A cross-sectional prospective observational study was conducted at Baltal base camp between 11^th July to 26^th July 2017. After taking the ethical clearance from the authorities and seeking informed consent from all patients coming to base camp hospital with orthopaedic morbidities, both traumatic and atraumatic were assessed and enrolled. Patients with blunt trauma chest, blunt trauma abdomen and head injury were excluded from the study. Also, persons who either used helicopter or small litters as a mode of travel were also excluded. Patients with aggravation of preexisting orthopaedic morbidities (low back ache, knee pain) were included in the study.

All patients were assessed clinically and radiographs were obtained, if required. Demographic parameters like age, sex, region of India/NRI, morbidity, mode of injury, referral reasons and given treatment were recorded. Analgesics were given for the management of soft tissue injuries. Fractures and dislocations were reduced under intravenous sedation given by the anaestheist in the team. After closed reduction adequate splintage was given in the form of slabs and cast and patients were kept under observation for atleast 24 hours for compartment syndrome. Open fractures were dealt with thorough lavage, dressings, intravenous antibiotics, analgesia, I.V. fluids and adequate splintage by crammer wires/Thomas splint/slabs before immediate referral to a higher centre.

A total of 253 patients presented to us with isolated orthopaedic complaints. Demographic details of the cases are described in [Table/Fig-1]. Analysis of the medical records revealed that majority of patients were travellers from northern part of India followed by that from eastern and central. Most of the injuries sustained were by males (54.94%). Young patients between the age group of 21-40 years were frequently injured (36%). There was no patient above 70 years. This could be due to cap of 70 years imposed by shrine board. Most common mode of injury was by fall. Travelling on foot was the more common method of travel amongst these patients.

Details of orthopaedic morbidities are described in [Table/Fig-2] and reasons for morbidities and referral are described in [Table/Fig-3]. The aggravation of any pre-existing orthopaedic illness was the most common complaint, followed by traumatic events like soft tissue injuries of the ankle and wrist. The most common fracture was the fracture at distal end of the radius. The most common mode of injury was fall either while walking or from a horse or pony. The most common reason for immediate referral was open fractures. [Table/Fig-4,5,6,7,8 and 9] gives a basic idea of the infrastructure and the facilities available at the medical base camp.

[Table/Fig-4]:

Base camp hospital at Baltal.

[Table/Fig-5]:

X-ray room.

[Table/Fig-6]:

Registration and medicine dispensing counter.

[Table/Fig-7]:

Out Patient Department.

[Table/Fig-8]:

Indoor patient ward.

[Table/Fig-9]:

Dressing and plaster room.

High altitude pilgrimages are very common in India and many experience the ill effects of the high altitude. Apart from medical conditions, trauma is an important cause of mortality and morbidity. Most of the previous published studies (one conducted at Government Gousia hospital, Srinagar by Mir IS et al., and two at Sher-i-Kashmir Institute of medical science, Srinagar by Koul PA et al., and Yatoo GH et al.,) on high altitude pilgrimage mainly focused on the medical conditions like high altitude pulmonary oedema, high altitude cerebral oedema, diabetes mellitus, coronary artery diseases, peptic ulcer disease and mental illnesses [2,4,5]. To best of our knowledge, this is the first medical camp based study of its kind estimating the orthopaedic burden of Amaranth yatra. Previous literature includes hospital based studies evaluating medical burden per se. Non traumatic surgical burden was estimated by one study [2].

In a study conducted by Al-Harthi AS et al., on Hajj pilgrimage highlighted the incidence of trauma during the Hajj period. Road traffic accident was the commonest mode of injury in their series and it was indicated that 83% of the trauma patients were either orthopaedic or neurosurgery cases [3]. On the contrary in this study, the most common injury was fall for obvious reasons. Similarly our study depicted the huge number of trauma cases which deserve more attention.

As per study conducted by Mir IS et al., of the 1,54,000 devotees who undertook the “yatra”, in 2006, medical aid was provided to 40,082 pilgrims [2]. Of these 40,082 pilgrims, 172 were admitted on the surgical side for various non-traumatic surgical disorders [2]. No data was provided regarding the traumatic causes for the admission.

