Children's fractures: a population based study

Epidemiology of Pediatric Fractures and Effect of Socioeconomic Status on Fracture Incidence in Türkiye: A Nationwide Analysis of 2 Million Fractures

BACKGROUND

Childhood fractures are an important public health issue worldwide as they potentially lead to long-term complications. This is the first study reporting a nationwide data pool of 2 million children. We aimed to investigate the epidemiology of pediatric fractures by sex, age, geographical region, and socioeconomic status (SES).

METHODS

Medical records of children diagnosed with fractures between 2016 and 2022 were collected from Türkiye's e-health database. Fractures were divided into 16 anatomic locations. Age was evaluated in four categories: <5, 5-9, 9-14, and 15-19 years. Regional rankings were stratified based on SES.

RESULTS

A total of 1,989,212 pediatric fractures were analyzed (1,371,398 boys, 617,814 girls). The overall fracture incidence was 1117/100,000 person-years, being higher for boys (n=1501) compared with girls (n=713) ( P <0.001). The mean fracture incidence between 0 and 19 years of age was 21.2% (boys: 28.5%; girls: 13.5%). The overall fracture incidence increased with age, peaking at 10 to 14 years for all children and decreasing thereafter. The 4 most common fracture locations were in the upper extremities. Wrist fractures accounted for 28.9% (575,192) of all pediatric fractures. Provinces with higher SES had significantly increased fracture risks.

CONCLUSIONS

This study provides the most accurate epidemiological analysis of childhood fractures in the Turkish population with landmark nationwide analysis for the pediatric literature. One fifth of children experienced fractures before maturity. The results highlight the influence of SES on fracture rates, as children in more urbanized and developed areas had an elevated risk of fractures.

LEVEL OF EVIDENCE

Level III-diagnostic.

Buried or exposed kirschner wires in paediatric upper extremity fracture fixation: A systematic review and meta-analysis of infection rates and complications

BACKGROUND

Paediatric upper limb fractures are commonly treated with Kirschner (K) wire fixation, which can be buried or left exposed. Although both techniques are widely used, controversy remains regarding infection risk, complications, and other clinical outcomes between buried and exposed K-wires. This systematic review and meta-analysis aimed to compare infection rates and secondary outcomes between buried and exposed K-wires in paediatric upper limb fractures located distal to and including the elbow, and proximal to the carpus.

METHODS

A systematic review of the literature was conducted according to PRISMA guidelines, with searches performed across Medline, EMBASE, and the Cochrane Library up to July 2023. Studies were included if they directly compared buried and exposed K-wires in paediatric patients (under 18 years old) and reported on infection rates. Meta-analysis was conducted to compare overall infection rates. Pooled means were used to compare secondary outcomes. Bias was assessed using the ROBINS-I and RoB2 tools.

RESULTS

Fifteen studies involving 1,854 participants were included. The meta-analysis showed that buried K-wires were associated with a significantly lower risk of overall postoperative infection compared to exposed K-wires (RR 0.33; 95 % CI 0.22 to 0.50; p< 0.001). The risk of deep infection requiring further surgery was 1.74 % in buried K-wires (95 % CI: 0.72 % to 2.75 %) and 2.07 % in exposed K-wires (95 % CI: 0.55 % to 3.59 %). Skin erosion was a common complication of buried K-wires, with a pooled mean rate of 13.0 %. Buried K-wires were associated with a higher likelihood of requiring removal in theatre (84.4 % vs. 4.2 %). Time to K-wire removal was longer in the buried group (10.9 weeks vs. 5.3 weeks). Re-operation and bone union failure rates were similar between groups.

CONCLUSION

Our systematic review and meta-analysis suggest that, while buried K-wires are associated with lower overall infection rates, the risk of deep infection is comparable between buried and exposed K-wires. Buried K-wires show higher rates of skin erosion and increased need for removal in theatre. Given these findings, exposed K-wires offer a safe and more cost-effective option for paediatric upper limb fracture fixation. Further studies are needed to assess patient-reported outcomes and environmental impacts.

Introducing the forearm fracture index to define the diametaphyseal junction zone through clinical evaluation in a cohort of 366 diametaphyseal radius fractures

BACKGROUND

Unstable diametaphyseal radius fractures (DMRFs) can be prone to complications, and treatment strategies are heterogeneous. Studies are difficult to interpret as definitions of the diametaphyseal junction zone (DMJZ) are impractical for clinical use, imprecise, or prone to error.

METHODS

We introduce the forearm fracture index (FFI) to define DMRFs in radiographs and ultrasound. The FFI is calculated by the ratio of the fracture's distance to the distal radius growth plate over the width of the radius growth plate. The higher the FFI, the more proximal the fracture is. We define DMRFs to have an FFI between 1 and 2. All DMRFs treated at our institution between 2010 and 2020 were identified, and demographic data, fracture characteristics, and therapeutic strategies were assessed retrospectively. Comparative sub-analysis was performed between DMRFs(-) as defined in previous publications (Lieber in Unfallchirurg 114:292-299, 2011) and DMRFs( +) that were more proximal but still met our criteria.

