with spinal injuries (5 cases). 29.9% of our patients had upper limb fractures (Table 1) and 46.7% had lower limb fractures (Table 2). The most common injured bone in the upper limb was the humerus and in the lower limb the femur. 73.3% of humeral fractures were associated with radial nerve injuries and 22.7% of vertebral fractures were associated with spinal injuries.
Table 1
Incidence of upper limb fractures
Both bone forearm fractures Clavicle fractures Distal radial fractures Galaezi fractures Glenohumeral dislocations Humeral fractures Hand and wrist fractures Scapular fractures None Others
Frequency
Percent
4 5 9 2 2 15 6 1 162 4
1.9 2.4 4.3 1.0 1.0 7.1 2.9 0.5 77.1 1.9
15.2% of our patients had head injury with 6.2% intracranial and 7.6% superficial injuries. 8.1% of our patients had thoracic injuries with 8 patient with rib fractures and 8 patients with intrathoracic injuries. 8.6% of our patients had abdominal injuries which required surgery and 5 patients had urologic injuries which were all associated with pelvic fractures. The incidence of renal failure increased with increase in time from rescue to first medical aid but was relatively independent of time being under Table 2
Incidence of lower limb fractures Frequency
Bimaleolar and pilon fractures Femoral shaft and supracondylar fractures Fractures of foot Hip fracture or dislocation, including acetabulum Tibial plateau fractures Tibiofibular fractures Others None
Percent
12 28
5.7 13.3
15 17
7.1 8.1
9 16 1 112
4.3 7.6 0.5 53.3
30
Figure 4 Increase in the chance of renal failure by each hour passing from rescue to receiving first aid.
rubble. As calculated by logistic regression coefficient, there is a meaningful relation between the time being under rubble and incidence of compartment syndrome: each hour passing, the chance of incidence of compartment syndrome increases by 15.23% in the upper limbs and 13.3% in the lower limbs. In addition, a 5% increase in the chance of renal failure happens with each passing hour from the rescue to receiving first aid (Fig. 4). Ninety patients were treated conservatively, 69 underwent open reduction and internal fixation, 20 underwent debridement or repair and 17 had external fixation. Seven patients had amputations and seven needed skin grafts.
Discussion Dealing with casualties in settings of disaster is one of the challenging topics in trauma management. Epidemiologic data inferred from this report are interesting in some aspects. As can be observed, most patients passed a short time under rubble (mean: 1.5 h), but the first aid teams have had long delays reaching patients. (mean: 13.5 h). This shows the lack of coordination and irregularities that exist in first hours of catastrophe (most medical centres in the disaster zone had been damaged) and the lack of appropriate systems for addressing the needs of casualties in such situations. As noticed above, the incidence of compartment syndrome and renal failure have inverse relations with the elapsed time from injury to first aid visit. We had seven amputations, most due to severe crush injuries that had lead to vascular compromise
T. Mohammad Naghi et al.
and eventual infection, a situation that could have been preventable by early fasciotomy. In addition, the initiation of early therapy to prevent acute tubular necrosis due to crush syndrome is well shown by the relation between time elapsed since injury to first medical aid and incidence of renal failure (see above). Still, comparing our results with those of 1999 Marmara earthquake in Turkey, we had less renal failure in our patients. (18.3% in comparing with 2.9%).5 As observed in the 1999 earthquake in Turkey, fasciotomy is a predictor of the need for dialysis in our cases too.10 We had fewer amputations and fasciotomies compared with reports from that earthquake.10 This may reflect the efficacy and importance of the early initiation of renal and limb protective protocols used in many of these cases. It is also interesting to note the effect of the time spent under rubble in victims of the Turkish earthquake and our cases. In a report by Sever et al.,11 the mean time under rubble in victims of the Turkish earthquake was 8 h, compared with 1.5 h mean time in our cases. This may be another factor that explains the difference between the number of fasciotomies and amputations in the Turkish earthquake and our cases. As Sever et al noticed in their report, there has been a positive correlation between the time passed under rubble and the number of amputations.11 It is a reminder of the importance of early rescue efforts on outcome. A similar comparison can be made between the victims of the 1989 Armenian earthquake and our cases.12 Another interesting feature of our cases was the incidence of radial nerve injuries. We had 15 cases of radial nerve injuries from which, 93.3% were associated with humeral shaft fractures. In addition, 73.3% of our humeral fractures were associated with radial nerve injuries. It is noteworthy that as most authors have reported, radial nerve palsy accompanies fractures of humeral shaft in 6— 15% of cases.4 The higher rate of radial nerve injury observed in our patients may reflect a lack of proper handling of the fracture while carrying the patients or traction on taking the victims out of rubble. 2.9% of our cases were associated with spinal injuries, all being concomitant with vertebral fractures. 22.7% of vertebral fractures were associated with spinal injuries which is comparable to the data reported by other authors in other circumstances.3 The most frequently injured nerve in our patients was the sciatic nerve, which was associated with fractures or dislocations of lower extremities in 68% of cases. The incidence of neural injuries in extremities in our study points to the importance of use of proper methods in rescuing and handling the patients after the catastrophe.
