Incidence and cause of fractures in European districts

Upper Extremity Fractures in the Emergency Department: A Database Analysis of National Trends in the United States

BACKGROUND

Upper extremity (UE) fractures are a common reason for emergency department (ED) visits, but recent data on their epidemiology are lacking. This study aimed to describe the incidence, demographics, patient characteristics, and associated health care factors of UE fractures, hypothesizing that they would remain prevalent in the ED setting.

METHODS

Using the Nationwide ED Sample database, patients presenting to the ED with UE fractures in 2016 were identified, and population estimates were used to calculate incidence rates. Data on insurance status, trauma designation, cost, and teaching status were analyzed.

RESULTS

The study identified 2 118 568 patients with UE fractures, representing 1.5% of all ED visits in 2016. Men accounted for 54.2% of UE fractures, with phalangeal fractures being most common. Distal radius and/or ulna fractures were most common in women (30.4%). The greatest proportion of UE fractures (23.2%) occurred in patients aged 5 to 14 years (1195.5 per 100 000). Nontrauma centers were the most common treating institutions (50.4%), followed by level I (19.5%), II (15.3%), and III (12.8%) centers. The greatest proportion of fractures (38.3%) occurred in the southern United States. Emergency department cost of treatment was almost 2-fold in patients with open UE fractures compared with closed.

CONCLUSION

This study provides important epidemiological information on UE fractures in 2016. The incidence rate of UE fractures in the ED has remained high, with most occurring in the distal radius, phalanges, and clavicle. In addition, UE fractures were most common in younger patients, men, and those in the southern United States during the summer. These findings can be useful for health care providers and policymakers when evaluating and treating patients with UE fractures.

Epidemiology and treatment of pediatric tibial fractures in Sweden: a nationwide population-based study on 5828 fractures from the Swedish Fracture Register

Purpose

Pediatric tibial fractures have been described internationally as mainly caused by fall during leisure activities and organized sports and showing a higher incidence in boys. Still, most studies are single center studies or have a small sample size. This study aimed to analyze sex and age distribution, seasonal variation, injury mechanisms and treatment of pediatric tibial fractures based on the nationwide Swedish Fracture Register (SFR).

Methods

All tibial fractures in patients < 16 years at injury and registered in 2015–2019 were extracted from the SFR. We analyzed patient characteristics such as sex and age, injury mechanism, fracture location and treatment.

Results

The study cohort consisted of 5828 pediatric tibial fractures in 5719 patients. Median age of the patients was 7 years and 58% were boys. Shaft fractures were most common, followed by the distal and proximal tibia. The lowest incidence was observed during autumn. The most common cause of injury was fall mostly involving winter sports, stumbles and fall from play equipment. Play/free time and sports were the most common activities, common places of injury were sports facility and home. 1% were open fractures. 78% were treated non-surgically. Screw fixation was performed in 52% of surgically treated fractures, predominantly in the distal segment.

Conclusion

Injury mechanism differs between age groups; play/free time injuries are common in younger children compared with sport activities in older children. Most patients are treated non-surgically. Open fractures are rare. Information on injury patterns is useful working preventively, for example safety work in playgrounds.

Artificial intelligence for radiological paediatric fracture assessment: a systematic review

BACKGROUND

Majority of research and commercial efforts have focussed on use of artificial intelligence (AI) for fracture detection in adults, despite the greater long-term clinical and medicolegal implications of missed fractures in children. The objective of this study was to assess the available literature regarding diagnostic performance of AI tools for paediatric fracture assessment on imaging, and where available, how this compares with the performance of human readers.

MATERIALS AND METHODS

MEDLINE, Embase and Cochrane Library databases were queried for studies published between 1 January 2011 and 2021 using terms related to 'fracture', 'artificial intelligence', 'imaging' and 'children'. Risk of bias was assessed using a modified QUADAS-2 tool. Descriptive statistics for diagnostic accuracies were collated.

RESULTS

Nine eligible articles from 362 publications were included, with most (8/9) evaluating fracture detection on radiographs, with the elbow being the most common body part. Nearly all articles used data derived from a single institution, and used deep learning methodology with only a few (2/9) performing external validation. Accuracy rates generated by AI ranged from 88.8 to 97.9%. In two of the three articles where AI performance was compared to human readers, sensitivity rates for AI were marginally higher, but this was not statistically significant.

CONCLUSIONS

Wide heterogeneity in the literature with limited information on algorithm performance on external datasets makes it difficult to understand how such tools may generalise to a wider paediatric population. Further research using a multicentric dataset with real-world evaluation would help to better understand the impact of these tools.

Epidemiology and management of 10,486 pediatric fractures in Shenzhen: experience and lessons to be learnt

Purpose

To explore and analyze the causes and related influencing factors of pediatric fractures, and provide theoretical basis for reducing the incidence and adverse effects of pediatric fractures.

Methods

This study retrospectively analyzed the epidemiological characteristics of fractures in pediatric aged ≤18 years old who were admitted to the our hospital between July 2015 and February 2020.

Results

A total of 10,486 pediatric patients were included in the study, of whom 6961 (66.38%) were boys, and 3525 (33.62%) were girls. For the fracture incidence, age group of the 3-6 years reached the peak. 5584 (60.76%) children were operated upon within 12 h after admission. The top three types of fractures were the distal humerus (3843 sites, 27.49%), distal ulna (1740 sites, 12.44%), and distal radius (1587 sites, 11.35%). The top three causes of injury were falls (7106 cases, 82.10%), car accidents (650 cases, 65.72%), and clipping (465 cases, 5.37%). Fractures predominantly occurred between July and November (4664 cases, 48.87%) and on Saturdays and Sundays (3172 cases, 33.24%). The highest number of hospital visits occurred between 20:00 and 00:00 (4339 cases, 45.46%).

Conclusion

For pediatric fractures, we should take appropriate and effective preventive measures to reduce the incidence of children’s fractures according to the distribution characteristics of age, gender, cause of injury, and fracture site.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03199-0.

Epidemiology of childhood fractures in Israel during 2000-2019

BACKGROUND

Differences have been reported in incidence rates of fractures in the pediatric population, between countries and over time. The aim of this study was to evaluate the incidence and characteristics of fractures over 20 years among Israeli children.

METHODS

Incidence rates of fractures were derived from the electronic database of Meuhedet Health Services, a health maintenance organization providing healthcare services to 1.2 million people in Israel. Demographic and clinical data were extracted of all the fractures in individuals aged <18 years during 2000-2019. Fracture sites were determined according to ICD9 definitions. Fracture data were analyzed by age, sex, season and sector (general Jewish population, ultra-orthodox Jews and Arabs).

RESULTS

During the study period 188,283 fractures occurred in 142,049 individuals. The most common were fractures of the upper limb (65%), followed by fractures of the lower limb [20%]. The overall fracture rate was 251 per 10,000 person- years (PY), and was higher for boys than girls (319 vs. 180 per 10,000 PY, p < 0.001). During 20 years, standardized fracture rates decreased significantly in the general Jewish population, among both boys (from 457 to 325 per 10,000 PY, p < 0.001) and girls (from 244 to 196 per 10,000 PY, p < 0.001); increased among ultra-orthodox Jewish boys (from 249 to 285 per 10,000 PY, p = 0.002) and girls (from 147 to 194 per 10,000 PY, p < 0.001); and did not change significantly among Arab boys and girls. The fracture rate peaked among girls aged 10-11 years and among boys aged 12-13 years. Seasonal variation showed a bimodal distribution with peaks during spring and autumn.

CONCLUSIONS

The incidence of pediatric fractures is affected by age, gender, sector and season. Recognition of fracture characteristics may help identify specific populations and conditions for targeted prevention strategies.

Factors That Drive Annual Variation in Pediatric Elbow Fracture Occurrence, Severity, and Resource Utilization

BACKGROUND

Elbow fractures are the most common pediatric fractures requiring operative treatment. To date, few studies have examined what annual factors drive pediatric elbow fracture incidence and no studies have examined which annual factors drive elbow fracture severity or resource utilization. The goal of this study was to not only document the annual patterns of pediatric elbow fracture incidence and severity but also the impact of these patterns on resource utilization in the emergency department, emergency medical service transportation, and the operating room (OR).

METHODS

Retrospective cohort study of 4414 pediatric elbow fractures from a single tertiary hospital (2007 to 2017). Exclusion criteria included outside treatment or lack of diagnosis by an orthopaedist. Presentation information, injury patterns, transport, and treatment requirements were collected. Pearson correlations were used to analyze factors influencing fracture incidence, severity, and resource utilization.

