Differences in the rates of admission and major orthopedic surgery care between Turkish and displaced children injured in a major earthquake

We aimed to provide a general overview of admission and the initial orthopedic surgeries conducted for musculoskeletal injuries in children admitted to the state hospitals in the Adana metropolitan area during the first week following the earthquake and to investigate the differences between the groups according to nationality.

The chaotic conditions that developed immediately after the first quake were greatly exacerbated by the second quake nine hours later. The emergency department of the hospitals was crowded, and the identification of the cases, which was considered to be the initial step, became extremely difficult. Zones in the hospitals, such as meeting rooms and halls, were converted into care stations for children in good clinical condition. Non-medical care was provided by the social services staff, and further identification methods, including DNA analysis, were carried out, and the children were gradually returned to their families.

The sudden increase in emergency room admissions was the initial challenge faced after the earthquake. Previous research has shown that the patient density in emergency rooms can increase up to 66% within the first 24 h following an earthquake [13, 14]. Regarding orthopedics, the records show that the peak daily admissions of cases requiring orthopedical intervention occurred on the second day. The total number of admissions in need of orthopedical care observed in the first three days represented 79.46% of the total. Thus, under similar disaster conditions trauma centers should expect to encounter the great majority of the cases in the first three days. Studies highlight that the initial days following a major earthquake are the most crucial days for healthcare facilities since the highest number of admissions and the lowest level of support from the authorities and non-profit organizations are anticipated [15, 16].

Jacquet et al., in their review on children with earthquake-related injuries, reported that fractures were the most common injury, ranging between 18.1% and 55.2%, and frequently occurred in the extremities [11]. The report on the Gujarat earthquake stated that the fracture rate of 1248 injury cases, of whom were children, was 51%. The rate in our study was slightly lower as 20.33%, yet the distribution according to the site of fracture was in parallel with the literature, having most commonly occurred at extremities, followed by the pelvis.

The analysis considering the orthopedical approach showed that there were 246 (28.99%) cases requiring major orthopedical surgery, which was slightly lower than the numbers of Bar-On et al. The authors stated that children presented with much higher rates of fractures, particularly in the femur, and the rate of surgery was 44% [17]. Similarly, MacKenzie et al., in their review, presented that the combined rate of major surgeries, including open reduction and internal fixation, external fixation, and amputation in the treatment of earthquake-related injuries was approximately 43.5% [18]. The comparison of the number of fracture surgeries performed between the nationality groups showed that the rate of CUN was lower than in the other two groups. There were no cases that underwent fracture surgery in CUN, whereas the rate of Syrian children was nearly half compared to Turkish patients (4.64% vs. 8.05%).

Tang et al. stated that crush injuries were one of the most common injuries occurring in an earthquake [19]. Gök and Melik reported that 265 patients were admitted to the emergency department in the first seven days after the earthquake, and 32 (28.5%) were diagnosed with acute compartment syndrome. They also highlighted that fasciotomy was performed on 43 extremities [5 (11.6%) upper and 38 (88.4%) lower] of these patients, and 16 (50%) of the fasciotomy patients were operated on in the emergency department [20]. The rate of crush injury cases in our study was 26.42% (n = 256), and 168 fasciotomies were performed. The overall rate of fasciotomies was 17.34%, whereas the rate was 64.29% when considered only for the cases with crush injuries, with the lower limb being the most common limb operated for fasciotomies. Hatamizadeh et al., presenting a slightly lower rate of 12.6%, reported that lower limb fasciotomies were performed on 14 of the 15 children among the 119 admitted after the Bam, Iran earthquake [21].

Selçuk et al., in their report studying the outcomes of the same earthquake as ours, stated that out of 26 children admitted presenting with crush syndrome, 5 (19.23%) required limb amputations [22]. Another study by Sarı et al. conducted on the cases of the same quake zone showed that the number of amputations performed on children was 7 (5.38%) [23]. Our findings regarding amputations were slightly lower (n = 35). The percentage of amputations according to the total number of children requiring orthopedic intervention was 3.61%; however, when compared to children with crush injuries, the rate was 13.67%.

Furthermore, the duration of stay in the hospital of an earthquake-injured child, particularly the ones who underwent orthopedic surgery, is considerably increased [24]. Besides, Morelli et al. indicated that the mean hospitalization duration in children with earthquake injuries ranged between 1.4 and 10.7 days [25]. Our findings show that at the end of the first week after the quakes, 60.68% of the children were discharged (n = 588), indicating a similar rate to the reports.

The clinical findings of our study may have presented controversial results compared to the results of the analyses of the cases collected in earthquake foci or other level I trauma centers. We attribute the difference to the high rate of occurrence of severe cases at the foci and the accumulation of patients with critical medical conditions at the level I trauma centers since the most severe cases were immediately transferred to these centers. However, the rates are different when, as in our study, the data of the hospitals with level II and above trauma centers are analyzed in a single pool.

Moreover, the high admission rate of 371 Syrians (32.71%) was noteworthy. Although there are studies indicating that language and cultural barriers play a crucial part in accessing medical care, particularly in admissions to hospitals [26,27,28], the high admission rate shows that a high number of earthquake-injured displaced children in Adana had access to the hospitals and the treatments in the event of a major earthquake. In addition, the high rate of injury among Syrian children relative to the host population is striking, as the Syrian population in the region is up to about 8%, suggesting that the difference in admission rates compared to Turkish children should have been much lower. Although there should be more explanations, the high injury rates in Syrian children may be attributed mainly to the poor level of disaster awareness and knowledge and the housing and community conditions. Reports suggest that even residents of countries where disasters most frequently occur can be troubled when settled in other countries. Bhandari et al. stated that Nepalese who immigrated to Japan demonstrated poor levels of information and skills regarding geological disasters. The authors also noted that the barriers to accessing relevant information were also significant [29]. In terms of the conditions of accommodation, Türkoğlu and Elmastaş stated that 87.5% of displaced Syrians lived in detached houses in low-income neighborhoods [30].

Armenian et al. in a study involving 32.743 people suggested that the chance of getting injured was 1.8 times higher, a type of housing similar to the most displaced Syrian lived in [31]. Finally, although the admission rate of Turkish children was 53.35%, as the global numbers of UNHCR stating that more than 2 million children were born as refugees between 2018 and 2023, and the high rate of refugees settled in Adana province, we assume that the ratios in terms of nationality might require a slight correction in favor of the displaced [2]. Unfortunately, we did not have the resources to confirm the origin of the survivors.

Limitations

The retrospective design of the study is one important limitation. In addition, there was too much missing information in the medical records from which we obtained the data for our analysis. Not to mention that the medical records kept at the beginning of the recovery from severe disasters are often incomplete. Nevertheless, we confirm that the data analyzed in our study is accurate. Finally, the generalization of the outcomes of the analysis may not be possible for all displaced children residing in the Adana province. Thus, overall interpretation requires attention. The injury overload exceeding the healthcare capacity of the metropolitan state hospitals caused by the severe earthquake, summed by the intense admission of unaccompanied children who were not capable of accurately providing medical and demographic information, limited the availability of precise data regarding the cases.

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