Musculoskeletal injuries associated with earthquake
It has been demonstrated that the incidence of fractures and injuries in an earthquake depends on the position of the patients at the time of the incident.7 If the patients are standing or sitting at the time of injury, the most frequent observed fractures will be those of vertebral column and if the patients are lying in supine or lateral positions at the time of the earthquake, most of the fractures will be those of the pelvis and thoracic cage skeleton.7 Such a relation was observed among our patients too. As the patients were mostly lying at the time of earthquake (early morning), the incidence of pelvic fractures (especially the lateral compression type taking into account the position of most people while lying) was three times more than vertebral fractures (30% in comparison with 10.5%). Most of the fractures happened in the lower limbs (46.7%) with the axial skeleton being the next most common (36.2% + 3.8% rib fractures). The upper limbs were the least affected (29.9%). Other authors have observed the higher incidence of injuries in lower extremities too.8 Depending on factors like the time of incident and cultural habits of victims, the pattern of injuries may differ.6,7 The most common fractured bones in this report in the extremities were those of the roots of limbs (femur and humerus), which is predictable, given the proximity of these bones to the axial skeleton and the larger body area they contribute to. In a report published by Ozdogan et al.,9 it has been predicted that an expected 10% of victims in an earthquake will have thoracic and lung injuries. This prediction correlated well with 8.1% of our patients having thoracic injuries. As can be inferred from our results, most of the patients in such a trauma setting can be treated conservatively. Debridements, fasciotomies and soft tissue reconstructions and finally amputations are the surgical procedures that are most often used in management of these injuries. Providing the required facilities for above-mentioned procedures will be a priority in such disaster settings. In treating victims of this earthquake, we adhered to the following protocols and believe that complying with them was one of the reasons we achieved better results than victims of other recent comparable disasters: (1) One striking intra-operative feature of these patients is the relative abundance of muscular detachments, tendon ruptures and severe soft tissue contusions. This implies avoiding unnecessary operations and following a more conservative approach for treatment of these injuries until the complete healing of soft tissue injuries.
31 (2) In patients with compartment syndrome, if the patient was admitted in the following 48—72 h after the incident, intravenous access for adequate fluid therapy was established and fasciotomy was performed. If the patient was admitted after the first 48—72 h following the incident–— with regard to the high rate of infection and wound complications–—no fasciotomies were performed and a rehabilitative program that included physiotherapy, contracture prevention and reconstructive surgeries in the later stages was instituted. We avoided amputations if sepsis and renal failure were controllable and responsive to conservative measures. (3) With regard to severe psychological impacts of the disaster, we requested for psychiatric consultation from the first day of admission with outpatient post-discharge follow-ups. (4) Most of the pelvic fractures in these patients were associated with severe soft tissue contusions and was classified as stable fractures that led us follow a more conservative approach in their treatment. (5) We had relatively few cases of acute tubular necrosis due to crush syndrome in comparison with other reports. Our strategy was early intensive fluid therapy and consultation with a nephrologist from the very first hours of admission. (6) Neural palsies, as was the case in humeral fractures, were probably most due to traction of fractured limbs or inappropriate handling while rescuing the patient from the rubble. A careful approach in such situations will prevent prolonged morbidity.