RESULTS

516 DMRFs were identified, representing 13.0% of all screened radius fractures. Excluding buckle fractures and patients lost to follow-up, 366 DMRFs were eligible for further analysis. Conservatively managed DMRFs were more distal than those managed operatively, represented by a lower FFI (1.28 vs. 1.34, p = 0.0051). 21 (5.7%) of all DMRFs were identified as DMRFs( +). These were significantly more dislocated and necessitated surgery more often than DMRFs(-) (52.4 vs. 24.6%, p = 0.009).

CONCLUSIONS

The FFI may be a good tool to identify and describe DMRFs. It can help guiding treatment decisions and make future studies on this entity more comparable.

LEVEL OF EVIDENCE

Study of Diagnostic Test, Level II.

Supportive bandage, removable splint, or walking casts for low-risk ankle fractures in children: a feasibility randomized controlled trial

Aims

It is unclear if a supportive bandage, removable splint, or walking cast offers the best outcome following low-risk ankle fractures in children. The aim of this study was to evaluate the feasibility of a randomized controlled trial to compare these treatments.

Methods

Children aged five to 15 years with low-risk ankle fractures were recruited to this feasibility trial from 1 February 2020 to 30 March 2023. Children were randomized to supportive bandage, removable splint, or walking cast for two weeks. Follow-up at two, six, and 12 weeks was undertaken to determine feasibility for a definitive trial. Outcomes collected included complications, the Patient-Reported Outcomes Measurement Information System (PROMIS) mobility score, Paediatric Quality of Life Inventory, youth version of the EuroQol five-dimension health questionnaire, and Activities Scale for Kids - Performance.

Results

A total of 87 children from six hospitals were randomized at a rate of 0.9 participants per site per month. Two children in the supportive bandage group crossed over to an alternative device. Complications were reported in six children. One child in the cast group developed skin blisters. One child in cast and one in bandage sustained a reinjury during the 12-week follow-up, and two children (one splint and one cast) required additional immobilization after the two-week treatment for persistent pain. Of the 84 participants who remained in the study at six weeks, 43 (51.2%) returned follow-up questionnaires at six weeks. Of the patient-reported outcome measures (PROMs), proxy-reported PROMIS mobility showed good responsiveness, low ceiling effects, and low missing item rates. In an exploratory analysis, small differences were observed between groups, with no evidence that any of the treatments were superior.

Conclusion

This feasibility study showed acceptable recruitment and retention rates. There remains equipoise regarding the best treatment of these injuries. All three treatments appear well tolerated with similar complication rates. A primary outcome of complications or treatment failure would provide the highest study retention with secondary PROMs and economic analysis.

Monkey Bar-Associated Pediatric Fractures: A National Epidemiologic Study of Emergency Department Visits

INTRODUCTION

Emergency department (ED) visits because of pediatric fractures are not only burdensome for patients and their families but also result in an increased healthcare expenditure. Almost half of all children experience at least one fracture by the age of 15. Many fractures occur in playgrounds, with monkey bars and other climbing apparatuses noted as frequent mechanisms of injury. Our purpose was to identify the pattern of injury and the population sustaining monkey bar-associated fractures.

METHODS

We queried the National Electronic Injury Surveillance System database for all monkey bar-associated injuries in patients aged 0 to 18 years from January 1, 2009, to December 31, 2019. We described demographic data, patient disposition from the ED, fracture pattern, and injury setting using unweighted and weighted estimates. Weighted results that more closely reflect national estimates were calculated.

RESULTS

During the study period, 30,920 (862,595 weighted) monkey bar-associated injuries presented to EDs; 16,410 (53.1%) (weighted injuries: 408,722 [47.4%]) were fracture injuries. The average age of kids sustaining fractures was 6.5 years, with most injuries (66.4%) occurring in kids between 6 and 12 years. A higher percentage of male patients presented to the ED with fractures compared with female patients (53% versus 47%). Upper extremity fractures were most common, 382,672 (94%) with forearm fractures constituting the majority (156,691 [38%]). Most children were treated and released (354,323 [87%]), with only 35,227 children (9%) being admitted for treatment. Places of recreation/sports were the most common setting of fractures (148,039 [36%]), followed by schools (159,784 [39%]). A notable association was observed between year and ethnicity and between month period and injury setting.

CONCLUSION

Monkey bar-associated injuries are a major cause of upper extremity fractures in children, with most injuries occurring in recreational areas or schools. Young elementary school children are at the highest risk of injury. ED visits because of monkey bar-associated fractures have increased over the study period, and these injuries continue to be a major cause of fractures in children. Additional measures should be installed to decrease these preventable fractures among children, with schools as a potential starting point.

The Effects of the COVID-19 Pandemic on Pediatric Orthopedic Injuries: A Single-Center Retrospective Study

OBJECTIVES

The COVID-19 pandemic has had a profound effect on the pediatric population worldwide. The consequences of the lockdown and the reallocation of hospital resources have caused notable changes in the presentation of pediatric orthopedic injuries. Through our use of patient records, we were able to display the epidemiological trends, as well as analyze the changes in the type and mechanism of various injuries. Our purpose is to further understand the considerable effects of the COVID-19 pandemic on pediatric orthopedic trauma and help guide the allocation of future healthcare resources.

