First aid refers to the initial assistance or treatment given to an injured or suddenly ill person before the arrival of professional medical help. In orthopaedic emergencies — fractures, dislocations, sprains, crush injuries, and traumatic amputations — appropriate and timely first aid can be the difference between complete recovery and permanent disability.[1,2] Orthopaedic injuries are among the most common medical emergencies encountered in both urban and rural settings, frequently arising from road traffic accidents, falls, sports injuries, and occupational hazards. Despite the high incidence of orthopaedic trauma, a persistent gap exists in public awareness of appropriate first aid measures. Incorrect or delayed first aid — improper splinting, unnecessary movement of the injured limb, direct pressure over an open fracture, or failure to immobilise a suspected spinal injury — can result in neurovascular complications, increased blood loss, and worsening of the fracture pattern. Studies from various parts of India have consistently found that the general public, and even patients’ attendants, possess inadequate knowledge of basic first aid principles.[3,4] Banerjee et al., in a study of bystanders at road traffic accident scenes in West Bengal, found that only 22% had any knowledge of appropriate first aid for fracture management, and fewer than 10% could correctly describe steps for wound management and immobilisation.[10] Nair et al., studying college students in Kerala, reported that although 68% recognised that fractures required immobilisation, fewer than 30% knew the correct method of improvised splinting using locally available materials.[11] In a tertiary care orthopaedic setting, patients present with injuries ranging from simple closed fractures to complex polytrauma, and a substantial proportion arrive having received no first aid or, worse, incorrect pre-hospital management. Singh et al., auditing pre-hospital care of fracture patients at a North Indian tertiary centre, found that the majority of patients with limb fractures had received no pre-hospital immobilisation, and nearly 40% had been transported in positions that could have worsened their injury — a pattern with direct relevance to the population studied here.[12] Thakur et al. additionally found that patients from rural backgrounds were significantly more likely to have received inappropriate first aid than those from urban areas, suggesting that socioeconomic and educational factors strongly influence first aid practice.[13] Kaur et al. demonstrated that a structured educational intervention could meaningfully improve first aid knowledge scores among patients and attendants in a hospital setting, underscoring that this knowledge gap is addressable.[14] Mandya Institute of Medical Sciences (MIMS), Mandya, is a tertiary care teaching hospital serving a large catchment area with both urban and rural communities and varying levels of literacy and healthcare awareness. Given the limited formal data on first aid awareness from this specific region, this study was undertaken to assess the level of first aid awareness among orthopaedic patients attending MIMS, Mandya, and to identify the socio-demographic and clinical factors associated with adequate or inadequate knowledge, with a view to informing targeted educational interventions.

Study design: Descriptive cross-sectional study. Study period: Three months. Sampling technique: Consecutive sampling. Sample size: 90. Sample size calculation: In a study from Kerala, Nair et al. reported that although most respondents recognized that fractures required immobilization, only about 30% knew the correct method of improvised splinting, and Banerjee et al. similarly found that only 22% of road traffic accident bystanders in West Bengal had adequate first aid knowledge for fracture management.[10,11] Based on this range reported in the literature, an expected prevalence of adequate first aid knowledge of p = 30% was adopted for this study (a conservative estimate that yields the larger, more cautious sample size compared with the 22% figure). The sample size was calculated using the formula n = ZZ₁₋α/₂ × pq / dZ, where Z₁₋α/₂ = 1.96 (critical value for a two-tailed test at α = 0.05, i.e., 95% confidence level), p = 30% (expected prevalence of adequate first aid knowledge, from Nair et al.[11]), q = 100 − p = 70%, and d = 10% (absolute precision). Substituting the values: n = (1.96)Z × 30 × 70 / (10)Z = 3.8416 × 2100 / 100 = 80.67 ≈ 81. Adding 10% for anticipated non-response, a total of 90 participants will be enrolled in the study. Inclusion criteria: (1) Patients aged 18 years and above attending or admitted to the orthopaedic department for an acute orthopaedic condition; (2) willingness to provide written informed consent. Exclusion criteria: (1) Altered consciousness or inability to communicate; (2) known psychiatric illness or cognitive impairment. Data collection tool: A structured, interviewer-administered questionnaire, available in both English and Kannada, was used. It recorded socio-demographic details (age, sex, occupation, education, and socioeconomic status by the Modified Kuppuswamy Scale, 2021), clinical details of the presenting orthopaedic injury (type, mode, and site of injury), whether any first aid was received before hospital arrival and, if so, its type and clinician-assessed appropriateness, and a 20-item first aid knowledge questionnaire covering the definition of first aid, fracture and dislocation management, wound and haemorrhage control, spinal-injury precautions, and soft-tissue injury care — each item scored 1 for a correct response and 0 for an incorrect or ‘don’t know’ response, giving a maximum possible score of 20. A score of ≥12/20 (≥60%) was taken as adequate awareness, in keeping with the pre-specified scoring criteria (≥16/20 excellent, 12–15/20 adequate, <12/20 inadequate). Post-hoc domain grouping: For descriptive purposes, the 20 items were additionally grouped into five thematic domains — (A) first aid concept and emergency recognition (4 items), (B) fracture and dislocation management (6 items), (C) wound and haemorrhage control (5 items), (D) spinal injury and special situations (2 items), and (E) soft-tissue injury care (3 items) — to help localise specific knowledge gaps; this grouping was not part of the original validated scoring key and should be interpreted as descriptive rather than as a separately validated sub-scale. Statistical analysis: Data were entered in Microsoft Excel and analysed using Python (SciPy/pandas). Descriptive statistics (frequencies and percentages for categorical variables; mean and standard deviation for continuous variables) were computed. The chi-square test was used to assess the association between adequate awareness (≥12/20) and age group, sex, education, occupation group, type and mode of injury, and whether first aid had already been received. A p-value <0.05 was considered statistically significant.