RESULTS

Pediatric elbow fracture incidence positively correlated with monthly daylight hours, but significantly fewer elbow fractures occurred during summer vacation from school compared with surrounding in school months. While fewer overall fractures occurred during summer break, the fractures sustained were greater in severity, conferring higher rates of displacement, higher risk of neurovascular injury, and greater needs for emergency transportation and operative treatment. Yearly, elbow fractures required 320.6 OR hours (7.7% of all pediatric orthopaedic OR time and 12.3% of all pediatric orthopaedic operative procedures), 203.4 hospital admissions, and a total of 4753.7 miles traveled by emergency medical service transportation to manage. All-cause emergency department visits were negatively correlated with daylight hours, inversing the pattern seen in elbow fractures.

CONCLUSION

Increased daylight, while school was in session, was a major driver of the incidence of pediatric elbow fractures. While summer vacation conferred fewer fractures, these were of higher severity. As such, increased daylight correlated strongly with monthly resource utilization, including the need for emergency transportation and operative treatment. This study provides objective data by which providers and administrators can more accurately allocate resources.

LEVEL OF EVIDENCE

Level III-Retrospective comparative study.

Incidence, pattern and mechanisms of injuries and fractures in children under two years of age

Background

Fractures in children under 2 years of age are rare, and little has been published on their mechanisms. We aimed at examining the incidence, mechanisms, pattern and fracture characteristics in a large, population-based cohort of otherwise healthy children.

Methods

This retrospective, cross-sectional study includes all children aged 0–2 years, attending the Accident and Emergency department in Bergen between 2010 and 2015, due to an injury warranting radiography. Clinical data was categorized from the medical notes, and all radiographs were reviewed by an experienced paediatric radiologist.

Results

In total 408 children (212 male), 3–23 months of age (mean 17.7 months), were included. 149 (77 male) children had a total of 162 fractures, yielding an annual incidence of 5.4 per 1000, varying from 0.7 per 1000 for those under 12 months of age, increasing tenfold to 7.3 per 1000 for children aged 12–24 months of age. More than half of the fractures (53.1%) were seen in children aged 18–23 months, while none was found in those under 7 months of age. The youngest age group had mostly femur and tibia fractures, the oldest mostly forearm fractures (n = 55, 33.9%), followed by tibia fractures (21.6%) and fractures to the clavicle (14.8%). The reported mechanisms for the 162 fractures were fall from a chair/bed/table (41.4%), fall from own height (18.5%) or crush injury (15.4%). In 8 of 162 (4.9%) fractures, the history was clearly inconsistent and suspicious of non-accidental injury (NAI).

Conclusion

Injuries and fractures in young children in general, and non-ambulant children in particular, are rare and should be thoroughly assessed for NAI. Level of evidence: Retrospective, population based cross-sectional study. Level 3.

Epidemiology and the economic burden of pediatric fractures in China: A retrospective study of 14,141 fractures

BACKGROUND

Previous studies have explored the epidemiology of fractures in children, however, differences in incidence over time and between countries and regions was noted. The purpose of the present study was to investigate the epidemiology and the economic burden of pediatric inpatients with fractures in China.

METHODS

A total of 14,141 pediatric inpatients (≤18 years of age) with fractures were included in the present study. Information on the clinical characteristics of each patient were obtained from the home page of their medical records. Pediatric inpatients with fractures were defined as patients that were 18 years of age or younger, and were primarily diagnosed as having a fracture. One-way ANOVA was used to assess differences in the economic burden of the treatment of the fractures.

RESULTS

Pediatric fractures accounted for 32.6% of all injures children recorded in the medical records. Fractures were more common among boys than among girls. The majority of fractures occurred in children that were 6-12 years old. The most common fracture sites were the shoulders and upper arms (44.6%), followed by the elbow and forearm (21.23%). The leading cause of fractures were falling down (61.3%). The majority of fractures occurred in summer (30.3%). The cost of hospitalization increased with the age of the inpatients. Furthermore, fractures of the long bones of the extremities, and fractures caused by traffic accidents, usually incurred higher hospitalization costs. The cost of materials and treatment of the fractures were the key factor affecting the cost of hospitalization.

CONCLUSION

The occurrence of pediatric fractures is affected by age, gender, reason, season and fracture sites. Appropriate precautions should be taken to reduce the incidence of fractures in children.

Change in paediatric upper extremity fracture incidences in German hospitals from 2002 to 2017: an epidemiological study

INTRODUCTION

Recent studies investigating the frequency of paediatric fractures in Germany are not available. The primary aim of this study was to report frequencies of the most common paediatric upper extremity fractures treated in German hospitals in 2002 and 2017 and to detect changes over time.

METHODS

This study used inpatient data from the German National Hospital Discharge Registry. Absolute frequencies and incidences of the following fracture localisations were analysed: clavicle, proximal humerus, humerus shaft, distal humerus, ulna shaft, radius shaft, forearm shaft, distal radius, and distal forearm. Four age groups were formed: 0-4, 5-9, 10-14, and 15-19 years. The boy-girl ratio (BGR) was calculated for all fracture localisations for both years, respectively. Incidence rate ratios (IRRs) were calculated to compare fracture incidences between 2002 and 2017.

RESULTS

The absolute number of the nine fracture localisations together decreased from 38,480 in 2002 to 35,128 in 2017. The overall BGR was 2.0 in both years. The BGR increased with increasing patient age. The incidence of clavicle fractures increased from 2002 to 2017 (IRR ≥ 1.72), while that of humerus fractures (proximal, shaft, and distal) remained the same or decreased (IRR ≤ 1.00) within all age groups. The incidence of isolated ulna or radius shaft fractures increased slightly or remained the same in the two lower age groups (IRR ≥ 1.00), while it decreased in the two higher age groups (IRR ≤ 0.80). Furthermore, complete forearm fractures were more frequent in the 0-4, 5-9, and 10-14 year age groups (IRR ≥ 1.44) in 2017 compared to 2002. The incidence of distal radius und forearm fractures changed only slightly.

CONCLUSIONS

The absolute number of paediatric upper extremity fractures decreased from 2002 to 2017, while the incidence of in-hospital treatment of clavicle and forearm fractures increased significantly, indicating a trend towards operative treatment.

Substantial decrease in paediatric lower extremity fracture rates in German hospitals in 2017 compared with 2002: an epidemiological study

Background

There are no recent studies on the frequency of paediatric lower extremity fractures in Germany. The aims of this study were to report fracture rates of paediatric lower extremity fractures treated in German hospitals in 2002 and 2017 and to detect changes over time as well as to evaluate the gender and age distribution for each fracture location.

Methods

Data from the German National Hospital Discharge Registry, which covers over 99% of all German hospitals, were used for this study. The absolute frequencies and incidence of lower extremity fractures as well as age at the time of fracture and gender were included in the data. The population was subdivided into four age groups: 0–4, 5–9, 10–14, and 15–19 years. The boy: girl ratio (BGR) for all fracture locations was calculated by dividing the absolute frequency of boys by that of girls. The fracture incidence in 2017 was compared with 2002 by calculating the incidence rate ratio (IRR).

Results

The total number of fractures decreased by 39.9% from 2002 to 2017. The most common fracture locations in 2002 were femoral shaft, tibial shaft, distal tibia, and lateral and medial malleolus; the absolute number of all these fractures was lower in 2017 than in 2002 in all age groups. The incidence of hip and thigh fractures, knee and lower leg fractures, and foot fractures decreased by 39.0, 41.1, and 33.3%. Proximal tibial fractures increased both in absolute numbers and in incidence in the age groups 0–4, 10–14, and 15–19 years (IRR ≥ 1.1). The overall BGR was 2.3 in 2002 and 2.0 in 2017, indicating that the number of girls relative to that of boys who suffered a lower extremity fracture was higher in 2017 than in 2002. Furthermore, the BGR of all fracture locations increased with age in both years.

Conclusions

The number of paediatric lower extremity fractures treated in German hospitals in 2017 was significantly lower than that in 2002. However, the fracture frequency in girls decreased to a lesser extent than that in boys. The incidence of proximal tibial fractures increased.