METHODS

We conducted a retrospective cohort study on pediatric patients admitted for any orthopedic injury over a 3-year period (September 2018 to August 2021) at a Midwest level 1 trauma center. Cases were stratified into two groups based on the United States' COVID-19 lockdown (19 March 2020): Pre-COVID-19 cases were any cases prior to the lockdown and Intra-COVID-19 which are cases following the lockdown. Numerical data and categorical variables were summarized and differences between the case groups were examined using either two-Proportion Z-Test, Independent Two-Sample t-test, Pearson's chi-squared, or Fisher's exact tests.

RESULTS

A total of 3179 pediatric orthopedic referrals occurred between the Pre-COVID-19 and Intra-COVID-19 study periods. We observed a general decrease in orthopedic injuries following the COVID-19 lockdowns with 1235 injuries compared to 1606 Pre-COVID-19. Patterns in the locations of injuries changed; notably, fractures of the humerus, tibia, and fibula decreased significantly (p < 0.05). Several mechanisms of injuries decreased significantly following the onset of COVID-19 including injuries caused by monkey bars, basketball, and automobiles (p < 0.01). There was a significant increase in the overall injury severity during the Intra-COVID-19 period (p < 0.05).

CONCLUSIONS

Although there was a reduction in acute orthopedic trauma referrals, many injury mechanisms displayed similar trends regardless of restrictions. We clinically observed an overall increase in the severity of pediatric orthopedic injuries during the COVID-19 pandemic.

Management of Pediatric Type III Tibial Shaft Fractures: A Cohort Study Utilizing the Trauma Quality Improvement Program Database

BACKGROUND

Pediatric open tibial fractures represent a challenging subset of injuries with limited literature to guide management. For children, the epidemiology, management, and outcomes of tibial-shaft fractures have not been fully described.

METHODS

A retrospective analysis of the Trauma Quality Improvement Program Data Bank from 2017-2020 was used to query demographics, injury patterns, and management strategies in pediatric open tibial fractures. Fractures were compared by age group (0-5, 6-12, 13-17 years) and type (I/II vs type III). A subgroup analysis was performed on patients with type III open fractures.

RESULTS

A total of 3480 open tibial fractures were identified, 3049 were type I/II, and 431 were type III. Motor vehicle accidents (48%) were the most common mechanism of injury (P < 0.001). Subanalysis of 128 type IIIb/c tibial fractures revealed local flap reconstruction (25%) skin graft (25%), and free tissue transfer were the most common management strategies and soft-tissue coverage was achieved after 162 hours (interquartile range = 109-231). Negative pressure wound therapy was utilized in 63% of cases but used in isolation in only 23% of cases. Immediate fixation with intramedullary nailing was more frequently used in the 13-17 age group while plate fixation was more commonly used in younger age groups.

CONCLUSIONS

Soft-tissue management patterns following open tibial shaft fractures mirror those seen in adult cohorts. The median time to achieve soft-tissue coverage exceeds the traditional 72-hour target advocated by Godina. Age-based variation is seen in orthopedic management of these fractures based on growth maintenance concerns.

[Greenstick fractures of the forearm shaft-Is it obligatory or facultative to break the cortex?]

BACKGROUND

To break or not to break-That is the question that has been asked in pediatric traumatology for many years regarding the treatment of greenstick fractures of the diaphyseal forearm shaft.

OBJECTIVE

The frequency of greenstick fractures of the forearm shaft in children and adolescents; the influence of breaking the fracture on the refracture rate.

METHODS

Analysis and discussion of relevant articles, analysis of the refracture rate of pediatric greenstick fractures of the forearm shaft in our own patient population.

RESULTS

Greenstick fractures frequently occur in the area of the forearm shaft and incomplete consolidation leads to an increased refracture rate. In the patient collective of the authors of 420 children with greenstick fractures of the diaphyseal forearm, there was a refracture rate of 9.5%; however, the rate for non-completed fractures was significantly higher compared to the group with completed fractures (15.2% vs. 3%). While in the subgroup of conservatively treated fractures (n = 234), breaking the intact cortex significantly reduced the refracture rate, breaking the intact cortical bone during surgical treatment with elastic stable intramedullary nailing (ESIN) did not change the refracture rate.

CONCLUSION

As part of the conservative treatment of greenstick fractures of the diaphyseal forearm, completing the fracture can be recommended in order to lower the refracture rate. Completing the fracture does not appear to be necessary during surgical treatment using ESIN.

Comparison of Titanium versus Resorbable Intramedullary Nailing in Pediatric Forearm Fractures