References 1. Better OS, Stein JH. Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med 1990;322:825—9. 2. Crippen D. The World Trade Center Attack: similarities to the 1988 earthquake in Armenia: time to teach the public lifesupporting first aid? Crit Care 2001;5(6):312—4. 3. Fletcher DJ, Taddonio RF, Byrne DW, Wexler LM, Cayten CG, Nealon SM, et al. Incidence of acute care complications in vertebral column fracture patients with and without spinal cord injury. Spine 1995;20(10):1136—46. 4. Gregory PR. Fractures of the shaft of the humerus. In: Bucholz RW, Heckman JD, editors. Rockwood and Green’s fractures in adults. 5th ed. New York: Lippincot; 2001. p. 991—2. 5. Kantarci G, Vanholder R, Tuglular S, Akin H, Koc M, Ozener C, et al. Acute renal failure due to crush syndrome during Marmara earthquake. Am J Kidney Dis 2002;40(4):682—9. 6. Kurt N, Kucuk HF, Celik G, Demirhan R, Gul O, Altaca G. Evaluation of patients wounded in the 17 August 1999 Marmara earthquake. Ulus Travma Derg 2001;7(1):49—51.
32
7. Maruo S, Matumoto M. Spinal fractures resulting from the 1995 Great Hanshin Earthquake of the Kobe-Osaka area of Japan. Spinal Cord 1996;34(7):382—6. 8. Oda J, Tanaka H, Yoshioka T, Iwai A, Yamamura H, Ishikawa K, et al. Analysis of 372 patients with Crush syndrome caused by the Hanshin-Awaji earthquake. J Trauma 1997;42(3):470—5 [discussion 475—6]. 9. Ozdogan S, Hocaoglu A, Caglayan B, Imamoglu OU, Aydin D. Thorax and lung injuries arising from the two earthquakes in Turkey in 1999. Chest 2001;120(4):1163—6. 10. Sever MS, Erek E, Vanholder R, Akoglu E, Yavuz M, Ergin H, et al. Clinical findings in the renal victims of a catastrophic
T. Mohammad Naghi et al.
disaster: the Marmara earthquake. Nephrol Dial Transpl 2002;17(11):1942—9. 11. Sever MS, Erek E, Vanholder R, Ozener C, Yavuz M, Kayacan SM, et al. Lessons learned from the Marmara disaster: time period under the rubble. Crit Care Med 2002;30(11):2443—9. 12. Shaposhnikov IuGG, Kozhin NP, Nikogosian RV, Nuzhdin VI, Popova MM, Krupatkin AI, et al. The outcomes in crush syndrome of the extremities half a year after the earthquake in Armenia. Voen Med Zh 1990;(4):44—5. 13. Stein H, Hoerer D, Weisz I, Langer R, Revach M, Stahl S, et al. Musculoskeletal injuries in earthquake victims: an update on orthopedic management. Orthopedics 2000;23(10):1085—7.
www.elsevier.com/locate/injury
Musculoskeletal injuries associated with earthquake A report of injuries of Iran’s December 26, 2003 Bam earthquake casualties managed in tertiary referral centers Tahmasebi Mohammad Naghi*, Kiani Kambiz, Jalali Mazlouman Shahriar, Taheri Afshin, Shahriar Kamrani Reza, Panjavi Behnam, Alami Harandi Bahador Department of Orthopedic and Trauma Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Accepted 28 June 2004
KEYWORDS Musculoskeletal injuries; Iran; Earthquake
Summary This is a descriptive analysis, performed on victims of Iran’s December 26, 2003 Bam earthquake that were referred to tertiary referral trauma management centre in Tehran. Two hundred and ten patients were included in this study. Associated musculoskeletal injuries and renal function of the patients were recorded. The mean time under rubble was 1.9 h in our patients with a mean rescue to first medical aid time of 13.5 h. We had 19 cases of compartment syndrome and 6.7% of patients had impaired renal function. The incidence of compartment syndrome had a direct relation to the time under rubble and the incidence of renal failure was directly related to rescue to first medical aid time. Axial skeleton fractures, amongst them the lateral compression type pelvic fractures, were particularly common. Fracture associated neural injuries were also common. Institution of renal protective protocols from the very first hours after injury more conservative approaches to treatment of fractures in these crush trauma patients are strongly recommended. # 2004 Elsevier Ltd. All rights reserved.
