Earthquake victim admissions in the ER

During the first week following the earthquakes, 6506 victims were admitted to the Emergency Room (ER). A total of 1,092 people were admitted to the hospital due to musculoskeletal injuries associated with the earthquake. Among the cases, 827 (75.7%) patients underwent orthopedic surgery. There were 421 (50.9%) males and 406 (49.1%) females. The ages of the victims ranged from 0 to 93 years, with a median of 32 years. ER admissions of the earthquake victims during the first week are shown in Fig. 2.

Fig. 2

The distribution of earthquake victim admissions in the ER in the first week

Initial orthopedic evaluation of patients with extremity and pelvic fractures

The initial evaluation and treatments for patients presenting with extremity fractures were administered in the emergency room settings. Splints and arm slings were applied to patients with closed extremity fractures who were queued for surgery, while the cases with open extremity fractures were administered tetanus vaccine or immunoglobulin, antibiotic prophylaxis, wound irrigation, sterile dressing, and splints.

The majority of 243 (119 males and 124 females) patients with extremity fractures and pelvic fractures receiving surgical treatment were adults (n = 182, 74.9%). The age distribution of the surgically treated patients with extremity and pelvis fractures is presented in Fig. 3.

Fig. 3

The age distribution of the surgically treated patients with extremity and pelvic fractures

Among all fracture cases, eight of the upper extremity fractures were open fractures, including two humerus, three forearm, and two hand fractures. Twenty-three of the lower extremity fractures were open fractures, of which five were located on the femur, 17 on the tibia, and three on the foot. There were no open fractures of the pelvic ring.

The analysis showed that the median age of patients who underwent surgery due to fractures was 36 years, with a range of 1 to 91 years, which was statistically increased compared to patients who received surgery for other musculoskeletal injuries (p < 0.001). The daily number of fractures surgically treated for extremity and pelvic fractures for the first week is presented in Fig. 4.

Fig. 4

Daily distribution of the number of surgically treated extremity and pelvic fractures

Acute management and surgical treatment of extremity and pelvic fractures

Adana City Training and Research Hospital has over 7,000 employees and 1,500 beds. There were eight lecturers, 15 orthopedic physicians, and 24 resident doctors at the time of the earthquake assigned to the Orthopedics and Traumatology Clinic of the hospital.

We used a social networking platform WhatsApp (Meta Platforms, Inc. ® ATTN/CA, USA) to create groups to track emergency patient admissions, preoperative and postoperative patients with fractures, and patients in inpatient wards, and these new technologies played a critical role in facilitating communication.

Although the social networking platforms were in use and the communication among the personnel was dramatically increased, the high volume of patients overwhelmed the clinic staff. On a regular workday, there were six operating rooms allocated for the orthopedics clinic, but suddenly became insufficient under post-earthquake circumstances, and the number of rooms was increased to 15. Also, the usual “working hours” term was off-use, and almost all staff were required to stay at the hospital and carry on the duties for the first few days.

Fortunately, five additional orthopedic surgeons from other hospitals, selected and authorized by the Ministry of Health, were assigned on the third day and joined the ACH Orthopedics and Traumatology Clinic staff for help, and the workload per surgeon decreased. A similar staff increase was observed in all levels.

During the first three days, the ratio of the extremity and pelvic ring surgery cases among all fracture surgeries was 50%. The OT Clinic staff encountered a significant accumulation of fracture surgery cases, resulting in a lack of resources in the operating theatres. Especially, the three C-arm fluoroscopy systems assigned to the clinic failed to meet the increased demand. The surgery priority was given to cases with open fractures, fractures in the lower extremities, and injuries accompanied by crush injuries with compartment syndrome. The cases with closed fractures and upper extremity fractures in the queue for surgery were temporarily fixated by splints. The arrival of three more fluoroscopy devices resulted in an increase in the number of surgical procedures performed, thereby leading to a reduction in the concentration of patients with fractures.

In the group of patients who underwent surgical intervention for fractures, 38 (17%) had pelvic ring fractures. The most common lower extremity fractures among all fracture cases were tibial shaft (30.8%) and femoral shaft (20.6%) fractures. A total of 33 patients had surgical procedures for the treatment of two or more significant bone fractures involving either the extremity or the pelvic ring. The distribution of patients who underwent surgical treatment for fractures categorized according to the anatomical location of the fracture and fixation methods is demonstrated in Table 1.

Table 1 Distribution of patients who underwent surgical treatment for fractures, categorized according to the anatomical location and fixation methods of the fracture

In addition to the fracture surgeries, fasciotomies were performed on 35 fracture patients with fractures located on the tibia/fibula, femur, humerus, radius/ulna, and hand. (21, 9, 2, 2, and one, respectively). Among the patients with musculoskeletal injuries, 10.4% of patients with fasciotomy had fractures at the same time; 38.1% without fasciotomy had no fracture (p = 0.0001).

Furthermore, debridement surgery was conducted on 56 patients with fractures. In 14.3% of patients with musculoskeletal injuries who underwent debridement, a fracture was also present at the same time; in 38.6% of patients who did not undergo debridement, no fracture was detected (p = 0.0001).

In 35 of the cases, fasciotomy was also applied in addition to the debridements; the remaining received exclusively external fixators for the open fractures. Following the cleaning of the fasciotomy sites with hypochlorous acid, vacuum-assisted closure (VAC) was applied at three-day intervals during the postoperative monitoring of patients with no indications of infection who underwent surgery for fractures for open wounds and fasciotomies. Wounds of patients who underwent surgical treatment for closed fractures were dressed daily with tincture of iodine and gauze. A wound care bandage made of paraffin antiseptic gauze was used in fracture cases accompanied by deep abrasion wounds.

During the first week, 13 (5.8%) of the patients who underwent surgical treatment for their fractures underwent transhumeral, forearm, transfemoral, knee disarticulation, and transtibial amputation surgery (n = 1, 1, 2, 1, and 8, respectively) (p = 0.547).

Early follow-up patients with fractures and postoperative rehabilitation

The large volume of patients requiring fracture surgery increased the burden of wound care. Wound care teams were formed and assigned to each hospital block to ensure uninterrupted wound care after surgery. The teams comprised of two wound care personnel, an orthopedic specialist, and a resident physician. Due to the loss of homes in the earthquake, most patients resisted being discharged. Hence, an efficient discharge procedure did not take place. Specifically, after surgery for extremity fractures, patients whose course of treatment was finished but could not be released were moved to the physical therapy and rehabilitation wing of ACH, where physiotherapists and orthopedic specialists managed post-operative wound care and orthopedic rehabilitation. In cases without accommodations or a companion, the social services department was notified at the time of discharge.