Pediatric forearm fractures, particularly involving the shaft or diaphysis, are common injuries typically resulting from accidental trauma during various activities. Traditional treatment involves closed reduction and casting; however, surgical intervention may be necessary in certain cases. The gold standard surgical approach utilizes elastic stable intramedullary nailing (ESIN), but a newer technique uses bioabsorbable intramedullary nails made of poly(lactic-co-glycolic acid) (PLGA). This study aims to compare the outcomes of these two surgical methods in pediatric diaphyseal forearm fractures. We retrospectively reviewed 86 patients who underwent operative treatment due to the diaphyseal fractures of the forearm in the Surgical Division, Department of Pediatrics, Medical School, University of Pécs, Pécs, Hungary between 2018 and September 2022. The mean age was 9.48 (ranging from 4 to 17). A total of 41 patients underwent surgery with PLGA implants (RESIN technique), while 45 patients were treated with titanium elastic nails (ESIN technique). Various factors including patient demographics, injury mechanisms, fracture characteristics, and complications were assessed. Both groups showed similar gender distribution, with a majority of fractures occurring in boys (the male-female ratio was 31:10 in the PLGA group, while in the titanium elastic nailing (TEN) group, this ratio was 29:16, with no statistical difference between the groups (p > 0.005). The average age of the patients treated with PLGA implants (8.439 years) was lower compared to those treated with titanium nails (10.422 years). A statistically significant difference was found regarding the average age of the two groups (p = 0.0085). Left-sided injuries were more prevalent in both groups (59% of the cases in the PLGA group and 69% in the TEN group, with no statistically significant difference, p = 0.716), and fractures typically involved both the radius and ulna. This represents 93% of the cases in the PLGA group and 80% in the TEN group. Regarding the involvement of bones, we also did not find a statistically significant difference (p = 0.123). The mechanisms of injury predominantly involved indirect force, such as falls (30 cases in the PLGA group and 27 cases in the TEN group), and no statistically significant difference was found (p = 0.139) regarding the mechanism of the injury. Complication rates were lower in the PLGA group (7%) compared to the titanium group (20%). The treatment of pediatric diaphyseal forearm fractures using PLGA implants appears to be a viable alternative to traditional titanium implants. Advantages include no need for secondary surgery and associated cost savings and reduced complication rate and stress associated with anesthesia and surgery. Prospective randomized trials are warranted to further validate these findings and explore long-term outcomes.

Paediatric open fractures presenting to a level 1 trauma centre: a 10 year epidemiological study

PURPOSE

The epidemiology of paediatric fractures has been previously described, however there is limited data available on open fractures in this population. The purpose of this study was to investigate trends, mechanism of injury (MOI) and severity of paediatric open fractures and undertake an epidemiological study.

METHODS

All children ≤ 16.0 years presenting with open fractures were identified between 01/04/2013 and 01/04/2023. Those with craniofacial, thoracic and distal phalangeal fractures were excluded. Incidence was calculated based on those presenting within the local geographical region. Social deprivation was measured using the Index of Multiple Deprivation (IMD).

RESULTS

There were 208 open fractures with a median age of 11.0(q1 7.4-q3 13.4) years, and 153(74.6%) were in males. The MOIs were road traffic collisions 73(35.1%), sports/play 45(21.6%), fall > 2m 29(13.9%), simple fall 25(12.0%), crush 16(7.7%), bites 8(3.8%), assault 6(2.9%), and other 6(2.9%). Nineteen children (9.1%) presented with polytrauma. Gustilo-Anderson grade for long bone fractures were I-61(29.3%), II-24(11.5%), IIIa-36(17.3%), IIIb-30(14.4%) and IIIc-7(3.4%). There were 129 children presenting within the local geographical region providing an annual incidence of 8.0/100,000. Radius and ulna were the most frequently injured 49(38.0%) followed by tibia and fibula 44(34.1%). There were 69(53.5%) children presenting from an IMD quintile 1 with open fractures.

CONCLUSION

Paediatric open fractures are commonly seen in the adolescent male and affect those who are from a more socially deprived background. These injuries account for 3.2% of fractures admitted to a MTC. Data suggests children principally sustain open fractures through two distinct injury patterns and ten-year trends suggests that there is a gradual decline in the annual incidence.

Fractures in Childhood and Young Adulthood According to Maternal Smoking in Late Pregnancy. A Danish Cohort Study

Fractures account for the most frequent cause of hospitalization during childhood and numbers have increased over time. Of all fractures in childhood and young adulthood, 66% are recurrent fractures, suggesting that some people are predestined for fractures. The aim of this study was to investigate the association between maternal smoking during late pregnancy and the risk of fractures in the children.The study included 11,082 mothers and their children from the cohort "Healthy Habits for Two" born between 1984 and 1987. Information about maternal smoking during pregnancy came from questionnaires filled out in pregnancy, while information about fractures was derived from the Danish National Patient Registry. Over a follow-up of 24 years (1994-2018), Cox regression with multiple failures was used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for fractures in childhood and young adulthood according to maternal smoking in late pregnancy. Information about body mass index (BMI) and smoking status in young adulthood was included as time variant covariates.During an age span of 8-32 years, 6,420 fractures were observed. Of the mothers, 39.1% smoked during late pregnancy. Compared to children of mothers who did not smoke, children of mothers who smoked 1-9 cigarettes per day and 10+ cigarettes per day had an increased risk of fractures (HR 1.14 [CI: 1.06; 1.21] and HR 1.14 [CI: 1.07; 1.22], respectively). After adjusting for BMI and smoking status in young adulthood, the findings were slightly strengthened, showing an increased risk of fractures of 23 and 25% in children of mothers smoking 1-9 cigarettes per day and 10+ cigarettes per day, respectively.Maternal smoking during late pregnancy was associated with a higher risk of fractures in the child. This result indicates that exposure to cigarette smoke in utero may play a role in lifelong bone health.

The incidence of fractures in children under two years of age: a systematic review

BACKGROUND

Epidemiological research on fractures in children under the age of two is of great importance to help understand differences between accidental and abusive trauma.

