ORTHOPEDIC CASE BURDEN AT NUNUKAN HOSPITAL: FOCUS ON TRAUMA CASE

Incidence of orthopedic case is quite high in Nunukan Hospital, most of them need both non-operative and surgical intervention due to congenital, debridement, fracture, rupture of tendon and blood vessel, even amputation. Until now, data orthopedic case profile especially trauma case in Nunukan Hospital is not available. Also, the urgency of having an orthopedic surgeon is unbearable which unavailable in Nunukan, this made the management can’t be done comprehensively and as soon as possible. The aim of this research was to describe the incidence of orthopedic case at Nunukan hospital as basic data for further research. This Retrospective Study was conducted at Nunukan Hospital, North Kalimantan – Indonesia. The data is collected by using logbook and medical records during January 2016 April 2017. Total of 231 cases were obtained. Male patients accounted for 73.6% (170 patients) and Female was 26.4% (61). The age ranged from 1 day to 82 years old. There are 8-21 cases happened per month (average: 14 cases). Based on case category, trauma occurred for 88.7%% (205). Five top diagnoses are; Close Fracture happened for 44.6% (103 cases), followed by Open Fracture 17.7% (41 cases), Lacerated wound 11.3% (26 cases), Traumatic Amputation 7.4% (17 cases) and CTEV 7.4% (17 cases). Most pathology within the period located in Foot for 29.9% (69). The multiple fracture, vascular, and soft tissue injury were observed. Orthopedic fractures were the most common injuries among patients with 88.7% in Nunukan Hospital from January 2016 to April 2017. There are 14 cases happened for each month with most of the patient were adult. Most of injuries happened at foot region.


INTRODUCTION
Orthopedics ward admissions range variety of cases, from relatively healthy patients admitted for deformity corrections to those with fractures, multiple trauma, tumor, or chronic illnesses. These cover a whole spectrum of ages, complication and added medical co-morbidities. Managing these illnesses or injuries were hard, could lead to surgical and medical complications with mortality being one of them. The pattern of mortality and morbidity reflects the burden of disease in a particular community. This pattern expresses geographic variations between communities and countries. Quoted figures for mortality in orthopedics and trauma varies with lower figures in the advanced world. [1][2][3] In the year 1998/1999, there were 3.8 million acute admissions in hospitals throughout the United Kingdom and acute admissions for orthopedics and trauma patients constituted 8% of these. 4 Centralized data of this nature are not available in Indonesia, but, to the best of our knowledge, there are few report on pattern of mortalities among orthopedics and trauma admissions in our country.
Nunukan Hospital located in Nunukan Regency in North Kalimantan of Indonesia. Nunukan Regency has an area of of 14,247.50 km 2 with 193,390 populations. It is located 136 km from the Capital City of North Kalimantan, Tarakan. The transportation available is via speedboat, airplane, or vehicle, ranging for thirty minutes to 2,5 hours to get to Tarakan from Nunukan, or vice versa. 5 Incidence of orthopedic case is quite high in Nunukan Hospital, most of them need both non-operative and surgical intervention due to congenital, debridement, fracture, rupture of tendon and blood vessel, even amputation. Until now, data orthopedic case profile in Nunukan Hospital especially trauma case is not available. Also, the urgency of having an orthopedic surgeon is unbearable which unavailable Nunukan. Any management of orthopedic cases would be handled by general surgeon which made the management can't be done comprehensively and as soon as possible. The aim of this research was to describe the incidence of orthopedic case at Nunukan hospital for the basic data for further research.

RSEARCH METHODS
This Retrospective Study was conducted at Nunukan Hospital, North Kalimantan -Indonesia. The data is collected by using logbook and medical records during January 2016 -April 2017. Inclusion criteria included all patients brought into both of emergency and nonemergency department as orthopedic consultation. Patients with incomplete registered information and data were excluded from the study. Variables included age, gender, location of fracture, presence of open or closed fractures, concomitant soft tissue, vascular injuries and management were recorded, tabulated and analyzed by using statistical software.