From July 2011 to Aug 2011, during the Shri Amarnath Yatra in 45 days period, 185 pilgrims were admitted to a hospital in Srinagar. Acute myocardial infarction, polytrauma, head injury, High altitude pulmonary oedema, gastroenteritis, diabetes, COPD and stroke were the diagnosis in these pilgrims in decreasing order of incidence. Six people died, out of which four were >65 years of age. We believe that most of the people who died, succumbed before being brought to the hospital in absence of prompt medical attention. This is highlighted by the fact that the recorded death toll in 2011 and 2012 among 600,000 pilgrims was only 239 [4].

Similarly in an another study conducted in year 2015 at a medical college level highlighted the total incidence of trauma victims close to 30% of the total patients received. It represents a significant proportion and the victims were between 21-72 years of age which is comparable to this study [5].

A study by Shah AR mentioned that number of shortcomings/dysfunctions had come up in the management of pilgrims around the holy cave. This study provided holistic overview of Amarnath pilgrimage and sum up the basic issues, challenges faced by the pilgrims [6].

Majority of the published medical literature of high altitude pilgrimage is from Gosainkunda Lake (4300 m), Nepal and Shri Amarnath Yatra (3900 m), India. These studies mainly focus on the medical conditions and they concluded that Acute Mountain Sickness, Coronary Artery Diseases, complications of diabetes mellitus, and peptic ulcer diseases are important reasons for admission [7]. Poorly acclimatised people from the plains are at high risk of developing these. The situation is worsened due to scarcity of the resources, lack of infrastructure, rapid changing weather and difficult terrain. Government has enforced mandatory thorough medical examination prior to any such high altitude pilgrimage [8]. But there are many flaws in this policy. Many of the medical certificates depicting their fitness for yatra are obtained by fradulant means. Mostly the general practioners conduct the medical examination but mostly respiratory, cardiac and orthopaedic problems are anticipated. Somehow even some unregistered persons manage to commence the yatra.

However, orthopaedic injuries are manifestations of difficult geographical terrain that takes a toll on the body. These cannot be predicted and only way out is improving the conditions of the trail to the shrine making it easier to tread upon with minimal falls and slips leading to these injuries.

In the present study, age of the patients is an important issue. These patients between 20-40 years of age are the economically productive, and accidents involving them in absence of proper management facilities, could prove detrimental and cause financial burden on the country as a whole. The difficult terrain with random ascents and descents could be the reason for the majority of injuries occurring due to falls or slips in patients. This highlights the importance of maintenance of the trail with adequate engineering inputs. Aggravation of pre-existing orthopaedic illnesses like backache is shown to be the most common ailment, and this highlights the importance of pre-conditioning and optimisation before undertaking the trip.

Based on the experiences of this study, we recommend the following measures for a successful and safe pilgrimage.

There were several difficulties faced during procuring results of the study at this place. Linguistic difficulties were there as there were patients from all over India, speaking different languages that makes history taking a bit difficult like knowing the mechanism of injury. More-so-ever no previous medical record of the patients with preexisting co-morbities was available. There were several workplace difficulties encountered like lack of good quality X-rays and specialised technicians and plaster assistants. These medical camps should be well equipped and supported by more medical personnel. Transportation of the patients to a higher centre is quiet difficult in such scenarios due to huge gathering of people at a specific time and small area. Beside this there were several logistic difficulties encountered.

The present study had several limitations. First of all it was conducted in a limited time at medical camp. Second it’s a cross-sectional, single centre, single surgical team study with potential of selection bias of the patients enrolled in the study. No follow-up of the patients could be obtained due to short stay. Exact prevalence of the trauma victims cannot be commented upon.

Trauma is one of the leading causes of morbidity and mortality during pilgrimage. There is a heavy toll of Orthopaedic cases which needs to be explored and adequately addressed. Adequate preventive measures should be taken for a hassle-free and safe trip. Additionally, the establishment of adequate health care facility all through the trail to the shrine is of paramount importance, to initiate early treatment to decrease associated morbidity and mortality.