Impact of open fractures
Open fractures not only present significant medical challenges but also create profound social, economic, and healthcare burdens. The impact of open fractures extends beyond the immediate injury and affects multiple aspects of a patient's life, including mobility1, employment, and mental health2.
We will discuss the non-financial and financial impacts of open fractures on both patients and healthcare systems.
Impact on health and social well-being
Open fractures often lead to prolonged hospitalizations, physical rehabilitation, and in many cases, permanent disability3. In severe cases, open fractures can be life-threatening due to massive blood loss in the acute phase.
Common long-term negative effects include:
Fracture-related infection - Open fractures carry a high risk of fracture-related infection (FRI), which may persist long term and, in severe cases, progress to life-threatening septicemia.
Disability and reduced mobility - Open fractures frequently result in permanent functional impairments, particularly if they involve weight-bearing bones such as the tibia or femur. The loss of mobility can lead to difficulties in performing daily tasks and can severely limit a person’s independence, especially in LMICs where access to assistive devices or rehabilitation may be limited4.
Psychosocial effects - The emotional burden of living with a disability due to a traumatic injury can cause significant psychological stress. Depression, anxiety, and post-traumatic stress disorder (PTSD) are common among individuals who suffer severe trauma, particularly in younger people who may face challenges in adjusting to a new way of life. Additionally, the inability to engage in social activities or employment5 can lead to social isolation6 and a loss of self-esteem7.
Social stigma - In certain cultures or regions, people with visible disabilities, such as those caused by open fractures, may face social stigma or discrimination. This can further affect their mental health and hinder their reintegration into society8.
These impacts disproportionately affect low- and middle-income countries (LMICs), where healthcare resources for rehabilitation, prosthetics, and mental health services may be insufficient9.
The financial burden
The financial burden of open fractures is substantial, both for patients and healthcare systems. Open fractures are generally more costly to treat than closed fractures due to the risk of infection, longer recovery times, and the need for more intensive medical interventions such as surgery, wound care, and rehabilitation1.
Increased healthcare costs - Open fractures, particularly those involving the tibia, are associated with higher rates of complications9, such as infections, non-union, and malunion, compared to closed fractures. Studies have shown that open tibial fractures are eight times more likely to be complicated by infections and malunions10. Infections alone can lead to a 6-fold increase in hospital length-of-stay and a 5-fold increase in total healthcare costs11.
Catastrophic health expenditure - In LMICs, the financial burden is exacerbated by the high costs of treatment, transportation, and accommodations. A 2019 study in Tanzania found that 85% of injured patients in emergency departments faced catastrophic health expenditures, meaning the cost of treatment exceeded a significant proportion of their household income. These out-of-pocket expenses can drive families into poverty, especially in areas where public health systems are underfunded and private insurance coverage is limited12.
Length of stay - The total length of stay in the hospital is the primary cost driver when treating open fractures. The longer a patient remains hospitalized due to complications such as infections, the greater the financial strain on the healthcare system. This not only affects hospital budgets but also places additional burdens on healthcare staff and resources, potentially delaying care for other patients13.
Impact on work and productivity - In many cases, young patients with open fractures who are the primary breadwinners for their families may be unable to work for extended periods, leading to a loss of income and an increase in the financial burden on the household. In LMICs, where social safety nets may be minimal, this loss of income can have devastating effects on families13.
Long-term care and rehabilitation - Many patients require ongoing rehabilitation, physical therapy, and sometimes prosthetic devices, which are often not readily available or affordable in resource-limited settings13.
Total length of stay in hospital is the most critical cost driver in treating open fractures.
Global health considerations
Surgical care, including open fracture care, is still the neglected stepchild of global health.
The financial and non-financial burdens of open fractures are critical issues that need to be addressed, especially in low-resource settings worldwide.
Global health initiatives should focus on improving access to timely and effective treatment for open fractures, including better trauma care, more affordable surgical options, and post-injury rehabilitation programs. Efforts to reduce the financial burden on patients should also include policies aimed at reducing out-of-pocket costs, strengthening social safety nets, and improving access to affordable medical care.
