Orthopedic trauma represents one of the leading causes of emergency department visits worldwide and contributes substantially to morbidity, disability, healthcare expenditure, and mortality. Road traffic accidents, falls, sports-related injuries, and occupational trauma are the predominant causes of musculoskeletal injuries requiring urgent evaluation and intervention. Although advances in trauma systems and surgical management have improved survival, patient-related factors such as advanced age, diabetes mellitus, obesity, and other chronic medical conditions continue to influence clinical outcomes following orthopedic trauma. Early identification of high-risk patients is therefore essential for optimizing treatment strategies and improving prognosis (1, 2).

Diabetes mellitus (DM) is one of the most prevalent chronic non-communicable diseases globally, affecting more than 530 million adults, with India accounting for one of the largest diabetic populations. Chronic hyperglycaemia is associated with microvascular and macrovascular complications, impaired immune function, endothelial dysfunction, neuropathy, and delayed tissue repair. These pathophysiological changes adversely affect fracture healing and increase susceptibility to postoperative complications, particularly in patients sustaining traumatic musculoskeletal injuries (3-5).

Several studies have demonstrated that diabetic patients experience higher rates of wound infection, delayed union, non-union, implant-related complications, prolonged hospitalization, and increased healthcare utilization following orthopedic procedures. Hyperglycaemia impairs osteoblast differentiation, collagen synthesis, angiogenesis, and inflammatory regulation, all of which are fundamental to fracture healing. In addition, diabetes is frequently accompanied by hypertension, chronic kidney disease, obesity, and cardiovascular disorders that further complicate peri-traumatic management and recovery (6-9).

Emergency physicians and orthopedic surgeons are increasingly challenged by the growing number of trauma patients with diabetes presenting to tertiary care hospitals. Early recognition of diabetes-related risk factors at the time of admission may facilitate timely glycaemic optimization, infection prevention, multidisciplinary care, and individualized treatment planning. Biomarkers such as admission random blood glucose, glycated haemoglobin (HbA1c), serum lactate, and serum albumin have emerged as potential predictors of adverse outcomes in trauma patients and may improve early risk stratification when combined with established clinical assessment tools (10-12).

Despite growing evidence from developed countries, there remains limited prospective data from Indian tertiary-care emergency departments evaluating the influence of diabetes mellitus on clinical outcomes among orthopedic trauma patients. Regional variations in patient demographics, injury patterns, healthcare accessibility, and comorbidity profiles necessitate institution-specific evidence to guide clinical decision-making.

Therefore, the present study was undertaken to evaluate the impact of diabetes mellitus on clinical outcomes among orthopedic trauma patients presenting to the Emergency Department.

MATERIALS AND METHODS

This hospital-based prospective observational study was conducted in the Department of Emergency Medicine in collaboration with the Department of Orthopaedics at MNR Medical College and Hospital, Sangareddy, Telangana, India from January 2025 to March 2026. The written informed consent was obtained from all eligible participants or their legally authorized representatives before enrolment after obtained prior approval from the institutional ethic committee. A total of 122 consecutive adult patients presenting to the Emergency Department with acute orthopedic trauma requiring evaluation and management.

Inclusion Criteria: Patients aged ≥18 years, with acute orthopedic trauma within 24 hours of injury, radiologically confirmed fractures, dislocations, major musculoskeletal injuries requiring emergency orthopedic evaluation and patients willing to provide written informed consent.

Exclusion Criteria: Patients <18 years of age, pathological fractures secondary to malignancy, metabolic bone disease, polytrauma patients with severe traumatic brain injury, major thoracoabdominal injuries requiring immediate transfer to other specialties, with chronic osteomyelitis, pre-existing musculoskeletal infections, pregnancy, patients who declined consent or were lost before completion of in-hospital follow-up

Patients were categorized into two groups based on the status of diabetes mellitus. Group A with diabetes patients and group B with non-diabetic patients. Diabetes mellitus was defined as a previously diagnosed condition receiving treatment with oral hypoglycaemic agents or insulin, or newly diagnosed diabetes based on admission blood glucose levels and glycated haemoglobin (HbA1c) according to the current diagnostic criteria. Following admission to the Emergency Department, all eligible patients underwent a standardized clinical evaluation. Demographic characteristics and associated medical comorbidities such as hypertension, ischemic heart disease, chronic kidney disease, and peripheral vascular disease were recorded. Details of injury including mechanism of trauma, time from injury to hospital presentation, mode of transport, type of fracture (open or closed), anatomical site involved, Injury Severity Score (ISS), and Gustilo-Anderson classification for open fractures were documented. Baseline vital signs including heart rate, systolic and diastolic blood pressure, respiratory rate, oxygen saturation, temperature, and Shock Index were recorded at presentation.

Patients underwent routine laboratory investigations comprising complete blood count, random blood glucose, fasting blood glucose (when feasible), HbA1c, serum electrolytes, renal function tests, liver function tests, serum albumin, C-reactive protein (CRP), and serum lactate where clinically indicated. Radiological evaluation included plain radiographs of the affected region, while computed tomography (CT) or magnetic resonance imaging (MRI) was performed when indicated for complex injuries.

Diabetic status was confirmed using previous medical records, medication history, admission blood glucose levels, and HbA1c estimation. Glycaemic control among diabetic patients was categorized as good (HbA1c <7.0%), moderate (7.0–8.9%), or poor (≥9.0%).

All patients received emergency management according to institutional Advanced Trauma Life Support (ATLS)-based protocols, including pain management, immobilization, wound care, tetanus prophylaxis, antibiotic administration for open fractures, fluid resuscitation, and definitive orthopedic intervention as indicated. The decision regarding conservative management or surgical treatment was made by the attending orthopedic surgeon according to standard clinical guidelines.