RESULT AND DISCUSSION
Total of 231 cases were obtained. There are 8-21 cases happened per month (average: 14 cases). Male patients accounted for 73.6% (170 patients) and Female was 26.4% (61). Men were predominantly injured at a ratio of 3:1 (Table 1 and Figure 1). In an American study, another similar result was also found, 6 which also reported the gender difference that males are much more likely to get injury than females, especially among adults and the elderly. Our study was consistent with previous studies. Table 1 and Figure 1 demonstrate that males are much more likely to be killed in a road traffic injury than females.
The age ranged from 1 day to 82 years old. Average age at time of injury was 26.0 years. Most of the patient were adult, ranged from 21 to 40 years old with total of 76 patients (31.4%). (Table 2 and Figure 2). Study in the USA, 5,838 admissions of an academic Level I trauma center registered over 10 years were reviewed and showed that there were 19.4% patients were 14 years old or less, 64.1% who were 15 to 55 years old, 7.2% were 56 to 65 years old, and 9.3% older than 65 years. 6 Another National Trauma Databank study during a 5-year period revealed that there were 4,095 patients (32.9%) ≤14 years, 3,806 (30.7%) 15 to 35 years old, 3,413 (27.5%) 36 to 55 years old, 688 (5.5%) 56 to 65 years old, and 427 (3.4%) >65 years old. The overall mortality was 3.7% and ranged from 2.4% in the age stratum of ≤14 years to 12.2% in the stratum of >65 years. 7 A cross-sectional study in India showed majority of the victims were in the age group of 18-37 years. 8 In Africa, a retrospective analysis of nonfatal road traffic crash victims still showed that the age group of 15-44 years was the most affected (81.9%). 9   Figure 3; Figure  4). A cross-sectional study in India showed that fractures were the most common injury among the victims of nonfatal road traffic accidents. 8 In Africa, a retrospective analysis of nonfatal road traffic crash victims still showed that the most common injuries were fractures (69.0%). 9 Of all trauma case (205 cases), road traffic injures (RTIs) are responsible for a substantial proportion of deaths and injuries and are responsible for reduced quality of life than most human diseases. Motorcycle collisions in road traffic are a significant cause of mortality and morbidity among adults age. Study in the United States, the rate of injuries related to motorcycle collisions is among the highest of developed countries. 10 In 2004, study of motor vehicle accidents were the leading cause of death among individuals between the ages 3 years and 33 years. 11 It was also found that Per vehicle mile traveled, motorcycle riders are eight times more likely to be injured than drivers of other vehicles. 10 Nowadays, motorcycle use is becoming more popular and the numbers of users are rapidly increasing. Society also incurs a tremendous loss of productivity because injuries occur predominantly in young, working-age individuals. 12 Human behavior factors, vehicle factors, and road factors contribute to the causation of road traffic crushes. 13

Main Diagnoses
This study found pathology in lower extremities (53.2%) had a higher rank rather than upper one (46.8%), with most common site of pathology involved the foot (69 of 231 case) (Table 5 and Figure 5). In correlation with this report, multiple studies have shown that between 30% and 70% of nonfatally injured riders sustain lower extremity injuries. [14][15][16][17] Of these injuries, fractures are most frequent and have the most severe outcomes, in terms of permanent disability, economic costs, and return to work. [15][16][17][18][19][20][21][22] In this study we found foot injury was common rather than the other, but in different studies among fractures, the tibia is the most common site of injury, followed by the femur, foot, and patella. 17 In Africa, a retrospective analysis of nonfatal road traffic crash victims still showed the tibia/ fibula being the most fractured bones (30.3%). 9 Another hospital-based study of 450 cases admitted due to traffic accidents in India revealed that the most common type of injury was fracture (49.33%) and the most common site of fracture was lower limb (48.2%), and several risk factors such as age, sex, type of vehicle, use of alcohol, absence of driving license, nonuse of helmets, and casual attitude are associated with increased occurrence of road traffic accidents 23 Many Studies have demonstrated that owing to the nature of most motorcycle injuries, the lower extremities are at increased risk for trauma because of their position in regards to the motorcycle. [17][18][19][20] Commonly, motorcycle collisions that do not involve the driver being ejected from his or her vehicle will include a lower extremity intimately involved or trapped under the motorcycle during or after the accident. 17 Motorcycle drivers and passengers do not differ in their risk for lower extremity injury. 17 Men predominantly were injured in our study, corresponding with the national motorcycle registry, which shows men owning and riding the majority of motorcycles.   This study found there were associated injury occured after trauma. There are 43 patients (20%) sustained multiple fractures, 29 patients (14%) for vascular injury (vein and/ or arterial rupture), and 50 patients (32%) for soft tissue injury (tendon rupture and/ or muscular tear) ( Table 6 and Figure 6). For management of surgical for trauma case, the details and distribution had shown at Table 7. Open redutction had done for 38.1% of cases. Close reduction for 33.1%. Amputation management had done for 8%.
This study still provide some weakness. Including the mechanism of injury, protective equipment worn during crash, and length of hospital stay.