NUMBER AND GENDER OF INDIVIDUALS AFFECTED
Traumatic injury is a major public health issue in the United States and throughout the world. In the United States in 2002 there were 54 million office visits, 21 million emergency room visits, 4.5 million outpatient visits and 2 million hospitalizations dealing with traumatic injuries; 1.3 million fractures resulted in hospitalizations. Trauma results in over 150,000 deaths in the US each year, is the most common cause of death between the ages of 1 and 44, and causes more deaths in the age group 1-15 than all other mechanisms combined.
Trauma includes fractures, sprains, and strains.
The term "fracture" means a broken bone, no matter how badly displaced it may be. Fractures can be caused by direct or indirect forces to a bone, or through complications from osteoporosis. Falls, sports injuries, and motor vehicle accidents are common causes of fractures. An open fracture is a broken bone with torn or cut skin, and in these cases, there are higher risks of infection and healing problems. With open fractures, the soft tissue barrier separating the bone from the environment is disrupted and the fracture is exposed to the atmosphere.
An individual is most likely to sustain a broken bone (fracture) inside the home. Motor vehicle accidents are also a large source of injuries, particularly to the musculoskeletal system. In 1996, there were approximately 6.8 million police-reported motor vehicle accidents (U.S. Department of Transportation). Men (young men particularly) are more likely to be involved in a motor vehicle accident than women.
Men are also more than twice as likely as women to sustain a broken bone (fracture) as a result of a motor vehicle accident. The workplace is a substantial source of injury, illness and disability. More than 6 million occupational injuries and illnesses occurred in 1997.
Fractures are most likely at two stages in life. The first peak is in the first 2 decades of life. After adulthood, the likelihood of fracture declines with age until age 65 at which time the incidence of fracture begins to increase, reflecting the increasing rate of hip, wrist and spine fractures in the older population. The aging of the United States population will increase the relative impact of musculoskeletal conditions: over the next thirty years, the percent of the population age 65 and over will increase from 12.8% to 20.0% of the population. In older individuals (65 years and older) women are far more likely to sustain a broken bone. This is likely to be related to the higher incidence of osteoporosis in older women.
Sprains and Strains
A "sprain" occurs when a ligament, the fibers that connect bone ends at the joint, stretches or tears. A "strain" is a pull, stretch or tear to a muscle or a tendon, which connects the muscle to bone. Sprains and strains can be caused by any direct or indirect impact to the body: through sports, on the job, or at home. Sprains and strains can be chronic, caused by repeated movements or pressure applied to one part of the body such as swinging a baseball bat, or acute, caused by sudden and powerful movements such as jumping or reaching. Anyone can get sprains and strains, but especially athletes and people whose jobs involve repetitive motions. Sports injuries account for a large proportion of sprains and strains.
MORTALITY AND MORBIDITY
Broken bones (fractures) are the most likely musculoskeletal injury to require medical attention. Sixty-four percent of fractures result in a person restricting his or her normal activities. Fractures of the lower limb are most likely to result in activity modification. Musculoskeletal injuries also result in a substantial number of missed work and school days. Among currently employed persons, musculoskeletal injuries are responsible for over 147 million lost work days, and the number one reason for lost work days in people under 45. Among children ages 5 to 17, musculoskeletal injuries are responsible for 21 million missed school days.
The cost of treating musculoskeletal injuries amounted to $41.3 billion in 1995. About 83% of this total was related to direct costs (hospital and physician services); the remaining 17% was related to indirect costs (lost time from work, etc)
Musculoskeletal injuries result in a substantial use of health care resources and are responsible for a large number of hospitalizations and physician visits each year. During the period from 2000 through 2002, around 1.9 million hospitalizations occurred annually in the United States for musculoskeletal traumatic injuries, and in 2002 accounted for 24% of hospitalizations for musculoskeletal conditions. These injuries resulted in around 11 million patient days per year, with an average length of hospital stay of six days. Musculoskeletal injuries also result in large numbers of physician visits. During 2000 and 2001 there were more than 46 million office visits for any musculoskeletal condition with a traumatic injury, however in 2002 this number increased to 54 million office visits.
Injuries affecting the musculoskeletal system account for the majority of occupational injuries and illnesses that result in lost days at work. The average cost per Workers' Compensation claim files was $10,500 in 2002.