Preschool Obesity Is Associated With an Increased Risk of Childhood Fracture: A Longitudinal Cohort Study of 466,997 Children and Up to 11 Years of Follow-up in Catalonia, Spain

This study aimed to determine if having an overweight or obese range body mass index (BMI) at time of beginning school is associated with increased fracture incidence in childhood. A dynamic cohort was created from children presenting for routine preschool primary care screening, collected in the Information System for Research in Primary Care (SIDIAP) platform in Catalonia, Spain. Data were collected from 296 primary care centers representing 74% of the regional pediatric population. A total of 466,997 children (48.6% female) with a validated weight and height measurement within routine health care screening at age 4 years (±6 months) between 2006 and 2013 were included, and followed up to the age of 15, migration out of region, death, or until December 31, 2016. BMI was calculated at age 4 years and classified using WHO growth tables, and fractures were identified using previously validated ICD10 codes in electronic primary care records, divided by anatomical location. Actuarial lifetables were used to calculate cumulative incidence. Cox regression was used to investigate the association of BMI category and fracture risk with adjustment for socioeconomic status, age, sex, and nationality. Median follow-up was 4.90 years (interquartile range [IQR] 2.50 to 7.61). Cumulative incidence of any fracture during childhood was 9.20% (95% confidence interval [CI] 3.79% to 14.61%) for underweight, 10.06% (9.82% to 10.29%) for normal weight, 11.28% (10.22% to 12.35%) for overweight children, and 13.05% (10.69% to 15.41%) for children with obesity. Compared with children of normal range weight, having an overweight and obese range BMI was associated with an excess risk of lower limb fracture (adjusted hazard ratio [HR] = 1.42 [1.26 to 1.59]; 1.74 [1.46 to 2.06], respectively) and upper limb fracture (adjusted HR = 1.10 [1.03 to 1.17]; 1.19 [1.07 to 1.31]). Overall, preschool children with an overweight or obese range BMI had increased incidence of upper and lower limb fractures in childhood compared with contemporaries of normal weight. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.

Fracture risk factors among children living in New Zealand

Factures are common during childhood. There are limited data available regarding relationships between bone fracture history and calcium intake, sugar sweetened beverages (SSBs) intake, vitamin D status, physical activity (PA), ethnicity, and body composition in New Zealand (NZ) children. Identifying groups of NZ children at risk of fracture and associated predictors may help to improve bone quality during childhood and decrease the risk of fractures throughout life. The aim of this study was to investigate fracture history and associated risk factors in New Zealand children. Children aged 8-12 years were recruited. Capillary blood spots collected from a finger prick were as analyzed for 25(OH)D concentrations. Bioelectrical impedance analysis (InBody720, Seoul, Korea) was used to measure body fat percentage (%BF). Information about fracture history, siblings' history of fractures, family osteoporosis history, PA, ethnicity, and intake of calcium containing foods, and SSBs was collected using questionnaires. Children (n = 647, 354 girls), mean ± SD age 9.8 ± 0.7 years were recruited from six Auckland primary schools. NZ European (n = 252) (NZE) and South Asian (n = 68) children reported the lowest (20.2 %) and highest (44.1 %) fracture incidence, respectively. NZE compared to South Asian children, had higher 25(OH)D concentrations (74.6 ± 19.8 vs. 48.4 ± 19.3 nmol/L, P < 0.001), higher total calcium intake (764.0 ± 394.4 vs. 592.7 ± 266.3 mg/d, P < 0.018), and lower %BF (19.5 ± 6.6 vs. 23.4 ± 8.4, P < 0.003). Māori children had the next highest fracture rate (32.5 %). This group had adequate 25(OH)D (64.2 ± 18.9 nmol/L), but high %BF (23.9 %) and most participated in vigorous PA. After stratifying by sex, binary logistic regression analysis revealed the main determinants of fracture history for boys were high %BF, low 25(OH)D, low calcium intake, high SSBs consumption, siblings' fracture history, family osteoporosis history, and being South Asian; and in girls, high SSBs consumption, siblings' fracture history, and family osteoporosis history. We found South Asian ethnicity was a significant risk factor for boys. Some children were at high risk of vitamin D deficiency and for whom supplementation may be necessary in winter. Good nutrition (especially good sources of calcium and reducing SSBs intakes) should be recommended to children during growth and development to reduce their risk of fractures.

Recording Risk Factors of Physical Abuse in Children Younger Than 36 Months With Bone Fractures: A 12-Years Retrospective Study in an Italian General Hospital Emergency Room

Skeletal fractures (SFs) are very common in pediatrics. In some cases, they are secondary to child abuse. Differentiation of accidental from non-accidental fractures (NAFs) is essential as in abused children risk of further injuries leading to severe clinical problems and death is significant. Main objectives of this study were to evaluate the characteristics of SFs of children ≤3 years of age presenting to the Emergency Room (ER) of a Children's Teaching Hospital over a 12-year period and the attention paid by ER physicians to the identification of the indicators that increase suspicion of NAF and that suggest referring of the patient to the child protection agencies. This is a descriptive, retrospective study of the medical records of all the pediatric patients ≤ 36 months of age admitted to the ER of the Azienda Ospedaliera Santa Maria della Misericordia, University of Perugia, Perugia, Italy, for radiological documented SFs between January 1, 2004, and March 31, 2016. Available information was used to evaluate whether indicators of possible child abuse were documented by the ER staff and whether diagnosis of potential abuse was followed by further screening or referral to child protection agencies. During the study period, 11,136 accesses of the ER by children younger than 36 months were documented, among whom 417 presented long bone or skull fractures. Skull fractures were significantly more common among children <12 months of age (p = 0.001), whereas radius/ulna and humerus fractures were diagnosed significantly more frequently in children 12-36 months of age (p = 0.036 and p = 0.022, respectively). Recorded medical history was considered inadequate in 255 (61.2%) cases with no difference related to patient's age. Our study showed that the majority of charts in case of SFs were found to contain inadequate documentation to explain causes at the heart of the fractures and, therefore, to rule out any inflicted trauma. The development of specific referral guidelines, along with the continuous education and training of health professionals, as well as the preparation of structured medical forms, are essential measures to activate in order to improve the referral of children from the ER to child protection agencies.

Plate Fixation for Unstable Displaced Distal Radius Fractures in Children

Background  Distal radius fractures in children are normally treated by plaster immobilization. For displaced unstable distal radius fractures, closed reduction and Kirschner wire (k-wire) fixation can be performed. Disadvantages of k-wire fixation are the need for postoperative plaster treatment for several weeks, which may induce stiffness, and the risks of complications such as tendon irritation and pin-track infections. More invasive volar plate fixation is less popular, although this allows for direct mobilization and enhances anatomical reduction. Purpose  To present the functional outcomes of pediatric patients treated with volar plate fixation for unstable displaced distal radius fractures. Patients and Methods  A retrospective cohort study of all consecutive pediatric patients between September 2010 and July 2017 was performed. A total of 26 patients with a median age of 12.5 years were included. The primary objective was functional outcome determined by the Patient-Rated Wrist Evaluation (PRWE) questionnaire. Secondary objectives were range of motion, grip strength, radiological parameters, complications, and incidence of plate removal. Results  Median PRWE score was 3 after a median follow-up of 29 months. Range of motion and grip strength did not differ significantly between the injured and uninjured wrists. No wound infections were found. Plate removal was performed in 15 patients (58%). Conclusion  Volar plate fixation for unstable displaced distal radius fractures in children provides good functional and radiological outcomes with minor complications. Level of evidence  This is a Level IV cohort study.

Risk of Recurrent Fracture: A Population-Based Study

OBJECTIVES

To determine if children who sustain a fracture in childhood had an increased rate of fracture later in childhood or early adulthood. The a priori null hypothesis was that children who sustained a fracture would not have an increased rate of future fractures compared with children who did not sustain a fracture when controlling for important covariates.

METHODS

This is a population-based retrospective cohort study using health care databases in Ontario. Approximately 2.5 million healthy children aged 0 to 15 years living in Ontario, Canada between April 1, 2003, and March 31, 2004, were included and followed for 7 years. The exposure was occurrence of any fracture during a 1-year baseline period. The main outcome was any fractures during a 7-year follow-up period.

RESULTS

A total of 43 154 children suffered a fracture during the baseline year (17.5 fractures per 1000 child years). Children with a baseline fracture had a 60% higher rate of fracture (incidence rate ratio: 1.60; 95% confidence interval: 1.46-1.75; P < .0001) during the follow-up period after adjustment for sex, rurality, history of previous fracture, and the occurrence of other injuries (head and soft-tissue).

