4. Electronic Theses and Dissertations (ETDs) - Faculties submissions

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    Analysis of Orthopaedic Injuries in Polytrauma Patients at Charlotte Maxeke Johannesburg Academic Hospital
    (University of the Witwatersrand, Johannesburg, 2022) Laney, Wezley; Naicker, Dharshen; Milner, Brenda
    Background: Traumatic injuries represent a significant burden globally, accounting for ten percent of the global burden of disease. In South Africa we commonly see patients who have sustained major trauma, often with multiple injuries. This significant burden of trauma necessitates the demand for rapid diagnostic assessment of injuries for appropriate therapeutic intervention. A whole body computed tomography (CT pan scan) allows for a rapid multisystem injury diagnosis of trauma patients. There is a scarcity of literature evaluating the extent of orthopaedic injuries in polytrauma patients. Study Aim: The aim of the study was to evaluate the local epidemiology of orthopaedic injuries in polytrauma patients who have undergone a CT pan scan. Methods: A retrospective, observational analysis, based at Charlotte Maxeke Johannesburg Academic Hospital, was done of polytrauma patients who underwent a CT pan scan, during a 2-year period from 01/01/2018 – 31/12/2019. A database was compiled by accessing the picture archiving and communication system for CT reports. The qualitative data was reported using frequencies and percentages. Categorical variables were analysed using the Chi-squared test (or Fisher’s exact test). Results: Over the two-year study period a total of 296 polytrauma patients had a reported CT pan scan performed. Of these, 85% were male and 15% were female with a median age of 33 years. The most common mechanism of injury was motor vehicle accidents (33.1%). The prevalence of orthopaedic injuries in polytrauma patients was 53.3%. A total of 1012 injuries were found. One hundred and ninety-six (196) spinal fractures were detected; a total of 137 pelvic/sacral fractures, 101 long bone fractures with 75% lower limbs and 25% were upper limb fractures. The most common non-orthopaedic injury sustained was a chest injury. The most common combination of orthopaedic and non-orthopaedic injuries identified in the study was a chest injury with an associated pelvic/sacral fracture secondary to a PVA. Interpersonal and intentional injuries were significantly associated with a higher risk of thoracic spine fractures (RR 1.8, CI 1.1-2.9). Road traffic accidents were significantly associated with a higher risk of scapular/clavicular fractures (RR 2.0, CI 1.2-3.5) and a higher risk of tibial/fibula fractures (RR 3.5, CI 1.2-10.3) Conclusion: The majority of polytrauma patients seen at CMJAH were young males, who sustained injuries during road traffic accidents. Fractures accounted for 94% of all orthopaedic injuries. The most common orthopaedic injury detected in our cohort, overall, was a spinal fracture, most commonly involving the cervical spine. A patient involved in a road traffic accident is 3.5 times more likely to sustain a tibia/fibular fracture as opposed to any other fracture. The most common non-orthopaedic injury sustained was a chest injury. Importantly, 1 in 4 of these patients sustained an associated cervical spine injury and 1 in 3 a pelvic injury, similarly with head injuries. The most common combination of injuries is a chest injury with an associated pelvic/sacral fracture secondary to a pedestrian vehicle accident. The findings highlight the significant burden of orthopaedic injuries in polytrauma patients. In addition, the findings of this study, highlight injury patterns that should be anticipated in polytrauma patients.