Introduction * Corresponding author. Tel.: +98 21 84902238; fax: +98 21 2521330. E-mail address: [email protected] (Tahmasebi Mohammad Naghi).
During severe seismic activities of earth, translated as more than 6—7 in Richter’s scale, cracks and fissures appear in the ground, trees and rocks are uprooted and buildings collapse. The amount of
0020–1383/$ — see front matter # 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2004.06.021
28
destruction is in direct relation with the quality of the structure of buildings and ‘‘preventing collapse’’ engineering standards, in the case of Bam, mudbrick buildings with the least tolerance of seismic waves. During the collapse of a single story building 80% of those trapped inside die.1 The immediate causes of death are head, chest and abdominal crush injuries, followed later by suffocation, exsanguinations and onset of acute renal failure.13 The speed and skill with which the rescue teams save the casualties and the quality of post-rescue care are the next important factors. Soft tissue crush injuries, fractures, compartment syndromes and renal failure due to crush syndromes are musculoskeletal complications that should be addressed from the very first hours or they will result in life-threatening or life-long consequences that could have been preventable. Every major disaster warrants retrospective studies so we can learn how to improve all levels of Emergency Medical Services. The problems, needs and challenges no longer differ between countries, and creating specialized search and rescue teams, including physicians and structural engineers, might be useful.2 Therefore, the report presented here gives a clear view on how to cope with future disasters with better experience and equipment.
Methods and materials On December 26, 2003, 5:30 a.m. local time, an earthquake measuring 6.8 on the Richter scale, shook the ancient city of Bam (Fig. 1) in southern east Iran and destroyed more than 20,000 homes. More than 40,000 of 90,000 residing population of the city perished and nearly 30,000 were injured. Up to 12,000 casualties were airlifted to other parts of country, including Tehran. The hospitals of Tehran University of Medical Sciences were among those who admitted some of the casualties. The first group of patients arrived at 10:30 p.m. the same day. These patients had not been screened before referral and trauma of every genre, from trivial to major, existed among them. Patients who were referred on later days were those with major soft tissue or skeletal injuries who had undergone primary management in local area care-giving centres. We recorded the musculoskeletal injuries of patients who were admitted in Shariati Hospital and some of the casualties whose records were available for follow-up in Imam and Sina hospitals of Tehran. Patients admitted into our hospital (Shariati), underwent a uniform protocol of initial management and apart from the trauma team, a nephrol-
T. Mohammad Naghi et al.
Figure 1 The ancient citadel of Bam, dating back to preIslamic Iran, before and after the earthquake.
ogist and a psychologist visited all patients. A total of 210 patients were included in the study. A questionnaire was used for gathering information pertaining to head and neck, urologic and abdominal injuries and information regarding the timing of care-giving and type of treatment given was also recorded on the same questionnaire. Finally, the data were analysed using descriptive statistics and regression logistic analysis by SPSS1 software.
Results The mean age of the patients was 30.2 years with a range of 7—70 years. 57.6% of patients were females and the mean time under rubble was 1.9 h (Fig. 2) The mean time from rescue to first medical aid was 13.5 h (with a range of 1—72 h) as stated by patients and the mean time from first aid to referral to Tehran was 3 days (with a range of 0.5—16 days). We had 7 patients with upper limb compartment syndrome and 12 patients with lower limb compartment syndromes. (The compartment syndrome was defined as intra-compartmental pressure of more than 30 mmHg.) Nine patients with crushing injuries
Musculoskeletal injuries associated with earthquake
29
Figure 3 The most common type of pelvic fracture was lateral compression (LC), followed by anteroposterior compression (APC) and vertical shearing (VS) types. Figure 2 The histogram of time being under rubble. The mean time under rubble was 1.5 h.