Musculoskeletal Disorders with Days Away from Work
by Nature of Injury or Illness, 2002
There is usually a history of injury associated with fracture, although fractures that occur through abnormal or osteoporotic bone may not be associated with a history of significant trauma. When a bone fractures there may be an audible cracking sound, followed by acute pain and swelling. There will usually be tenderness around the fracture. A medical examination is imperative to determine the nature and severity of a fracture. Xrays are usually required to confirm the diagnosis and to show the position, displacement and pattern of the fracture.
Sprains and strains
An examination by a physician may be necessary to determine the nature and severity of sprains and strains. Signs of a sprain include pain, swelling, and bruising, to varying degrees, and the patient may hear or feel a pop at the affected joint. Severe sprains incur intense pain at the time of injury as the ligament ruptures, rendering the joint loose and unusable. Moderate strains partially tear the ligament, causing some loosening, instability, and swelling, while mild sprains pull on the ligament without causing it to loosen.
Signs of a strain include pain, swelling, cramping, muscle spasms and weakness. Similar to sprains, severe strains tear the muscle or tendon and can make that part of the body immobile; moderate strains pull or partially tear the muscle or tendon, causing some immobility; and mild strains pull the muscle or tendon slightly. Common strains include back strain and hamstring strain.
The musculoskeletal system has a highly evolved ability to heal itself and restore function after injury. In many cases, treatment may involve immobilization and protection using casts or splints, usually for a period of several weeks, depending on the patient and the details of the specific injury.
Some fractures may be best treated with a surgical procedure, to improve the position of the bone pieces and/or to hold them in position while they heal. Bones may be stabilized by pins placed through the skin and connected together with bars outside the skin (called external fixation). Alternatively, bones may be stabilized with metal rods, plates, screws or pins placed under the skin (called internal fixation), through direct anatomical exposure of the fracture (open reduction) or through smaller incisions and indirect positioning of the fracture (closed reduction.) Open fractures usually require surgery to clean the soft tissue wound and reduce the risk of infection. The choice of appropriate treatment and the timing of surgery is highly individualized and varies based on the patient's medical condition, expectations and the details of the specific fracture. These decisions should be made by the patient under the guidance of a physician experienced in fracture care.
Fracture healing may be delayed or prevented by certain medical conditions (e.g. diabetes, malnutrition), medications (anti-inflammatory drugs), or habits (cigarette smoking). It is important to follow physician advice regarding restrictions, activity level, and exercise. Both too much and too little use of the fractured limb can interfere with healing and functional recovery. Pain from a fracture will go away before the bone has healed completely, so patients must be careful not to put too much stress on the bone even though it feels solid. Fractures take between several weeks and several months to heal, and joints and muscles can feel stiff after casts or splints have been removed. As the bone heals, the muscles around it may atrophy, or weaken, so they must be rehabilitated and strengthened after the bone has healed enough to support exercise. Physical therapy regimens are sometimes necessary in cases of severe fracture.
Sprains and strains
Treatment for sprains and strains varies depending on the severity of the injury. Rest, ice, compression and elevation (RICE) can alleviate pain and immediate swelling, but a doctor should assess the particular injury both to determine its severity and to prescribe a proper treatment plan. Very severe sprains and strains in which the ligament or muscle/ tendon has ruptured partially or wholly may require surgery and months for physical therapy. Some sprain/strain injuries are recurrent, including ankle and hamstring strains.
Prevention of fracture involves common sense and avoidance of high risk behavior, such as drinking and driving. In 2003, motor vehicle accidents resulted in 42,643 deaths and 2.89 million injuries. In addition, around 147,000 pedestrians or cyclists were injured or killed in vehicular accidents. Seatbelts and airbags, as well as other changes, have positively impacted traffic related morbidity and mortality, and these safety initiatives should continue to be pursued in all motorized or high speed activities.
Public awareness programs such as ladder safety, playground safety and others are important for educating people of about ways we can decrease the risk of injury. Environmental modification, such as removal of loose rugs, clutter and poor lighting for elderly patients at risk of fall can be effective. In addition, healthy bones will go far towards avoiding injury in day-to-day activities. Calcium is a vital component of strong bones, and should be consumed as much as possible before the age of 25, when bone mass is still increasing. Low calcium intake also increases the risk of developing osteoporosis, which itself drastically increases the risk of fracture. Good nutrition and exercise are crucial for maintaining muscle and joint strength, both of which will stabilize joints and balance, thus reducing the risk of falls.