Statistical Analysis

The collected data were extracted into Microsoft Excel sheet and analyzed using SPSS v.26.0. Continuous variables were presented as mean and standard deviation (SD). Categorical variables were represented as frequencies and percentages. Comparisons between study groups were performed using the independent samples Student's t-test for normally distributed continuous variables and the Mann Whitney U test for non-normally distributed variables. The Chi-square test was used to compare categorical variables as appropriate. Univariate logistic regression analysis was initially performed to identify variables associated with adverse clinical outcomes. ROC curve analysis was performed to evaluate the predictive performance of admission blood glucose and HbA1c for wound infection and prolonged hospital stay. Statistical significance was defined as a p-value <0.05.

RESULTS

Table 1: Demographic and clinical characteristics of the study population (n=122)

Table 2: Clinical presentation and laboratory investigations among study groups.

Graph 1: Emergency department management

Graph 2: Surgical characteristics

Table 3: Details of in-hospital complications and hospital stay and functional outcome.

Table 4: Multivariate logistic regression analysis for predictors of poor clinical outcome.

Graph 3: ROC curve analysis for predictors of poor clinical outcome.

DISCUSSION

In the present study, diabetic patients had a significantly higher mean age than non-diabetic patients (56.6±13.1 vs 42.6±15.0 years; P=0.001). Similar observations have been reported by Richards et al., who found that diabetic trauma patients were generally older and had a higher prevalence of cardiovascular and renal comorbidities, contributing to increased perioperative risk and postoperative complications (10). Diabetes is frequently associated with hypertension, chronic kidney disease, ischemic heart disease, and obesity, all of which adversely affect physiological reserve and fracture recovery (4, 5). Our findings of significantly higher rates of hypertension, chronic kidney disease, and ischemic heart disease among diabetic patients support these previous reports.

Although the mechanism and anatomical distribution of injuries were comparable between diabetic and non-diabetic patients, laboratory investigations demonstrated marked metabolic and inflammatory differences. Diabetic patients exhibited significantly higher admission random blood glucose, HbA1c, leukocyte counts, serum creatinine, and C-reactive protein levels, together with lower haemoglobin and serum albumin concentrations. Hyperglycaemia promotes oxidative stress, endothelial dysfunction, impaired neutrophil chemotaxis, and dysregulated inflammatory responses, thereby increasing susceptibility to infection and delaying tissue repair. Experimental studies have shown that chronic hyperglycaemia suppresses osteoblast activity while enhancing osteoclast-mediated bone resorption, ultimately impairing fracture healing (8, 9).

Emergency department management and definitive surgical procedures were broadly similar between the two groups, suggesting that differences in outcome were primarily attributable to patient-related biological factors rather than variations in treatment. However, diabetic patients required blood transfusion more frequently and experienced a longer interval to definitive surgery, although the latter did not reach statistical significance. Previous studies have likewise demonstrated that optimization of glycaemic status and associated medical comorbidities may delay operative intervention but is often necessary to reduce perioperative complications (11).

One of the most important findings of the present study was the significantly higher incidence of wound infection and delayed wound healing among diabetic patients. The wound infection rate was more than twice that observed in non-diabetic patients (23% vs 9.8%), while delayed healing occurred in 14.8% and 4.9% of patients, respectively. Similar findings have been reported in several orthopedic studies, where diabetes increased the risk of surgical-site infection by two- to three-fold (6). Hyperglycaemia impairs leukocyte phagocytic activity, collagen synthesis, angiogenesis, and fibroblast proliferation, resulting in delayed soft tissue repair and increased bacterial colonization (7, 13). Although higher rates of sepsis, acute kidney injury, ICU admission, and re-operation were also observed in diabetic patients, these differences were not statistically significant, possibly because of the relatively modest sample size.

Hospital resource utilization was substantially greater among diabetic patients. Mean hospital stay and ICU stay were significantly longer than those of non-diabetic patients, consistent with previous reports demonstrating prolonged hospitalization and increased healthcare costs associated with diabetes following trauma (14). Longer hospitalization may reflect slower wound healing, increased infection rates, medical optimization, and rehabilitation requirements. Functional recovery was also inferior in diabetic patients, as evidenced by lower rates of independent ambulation and significantly reduced Barthel Index scores at discharge. Diabetes-related peripheral neuropathy, impaired muscle strength, delayed fracture union, and chronic vascular insufficiency likely contribute to delayed mobilization and poorer rehabilitation outcomes (3).

The multivariable logistic regression analysis identified diabetes mellitus, age greater than 60 years, open fractures, HbA1c ≥8%, Injury Severity Score >16, and serum albumin <3.5 g/dL as independent predictors of poor clinical outcome. These findings agree with earlier investigations showing that poor pre-injury glycaemic control and hypoalbuminemia independently increase the likelihood of postoperative infection, delayed healing, prolonged hospitalization, and mortality (15, 16). The ROC analysis further suggested that serum lactate demonstrated the greatest predictive accuracy for adverse outcomes, followed by admission blood glucose and HbA1c, indicating that combining metabolic and injury related biomarkers may improve early risk stratification in emergency settings.

CONCLUSION

Diabetes mellitus was associated with significantly poorer clinical outcomes among orthopedic trauma patients presenting to the emergency department. Diabetic patients exhibited higher rates of wound infection, delayed wound healing, prolonged hospital stay, and poorer functional recovery compared with non-diabetic patients. Advanced age, open fractures, poor glycaemic control, higher injury severity, and hypoalbuminemia were identified as independent predictors of adverse outcomes. These findings emphasize the importance of early risk stratification, optimal glycaemic control, prompt multidisciplinary management, and nutritional optimization to minimize complications and improve recovery. Larger multicenter studies with long-term follow-up are warranted to validate these findings and guide evidence-based trauma care.

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