CONCLUSIONS

The occurrence of a fracture during childhood was associated with an increased rate of future fractures compared with children who did not suffer a fracture. Attempting to improve childhood bone health by targeting children who present to a fracture clinic with multiple fracture risk factors may be a useful strategy for secondary prevention of fractures and may have beneficial effects on long-term bone health.

Epidemiologic Features of Traumatic Fractures in Children and Adolescents: A 9-Year Retrospective Study

Purpose

Fractures are common among all types of paediatric injuries, with differences in incidence over time. Here, we present the epidemiologic features of traumatic fractures in a population of youth ≤ 18 years of age who were admitted to our university-affiliated hospitals from 2002 to 2010.

Methods

We retrospectively reviewed 2450 children and adolescents who had traumatic fractures. The data include variables such as age, sex, date of injury, and the mechanism of injury. For the period of 2002-2010, there were 2450 injury events that resulted in at least 1 fracture.

Results

Low falls (1042, 42.5%) and upper limb fractures (1068, 43.6%) were the most common aetiologies and fracture sites. With increasing age, the proportion of injuries due to motor vehicle collisions (MVCs) decreased and the injuries due to being hit by others and due to sprains increased. With increasing age, the proportion of craniofacial fractures (CFFs) decreased, and lower limb fractures (LLFs), spinal fractures (SFs), and fractures of ribs and the sternum (RSFs) increased. Over time, the proportion of injuries due to MVCs and mechanical injury decreased. Male patients presented with a significantly higher proportion of injuries due to low falls, being struck by an object, being hit by others, and due to sprains. There were a significantly lower proportion of injuries due to MVCs in female patients. Male patients presented with a significantly higher proportion of ULFs in the ≤6-year-old age group and a significantly lower proportion of LLFs and SFs in the 12-18-year-old age group than did female patients.

Conclusions

Low falls and upper limb fractures were the leading cause and fracture sites. To further improve the prevention and treatment of traumatic fractures in children and adolescents, policy makers should pay attention to these characteristics.

Diagnosis of Recurrent Fracture in a Pediatric Cohort

Significant fracture history in children is defined as having at least one vertebral fracture, at least 2 fractures by age 10, or at least 3 fractures by age 19. Between September 2011 and December 2014, clinical data were collected on children with a significant fracture history that attended a major Australian children's hospital. Fifty-six patients were identified as having 305 fractures in total, including 44 vertebral fractures. 18% of patients (10/56) were diagnosed with osteogenesis imperfecta (OI) by a bone health expert, molecular testing or both, and they sustained 23% of all fractures (71/305). Analysis of serum bone biochemistry showed all median values to be within a normal range and no clinically significant differences between patients with and without OI. The DXA and pQCT derived bone mineral density (BMD) and bone mineral content (BMC) Z scores were reduced overall. DXA derived total body and lumbar spine areal BMD-for-age and BMC-for-age Z scores were significantly lower in children who had vertebral fractures or who were later diagnosed with OI. Similarly, pQCT performed on radii and tibiae showed Z scores significantly less than zero. pQCT-derived limb muscle cross sectional area Z scores were significantly lower in the OI subgroup. In conclusion, this study describes the bone phenotype of children referred to a tertiary hospital clinic for recurrent fractures and highlights a subset of children with previously undiagnosed OI, but a larger cohort without classic OI. Thus it can be clinically challenging to differentiate between children with OI type 1 (mild phenotype) and non-OI children without bone densitometry and genetic testing. We conclude that recurrent fractures in children should prompt a comprehensive bone and systemic health assessment to eliminate an underlying pathology.

Functional outcome of displaced radial head fractures in children treated by elastic stable intramedullary nailing

The objectives of this study were to retrospectively investigate the clinical and radiological outcomes of displaced radial head fractures in children treated by elastic stable intramedullary nailing (ESIN) and evaluate the functional outcome of these injuries using the short version of the Disabilities of the Arm, Shoulder and Hand outcome questionnaire (Quick DASH). A total of 24 patients (nine males and 15 females) fulfilled the inclusion criteria. The mean age at the time of injury was 10.7±2.8 years (range: 9.5-16.33 years). Before surgery, the mean angulation was 53.8°±18.4° (range: 28°-82°) differentiating fractures on the basis of Judet's classification. The mean Quick DASH score was a good 4 (range: 0-15.9). Functional outcomes were similar irrespective of the severity of fracture displacement (P>0.05), presence or absence of associated fracture (P>0.05), and time immobilized (P>0.05). The Quick DASH score was better in children younger than 9 years of age (1.62) than children older than 9 years of age (4.95), but without a statistically significant difference (P=0.058). Children with displaced radial head fractures treated with ESIN showed good functional outcomes. Associated fracture injuries were not a predictive factor of functional outcome. Open reduction must be avoided as it carries an increased risk of complications.

Appendicular fracture epidemiology of children and adolescents: a 10-year case review in Western Australia (2005 to 2015)

Fracture incidence data of Australian children and adolescents have not been reported in the literature. A 10-year case review of fracture presentations in Western Australia is provided. Between 2005 and 2015, fracture incidence increased relative to population growth. This is concerning, and interventions are required to reverse this trend.

PURPOSE

Fracture incidence in 0-16-year-olds is high and varies between countries. Boys have a 1.5:1 ratio of fracture incidence compared to girls. There are no specific data for Australia. Western Australia is a state with unique geography and population distribution having only a single tertiary paediatric hospital (Princess Margaret Hospital, PMH, in Perth) managing the majority of children and adolescents with fractures in the Emergency Department (ED). The aims of this study were to characterise fracture presentations to PMH-ED and compare the incidence to population data.

METHODS

A database audit of fracture presentations between 2005 and 2015 for fracture rates with a sub-analysis for gender, fracture site and age and a comparison to Perth Metropolitan and Western Australian population data was performed.

RESULTS

Analysis included 31,340 presentations. Fracture incidence, adjusted for the annual population size, increased from 0.63% in 2005 to 0.85% in 2015 (p < 0.001). The month of May reported the highest fracture rate (p < 0.001) corresponding with the start of the winter sports season. Males had a 1.5 times higher fracture incidence than females (p < 0.001), with upper limb fractures three times more common than lower limb fractures (p < 0.001). Fracture incidence increased with age until the early teenage years (15 years for males; 12 years for females) when a decline occurred.

CONCLUSIONS

Increased fracture incidence in Western Australia between 2005 and 2015 identifies a concerning trend for bone health in children and adolescents. Further research is needed to identify potential lifestyle factors that impact fracture incidence translating into evidence-based strategies to reverse these trends and improve bone health.

Increasing incidence of fracture and its sex difference in school children: 20 year longitudinal study based on school health statistic in Japan

BACKGROUND

Studies on the epidemiology of pediatric fractures have been scarce in recent years although fractures are very common in childhood. Boys have a higher incidence of fractures than girls. Currently, societal trends have seemed to influence the difference in activity patterns between boys and girls, but the sex difference regarding longitudinal changes in fracture incidence is not well known.

METHODS

We analyzed the school accident report in Niigata city, Japan and compared the incidence of fractures in elementary and junior high school students and the sex-related risk ratio between two 9-year periods separated by 20 years from their start and end points (1999-2007 and 1979-1987).

RESULTS

The study included 383,273 students from 1999 to 2007 and 561,109 students from 1979 to 1987. Comparing these periods, the fracture incidence increased significantly by 2.4 times in boys vs 2.1 times in girls from elementary school and by 2.2 times in boys vs 2.9 times in girls from junior high school (all p ＜ 0.001). The sex-related risk ratio of boys to girls increased significantly from 1.47 to 1.64 in elementary school students. In contrast, it decreased significantly from 3.29 to 2.52 in junior high school students and the change was markedly significant because of the drastic increase in fracture incidence in junior high school girls.

CONCLUSIONS

The reasons proposed for the increase in schoolchildren's fractures were an improvement in diagnosis owing to social background and increased participation in sports activities despite the general decline in children's physical fitness and exercise ability. In junior high school girls, in particular, there was an increase in fracture risk due to increased participation in sports activities.

EPIDEMIOLOGY OF FRACTURES AND DISLOCATIONS IN CHILDREN

Fracture is quite a common occurrence in the age group of children, with a fairly wide variety of epidemiology throughout the world, hence it could be considered as a major health problem. A retrospective study of all pediatric fractures presenting to Dr. Soegiri General Hospital Lamongan, Indonesiain 2015 was undertaken. It showed that 79.5% of children’s fractures occurred in males and that 86.76% presented as a single fracture, whileelbow dislocation is the most prevalent dislocation in this study.Analysis of pediatric fractures shows that there is a trimodal distribution of single fracture with age, withdistal radius/ulna fracture as the most prevalent single fracture.The commonest cause of single fracture are road traffic accident, and the majority involve the upper limb. Those suggested that there should be more concern about road safety program in Indonesia.

