On-line version ISSN 2309-8309
SA orthop. j. vol.10 n.3 Pretoria Jan. 2011
Musculoskeletal trauma - are we winning?
The management of musculoskeletal trauma in SouthAfrica is indeed a losing battle with over 70 000 SouthAfricans dying every year, and a further 3.5 million seeking health care, as a result of trauma.Approximately 9 000 people are killed on SouthAfrica's roads every year, and more than 33 000 seriously injured. Our road traffic death rate of 11.7 per 100 million kilometres travelled ranks in the top ten in the world. In 2009 there were 10.857 fatal crashes due to road traffic accidents. During this period driver fatalities increased by 84 (1.18%) to 5 023 and pedestrian fatalities decreased by 249 (5.06%) to 4 678. The biggest increase in the number of driver fatalities was recorded in KwaZulu-Natal. Ninety-two per cent of all drivers killed in crashes were male. Approximately 25% of the weekly crashes occur on a Saturday. Minibus passenger fatalities were 880 in 2009. The human factor contributed 82.85% to fatal crashes during 2009, vehicle factor contributed 9.13% and road and the environment 8.02%.
The Medical Research Council (MRC) survey shows that 61% of pedestrians and 59% of drivers killed in road crashes were under the influence of alcohol. Traffic offences in all provinces which contribute to the occurrence or seriousness of road crashes are speed, alcohol, unsafe/illegal overtaking and not wearing seatbelts.
Almost 63% of all orthopaedics operations performed during the year 2009 were for assaults, gunshots or MVAs. Therefore trainee health professionals, particularly registrars, are restricted in their exposure to pathologies other than those caused by trauma. This has impacted negatively on their training with inadequate exposure in dealing with pathologies of different aetiologies.
Deficiencies in the delivery of musculoskeletal trauma care in low and middle income countries can be attributed to failure of the health system to deliver the necessary service to prevent death and disability. Strengthening the delivery of services for musculoskeletal injuries in these countries requires a multi-disciplinary, multisectoral approach, which can be accomplished by addressing weaknesses in the health system. Reducing the delays in referral and instituting appropriate initial management may reduce the cost and complexity of the definitive treatment required.
The health system is tasked with prevention, treatment and rehabilitation following injuries. Injury prevention efforts include improvements in road infrastructure, such as building/upgrading roads and sidewalks, installing speed humps, using reflective devices, public education programmes, and appropriate legislation to influence driving behaviour. Efforts to improve treatment should be aimed at prehospital care, the provision of service once a patient reaches a health care facility, and rehabilitation to maximise function and promote social reintegration.
The retention of trained service providers is essential and their knowledge and skills must be maintained and enhanced through continuing education. There has been a human resource crisis in low and middle income countries; in addition to a paucity of trained surgeons, migration of health professionals both within and between countries has been a major problem. Therefore, many countries have emphasised the provision of multi-skilled professionals rather than training specialists.
It is necessary for health authorities to assess the impact of musculoskeletal injuries. The costs to the individual, the community and society must be quantified relative to other competing health priorities. Epidemiologic data on musculoskeletal injuries and their sequelae are lacking in most low and middle income countries, despite the fact that injury is now recognised as a global public concern. The data will help to plan and prioritise national goals for the management of musculoskeletal trauma in the future and reduce the level of poverty.
The unacceptably high levels of trauma have prompted the WHO to dedicate this decade as the 'Decade of action for road safety'.
Prof S Govender
Department of Orthopaedics
Nelson Mandela Medical School
University of KwaZulu-Natal