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    Investigating the physiotherapy management of patients with polytrauma admitted to acute care settings and factors that influence service delivery after discharge: a Namibian survey
    (University of the Witwatersrand, Johannesburg, 2024) Chirombo, Hannah E.; Van Aswegen, Helena
    Introduction: Globally 5.8 million deaths per year are because of multiple traumatic injuries with as much as 16,000 deaths a day. Traumatic physical injuries thus pose a notable risk worldwide resulting in morbidity and mortality. Most commonly road traffic collisions are the largest contributing factor to traumatic physical injuries. Namibia ranks highly in Africa in the proportion of cases of motor vehicle crashes (MVC) per population and are the fifth leading cause of death. With Namibia also ranking highly on violence, many people often require rehabilitation following physical trauma. Delivery and accessibility of rehabilitation services in Namibia is hindered by a critical shortage of rehabilitation service providers employed by the state as most are attracted by the private sector. In the existing literature, auditing of usual care physiotherapy practice following polytrauma is not frequently documented. For a country with a high incidence of MVCs, it is imperative to look at usual care in physiotherapy for patients with polytrauma. Aim: To describe the physiotherapy management of patients with polytrauma in acute care settings in Namibia and the factors that influence service delivery to these patients after discharge. Methodology: A cross-sectional survey was conducted using an electronic survey tool. A study-specific questionnaire was developed, and content validation of the questionnaire was conducted by two physiotherapy experts in the field of traumatology. Convenience sampling was used to invite all registered physiotherapists practicing in Namibia’s state and/or private acute care facilities to participate (n=133). Descriptive statistics were used to summarise the data. Categorical data was summarized as frequencies and percentages and presented in tables, pie charts, and graphs. Continuous data were summarised as medians and interquartile ranges. Qualitative content analysis was done on data obtained from patients’ answers to open-ended questions. Results: Fifty-five questionnaire links were opened by the respondents; 52 responses were considered in this study yielding a 39% response rate (n=52/133). Female physiotherapists made up most of the respondents (n= 33; 64%). Most respondents were young with a median age of 30 years (IQR= 28-31) and an average of six years (IQR= 3.3-7) of clinical practice. Respondents worked in private institutions (n=18; 35%), public sector (n=16; 31%) and both public and private sector (n=18; 35%). The majority of the respondents encountered patients with polytrauma in the ICU setting and hospital ward. Most participants (n=47, 93%) reported that majority of the patients with polytrauma that they see in their places of work are males. The most frequent mechanism of injury resulting in polytrauma was motor vehicle crashes (n= 47; 93%), whilst stab wounds and gunshot wounds were rare causes of polytrauma. Frequently injured body regions were the lower limb (n=40; 77%) and head and neck (n=37; 71%). Physiotherapists commonly used breathing exercises (n=44; 85%), suctioning (n=42; 81%), manual chest therapy (n=39; 75%), body positioning to optimize oxygenation (n=38; 73%), respiratory muscle strengthening (n=35; 67%), active cycle of breathing techniques (n=34; 65%), incentive spirometry (n=34; 65%), positive expiratory pressure therapy (n=31; 60%), body positioning to aid postural drainage (n=28; 54%) and nebulisation therapy (n=25; 48%) to optimize/restore their polytrauma patients’ respiratory function. Whilst manual hyperinflation (n=32; 62%), ventilator hyperinflation (n=29; 56%) and intermittent positive pressure breathing (n=27; 52%), were ‘rarely used’. Physiotherapists frequently used early mobilisation out of bed (n=49; 94%), active range of motion (n=48; 92%), passive ROM (n=48; 92%), in bed mobilisation (n=46; 89%), and functional exercises (n=42; 81%) to restore/maintain optimal neuromusculoskeletal system function in patients with polytrauma. These techniques were immensely popular among respondents such that no one reported not using them in patient care. In the evaluation of treatment of the neuromuscular system the de Morton mobility index (n= 41; 78%), physical function in intensive care unit test (n=35; 67%) and Chelsea critical care physical assessment tool (n=34; 67%) were validated outcome measures ‘rarely used’ by most of the respondents, whilst the evaluation of muscle power (n=43; 83%), and medical research council sum score (n=43; 83%) were frequently used. Patients with polytrauma stayed between eight to 15 days and were then discharged into step-down facilities (n= 25; 48%), and subacute facilities of the same institution (n= 19; 37%) for extended care whilst some were discharged home (n= 21; 40%). Functional outcomes and hospital length of stay were factors reported to influence patients’ discharge. Respondents reported that they routinely provided home exercise programs focused on respiratory rehabilitation, cardiopulmonary endurance training, and patient and caregiver education to their patients. The lack of adequate human resources in the physiotherapy profession and insufficient knowledge by team members in Namibia about the role of physiotherapy in the care of patients with polytrauma injury were factors reported to affect in-hospital physiotherapy service delivery. Inadequate support systems for patients by their family/caregivers and the long distances that patients need to travel to access rehabilitation services after hospital discharge were factors reported to affect the continuity of physiotherapy service provision after discharge from an acute care facility. Good family support (n=11; 21%) as well as patient’s self-motivation and compliance to their treatment (n=10; 19%) were factors reported as enablers to physiotherapy service provision post-discharge. Conclusion: In Namibian acute care settings, patients with polytrauma are mostly male, sustained injury through motor vehicle crashes, and had an extended hospital stay before discharge to step-down facilities. Physiotherapy management is focused on prevention of respiratory system dysfunction and all physiotherapists prioritized active exercises and mobilisation out of bed in their patient management. Findings contribute to the limited existing body of knowledge regarding the physiotherapy management of Namibian patients who sustained polytrauma injury. The limited use of physiotherapy techniques that require adjustment of mechanical ventilator settings and the limited use of validated outcome measures by physiotherapists in their patient management are highlighted. The lack of human and financial resources are factors reported to impact physiotherapy service delivery in Namibia. Implications for clinical practice: Findings from this study provide a platform from which intervention- based studies can be conducted to better understand the effect of physiotherapy management on patient outcomes after polytrauma