Prenatal exposure to vitamin D from fortified margarine and risk of fractures in late childhood: period and cohort results from 222 000 subjects in the D-tect observational study

Prenatal low vitamin D may have consequences for bone health. By means of a nationwide mandatory vitamin D fortification programme, we examined the risk of fractures among 10-18-year-old children from proximate birth cohorts born around the date of the termination of the programme. For all subjects born in Denmark during 1983-1988, civil registration numbers were linked to the Danish National Patient Registry for incident and recurrent fractures occurring at ages 10-18 years. Multiplicative Poisson models were used to examine the association between birth cohort and fracture rates. The variation in fracture rates across birth cohorts was analysed by fitting an age-cohort model to the data. We addressed the potential modification of the effect of vitamin D availability by season of birth. The risk of fractures was increased among both girls and boys who were born before the vitamin D fortification terminated in 1985 (rate ratio (RR) exposed v. non-exposed girls: 1·15 (95 % CI 1·11, 1·20); RR exposed v. non-exposed boys: 1·11 (95 % CI 1·07, 1·14). However, these associations no longer persisted after including the period effects. There was no interaction between season of birth and vitamin D availability in relation to fracture risk. The study did not provide evidence that prenatal exposure to extra vitamin D from a mandatory fortification programme of 1·25 µg vitamin D/100 g margarine was sufficient to influence the risk of fractures in late childhood, regardless of season of birth. Replication studies are needed.

Association between Vitamin D Receptor Polymorphism and Serum Vitamin D Levels in Children with Low-Energy Fractures

OBJECTIVE

Fractures of bones, especially forearm fractures, are very common in children and their number is increasing. This study was designed to determine the impact of vitamin D serum levels and vitamin D receptor (VDR) polymorphisms on the occurrence of low-energy fractures in children.

METHODS

The study group consisted of 100 children with clinically relevant bone fractures and a control group consisted of 127 children without fractures. Total vitamin D [25(OH)D3 plus 25(OH)D2] serum concentrations were evaluated in every patient. Genotypes for 4 restriction fragment length polymorphisms of the vitamin D receptor gene (FokI, ApaI, TaqI, and BsmI) were determined by standard polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) techniques.

RESULTS

Differences in concentrations of vitamin D were observed between the group with bone fractures (median = 12 ng/ml) and the control group (median = 16 ng/ml; p = 0.000044). Higher levels of vitamin D reduced the risk of fracture by 1.06 times (p = 0.0005). No impact of particular VDR polymorphism on the occurrence of low-energy fractures in children was detected. However, there were significant differences in the prevalence of FokI polymorphism genotypes between the fracture and control groups (p = 0.05). Furthermore, the recessive "aa" genotype of ApaI polymorphism and the dominant "TT" genotype of TaqI polymorphism were associated with higher levels of vitamin D (p = 0.005 and p = 0.036, respectively).

CONCLUSIONS

Vitamin D deficiency is an independent risk factor for fractures in children. ApaI polymorphism recessive "aa" and TaqI polymorphism dominant "TT" genotypes are associated with higher levels of vitamin D in serum.

Fracture incidence rates in Norwegian children, The Tromsø Study, Fit Futures

This study describes childhood fracture rates in Norway, a country known for high fracture rates in the adult population. Fracture rates correspond with other reports from Scandinavia, although with a slightly higher proportion in girls. Indications of increased vulnerability during stages of puberty require further exploration.

INTRODUCTION

Fractures are common injuries during childhood. Incidence rates and patterns vary, but population-based data are scarce. The aim of this study was to describe the sex-, age- and maturation-specific incidence of fractures in a representative population-based sample from a region in Norway.

METHODS

All fractures in the population based convenient cohort Fit Futures, comprising 961 adolescents under 18 years, were recorded retrospectively from the local hospital. Details on individual's age and fracture site were recorded. A radiologist confirmed all fractures.

RESULTS

In the period from birth to cohort scanning, the register recorded 316 fractures in 253 individuals. Fractures were more common in boys (35%) than in girls (31%). The overall annual fracture incidence was 204 per 10,000 persons-year under the age of 18 and 205 under the age of 16. The majority of fractures involved the upper extremities and the most common site of fracture was the forearm with 24% of the fractures followed by phalanges with 23% of the fractures. Fractures peaked in girls at sexual maturation stage 3. Boys had a peak in stage 2. Timing of subsequent fractures was also consistent with stages of sexual maturation.

CONCLUSIONS

The overall incidence of fractures in childhood in Northern Norway corresponds with other reports from Scandinavia, although the proportion of fractures in girls is higher than in other studies. Both sexes seem especially vulnerable at stages related to sexual maturation. Whether this reflects bone vulnerability or other changes related to puberty requires further investigation.

Ethnic and geographic variations in the epidemiology of childhood fractures in the United Kingdom

BACKGROUND

Fractures are common in childhood, and there is considerable variation in the reported incidence across European countries, but few data relating to ethnic and geographic differences within a single country. We therefore aimed to determine the incidence of childhood fractures in the United Kingdom (UK), and to describe age-, ethnicity- and region- specific variations.

METHODS

The Clinical Practice Research Datalink (CPRD) contains anonymised electronic health records for approximately 7% of the UK population. The occurrence of a fracture between 1988 and 2012 was determined from the CPRD for all individuals <18years of age, and used to calculate fracture incidence rates for age, sex and ethnicity. Regional fracture incidence rates were also calculated based on general practitioner location within 14 Strategic Health Authorities (SHA) within the UK.

RESULTS

The overall fracture incidence rate was 137 per 10,000 person-years (py). This was higher in boys (169 per 10,000 py) than girls (103 per 10,000 py) and white children (150 per 10,000 py) compared to those of black (64 per 10,000 py) and South Asian (81 per 10,000 py) ethnicity. Marked geographic variation in incidence was observed. The highest fracture rates were observed in Wales, where boys and girls had 1.82 and 1.97 times greater incidence, respectively, than those residing in Greater London.

CONCLUSION

In the period 1988-2012, there was marked geographic and ethnic variation in childhood fracture incidence across the UK. These findings also implicate lifestyle and socio-economic differences associated with location and ethnicity, and are relevant to policy makers in the UK and internationally.

A clinical decision rule for the use of plain radiography in children after acute wrist injury: development and external validation of the Amsterdam Pediatric Wrist Rules

BACKGROUND

In most hospitals, children with acute wrist trauma are routinely referred for radiography.

OBJECTIVE

To develop and validate a clinical decision rule to decide whether radiography in children with wrist trauma is required.

MATERIALS AND METHODS

We prospectively developed and validated a clinical decision rule in two study populations. All children who presented in the emergency department of four hospitals with pain following wrist trauma were included and evaluated for 18 clinical variables. The outcome was a wrist fracture diagnosed by plain radiography.

RESULTS

Included in the study were 787 children. The prediction model consisted of six variables: age, swelling of the distal radius, visible deformation, distal radius tender to palpation, anatomical snuffbox tender to palpation, and painful or abnormal supination. The model showed an area under the receiver operator characteristics curve of 0.79 (95% CI: 0.76-0.83). The sensitivity and specificity were 95.9% and 37.3%, respectively. The use of this model would have resulted in a 22% absolute reduction of radiographic examinations. In a validation study, 7/170 fractures (4.1%, 95% CI: 1.7-8.3%) would have been missed using the decision model.

CONCLUSION

The decision model may be a valuable tool to decide whether radiography in children after wrist trauma is required.

All Wales Injury Surveillance System revised: development of a population-based system to evaluate single-level and multilevel interventions

Background

Injury surveillance has been established since the 1990s, but is still largely based upon single-source data from sentinel sites. The growth of electronic health records and developments in privacy protecting linkage technologies provide an opportunity for more sophisticated surveillance systems.

Objective

To describe the evolution of an injury surveillance system to support the evaluation of interventions, both simple and complex in terms of organisation.

Methods

The paper describes the evolution of the system from one that relied upon data only from emergency departments to one that include multisource data and are now embedded in a total population privacy protecting data linkage system. Injury incidence estimates are compared by source and data linkage used to aid understanding of data quality issues. Examples of applications, challenges and solutions are described.