OBJECTIVE

This systematic review aimed to evaluate studies reporting on the incidence of fractures in children under two years of age, excluding birth injuries. Secondary outcome measures included fracture location, mechanisms of injury and fracture characteristics.

METHODS

A systematic literature review (1946 to February 7th 2024), including prospective and retrospective cohort studies and cross-sectional cohort studies, was performed. Studies including children from other age groups were included if the actual measures for those aged 0-2 years could be extracted. We also included studies restricted to infants. Annual incidence rates of fractures were extracted and reported as the main result. Critical appraisal of was performed using the Appraisal tool for Cross-Sectional Studies.

RESULTS

Twelve moderate to good quality studies met eligibility criteria, of which seven were based on data from medical records and five were registry studies. Studies investigated different aspects of fractures, making comprehensive synthesis challenging. There was an overall annual fracture incidence rate of 5.3 to 9.5 per 1,000 children from 0-2 years of age; with commonest sites being the radius/ulna (25.2-40.0%), followed by tibia/fibula (17.3-27.6%) and the clavicle (14.6-14.8%) (location based on 3 studies with a total of 407 patients). In infants, the reported incidence ranged between 0.7 to 4.6 per 1,000 (based on 3 studies), with involvement of the clavicle in 22.2% and the distal humerus in 22.2% of cases (based on 1 study). Only a single metaphyseal lesion was reported (proximal humerus of an 11-month-old infant). Fracture mechanisms were detailed in four studies, with fall from chair, bed, table, own height or fall following indoor activities causing 50-60% of fractures.

CONCLUSIONS

There is a paucity of good quality data on fracture incidence in children under the age of two. Larger, prospective and unbiased studies would be helpful in determining normal pattern of injuries, so that differences from abusive trauma may be better understood.

Pediatric Forearm Fractures: Investigating the Functional Outcomes of Titanium Elastic Nailing for Unstable Both-Bone Fractures

Introduction

Diaphyseal forearm fractures pose a common challenge in children and adolescents, impacting forearm function due to rotational deformities and angulation. The landscape of pediatric forearm fracture treatment has seen limited progression, with increased surgical intervention adoption driven by factors such as functional implications, technological advancements, societal expectations, and legal concerns.

Materials and Methods

This study enrolled consecutive children aged 5-16 years with forearm fractures presenting between August 2018 and January 2020, requiring surgical intervention. The study assessed functional outcomes and complications in children treated with titanium elastic nailing.

Results

Sixteen patients underwent surgery for both-bone forearm fractures. Elastic nailing was the primary intervention, with 75% undergoing closed nailing. Patients' ages ranged from 5 to 15 years, with 87.5% being male. The study evaluated fracture characteristics, surgical procedures, post-operative care, and complications.

Conclusion

The study demonstrates promising outcomes for flexible intramedullary nailing in pediatric forearm fractures. Despite the observed complications, the majority of cases achieved excellent results in fracture union and patient recovery, supporting the efficacy of this technique. Larger cohorts are needed for a comprehensive understanding of its applicability and outcomes in pediatric forearm fracture management.

The construct validity and internal consistency of QuickDASH in pediatric patients with upper extremity fractures

BACKGROUND AND PURPOSE

Investigation of treatment options in the pediatric population necessitates the use of valid patient-reported outcome measures (PROMs). We aimed to assess the construct validity and internal consistency of the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) in the pediatric population with upper extremity fractures treated both operatively and conservatively.

PATIENTS AND METHODS

QuickDASH, along with several reference PROMs and objective outcome measures, was obtained from 148 5- to 18-year-old patients with a humeral medial epicondyle fracture or a fracture of the distal forearm in a cross-sectional setting with a single follow-up visit. Spearman's rank correlation and linear regression models were used to assess convergent validity, exploratory factor analysis (EFA) to assess structural validity, and Cronbach's alpha to investigate internal consistency.

RESULTS

The direction and magnitude of correlation showed by QuickDASH with reference outcome measures was consistent and demonstrated good convergent validity. EFA indicated a 3-factor model with poor fit indices and structural validity remained questionable. Construct validity was considered acceptable overall. QuickDASH demonstrated good internal consistency with an acceptable Cronbach's alpha (α = 0.75).

CONCLUSION

QuickDASH demonstrated acceptable construct validity and good internal consistency and is thus a valid instrument, with some limitations, to assess disability and quality of life in pediatric patients with upper extremity fractures.

Clinical Characteristics and Outcomes of Limb Fractures in Saudi Children

BACKGROUND

 Children's bones are at high risk of fracture as they grow. The clinical characteristics of fractures in children differ from those in adults. Studying fractures in healthy children is critical for identifying cases of fragility fractures. The aim of this study was to assess the clinical characteristics of limb fractures as well as clinical indicators of fracture healing outcomes in healthy Saudi children seen in an emergency room.

METHODS

A retrospective review of the treatment course of all pediatric fractures and related factors treated at King Abdullah Specialist Children's Hospital (KASCH) in Riyadh between 2016 and 2018 was conducted. Children with a primary bone disorder or chronic comorbidities known to affect bone health were excluded.