Sprains and strains
Building muscle strength through conditioning and stretching before exercising are two effective ways of minimizing injury. Wearing proper shoes in good condition will decrease the possibility of slipping, and using the proper equipment for any sport will also prevent injury.
Public education is vital to lower the incidence of fracture in the US. The importance of staying active and eating healthy cannot be overemphasized. Healthy lifestyle choices must be initiated in childhood and maintained throughout adulthood. The development of osteoporosis later in life is partially determined by the amount of bone deposited in the skeleton during early adulthood. Staying active as one ages has been shown to lower the risk of falling and sustaining an injury. Furthermore, nicotine and alcohol use have been implicated as risk factors for the development of osteoporosis. Modification of risky behavior (such as driving over the speed limit and while under the influence of alcohol) can certainly lower the risk of motor vehicle related trauma. More information on staying active and its effect on the musculoskeletal system can be found at numerous websites through the Public/Patient section at www.usbjd.org.
PUBLIC HEALTH POLICY ON TRAUMA
In some areas of the country, organized trauma systems exist involving rapid emergency response (911) systems, organized and systematic transport of injured patients to care, and trauma center hospitals with verified special abilities. These systems and centers have been proven to save lives, and are believed to reduce disability. However, due to inadequate funding mechanisms and highly expensive care, many trauma centers have closed leaving only 25-30% of the geographic area of the US covered by an organized trauma system. By the mid-1990's, an estimated 100 trauma centers in the US had closed, leaving large segments of the population without a nearby trauma center.
Public support for development of trauma care systems and trauma centers is vital. Several states have enacted legislation to provide funding for trauma care through surcharges on moving violations or license fees. In some communities, trauma care has become a major focus of philanthropy.
FUTURE RESEARCH DIRECTIONS
Road safety - Road traffic injuries are increasing precipitously, and by the year 2010, are estimated to account for as much as 25% of all health care expenditures in developing nations. We need to continue to find ways to decrease the incidence of motor vehicle related accidents through improvements in car manufacturing, public awareness and government involvement.
Work place safety - The workplace is a substantial source of injury, illness and disability. We need to continue to find ways to increase work place safety through industry modifications, government surveillance and involvement, and public awareness.
Decreasing regional variation in treating trauma conditions - There is a large variation in the way trauma care is provided throughout the US. Through the collaboration with experts in the field of trauma care and the use of multi-center clinical trials, we need to determine the optimum delivery system for trauma-care as well the best treatment options for specific traumatic conditions.
Clinical trials and basic science investigation is also targeting musculoskeletal trauma. Therapies to strengthen the skeleton as well as treatments to accelerate bone, ligament and tendon healing are emerging. Further recognition of the importance of musculoskeletal trauma and its related research holds a promise for major advances in the future.
American Academy of Orthopaedic Surgeons - www.aaos.org
American College of Surgeons - www.facs.org/trauma/ntdbannualreport2003.pdf
Orthopaedic Trauma Association -www.ota.org
Condition Kit on Musculoskeletal Trauma
Produced by the
United States Bones and Joint Decade, NFP
United States Bone and Joint Decade
The mission of the United States Bone and Joint Decade (USBJD) organization is "to provide national leadership and coordination of activities in the United States in the worldwide movement to improve patient care, to promote research and to advance understanding and treatment of musculoskeletal conditions during the International Bone and Joint Decade." The worldwide Bone and Joint Decade is an international collaborative movement sanctioned by the United Nations/World Health Organization.
This initiative was developed in response to the staggering statistic that musculoskeletal disease currently affects more than one billion individuals worldwide. In the United States, bone and joint disorders affect one in three Americans, remain the No. 1 reason people visit the doctor, and cost an estimated $300 billion per year. The Decade's aim is to reduce the burden of musculoskeletal disease, and to improve the quality of life for those who are challenged by a musculoskeletal condition by promoting greater awareness, educating the public about prevention, and increasing research to improve diagnosis and treatment.
President Bush proclaimed the Bone and Joint Decade in the United States. All 50 U.S. states have endorsed the Decade. Nearly 100 U.S. patient, healthcare professional, and other organizations support the Decade, as well as over 100 medical schools and colleges of medicine.
To learn more about the Decade, visit www.usbjd.org
United States Bone and Joint Decade, NFP
6300 N. River Road, Rosemont, IL 60018