(including lacerations, contusions and pre-compartment status) in the upper limbs and 13 patients with crushing injuries in lower limbs were seen. Fourteen patients (6.7%) had major soft tissue loss. Six patients (2.9%) had acute renal failure and nine patients (3.8%) had elevated creatinine levels that responded to therapeutic measures. Three patients with acute renal failure had fasciotomies. The most common peripheral nerve injury was to the sciatic nerve (25 cases) and radial nerve (15 cases) and six (2.9%) patients had spinal injuries, which were all associated with vertebral fractures. 93.3% (14) of the radial nerve injuries were associated with fractures (11 with humeral shaft fractures). Sixty-eight percent (17) of the sciatic nerve injuries were associated with lower limb fractures or dislocations. Eighteen patients had compartment syndrome (8.6%) and 16.7% (35) had major soft tissue injury. 36.2% (76) of the patients had axial skeleton fractures (pelvic and vertebral) with 22 (10.5%) vertebral fractures and 63 (30%) pelvic fractures. The most common type of pelvic fracture was lateral compression. (Fig. 3) (32 cases) with isolated fractures (20) and anteroposterior compression fractures (5 cases) the next most common. 22.7% of vertebral fractures were associated with spinal injuries (5 cases). 29.9% of our patients had upper limb fractures (Table 1) and 46.7% had lower limb fractures (Table 2). The most common injured bone in the upper limb was the humerus and in the lower limb the femur. 73.3% of humeral fractures were associated with radial nerve injuries and 22.7% of vertebral fractures were associated with spinal injuries.
Table 1
Incidence of upper limb fractures
Both bone forearm fractures Clavicle fractures Distal radial fractures Galaezi fractures Glenohumeral dislocations Humeral fractures Hand and wrist fractures Scapular fractures None Others
Frequency
Percent
4 5 9 2 2 15 6 1 162 4
1.9 2.4 4.3 1.0 1.0 7.1 2.9 0.5 77.1 1.9
15.2% of our patients had head injury with 6.2% intracranial and 7.6% superficial injuries. 8.1% of our patients had thoracic injuries with 8 patient with rib fractures and 8 patients with intrathoracic injuries. 8.6% of our patients had abdominal injuries which required surgery and 5 patients had urologic injuries which were all associated with pelvic fractures. The incidence of renal failure increased with increase in time from rescue to first medical aid but was relatively independent of time being under Table 2
Incidence of lower limb fractures Frequency
Bimaleolar and pilon fractures Femoral shaft and supracondylar fractures Fractures of foot Hip fracture or dislocation, including acetabulum Tibial plateau fractures Tibiofibular fractures Others None
Percent
12 28
5.7 13.3
15 17
7.1 8.1
9 16 1 112
4.3 7.6 0.5 53.3
30
Figure 4 Increase in the chance of renal failure by each hour passing from rescue to receiving first aid.
rubble. As calculated by logistic regression coefficient, there is a meaningful relation between the time being under rubble and incidence of compartment syndrome: each hour passing, the chance of incidence of compartment syndrome increases by 15.23% in the upper limbs and 13.3% in the lower limbs. In addition, a 5% increase in the chance of renal failure happens with each passing hour from the rescue to receiving first aid (Fig. 4). Ninety patients were treated conservatively, 69 underwent open reduction and internal fixation, 20 underwent debridement or repair and 17 had external fixation. Seven patients had amputations and seven needed skin grafts.
Discussion Dealing with casualties in settings of disaster is one of the challenging topics in trauma management. Epidemiologic data inferred from this report are interesting in some aspects. As can be observed, most patients passed a short time under rubble (mean: 1.5 h), but the first aid teams have had long delays reaching patients. (mean: 13.5 h). This shows the lack of coordination and irregularities that exist in first hours of catastrophe (most medical centres in the disaster zone had been damaged) and the lack of appropriate systems for addressing the needs of casualties in such situations. As noticed above, the incidence of compartment syndrome and renal failure have inverse relations with the elapsed time from injury to first aid visit. We had seven amputations, most due to severe crush injuries that had lead to vascular compromise