RESULTS

 The study included 143 patients (mean age ± SD = 8.23 + 3.76 years), and 71% (n = 102) were males. Motor vehicle accidents (MVAs) were the most common mechanism of injury, accounting for 50 (35%) cases, followed by fall injuries, sports injuries, and pedestrian accidents at 45 (31.4%), 16 (11.2%), and 13 (9.1%), respectively. A total of 178 fractures were reported, with the femur (n = 75, 42.1%) being the most common of the reported fracture sites, followed by the forearm (n = 44, 24.7%). The most common type of fracture was transverse fracture (n = 96, 54% of patients). Vitamin D levels were measured in 53/143 cases. Of these, vitamin D deficiency was found in 38 (71.7%) patients. The average time for fracture healing was 32.9 ± 30.2 weeks. The mechanisms of injury, including MVAs and sports injuries, as well as femur and forearm fractures, were clinical factors that were independently associated with a longer duration of fracture healing time (p < 0.001), but age, gender, and vitamin D status were not associated with that outcome.

CONCLUSION

 MVAs and fall injuries were the most common causes of fracture in our patients. MVAs and sports injuries were associated with prolonged healing time. Large prospective, multicenter, or field studies may be required to further explore clinical characteristics, outcomes, and environmental factors.

Distribution of fractured bones among children: Experience with the Comprehensive Pediatric AO classification in a children's orthopedic hospital in Bogotá-Colombia

INTRODUCTION

Fractures in children and adolescents are a public health issue. However, reliable epidemiological descriptions of the South American population must be improved. This study aims to present epidemiological data on fractures from a children's orthopedic hospital in one of the five largest cities in Latin America.

PATIENTS AND METHODS

Descriptive epidemiological data from 2015 to 2019 were used to characterize children's fractures. Demographic variables, the number of fractured bones, high-energy trauma findings, fracture characteristics, fingertip injuries, and associated complications discriminated by the type of treatment are presented. Long bone fractures were classified according to the AO classification. All children less than 18 years of age were included.

RESULTS

In a population of 3,616 children, 4,596 fractures were identified. More boys than girls sustain a fractured bone, with ratios as high as 6:1 around 15 years old. Distal forearm fractures were the most common (31.9%), followed by distal humerus (20.2%). Most of the complications were related to these two sites of fractures. The OR of complications between surgical and conservative management was 2.86.

CONCLUSION

Epidemiological data of fractures from the authors' institution display the usual trending reported in most populations. Gender-related and age-related differences were relevant. Most fractures and complications are related to upper limb low-energy trauma. The most frequent are loss of ROM and loss of reduction.

LEVEL OF EVIDENCE

Level III - retrospective cohort study.

Pediatric and Adult Fracture Incidence: A Decreasing Trend With Increasing Hospital Admissions

Large-scale studies examining fracture trends and epidemiological data are lacking. The purpose of this study was to evaluate the incidence of fractures presenting to US emergency departments using the National Electronic Injury Surveillance System. A total of 7,109,078 pediatric and 13,592,548 adult patients presenting to US emergency departments with a fracture between 2008 and 2017 were analyzed for patterns. Fractures accounted for 13.9% of pediatric injuries and 15% of adult injuries. Among children, fracture incidence was highest in the group 10 to 14 years old and most frequently involved the forearm (19.0%). Fracture incidence was highest in adults 80 years and older and most frequently involved the lower trunk (16.2%). On average, the rate of pediatric fractures decreased by 2.34% per year (95% CI, 0.25% increase to 4.88% decrease; P=.0757). Among adults, fracture incidence increased 0.33% per year (95% CI, 2.34% decrease to 2.85% increase; P=.7892). This change was significantly different between the pediatric and adult populations (P=.0152). There was an increase in the annual proportion of adults with fractures who were admitted (odds ratio per 1-year increase, 1.05; 95% CI, 1.03-1.07; P<.0001). There was no change in the proportion of pediatric patients with fractures who were admitted (odds ratio, 1.02; 95% CI, 0.99-1.05; P=.0606). The incidence of fractures decreased in pediatric patients yet was relatively stable in adult patients. Conversely, the proportion of patients with fractures who were admitted increased, particularly among adults. These findings may suggest that less severe fractures are presenting elsewhere, falsely inflating the observed rise in admissions. [Orthopedics. 2023;46(6):e369-e375.].

Functional recovery after reduced pediatric fractures of the forearm with respect to perceived limitations, common post-traumatic symptoms, range of motion, and dexterity: a prospective study

PURPOSE

Studies on functional recovery after pediatric forearm fractures are scarce. Outcome measures are usually (retrospectively) incorporated to compare treatments. How these parameters recover has only rarely fallen within the scope. Aim was to provide insight into "normal recovery" by evaluating how limitations, post-traumatic symptoms, range of motion (ROM) and dexterity recuperate.

MATERIALS AND METHODS

Prospective observational study regarding children 4 and 18 years with a reduced forearm fracture. Limitations, post-traumatic symptoms, ROM, and dexterity were evaluated 6 weeks, 3 and 6 months post-trauma. ROM of the unaffected side was used as a baseline.

RESULTS

Of 54 participants 25.9% and 5.9% perceived limitations after 3 respectively 6 months. Pain, swelling and hypertrichosis were common symptoms. Movements distal from the elbow were restrained 6 weeks post-trauma. Supination and palmar flexion were most affected, followed by dorsal flexion and pronation. Palmar flexion and pronation were still affected after 3 months and associated with treatment invasiveness. Dexterity was diminished at 6 weeks only.