A total of 90 orthopaedic patients were enrolled consecutively over the study period. The mean age was 54.2 ± 18.0 years (range 17–90 years); 74.4% (n=67) were male and 25.6% (n=23) were female. Socio-demographic and clinical characteristics are summarised in Table 1. Table 1: Socio-demographic and Clinical Profile of Study Participants (N = 90) Variable Category n % Age (years) Mean ± SD 54.2 ± 18.0 – Age group 18–39 years 18 20.0% 40–59 years 32 35.6% 60 years and above 40 44.4% Sex Male 67 74.4% Female 23 25.6% Education Illiterate 43 47.8% Primary 18 20.0% Secondary 19 21.1% Graduate and above 10 11.1% Socioeconomic status (Modified Kuppuswamy) Upper 1 1.1% Upper middle 19 21.1% Lower middle 34 37.8% Upper lower 27 30.0% Lower 9 10.0% Occupation group Farmer 34 37.8% Homemaker 22 24.4% Student 4 4.4% Driver 4 4.4% Other (teacher, engineer, salesperson, etc.) 26 28.9% Type of orthopaedic injury Closed fracture 61 67.8% Open fracture 13 14.4% Soft tissue injury 7 7.8% Dislocation 6 6.7% Sprain/Strain 2 2.2% Other 1 1.1% Mode of injury Road traffic accident 28 31.1% Fall from height 20 22.2% Workplace/Industrial injury 20 22.2% Fall from standing height 19 21.1% Sports injury 2 2.2% Assault 1 1.1% Site of injury Lower limb 51 56.7% Upper limb 33 36.7% Pelvis 4 4.4% Multiple 2 2.2% Table 2: Pre-Hospital First Aid Received and Its Appropriateness (N = 90) Parameter n % First aid received before hospital – Yes 40 44.4% First aid received before hospital – No 50 55.6% Type: Immobilisation/Splinting (of those treated, n=40) 28 70.0% Type: Wound dressing 5 12.5% Type: Ice application 5 12.5% Type: Compression bandage 2 5.0% Appropriateness: Appropriate (of those treated, n=40) 35 87.5% Appropriateness: Inappropriate 5 12.5% Overall first aid knowledge score The mean total knowledge score across all 90 participants was 10.92 ± 5.38 out of 20 (54.6%). Using the pre-defined threshold of ≥12/20 (≥60%), 47 participants (52.2%) had adequate awareness and 43 (47.8%) had inadequate awareness (Table 3, Figure 6). Table 3: Overall First Aid Knowledge Score (N = 90) Parameter Value Mean total knowledge score (/20) 10.92 ± 5.38 Mean knowledge score (%) 54.6% Adequate awareness (≥12/20, ≥60%) 47 (52.2%) Inadequate awareness (<12/20, <60%) 43 (47.8%) Table 2: Pre-Hospital First Aid Received and Its Appropriateness (N = 90) Parameter n % First aid received before hospital – Yes 40 44.4% First aid received before hospital – No 50 55.6% Type: Immobilisation/Splinting (of those treated, n=40) 28 70.0% Type: Wound dressing 5 12.5% Type: Ice application 5 12.5% Type: Compression bandage 2 5.0% Appropriateness: Appropriate (of those treated, n=40) 35 87.5% Appropriateness: Inappropriate 5 12.5% Overall first aid knowledge score The mean total knowledge score across all 90 participants was 10.92 ± 5.38 out of 20 (54.6%). Using the pre-defined threshold of ≥12/20 (≥60%), 47 participants (52.2%) had adequate awareness and 43 (47.8%) had inadequate awareness (Table 3, Figure 6). Table 3: Overall First Aid Knowledge Score (N = 90) Parameter Value Mean total knowledge score (/20) 10.92 ± 5.38 Mean knowledge score (%) 54.6% Adequate awareness (≥12/20, ≥60%) 47 (52.2%) Inadequate awareness (<12/20, <60%) 43 (47.8%) Table 2: Pre-Hospital First Aid Received and Its Appropriateness (N = 90) Parameter n % First aid received before hospital – Yes 40 44.4% First aid received before hospital – No 50 55.6% Type: Immobilisation/Splinting (of those treated, n=40) 28 70.0% Type: Wound dressing 5 12.5% Type: Ice application 5 12.5% Type: Compression bandage 2 5.0% Appropriateness: Appropriate (of those treated, n=40) 35 87.5% Appropriateness: Inappropriate 5 12.5% Overall first aid knowledge score The mean total knowledge score across all 90 participants was 10.92 ± 5.38 out of 20 (54.6%). Using the pre-defined threshold of ≥12/20 (≥60%), 47 participants (52.2%) had adequate awareness and 43 (47.8%) had inadequate awareness (Table 3, Figure 6). Table 3: Overall First Aid Knowledge Score (N = 90) Parameter Value Mean total knowledge score (/20) 10.92 ± 5.38 Mean knowledge score (%) 54.6% Adequate awareness (≥12/20, ≥60%) 47 (52.2%) Inadequate awareness (<12/20, <60%) 43 (47.8%) Domain-wise and item-wise knowledge gaps Domain-wise scoring (Table 4, Figure 7) showed the highest awareness for spinal injury and special