Research paper|Articles in Press

Epidemiology of open limb fractures attended by ambulance clinicians in the out-of-hospital setting: A retrospective analysis

Published:January 06, 2023DOI:



      Open limb fractures are a time-critical orthopaedic emergency that present to jurisdictional ambulance services. This study describes the demographic characteristics and epidemiological profile of these patients


      We undertook a retrospective analysis of all patients that presented to Queensland Ambulance Service with an open limb fracture (fracture to the humerus, radius/ulna, tibia/fibula or femur) over a two-year period (January 2018 – December 2019).


      Overall, 1020 patients were included. Patients were mainly male (65.9%) and middle-aged (age 41 years, IQR 22–59). Fractures predominately occurred in the lower extremities (64.9%) with transport crashes the primary mechanism of injury (47.8%). The location of the fracture varied depending on the cause of injury, with femur fractures associated with motorcycle crashes, and fractures to the radius/ulna attributed to falls of greater than one metre (p = 0.001). The median prehospital episode of care was 83 min (IQR 62–144) with aeromedical air ambulance involvement and the attendance of a critical care paramedic or emergency physician, both independent factors that increased this time interval.


      Open limb fractures are a relatively infrequent injury presentation encountered by ambulance clinicians. The characteristics of these patients is consistent with previously described national and international out-of-hospital trauma cohorts


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        • Zalavras C.G.
        • Marcus R.E.
        • Levin S.
        • Patzakis M.J.
        Management of open fractures and subsequent complications.
        J Bone Jt Surg Am. 2007; 89: 1535-1586
        • Kim P.H.
        • Leopold S.S.
        Gustilo-Anderson classification.
        Clin Orthop Relat Res. 2012; 470: 3270-3274
        • Santolini E.
        • West R.
        • Giannoudis P.V.
        Risk factors for long bone fracture non-union: a stratification approach based on the level of the existing scientific evidence.
        Injury. 2015; 46: 8-19
        • Kortram K.
        • Bezstarosti H.
        • Metsemakers W.
        • Raschkle M.J.
        • Lieshout E.M.
        • Verhofstad M.H.
        Risk factors for infectious complications after open fracture’s a systematic review and meta-analysis.
        Int Orthop. 2017; 2017: 1965-1982
        • O’Malley O.
        • Trompeter A.J.
        • Krishnanandan S.
        • Vesely M.
        • Holt P.
        • Goh G.
        • Papadakos N.
        • Bhatia V.
        • Hing C.B.
        How common are vascular injuries in open tibial fractures? A prospective longitudinal cohort study.
        Eur J Orthop Surg Trauma. 2019; 29: 1119-1124
      1. Ambulance Victoria. Clinical practice guidelines ambulance and MICA paramedics. 〈〉.

      2. Queensland Ambulance Service. Clinical practice guidelines – trauma/limb injury. 〈〉.

        • Association of Ambulance Chief Executives
        Joint Royal Colleges Ambulance Liaison Committee.
        JRCALC clinical guidelines. 5th ed. Class Professional Publishing, Bridgwater2019: 2019
        • Bhandari M.
        • Jeray K.J.
        • Petrisor B.A.
        • Devereaux P.J.
        • Heels-Ansdell D.
        • Schemitsch E.H.
        • et al.
        A trial of wound irrigation in the initial management of open fracture wounds.
        N Engl J Med. 2015; 373: 2629-2641
        • Halawi M.J.
        • Morwood M.P.
        Acute management of open fractures: an evidence-based review.
        Orthopaedics 2015. 2015; 38: 1025-1033
        • Rupp M.
        • Popp D.
        • Alt V.
        Prevention of infection in open fractures: where are the pendulums now?.
        Injury. 2020; 51: 57-63
        • Heckmann N.
        • Simcox T.
        • Kelley D.
        • Marecek G.S.
        Wound irrigation for open fractures.
        JBJS Rev. 2020; 8
      3. National Institute for Health and Care Excellence. Fractures (complex) assessment and management - methods, evidence and recommendations. 〈〉.

      4. British Orthopedic Association. BOAST – open fractures. 〈–4253-92f7d90e8df0fb2c/29bf80f1–1cb6–46b7-afc761119341447f/open%20fractures.pdf〉.

        • Pollak A.N.
        • Jones A.L.
        • Castillo R.C.
        • et al.
        The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma.
        J Bone Jt Surg Am. 2010; 92: 7-156
        • Australian Bureau of Statistics
        Aust Demogr Stat. 2019; (December) (December) (December)
        • Schultz B.V.
        • Hall S.
        • Parker L.
        • Rashford S.
        • Bosley E.
        Epidemiology of oxytocin administration in out-of-hospital births attended by paramedics.
        Prehosp Emerg Care. 2020; 25: 412-417
      5. Schultz B.V., Doan T.N., Bosley E., Rogers B., Rashford S. Prehospital study of survival outcomes from out-of-hospital cardiac arrest in ST-elevation myocardial infarction in Queensland, Australia (the PRAISE study). Eur Heart J Acute Cardiovasc Care 2020; European Heart Journal: Active Cardiovascular Care; 2020.

      6. Queensland Ambulance Service. Clinical practice procedures – assessment/paediatric. 〈〉.

      7. World Health Organisation. International statistical classification of diseases and related health problems – 10th revision. 〈〉.