CONCLUSIONS

Mild limitations are common. Further investigation of the association between pain, reduced sensitivity and hypertrichosis with treatment invasiveness is warranted. Regarding ROM supination, pronation, palmar and dorsal flexion should be incorporated in future studies. Dexterity is an unsuitable outcome measure.IMPLICATIONS FOR REHABILITATIONThis study relates to monitoring recovery from pediatric forearm fractures.Physicians ought to realize that one in four children experience limitations preceding 3 months post-trauma, in which case involvement of a hand therapist should be considered.Pain, swelling and especially hypertrichosis are common post-traumatic symptoms in children and should on itself not immediately raise concerns for complex regional pain syndrome (CRPS).To assess recovery of range of motion measuring pronation, supination, dorsal, and palmar flexion is sufficient.

Adolescent and Caregiver Perspectives on Living With a Limb Fracture: A Qualitative Study

BACKGROUND

Fractures occur in up to half of children by age 16 years. After initial emergency care for a fracture, function is universally impaired in children, and impacts extend to the immediate family. Knowledge of expected functional limitations is key to providing proper discharge instructions and anticipatory guidance to families.

OBJECTIVES

The primary objective of this study was to understand how changes in functional ability impact youth with fractures.

METHODS

We conducted individual, semistructured interviews from June 2019 to November 2020 with adolescents and their caregivers 7 to 14 days following their initial visit to a pediatric emergency department. We used qualitative content analysis methodology; recruitment proceeded until thematic saturation was achieved. Coding and analysis were concurrent with recruitment and interviews. The interview script was modified in an iterative process, to reflect emerging themes.

RESULTS

Twenty-nine interviews were completed. The most frequently affected functions were ( a ) showering and hygiene (requiring the most caregiver support), ( b ) sleep (due to pain and cast-related discomfort), and ( c ) exclusion from sports/activities. Many adolescents experienced disruptions to social activities and gatherings. Youth valued independence and took more time to complete tasks, regardless of inconvenience. Both adolescents and caregivers reported feelings of frustration from day-to-day impacts of the injury. Generally, caregivers' perspectives were in keeping with the experiences that adolescents described for themselves. Notable family impacts included "sibling burden," or conflicts that arose when a sibling had to take on extra chores/tasks.

CONCLUSIONS

Overall, caregivers' perspectives were congruent with the self-described experiences of adolescents. Key messages for optimized discharge instructions include pain and sleep management, allowing extra time to complete tasks independently, considering impact on siblings, preparing for changes in activities and social dynamics, and normalizing frustration. These themes highlight an opportunity to better tailor discharge instructions for adolescents with fractures.

Possibility of Avoiding Anesthesia in the Reduction of Greenstick and Angulated Forearm and Distal-End Radius Fractures in Children: A Comparative Study

Introduction Greenstick and angulated forearm bone fractures are the most common fractures in children and invariably require closed reduction under anesthesia. However, pediatric anesthesia is somewhat risky and not always available in developing countries like India. Therefore, this study aimed to evaluate the standard (quality) of closed reduction without anesthesia in children and to determine satisfaction among parents. Materials and methods The present study included 163 children with closed angulated fractures of the distal radius and fracture shafts of both forearm bones, who were treated by closed reduction. One hundred and thirteen were treated without any anesthesia (study group) on an outpatient department (OPD) basis, whereas 50 children of similar age and fracture type underwent reduction with anesthesia (control group). After reduction by both methods check X-ray was done to evaluate the quality of the reduction. Results The average age of the 113 children in the present study was 9.5 years (range: 3.5-16.2 years), of which 82 children had radius or ulna fractures, and 31 had isolated distal radius fractures. In 96.8% of children, ≤10° of residual angulation was achieved. Furthermore, 11 children (12.4%) used paracetamol or ibuprofen for pain control in the study group. Moreover, 97.3% of parents stated that they would like their children to be treated without anesthesia if any fracture occurred again. Conclusions Closed reduction of greenstick angulated forearm and distal-end radius fracture in children in the OPD without anesthesia achieved satisfactory reduction and high parent satisfaction while reducing the risks of pediatric anesthesia and its associated complications.

Fracture prevalence and its association with bone density among children living with HIV in Zimbabwe

OBJECTIVES

HIV infection impairs bone density in children living with HIV (CLWH). We aimed to determine the prevalence of self-reported fracture (past or current), associated risk factors and disability, by HIV status in Zimbabwean children.

DESIGN

Cross-sectional study.

METHODS

We recruited CLWH aged 8-16 years taking antiretroviral therapy (ART) for ≥2 years from HIV clinics, and HIV-uninfected children from schools in Harare. Interviewer-administered questionnaires collected data on fracture site and management, sociodemographics, dietary calcium and vitamin D, physical activity and HIV history. Dual-energy X-ray absorptiometry (DXA) measured size-adjusted bone density.