situations (65.6%) and first aid concept/emergency recognition (63.6%), moderate awareness for fracture and dislocation management (57.2%), and the lowest awareness for wound and haemorrhage control (46.7%) and soft-tissue injury care (43.3%). Table 4: Domain-wise First Aid Knowledge Scores (N = 90) Domain Mean score % Score A: First aid concept & emergency recognition (/4) 2.54 63.6% B: Fracture & dislocation management (/6) 3.43 57.2% C: Wound & haemorrhage control (/5) 2.33 46.7% D: Spinal injury & special situations (/2) 1.31 65.6% E: Soft-tissue injury care (/3) 1.30 43.3% Within the individual items, the weakest were knowledge of the correct timing of tourniquet application for limb bleeding (28.9% correct), the correct duration of ice application for a soft-tissue injury (33.3% correct), the meaning of the ‘RICE’ method (36.7% correct), warning signs of shock after major injury (40.0% correct), and the safety of removing an embedded foreign body from a wound (43.3% correct) (Table 5, Figure 8). Table 5: Weakest Individual Knowledge Items (N = 90) Item % Correct Q8: Correct timing of tourniquet application for limb bleeding 28.9% Q12: Correct duration of ice application (15–20 minutes) 33.3% Q13: Meaning of the ‘RICE’ method 36.7% Q16: Warning signs of shock after a major injury 40.0% Q7: Safety of removing an embedded foreign body from a wound 43.3% Factors associated with adequate awareness On chi-square testing (Table 6), adequate awareness was significantly associated with younger age group, male sex, havingany formal education, occupation group, mode and type of injury, and having already received pre- hospital first aid (all p<0.05). Mean total scores were markedly higher in participants aged 18–39 years (14.72 ± 3.01) than in those aged 60 years and above (7.63 ± 5.04); in those with any formal education (14.32 ± 3.19) than in illiterate participants (7.21 ± 4.80); and in male (12.87 ± 4.01) compared with female participants (5.26 ± 4.86) (Figure 9). Because the great majority of female participants in this sample were elderly, illiterate homemakers, the sex, age, education, and occupation associations are closely inter-related rather than fully independent effects, and this overlap should be kept in mind when interpreting Table 6. Table 6: Association Between Adequate Awareness and Selected Variable Variable n χ² p-value Age group (18–39 / 40–59 / ≥60 yrs) 90 31.30 <0.001 Sex (Male / Female) 90 21.18 <0.001 Education (Illiterate / Any formal education) 90 39.92 <0.001 Occupation group 90 32.58 <0.001 Mode of injury 90 21.76 0.001 Type of orthopaedic injury 90 13.83 0.017 Pre-hospital first aid already received (Yes/No) 90 7.88 0.005

This study assessed first aid awareness among 90 orthopaedic patients attending a tertiary care centre in Mandya, and identified the specific knowledge domains and patient subgroups where gaps were greatest. Only 44.4% of patients had received any pre-hospital first aid, closely mirroring the finding of Singh et al. at a North Indian tertiary centre that the majority of fracture patients arrived without pre-hospital immobilisation, and that a substantial minority had been transported in a manner that could have worsened the injury.[12] The pattern seen here — immobilisation/splinting accounting for 70% of the first aid that was given, but well over half of patients receiving none at all — suggests that even where bystanders or family members do intervene, their actions are skewed towards the single most visibly obvious measure (splinting an obviously deformed limb) rather than a broader first aid repertoire covering wound care, haemorrhage control, or shock recognition. The overall mean knowledge score of 54.6%, with 52.2% of patients meeting the adequate-awareness threshold, is considerably higher than the 22% adequate-knowledge figure reported by Banerjee et al. among road traffic accident bystanders in West Bengal,[10] and somewhat above the pattern implied by Nair et al.’s finding that fewer than 30% of Kerala college students knew the correct method of improvised splinting despite most recognising that fractures need immobilisation.