Results

The age profile and estimated incidence of injuries recorded in general practice, emergency departments and hospital admissions differ considerably. Data linkage has enabled the evaluation of complex interventions and measurement of longer-term impact of a wide range of exposures.

Conclusions

Embedding injury surveillance within privacy protecting data linkage environment can transform the utility of a traditional single-source surveillance system to a multisource system. It also facilitates greater involvement in the evaluation of simple and complex healthcare and non-healthcare interventions and contributes to the growing evidence basis underlying the science of injury prevention and control.

Nutrient and food intakes in early life and risk of childhood fractures: a systematic review and meta-analysis

BACKGROUND

The identification of detrimental dietary patterns early in life may contribute to reducing the high incidence of fracture among healthy children. However, information based on a systematic review of the effect of various dietary foods and nutrients on fracture risk is lacking.

OBJECTIVE

We conducted a systematic review and meta-analysis of observational studies that examined the association between dietary intake or serum nutritional concentrations and childhood fractures.

DESIGN

Studies published up until June 2015 were identified on the basis of a literature search in Medline, Web of Science, and Scopus databases and by hand searching references by first author based on predefined inclusion criteria. A meta-analysis was carried out for case-control studies that examined differences in mean calcium intake in the case compared with the control group. Random-effects analysis was performed on the basis of the effect estimates derived as the differences in mean calcium intakes between cases and controls.

RESULTS

From a total of 1960 articles, we identified 18 observational studies, which were primarily case-control in design. Randomized controlled trials were absent, potentially because of unethical aspects related to the enrollment of children randomly assigned to certain dietary exposures and later fracture rates. Overall, fracture risk seemed to be associated with milk avoidance, high energy intake, high cheese intake, high intake of sugar-sweetened beverages, and no breastfeeding. The pooled effect size of the 9 case-control studies that examined mean calcium intake, which had appropriate data for the meta-analysis, showed no association (P = 0.99) with fair heterogeneity (I(2) = 69.3%, P = 0.001) with the use of the random-effects model.

CONCLUSIONS

On the basis of a systematic review of studies that were judged to be of high or medium quality, there is an indication that some nutritional factors seem to be associated with an increased fracture risk among children. The results may be inflated by selection bias, bias in diet reporting, or residual confounding. More high-quality longitudinal observational or intervention studies are needed on the subject.

Descriptive epidemiology of traumatic injuries in 18890 adults: a 5-year-study in a tertiary trauma center in iran

Background:

Basic epidemiological data can provide estimates when discussing disease burden and in the planning and provision of healthcare strategies. There is little quantitative information in the literature regarding prevalence of traumatic injuries from developing countries.

Objectives:

The aim of the current preliminary study was to reveal the prevalence and age and gender distribution of various traumatic injuries in a tertiary referral orthopedic hospital in Iran.

Patients and Methods:

In a prospective descriptive study, all traumatic injured patients attending the Orthopedic Trauma Unit of our center in a five year period were included. Demographic details, the cause of injury, injury classification and treatment were recorded. For each of the five-year age groups and each gender we calculated the numbers with fractures, dislocations, soft tissue injuries, ligamentous injuries and lacerations and derived average age and gender-specific prevalence as well as seasonal variations.

Results:

A total of 18890 adults were admitted, 13870 (73.4%) males and 5020 (26.6%) females. There were 8204 (43.4%) fractures. The male fracture age distribution curve was unimodal and there was a detectable bimodal pattern in females. Under 65 years males are 3 times more likely to sustain a fracture than females which decreases to equal risk over the age of 65. The most common fracture site was distal radius/ulna (13.8%), followed by tibial diaphysis (8.8%), proximal femur (7.8%), finger phalanges (6.4%), metacarpals (6%) and metatarsals (5.9%). There were seasonal variations in fracture incidence with peaks in February, March and October. The least number of fractures occurred in June.

Conclusions:

The risk of traumatic injuries is higher among specific age groups with different patterns emerging for men and women. Thus, the descriptive epidemiology will provide useful information for treatment or injury prevention strategies, resource allocation, and training priorities.

The epidemiology of fractures in otherwise healthy children

Fractures in otherwise healthy children are important because they are common, impact on daily activity, and may identify those who may have an increased fracture risk as adults. This review covers the descriptive epidemiology of fractures in healthy children (aged 0-16) and provides an overview of what is known about the child-related determinants of fractures, dividing associations into those that are potentially modifiable and those that are not. Maternal-related influences during pregnancy have not been covered, nor have determinants related to the injury such as trauma level, landing surface, injury type, the physical environment, or societal impacts. Age, gender, low bone mass, and exposure to injury are the child-related determinants of fractures with the highest quality research showing a convincing association.

Population-based research on the relationship between summer weather and paediatric forearm shaft fractures

BACKGROUND

Paediatric forearm shaft fractures show an increasing incidence. The predictive factors of these fractures are not fully understood. Summer weather is suggested to have an effect on the risk of children's fractures. We studied the effect of rainfall, temperature and wind on paediatric forearm shaft fractures in summer.

METHODS

All 148 children's forearm shaft fractures in the geographic catchment district during the summer months in 1997-2009 were included. There were 1989 days in the study period. Daily meteorological readings captured the maximum daytime temperature, precipitation and wind speed. The direct daily association between fractures (yes/no) and different weather conditions was analysed in this population-based study.

RESULTS

The risk of forearm shaft fracture was 50% higher on dry days compared to rainy days (P=0.038). Temperature and wind speed had no statistically significant effect on fractures.

CONCLUSIONS

The results give support for the presumption by the general public and professionals that summer weather affects children's fractures. A 1.5-fold increase in the risk is especially significant as the forearm shaft fractures are challenging to manage and prone to complications. Paediatric trauma units should prepare themselves for these severe injuries on dry summer days.

Fractures in children: epidemiology and activity-specific fracture rates

BACKGROUND

Approximately one-third of pediatric fractures occur during sport or recreational activity. In this paper, we investigate the incidence and causes of pediatric fractures in our region and quantify the fracture rate per exposure time for the most common sport and recreational activities.

METHODS

We prospectively evaluated all children younger than sixteen years who presented to our institution with a new fracture within a twelve-month period. Exposure time to the most common childhood activities was measured by means of interviewing random parents from the study population. The main outcome measures were the annual fracture incidence in the population and fracture rates per 10,000 hours of exposure to various sports and recreational activities.

RESULTS

A total of 1403 fractures were included. The overall annual incidence was 180.1 fractures per 10,000 children younger than sixteen years. The distal part of the radius was most often fractured (436 fractures, 31.1%). Snowboarding was associated with the highest activity-specific fracture rate, estimated to be 1.9 (95% confidence interval [CI], 1.16 to 2.60) fractures per 10,000 hours of exposure. In comparison, the fracture rate per 10,000 hours of exposure was 0.79 (CI, 0.42 to 1.09) for handball, 0.44 (CI, 0.35 to 0.52) for soccer, and 0.35 (CI, 0.23 to 0.47) for trampolining.

CONCLUSIONS

The distal part of the radius is the most common fracture site in childhood. Fracture rates differ between various physical activities. The fracture rate for snowboarding was four times higher compared with that for other common childhood sport and recreational activities in our region.

A comparison of pediatric forearm fracture reduction between conscious sedation and general anesthesia

OBJECTIVES

The purpose of this study was to compare the outcomes of children whose fractures were manipulated with nitrous oxide with those fractures manipulated under a general anesthetic.

DESIGN

We undertook a retrospective analysis of all children who presented to the emergency department with an angulated or displaced nonphyseal forearm fracture requiring manipulation over a 6-month period.

PATIENTS/PARTICIPANTS

Twenty-eight forearm fractures were manipulated using conscious sedation, whereas 27 were manipulated in the operating theatre under general anesthesia.

MAIN OUTCOME MEASUREMENTS

The quality of reduction, the Cast Index, Padding Index, and Canterbury Index were similar between the 2 groups.

RESULTS

There was a significant difference between the need for remanipulation in the nitrous oxide group (9) compared with the need for remanipulation in the theatre group (3).

CONCLUSIONS

Despite a higher failure, manipulation of fractures in the emergency department using conscious sedation can achieve an adequate reduction and a high quality of cast. Failures were due to inherently more unstable fracture personalities.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The role of plain radiography in paediatric wrist trauma

OBJECTIVES

Acute wrist trauma in children is one of the most frequent reasons for visiting the emergency department (ED). Radiographic imaging in children with wrist trauma is mostly performed routinely to confirm or rule out a fracture. The aim of this study was to determine how many radiographs of the wrist show a fracture in children following wrist trauma.

