Musculoskeletal injuries tied to morbidity, death in polytrauma patients

An epidemiology study in Singapore has found that musculoskeletal injuries in polytrauma patients often result in morbidity or mortality and usually befall economically productive men injured in road traffic accidents and falls from height.

“We have suggested some measures to reduce polytrauma in motorcyclists, such as improved defensive driving, appropriate attire, and other road safety measures,” the researchers said. Additionally, “[w]e found that the bill size in foreign workers was significantly higher than what they are insured for, [so] we suggest that insurance requirements for this vulnerable group of patients be adjusted in view of this.”

Overall, 560 polytrauma patients (injury severity score [ISS] >17; mean age 44 years, 79.3 percent male) who suffered musculoskeletal injuries (ISS >2) from 2011 to 2015 in National University Hospital, Singapore, were included in this retrospective cohort study.

Of the patients, 45.4 percent were aged 21‒40 years and 39.3 percent were foreign migrant workers. The majority of road traffic accidents involved motorcyclists (63 percent). Polytrauma patients had a mean hospital stay length of 18.8 days, while those admitted to the intensive care unit (ICU) had a mean stay duration of 5.7 days (range, 0‒253 days). [Singapore Med J 2023;64:732-738]

“In our study, the most common mechanism of injury was nonpenetrating or blunt injury, with road traffic accidents and falls from a height making up 526 (92 percent) cases,” the researchers said.

“While previous studies suggest that falls are the main cause of multiple trauma in patients, this is not so in patients with musculoskeletal injuries. This may be attributable to the workplace safety and health (work at heights) regulations 2014,” they added. [https://www.wshc.sg/files/wshc/upload/cms/file/WAH_Reg_Jun_2015.pdf]

The mortality rate stood at 19.8 percent. Patient death was predicted by a Glasgow Coma Scale (GCS) score <12 and need for blood transfusion (p<0.05).

Patients who had lower limb injuries, figured in road traffic accidents, had GCS score <8, and needed blood transfusion were more likely to have an extended hospital stay (p<0.05), while those with reduced GCS score, need for transfusion, and upper limb musculoskeletal injuries were more likely to have a longer ICU stay.

Insurance coverage

Additionally, foreign workers tended to incur substantially higher inpatient costs, which greatly exceeded the minimum insurance coverage currently required.

“As of January 2010, it has become a requirement that each foreign worker is insured up to a minimum of SGD 15,000,” the researchers said.

“Since then, Singapore has undergone a compound average annual rate of inflation of 2.37 percent, which would correspond to SGD 18,090 in 2018, with no change in the minimum insurance coverage to reflect this,” they added. [http://www.mom.gov.sg/passes-and-permits/work-permit-for-foreign-worker/sector-specific-rules/medical-insurance]

Most foreign patients, however, came from low socioeconomic status backgrounds, making it nearly impossible for them to afford hospital bills. These bills would then have to be paid by the employer or be absorbed by the hospital, according to the researchers.

A possible solution would be to increase the minimum insurance coverage for foreign workers who are doing high-risk jobs such as construction, those operating heavy machinery, and those who travel extensively, particularly on motorcycles, they noted.

“Based on our sample averages, we would propose an increase to SGD 60,000 for these groups to ensure that the majority of foreign patients will be appropriately covered for their treatment without exerting an added strain on their employers or the hospital,” the researchers said.