[11] This difference is plausibly explained by the difference in sampling frame: our participants were themselves orthopaedic patients, many of whom had already experienced an injury, undergone examination, and received at least some explanation of their condition from treating staff or family members with prior exposure to trauma — a form of experiential learning that a general bystander population would not share. This is consistent with Thakur et al.’s observation that socioeconomic and educational background, and by extension prior exposure to healthcare settings, strongly shapes first aid practice.[13] Despite this relatively favourable comparison with bystander-based studies, nearly half of our patients still had inadequate awareness, and the domain-wise breakdown identifies exactly where the gap lies: wound and haemorrhage control (46.7%) and soft-tissue injury care (43.3%) were the weakest domains, and the single weakest items were the correct timing of tourniquet application and the correct duration of ice application — both practical, procedural pieces of knowledge rather than conceptual awareness that an injury is serious. This distinction matters for intervention design: generic messaging that “fractures need immobilisation” is unlikely to close this particular gap, whereas structured, skills-based teaching — for example using the kind of hands-on educational intervention described by Kaur et al., which measurably improved first aid knowledge scores among patients and attendants[14] — would target it directly. Adequate awareness was strongly associated with younger age, higher education, and non-homemaker occupation, a pattern consistent with Thakur et al.’s rural–urban and socioeconomic findings.[13] The apparent association with sex is almost certainly confounded: the female participants in this sample were overwhelmingly elderly, illiterate homemakers who had sustained a fall from standing height, a demographic cluster in which every one of age, education, occupation, and sex moved together. This overlap means the sex association should not be over-interpreted as an independent effect of sex itself, and a future study adequately powered for multivariable logistic regression — as originally planned in this protocol — would be needed to disentangle these inter-related factors. Several limitations should be noted. First, information on first aid received before hospital arrival relied on patient or accompanying-person recall and clinician judgement of appropriateness, which may be subject to recall and observer bias. Second, this was a single-centre study, which limits generalisability to other tertiary care settings and to the wider community-dwelling population, who would include a much larger share of uninjured individuals than this hospital-based, trauma-enriched sample. Taken together, these findings support two practical directions highlighted in earlier Indian literature: incorporating structured first aid education into community health worker programmes and school curricula, as recommended for this region,[15,16] and delivering skills-focused, procedure-specific teaching — particularly on haemorrhage control and soft-tissue injury care — to patients and attendants at the point of hospital contact, rather than relying on generic awareness messaging alone.

Among 90 orthopaedic patients attending a tertiary care centre in Mandya, fewer than half (44.4%) had received any first aid before reaching hospital, and just over half (52.2%) had adequate overall first aid knowledge, with a mean score of only 54.6%. Awareness was weakest for wound and haemorrhage control and for soft-tissue injury care, and was significantly lower among older, illiterate, and homemaker patients. These findings support the development of structured, procedure-specific first aid education — delivered through community health programmes, school curricula, and routine orthopaedic patient encounters — with particular attention to haemorrhage control and soft-tissue injury care, and to older and less-educated patients who appear to carry the largest knowledge deficit. Financial support and sponsorship Self-funded. Conflicts of interest There are no conflicts of interest. Acknowledgement The authors thank the Department of Orthopaedics and the Institutional Ethics Committee, Mandya Institute of Medical Sciences, Mandya, for their support, and gratefully acknowledge all the patients who voluntarily participated in this study.

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