title: Musculoskeletal trauma and all-cause mortality in India: a multicentre prospective cohort study.
abstract: BACKGROUND
  There is little data in low-income and middle-income countries (LMICs) quantifying the burden of fractures and describing current practices. The aim of the study was describe the severity of musculoskeletal injuries in LMICS and identify modifiable factors that predict subsequent early all-cause mortality.
  
  
  METHODS
  We did a multicentre, prospective, observational study of patients who presented to 14 hospitals across India for musculoskeletal trauma (fractures or dislocations). Patients were recruited during an 8-week period, between November, 2011, and June, 2012, and were followed for 30-days or hospital discharge, whichever occurred first. Primary outcome was all-cause mortality with secondary outcomes of reoperation and infection. Logistic regression analyses were conducted to identify factors associated with all-cause mortality.
  
  
  RESULTS
  We enrolled 4822 patients, but restricted analyses to 4612 (96%) patients who had complete follow-up. The majority (56·2% younger than 40 years old) of trauma patients were young (mean age 40·9 years [SD 16·9]) and 3148 (68%) were men. 2344 (518%) patients sustained trauma as a result of a road traffic accident. The most common musculoskeletal injury was a fracture (4514 [98%]) and 707 patients (15%) incurred an open fracture. Less than a third of musculoskeletal trauma patients (1374 [29%]) were transported to hospital by ambulance, and one in six patients (18%) arrived at the hospital later than 24 h after sustaining their injury. Over a third (239 [35%] of 707) of open fractures were definitively stabilised later than 24 h. 30-day mortality was 1·7% (95% CI 1·4-2·2) for all patients and 2·1% (95% CI 1·5-2·7) among road traffic victims (p=0·005). Musculoskeletal trauma severity including the number of fractures (3·1 [95% CI 2·4-3·9]) and presence of an open fracture (2·1 [95% CI 1·2-3·4]) significantly increased the odds of all-cause mortality.
  
  
  CONCLUSIONS
  Musculoskeletal trauma severity, particularly road related, is a key predictor of subsequent mortality. Improvement in road safety policies, and improvements in access to emergency medical services and timely orthopaedic care are critical to mitigate the burden of injury worldwide.
  
  
  BACKGROUND
  Regional Medical Associates, AO International, Hamilton Health Sciences Trauma Fund.
authors: Centre for Evidence-based Orthopaedics, Hamilton, ON USA. Electronic address: clary.foote@medportal.ca.
authors: Clary Jefferson
authors: CJ
authors: Foote
authors: Centre for Evidence-based Orthopaedics, Hamilton, ON USA.
authors: Raman
authors: R
authors: Mundi
authors: Sancheti Hospital, Shivajinagar, Pune, Maharashtra, India.
authors: Parag
authors: P
authors: Sancheti
authors: Tripunithura, Ernakulam, Kerala, India.
authors: Hitesh
authors: H
authors: Gopalan
authors: All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
authors: Prakash
authors: P
authors: Kotwal
authors: Dr L H Hiranandani Hospital, Powai, Mumbai, India.
authors: Vijay
authors: V
authors: Shetty
authors: Chandigarh, India.
authors: Mandeep
authors: M
authors: Dhillon
authors: McMaster University, Faculty of Health Sciences, Hamilton, ON, Canada.
authors: Philip
authors: P
authors: Devereaux
authors: St Joseph's Healthcare Hamilton, Hamilton ON, USA.
authors: Lehana
authors: L
authors: Thabane
authors: McMaster University, Faculty of Health Sciences, Hamilton, ON, Canada.
authors: Ilyas
authors: I
authors: Aleem
authors: The George Institute for Global Health, University of Sydney, NSW, Australia.
authors: Rebecca Q
authors: RQ
authors: Ivers
authors: CLARITY Research, Hamilton, ON, USA.
authors: Mohit
authors: M
authors: Bhandari