        • Australian Bureau of Statistics
        Aust Stat Geogr Stand (ASGS) Remote Struct. 2018;
        • Schultz B.V.
        • Rolley A.
        • Doan T.N.
        • Isoardi K.
        Epidemiology of out-of-hospital cardiac arrests that occur secondary to chemical asphyxiants: a retrospective series.
        Resuscitation. 2022; 175: 113-119
        • Dixon J.R.
        • Lecky F.
        • Bouamra O.
        • Dixon F.W.
        • Edwards A.
        • Eardley W.
        Age and the distribution of major injury across a national trauma system.
        Age Aging. 2020; 49: 218-226
        • Dinh M.M.
        • Russell S.B.
        • Bein K.J.
        • Vallmuur K.
        • Muscatello D.
        • Chalkley D.
        • et al.
        Age-related trends in injury and injury severity presenting emergency departments in New South Wales Australia: Implications for major trauma surveillance and trauma systems.
        Injury. 2017; 48: 171-176
        • Curtis K.A.
        • Mitchell R.J.
        • Chong S.S.
        • Balogh Z.J.
        • Reed D.J.
        • Cameron P.A.
        Injury trends and mortality in adult patients with major trauma in New South Wales.
        Med J Aust 2012. 2012; 197: 233-237
        • Brown E.
        • Williams T.A.
        • Tohira H.
        • Bailey P.
        • Finn J.
        Epidemiology of trauma patients attended by ambulance paramedics in Perth, Western Australia.
        Emerg Med Austral 2018. 2018; 30: 827-833
        • Boyle M.J.
        • Smith E.C.
        • Archer F.L.
        Trauma incidents attended by emergency medical services in Victoria, Australia.
        Prehosp Disaster Med. 2008; 23: 20-28
        • Court-Brown C.M.
        • Bugler K.E.
        • Clement N.D.
        • Duckworth A.D.
        • McQueen M.M.
        The epideiomology of open fractures in adults. A 15-year review.
        Injury. 2012; 43: 891-897
        • Molney M.
        • Farnebo S.
        • Adolfsson L.
        Incidence of distal ulna fractures in a Swedish county: 74/100,000 person-years, most of them treated non-operatively.
        Acta Orthop. 2020; 91: 104-108
        • Petit L.
        • Zaki T.
        • Hsiang W.
        • Leslie M.P.
        • Wiznia D.H.
        A review of common motorcycle collision mechanisms of injury.
        EFFORT Open Rev. 2020; 5: 544-548
        • Lack W.D.
        • Karunakar M.A.
        • Angerame R.
        • et al.
        Type II open tibia fractures – immediate antibiotic prophylaxis minimizes infection.
        J Orthop Trauma. 2015; 29: 1-6
        • Roddy E.
        • Patterson J.T.
        • Kandemir U.
        Delay of antibiotic administration greater than 2 h predicts surgical site infection in open fractures.
        Injury. 2020; 51: 1999-2003
        • Hendrickson S.A.
        • Donovan R.
        • Harries L.
        • Wright T.C.
        • Whitehouse M.R.
        • Khan U.
        Time to intravenous antibiotic administration (TIbiA) in severe open tibial fractures: Impact of change to national guidance.
        Injury. 2020; 51 (1086-90)
        • Gardezi M.
        • Roque D.
        • Barber D.
        • Spake C.S.
        • Glasser J.
        • Berns E.
        • et al.
        Wound irrigation in orthopaedic open fractures: a review.
        Surg Infect. 2021; 22: 245-252
        • Kavolus J.J.
        • Schwarzkopf R.
        • Rajaee S.S.
        • Chen A.F.
        Irrigation fluids used for the prevention and treatment of orthopaedic infections.
        J Bone Jt Surg Am. 2020; 102: 76-84
        • Smit L.
        • Boyle M.
        Does wound irrigation in the prehospital environment affect infection rates? – a review of literature.
        Austral J Para. 2015; 12: 4
        • Singer A.J.
        • Hollander J.E.
        • Subramanian S.
        • Malhotra A.K.
        • Villez P.A.
        Pressure dynamics of various irrigation techniques commonly used in the emergency department.
        Ann Emerg Med. 1994; 24: 36-40
        • Carr B.G.
        • Caplan J.M.
        • Pryor J.P.
        • Branas C.C.
        A meta-analysis of prehospital care times for trauma.
        Prehosp Emerg Care. 2009; 10: 198-206
        • van der Velden M.W.
        • Ringburg A.N.
        • Bergs E.A.
        • Steyerberg E.W.
        • Patka P.
        • Schipper B.
        Prehospital interventions: time wasted or time saved? An observational cohort study of management in initial trauma care.
        Emerg Med J. 2008; 25: 444-449
        • Lack W.
        • Seymour R.
        • Bickers A.
        • Studnek J.
        • Karunakar M.
        Prehospital antibiotic prophylaxis for open fractures: practicality and safety.
        Prehosp Emerg Care. 2019; 23: 385-388
        • Thomas S.H.
        • Arthur A.O.
        • Howard Z.
        • Shear M.L.
        • Kadzielski J.L.
        • Vrahas M.S.
        Helicopter emergency medical services crew administration of antibiotics for open fractures.
        Air Med J. 2013; 32: 74-79