METHODS

A retrospective cohort study was performed in three Dutch hospitals from 2009-2010. Data were extracted from patient records and radiographic reports.

RESULTS

Of the 1,223 children who presented at the ED after a wrist trauma, 51 % had a wrist fracture. The peak incidence of having a wrist fracture was at the age of 10 years; 65 % of the children younger than 10 years of age had a wrist fracture. Of all the patients without a wrist fracture, 74 % were older than 10 years of age.

CONCLUSION

Almost half of the paediatric patients with a trauma of the wrist had normal radiographs. The development of a clinical decision rule to determine when a radiograph of the wrist is indicated following acute wrist trauma is needed. This could likely reduce the number of radiographs.

MAIN MESSAGES

• Fifty-one percent of the children with wrist trauma have a wrist fracture. • Peak incidence of having a wrist fracture is at the age of 10 years. • Sixty-five percent of the children younger than 10 years of age had a wrist fracture. • Of all the patients without a wrist fracture, 74 % were older than 10 years of age. • The development of a clinical decision rule to reduce the number of radiographs is needed.

Effects of vitamin K on the morphometric and material properties of bone in the tibiae of growing rats

Suboptimal vitamin K nutriture is evident during rapid growth. We aimed to determine whether vitamin K(2) (menaquinone-4 [MK-4]) supplementation is beneficial to bone structure and intrinsic bone tissue properties in growing rats. Male Wistar rats (5 weeks old) were assigned to either a control diet (n = 8) or an MK-4-supplemented diet (22 mg d(-1) kg(-1) body weight, n = 8). After a 9-week feeding period, we determined the serum concentration ratio of undercarboxylated osteocalcin to γ-carboxylated osteocalcin and the urinary deoxypyridinoline level. All rats were then euthanized, and their tibiae were analyzed by micro-computed tomography for trabecular architecture and synchrotron radiation micro-computed tomography for cortical pore structure and mineralization. Fourier transform infrared microspectroscopy and a nanoindentation test were performed on the cortical midlayers of the anterior and posterior cortices to assess bone tissue properties. Neither body weight nor tibia length differed significantly between the 2 groups. Dietary MK-4 supplementation decreased the ratio of undercarboxylated osteocalcin to γ-carboxylated osteocalcin but did not affect deoxypyridinoline, indicating a positive effect on bone formation but not bone resorption. Trabecular volume fraction and thickness were increased by MK-4 (P < .05). Neither the cortical pore structure nor mineralization was affected by MK-4. On the other hand, MK-4 increased mineral crystallinity, collagen maturity, and hardness in both the anterior and posterior cortices (P < .05). These data indicate the potential benefit of MK-4 supplementation during growth in terms of enhancing bone quality.

The increasing incidence of paediatric diaphyseal both-bone forearm fractures and their internal fixation during the last decade

BACKGROUND

The incidence of children's forearm fractures is increasing worldwide. This is different from the declining trend observed in the overall injury rate, and the reason for the increase is not known. Diaphyseal forearm fractures comprise 3-6% of all paediatric fractures, and they offer a challenge to their treatment. The purpose of this study was to evaluate the incidence of diaphyseal both-bone forearm fractures in children during the last decade in Northern Finland. Another objective was to study the background factors, treatment, and re-displacement of these fractures.

MATERIALS AND METHODS

All 168 children (<16 years) admitted to our paediatric trauma centre due to diaphyseal both-bone forearm fractures during 2000-2009 were included. The type of injury, background factors, radiographics, treatments and re-dislocations were reviewed. The age-related incidence rates were evaluated.

RESULTS

The incidence of diaphyseal both-bone forearm fractures increased 4.4-fold (95% CI 2.0-10.8; P<0.001) between 2000 (8.2/100000) and 2009 (35.9/100000). The increase in the incidence was accelerating (P<0.001) and the overall increase was 338%. The incidence of surgical treatment for diaphyseal fractures increased 4.2-fold (95% CI 1.9-10.4, P=0.001), which is in relation to increasing number of fractures. However, internal fixation increased from 13.3% in 2000-2001 to 52.7% in 2008-2009 (P=0.015), as an alternative to conservative treatment. The re-displacement rate was high (29.9%) amongst the patients with conservative treatment compared to those who were invasively operated (1.4%) (P<0.001). The mean age of the patients increased by 2.4 years in the study period (P=0.019). Trampoline was the most important and still increasing reason for the fractures. At the beginning of the study, there were no trampoline-related fracture, but towards the end of the study 30-41% of the fractures were caused by a trampoline injury (P=0.004).

CONCLUSIONS

There was an accelerating increase in the incidence of paediatric diaphyseal both-bone forearm fractures during the last decade. Trampoline was the most important and still increasing reason for these fractures. The mean age of the patients was increasing. Increasing proportion of diaphyseal both-bone forearm fractures was treated operatively. Re-displacement was unusual amongst operated cases.

Children hospitalized with lower extremity fractures in the United States in 2006: a population-based approach

OBJECTIVE

The purpose of this study was to examine the demographic and hospitalization characteristics of children hospitalized with lower extremity fractures in the United States in 2006.

METHODS

Children aged 0 to 20 years with a diagnosis of lower extremity fracture in the 2006 Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) were included. Lower extremity fractures were defined by International Classification of Diseases, 9th Revision, Clinical Modification codes 820-829 under "Injury and Poisoning (800-999)." Patient demographic and hospitalization-related data were analyzed by chi-square testing and unbalanced analysis of variance.

RESULTS

There were more boys than girls with lower extremity fractures and 53% had private insurance as their primary payer. About one half of the children were between the ages of 13 and 20 years, but all ages were represented from age 0 to 20. White children accounted for 56%. Urban hospitalizations accounted for 93% of cases and 66 percent of admissions were to teaching hospitals. All patients had an average length of stay (LOS) 4.04 days, and infant patients had the longest average LOS of 5.46 days. The average number of diagnoses per patient was 3.07, and the average number of procedures per patient was 2.21. The average charge per discharge was $35,236, and the oldest patients had the largest average charge of $41,907. The average number of comorbidities increased with increasing patient age. There was a 55.6% greater mortality risk in non-teaching hospitals than in teaching hospitals and there was at least ten times the mortality risk in rural hospitals than in urban hospitals.

CONCLUSIONS

This study provides an understanding of the demographic and hospitalization characteristics of children with lower extremity fractures in the United States in 2006. This information may be useful in implementing measures to help prevent similar injuries in the future. Further research is required to determine causality of the associations found including increased mortality risk for this population at rural and non-teaching hospitals.

Decreasing incidence and changing pattern of childhood fractures: A population-based study

Fractures are common in children, and some studies suggest an increasing incidence. Data on population-based long-term trends are scarce. In order to establish fracture incidence and epidemiologic patterns, we carried out a population-based study in Helsinki, Finland. All fractures in children aged 0 to 15 years were recorded from public health care institutions during a 12-month period in 2005. Details regarding patient demographics, fracture site, and trauma mechanism were collected. All fractures were confirmed from radiographs. Similar data from 1967, 1978, and 1983 were used for comparison. In 2005, altogether 1396 fractures were recorded, 63% in boys. The overall fracture incidence was 163 per 10,000. Causative injuries consisted of mainly falls when running or walking or from heights less than 1.5 m. Fracture incidence peaked at 10 years in girls and 14 years in boys. An increase in fracture incidence was seen from 1967 to 1983 (24%, p < .0001), but a significant decrease (18%, p < .0001) was seen from 1983 to 2005. This reduction was largest in children between the ages of 10 and 13 years. Despite the overall decrease and marked decrease in hand (-39%, p < .0001) and foot (-48%, p < .0001) fractures, the incidence of forearm and upper arm fractures increased significantly by 31% (p < .0001) and 39% (p = .021), respectively. Based on these findings, the overall incidence of childhood fractures has decreased significantly during the last two decades. Concurrently, the incidence of forearm and upper arm fractures has increased by one-third. The reasons for these epidemiologic changes remain to be elucidated in future studies.

Epidemiology of fractures in children and adolescents

BACKGROUND AND PURPOSE

Fractures are most common in youth and in the elderly, with differences in incidence over time and between regions. We present the fracture pattern in a population of youths <or= 19 years of age, who were seen at Umeå University Hospital, Sweden.