Literature
1 Schade, A. T., Khatri, C., Nwankwo, H., Carlos, W., Harrison, W. J., & Metcalfe, A. J. (2021b). The economic burden of open tibia fractures: A systematic review. Injury, 52(6), 1251–1259. https://doi.org/10.1016/j.injury.2021.02.022
2 Rees, S., Tutton, E., Achten, J., Bruce, J., & Costa, M. L. (2019). Patient experience of long-term recovery after open fracture of the lower limb: a qualitative study using interviews in a community setting. BMJ Open, 9(10), e031261. https://doi.org/10.1136/bmjopen-2019-031261
3 Noorlander-Borgdorff, M. P., Kievit, W., Giannakópoulos, G. F., Botman, M., Tromp, T. N., Oflazoglu, K., Rakhorst, H. A., & De Jong, T. (2024). The economic impact of open lower limb fractures in the Netherlands: a cost-of-illness study. European Journal Of Trauma And Emergency Surgery, 50(5), 2605–2613. https://doi.org/10.1007/s00068-024-02637-1
4 Schade, A. T., Sibande, W., Kumwenda, M., Desmond, N., Chokotho, L., Karasouli, E., Metcalfe, A., & Harrison, W. J. (2022d). “Don’t rush into thinking of walking again”: Patient views of treatment and disability following an open tibia fracture in Malawi. Wellcome Open Research, 7, 204. https://doi.org/10.12688/wellcomeopenres.18063.1
5 Walter, N., Loew, T., Hinterberger, T., Alt, V., & Rupp, M. (2024). Managing more than bones: the psychological impact of a recurrent fracture-related infection. Bone & Joint Open, 5(8), 621–627. https://doi.org/10.1302/2633-1462.58.bjo-2023-0156.r1
6 Wimalan, B., Rupp, M., Alt, V., & Walter, N. (2023). The patients‘ perspective - a qualitative analysis of experiencing a fracture-related infection. Frontiers in Psychology, 14. https://doi.org/10.3389/fpsyg.2023.1126826
7 Singaram, S., & Naidoo, M. (2019b). The physical, psychological and social impact of long bone fractures on adults: A review. African Journal Of Primary Health Care & Family Medicine, 11(1). https://doi.org/10.4102/phcfm.v11i1.1908
8 Kaya, N. G. & Hitit Üniversitesi. (2023). Barrier-Free Cities for Individuals With Special Needs. Multidisipliner Yaklaşımlarla Coğrafya Dergisi, 1–3, 220–235. https://doi.org/10.29329/mdag.2023.596.3
9 Schade, A. T., Hind, J., Khatri, C., Metcalfe, A. J., & Harrison, W. J. (2019). Systematic review of patient reported outcomes from open tibia fractures in low and middle income countries. Injury, 51(2), 142–146. https://doi.org/10.1016/j.injury.2019.11.015
10 Zhang, J., Lu, V., Zhou, A. K., Stevenson, A., Thahir, A., & Krkovic, M. (2023). Predictors for infection severity for open tibial fractures: major trauma centre perspective. Archives Of Orthopaedic And Trauma Surgery, 143(11), 6579–6587. https://doi.org/10.1007/s00402-023-04956-1
11 Chebli, D., Dhaif, F., Ridha, A., Schade, A., & Khatri, C. (2024). A meta-analysis of the incidence of infections following open tibia fractures and the microorganisms that cause them in high-, middle- and low-income countries. Tropical Doctor, 54(3), 272–281. https://doi.org/10.1177/00494755241232171
12 Gulamhussein, M. A., Sawe, H. R., Kilindimo, S., Mfinanga, J. A., Mussa, R., Hyuha, G. M., Rwegoshora, S., Shayo, F., Mdundo, W., Sadiq, A. M., & Weber, E. J. (2023). Out-of-pocket cost for medical care of injured patients presenting to emergency department of national hospital in Tanzania: a prospective cohort study. BMJ Open, 13(1), e063297. https://doi.org/10.1136/bmjopen-2022-063297
13 Noorlander-Borgdorff, M. P., Kievit, W., Giannakópoulos, G. F., Botman, M., Tromp, T. N., Oflazoglu, K., Rakhorst, H. A., & De Jong, T. (2024b). The economic impact of open lower limb fractures in the Netherlands: a cost-of-illness study. European Journal Of Trauma And Emergency Surgery, 50(5), 2605–2613. https://doi.org/10.1007/s00068-024-02637-1
Joost Binnerts, Nienke Smits, Abeba Aleka Kebede
Experts: Pieter Haasnoot
Editors: Job Wernand, Pim Bongers, Eva Alkemade, Matthijs Botman, Renz Wierper.