T. Mohammad Naghi et al.
and eventual infection, a situation that could have been preventable by early fasciotomy. In addition, the initiation of early therapy to prevent acute tubular necrosis due to crush syndrome is well shown by the relation between time elapsed since injury to first medical aid and incidence of renal failure (see above). Still, comparing our results with those of 1999 Marmara earthquake in Turkey, we had less renal failure in our patients. (18.3% in comparing with 2.9%).5 As observed in the 1999 earthquake in Turkey, fasciotomy is a predictor of the need for dialysis in our cases too.10 We had fewer amputations and fasciotomies compared with reports from that earthquake.10 This may reflect the efficacy and importance of the early initiation of renal and limb protective protocols used in many of these cases. It is also interesting to note the effect of the time spent under rubble in victims of the Turkish earthquake and our cases. In a report by Sever et al.,11 the mean time under rubble in victims of the Turkish earthquake was 8 h, compared with 1.5 h mean time in our cases. This may be another factor that explains the difference between the number of fasciotomies and amputations in the Turkish earthquake and our cases. As Sever et al noticed in their report, there has been a positive correlation between the time passed under rubble and the number of amputations.11 It is a reminder of the importance of early rescue efforts on outcome. A similar comparison can be made between the victims of the 1989 Armenian earthquake and our cases.12 Another interesting feature of our cases was the incidence of radial nerve injuries. We had 15 cases of radial nerve injuries from which, 93.3% were associated with humeral shaft fractures. In addition, 73.3% of our humeral fractures were associated with radial nerve injuries. It is noteworthy that as most authors have reported, radial nerve palsy accompanies fractures of humeral shaft in 6— 15% of cases.4 The higher rate of radial nerve injury observed in our patients may reflect a lack of proper handling of the fracture while carrying the patients or traction on taking the victims out of rubble. 2.9% of our cases were associated with spinal injuries, all being concomitant with vertebral fractures. 22.7% of vertebral fractures were associated with spinal injuries which is comparable to the data reported by other authors in other circumstances.3 The most frequently injured nerve in our patients was the sciatic nerve, which was associated with fractures or dislocations of lower extremities in 68% of cases. The incidence of neural injuries in extremities in our study points to the importance of use of proper methods in rescuing and handling the patients after the catastrophe.
Musculoskeletal injuries associated with earthquake
It has been demonstrated that the incidence of fractures and injuries in an earthquake depends on the position of the patients at the time of the incident.7 If the patients are standing or sitting at the time of injury, the most frequent observed fractures will be those of vertebral column and if the patients are lying in supine or lateral positions at the time of the earthquake, most of the fractures will be those of the pelvis and thoracic cage skeleton.7 Such a relation was observed among our patients too. As the patients were mostly lying at the time of earthquake (early morning), the incidence of pelvic fractures (especially the lateral compression type taking into account the position of most people while lying) was three times more than vertebral fractures (30% in comparison with 10.5%). Most of the fractures happened in the lower limbs (46.7%) with the axial skeleton being the next most common (36.2% + 3.8% rib fractures). The upper limbs were the least affected (29.9%). Other authors have observed the higher incidence of injuries in lower extremities too.8 Depending on factors like the time of incident and cultural habits of victims, the pattern of injuries may differ.6,7 The most common fractured bones in this report in the extremities were those of the roots of limbs (femur and humerus), which is predictable, given the proximity of these bones to the axial skeleton and the larger body area they contribute to. In a report published by Ozdogan et al.,9 it has been predicted that an expected 10% of victims in an earthquake will have thoracic and lung injuries. This prediction correlated well with 8.1% of our patients having thoracic injuries. As can be inferred from our results, most of the patients in such a trauma setting can be treated conservatively. Debridements, fasciotomies and soft tissue reconstructions and finally amputations are the surgical procedures that are most often used in management of these injuries. Providing the required facilities for above-mentioned procedures will be a priority in such disaster settings. In treating victims of this earthquake, we adhered to the following protocols and believe that complying with them was one of the reasons we achieved better results than victims of other recent comparable disasters: (1) One striking intra-operative feature of these patients is the relative abundance of muscular detachments, tendon ruptures and severe soft tissue contusions. This implies avoiding unnecessary operations and following a more conservative approach for treatment of these injuries until the complete healing of soft tissue injuries.