MATERIAL AND METHODS

All injuries seen at the hospital have been recorded in a database since 1993. The data include variables such as age, sex, date, type of injury, mechanism of injury, and treatment. For the period 1993-2007, there were 10,203 injury events that had resulted in at least 1 fracture.

RESULTS

The incidence for the whole period was 201/10(4) person years. The incidence increased by 13% during the period 1998-2007, when we were able to control for registration errors. The most common fracture site was the distal forearm. The most common type of injury mechanism was falling. The peak incidence occurred at 11-12 years in girls and at 13-14 years in boys, with a male-to-female incidence ratio of 1.5. We found variations in mechanisms and activities at injury with age, and over time.

INTERPRETATION

Fractures are caused by a combination of intrinsic and extrinsic factors that vary with age. We believe the increase in incidence is partly explained by changes in children's activity patterns over time. Further research may help to identify preventive measures to reduce the number of fractures, in particular those involving hospital care, surgical treatment, and-most importantly-long-term impairment.

Low volumetric BMD is linked to upper-limb fracture in pubertal girls and persists into adulthood: a seven-year cohort study

The aetiology of increased incidence of fracture during puberty is unclear. This study aimed to determine whether low volumetric bone mineral density (vBMD) in the distal radius is associated with upper-limb fractures in growing girls, and whether any such vBMD deficit persists into adulthood. Fracture history from birth to 20 years was obtained and verified by medical records in 1034 Finnish girls aged 10-13 years. Bone density and geometry at distal radius, biomarkers and lifestyle/behavioural factors were assessed in a subset of 396 girls with a 7.5-year follow-up. We found that fracture incidence peaked during puberty (relative risk 3.1 at age of 8-14 years compared to outside this age window), and 38% of fractures were in the upper-limb. Compared to the non-fracture cohort, girls who sustained upper-limb fracture at ages 8-14 years had lower distal radial vBMD at baseline (258.9+/-37.5 vs. 287.5+/-34.1 mg/cm(3), p=0.001), 1-year (252.0+/-29.3 vs. 282.6+/-33.5 mg/cm(3), p=0.001), 2-year (258.9+/-32.2 vs. 289.9+/-40.1 mg/cm(3), p=0.003), and 7-year follow-ups (early adulthood, 307.6+/-35.9 vs. 343.6+/-40.9 mg/cm(3), p=0.002). There was a consistent trend towards larger bone cross-sectional area in the fracture cohort compared to non-fracture. In a logistic regression model, lower vBMD (p=0.001) was the only significant predictor of upper-limb fracture during the period of 8-14 years. Our results indicate that low BMD is an important factor underlying elevated upper-limb fracture risk during puberty, and that low BMD in pubertal girls with fracture persists into adulthood. Hence low vBMD during childhood is not a transient deficit. Methods to monitor vBMD and to maximise bone mineral accrual and reduce risks of falling in childhood should be developed.

Evidence-based review of bone strength in children and youth with cerebral palsy

Children with cerebral palsy have various risk factors for compromised bone health. Evidence concerning their bone fragility is gathering; however, there is no consensus regarding risk factors, indications for evaluation, follow-up, or treatment. We performed an evidence-based review targeted to address the following questions concerning children with cerebral palsy: Is bone strength impaired and what are the risk factors? Are these children at increased risk for bone fractures? What are the relations between bone mineral density and fracture risk? What methods can be used for bone health assessment? How can bone strength be improved? Currently, the most acceptable method for evaluating bone status in children is dual-energy x-ray absorptiometry. Evidence demonstrates reduced bone mass in children with cerebral palsy; yet, no clear association with fractures. Preventive methods are suggested.

Fracture rates in urban South African children of different ethnic origins: the Birth to Twenty cohort

Fracture rates were compared in children of different ethnic backgrounds from Johannesburg, South Africa. More white children fracture than black and mixed ancestry children. Reasons for this may be due to greater sports participation by whites and genetic protective factors in blacks. This has to be further investigated.

INTRODUCTION

Fracture rates in childhood are as high as those in the elderly. Recent research has been undertaken to understand the reasons for this, but there is little information available on ethnic differences in childhood fracture rates.

METHODS

Using the birth to twenty longitudinal cohort of children, we retrospectively obtained information on fractures and their sites from birth to 14.9 years of age on 2031 participants. The ethnic breakdown of the children was black (B) 78%, white (W) 9%, mixed ancestry (MA) 10.5% and Indian (I) 1.5%.

RESULTS

Four hundred and forty-one (22%) children had sustained a fracture one or more times during their lifetime (males 27.5% and females 16.3%; p < 0.001). The percentage of children fracturing differed between the ethnic groups (W 41.5%, B 19%, MA 21%, I 30%; p < 0.001). Of the 441 children reporting fractures, 89(20%) sustained multiple fractures. The most common site of fracture was the upper limb (57%).

CONCLUSION

More white children fracture than black and mixed ancestry children. This is the first study to show ethnic differences in fracture rates among children. The reasons for these differences have to be further elucidated. Greater sports participation by whites and genetic protective factors in blacks may be contributing factors.

The epidemiology of fractures in adolescents with reference to social deprivation

A relationship between social deprivation and the incidence of fracture in adolescents has not previously been shown. We have used a complete fracture database to identify adolescents who sustained fractures in 2000. The 2001 Scottish census was used to obtain age-specific population and deprivation data according to the Carstairs score. Regression analysis determined the relationship between the incidence of fractures and social deprivation. We analysed 1574 adolescents with fractures (1083 male, 491 female). The incidence of fractures in this group was 21.8 per thousand (31.0 male, 13.1 female). Social deprivation predicted the incidence in adolescent males and females. The incidence of fractures of the proximal upper limb and distal radius in females was overwhelmingly influenced by socioeconomic factors. Males of 15 to 20 years of age were more likely to sustain fractures of the hand and carpus if they lived in economically depressed neighbourhoods.

The epidemiology of fractures in children

A retrospective study of all paediatric fractures presenting to hospital in Edinburgh, Scotland in 2000 was undertaken. It showed that the incidence of fractures was 20.2/1000/year and that 61% of children's fractures occurred in males. Analysis of paediatric fractures shows that there are six basic fracture distribution curves with six fractures showing a bimodal distribution but most having a unimodal distribution affecting younger or older children. The incidence of fractures increases with age with falls from below bed height (<1m) being the commonest cause of fracture. The majority of fractures in children involve the upper limb. Lower limb fractures are mainly caused by twisting injuries and road traffic accidents. The incidence of fractures in cyclists and pedestrians remains relatively high whereas the incidence in vehicle occupants is low suggesting that road safety programs have been successful. Similar programs should be instituted for young cyclists. The importance of accident prevention programmes in the home is also highlighted.

Incidence and demographics of hand fractures in British Columbia, Canada: a population-based study

PURPOSE

To identify population-based hand fracture annual incidence rates, demographics, and seasonal and geographic variations from all patients seeking treatment for a hand fracture in British Columbia, Canada from May 1, 1996 to April 20, 2001.

METHODS

All Medical Service Plan and Hospital Separation records that included International Classification of Diseases-9 codes for metacarpal (815), phalangeal (816), and multiple (817) fractures were extracted from the British Columbia Linked Health Dataset, along with the individual registry demographic records linked to each hand fracture.

RESULTS

A total of 72,481 hand fractures were identified. Fifty percent were phalangeal fractures, 42% were metacarpal fractures, and 8% were multiple fractures. The total population annual incidence rate for a hand fracture was 36 per 10,000. Age-adjusted annual incidence rates ranged from 29 per 10,000 for people older than 20 years to 61 per 10,000 for people age 20 or younger. The most common age for a hand fracture was 14 years for males and 13 years for females. Males had a 2.08 greater relative risk for hand fracture and they maintained most of this increase in risk between the ages of 15 and 40. For females there was an increased relative risk for a hand fracture after the age of 65. Spring had the highest rates for hand fractures. People in the Northern half of the province had a 1.6 greater relative risk for sustaining a hand fracture, compared with people in the more urbanized, less-industrialized, and more-affluent Southwestern region.

CONCLUSIONS

Our study provides a robust projection of annual incidence rates for hand fractures because we were able to review all occurrences of a hand fracture within a population base of approximately 4 million people over a 5-year period. Our study also allowed for the examination of how age, gender, season, and geographic location influenced hand fracture incidence rates within a large, diverse population.