31 (2) In patients with compartment syndrome, if the patient was admitted in the following 48—72 h after the incident, intravenous access for adequate fluid therapy was established and fasciotomy was performed. If the patient was admitted after the first 48—72 h following the incident–— with regard to the high rate of infection and wound complications–—no fasciotomies were performed and a rehabilitative program that included physiotherapy, contracture prevention and reconstructive surgeries in the later stages was instituted. We avoided amputations if sepsis and renal failure were controllable and responsive to conservative measures. (3) With regard to severe psychological impacts of the disaster, we requested for psychiatric consultation from the first day of admission with outpatient post-discharge follow-ups. (4) Most of the pelvic fractures in these patients were associated with severe soft tissue contusions and was classified as stable fractures that led us follow a more conservative approach in their treatment. (5) We had relatively few cases of acute tubular necrosis due to crush syndrome in comparison with other reports. Our strategy was early intensive fluid therapy and consultation with a nephrologist from the very first hours of admission. (6) Neural palsies, as was the case in humeral fractures, were probably most due to traction of fractured limbs or inappropriate handling while rescuing the patient from the rubble. A careful approach in such situations will prevent prolonged morbidity.
References 1. Better OS, Stein JH. Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med 1990;322:825—9. 2. Crippen D. The World Trade Center Attack: similarities to the 1988 earthquake in Armenia: time to teach the public lifesupporting first aid? Crit Care 2001;5(6):312—4. 3. Fletcher DJ, Taddonio RF, Byrne DW, Wexler LM, Cayten CG, Nealon SM, et al. Incidence of acute care complications in vertebral column fracture patients with and without spinal cord injury. Spine 1995;20(10):1136—46. 4. Gregory PR. Fractures of the shaft of the humerus. In: Bucholz RW, Heckman JD, editors. Rockwood and Green’s fractures in adults. 5th ed. New York: Lippincot; 2001. p. 991—2. 5. Kantarci G, Vanholder R, Tuglular S, Akin H, Koc M, Ozener C, et al. Acute renal failure due to crush syndrome during Marmara earthquake. Am J Kidney Dis 2002;40(4):682—9. 6. Kurt N, Kucuk HF, Celik G, Demirhan R, Gul O, Altaca G. Evaluation of patients wounded in the 17 August 1999 Marmara earthquake. Ulus Travma Derg 2001;7(1):49—51.
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7. Maruo S, Matumoto M. Spinal fractures resulting from the 1995 Great Hanshin Earthquake of the Kobe-Osaka area of Japan. Spinal Cord 1996;34(7):382—6. 8. Oda J, Tanaka H, Yoshioka T, Iwai A, Yamamura H, Ishikawa K, et al. Analysis of 372 patients with Crush syndrome caused by the Hanshin-Awaji earthquake. J Trauma 1997;42(3):470—5 [discussion 475—6]. 9. Ozdogan S, Hocaoglu A, Caglayan B, Imamoglu OU, Aydin D. Thorax and lung injuries arising from the two earthquakes in Turkey in 1999. Chest 2001;120(4):1163—6. 10. Sever MS, Erek E, Vanholder R, Akoglu E, Yavuz M, Ergin H, et al. Clinical findings in the renal victims of a catastrophic
T. Mohammad Naghi et al.
disaster: the Marmara earthquake. Nephrol Dial Transpl 2002;17(11):1942—9. 11. Sever MS, Erek E, Vanholder R, Ozener C, Yavuz M, Kayacan SM, et al. Lessons learned from the Marmara disaster: time period under the rubble. Crit Care Med 2002;30(11):2443—9. 12. Shaposhnikov IuGG, Kozhin NP, Nikogosian RV, Nuzhdin VI, Popova MM, Krupatkin AI, et al. The outcomes in crush syndrome of the extremities half a year after the earthquake in Armenia. Voen Med Zh 1990;(4):44—5. 13. Stein H, Hoerer D, Weisz I, Langer R, Revach M, Stahl S, et al. Musculoskeletal injuries in earthquake victims: an update on orthopedic management. Orthopedics 2000;23(10):1085—7.