RESULTS

We recruited 303 CLWH [mean (SD) age 12.5 (2.5) years; 50% female] and 306 children without HIV [12.5 (2.5) years; 51% female]. Median age at HIV diagnosis in CLWH was 3.0 years [interquartile range (IQR) 1.2, 5.9], and median ART duration 8.1 years [IQR 6.2, 9.5]. 53.8% CLWH had self-reported disability and/or functional impairment, vs. 29.4% children without HIV. Fracture prevalence was 5.9% with no difference by HIV status [21/306 (6.9%) vs. 14/303 (4.6%), P  = 0.24]. Male sex was associated with fractures. Low size-adjusted bone density ( Z -score < -2) was associated with prevalent fractures in CLWH {risk ratio [RR] 1.14 (95% confidence interval (CI) -0.02, 2.29]}, but not in children without HIV [RR -0.04 (-2.00, 1.91)], P -interaction = 0.27. All sought medical attention for their fracture(s), but CLWH were less often admitted to hospital [2/14 (14.3%) vs. 7/21 (33.3%)].

CONCLUSION

Prevalent fractures may be associated with low lumbar spine bone density in CLWH. Fracture surveillance and strategies to reduce future fracture risk are warranted as CLWH enter adulthood.

Health Inequities in Pediatric Trauma

This review article highlights the disparities evident in pediatric trauma care in the United States. Social determinants of health play a significant role in key aspects of trauma care including access to care, gun violence, child abuse, head trauma, burn injuries, and orthopedic trauma. We review the recent literature as it relates to these topics. The findings from these recent studies emphasize the important principle that trauma care for children should be designed with a focus on equity for all children.

Change in treatment preferences in pediatric diaphyseal forearm fractures: a Danish nationwide register study of 36,244 fractures between 1997 and 2016

BACKGROUND AND PURPOSE

The choice between invasive and non-invasive treatment of diaphyseal forearm fractures in children can be difficult. We investigated the trends in choice of treatment of pediatric diaphyseal forearm fractures over a 20-year period.  Patients and methods: This is a population-based register study with data from 1997 to 2016 retrieved from the Danish National Patient Registry. The primary outcome was choice of primary treatment within 1 week divided into non-invasive treatment (casting only or closed reduction including casting) and invasive (Kirshner wires, intramedullary nailing [IMN], and open reduction internal fixation [ORIF]). The secondary outcomes were further sub-analyses on invasive treatment and age groups.

RESULTS

36,244 diaphyseal forearm fractures were investigated, yielding a mean incidence of 172 per 105/year. The proportion of fractures treated invasively increased from 1997 to 2016, from 4% to 23%. The use of Kirschner wires increased from 1% to 9%, IMN increased from 1% to 14%, and ORIF decreased from 2% to 1%. The changes were evident in all age groups but smaller in the 0-3-year age group.

CONCLUSION

We found an increase in invasive treatment of pediatric diaphyseal forearm fractures over the investigated period. A change in invasive methods was also found, as the rate of IMN increased over the investigated period and became the predominant surgical treatment choice.

Histologic Severity of Nonalcoholic Fatty Liver Disease Associates with Reduced Bone Mineral Density in Children

BACKGROUND

Lower whole body bone mineral density (BMD) has been reported in children with nonalcoholic fatty liver disease (NAFLD), but potential mediators remain uncertain.

AIMS

To assess BMD at multiple skeletal sites in children with confirmed NAFLD and controls with obesity, adjusting for known determinants of BMD, and examine potential mediators.

METHODS

We assessed age-, sex-, and race-specific, and height-adjusted BMD z-scores of whole body, lumbar spine, hip, femoral neck and forearm by dual-energy-x-ray absorptiometry in 79 children, 8-19 years old: 46 with biopsy-confirmed NAFLD [29 steatohepatitis (NASH)/17 fatty liver (NAFL)] and 33 controls without liver disease. We compared BMD z-scores by multivariable regression, adjusting for known BMD determinants and potential mediators (inflammatory and insulin resistance measures).

RESULTS

Unadjusted mean BMD z-scores in NAFLD were similar to controls, but significantly lower in NASH vs. NAFL at all sites. After covariate adjustment, mean forearm BMD z-score was higher in NAFL (β 0.60 ± SE 0.30, p < 0.05) and lower in NASH (β - 0.49 ± SE 0.26, p = 0.06) vs. controls (p = 0.002 for group), with similar trends at whole body and total hip; hs-CRP negatively associated with whole body and forearm BMD z-scores (p < 0.05), while visceral fat area negatively associated with femoral neck (p < 0.05). Only three children had clinically low whole body BMD z-scores (< - 2), one per group (control, NAFL and NASH).

CONCLUSIONS

NASH, but not NAFL, may be associated with increased risk of reduced BMD in children. Systemic inflammation, independent of body composition and load bearing, may mediate reduction in BMD in NASH.

Displaced Tibia Fractures in Adolescents: Closed Reduction and Casting Versus Flexible Intramedullary Nails

INTRODUCTION

Although there has been a recent trend towards the operative intervention of pediatric diaphyseal tibial fractures, there is sparse literature that supports this trend. This study compares the outcomes in children between 10 and 18 years of age with diaphyseal tibial fractures who undergo nonoperative treatment with closed reduction and casting (CRC) to those who undergo operative treatment with flexible intramedullary nailing.

METHODS

A retrospective chart review was performed of all patients between 10 and 18 years of age who underwent treatment for tibia fractures at the authors home institution between 2005 and 2018. Radiographs and medical records were reviewed for the duration of immobilization, time to fracture healing and complications including delayed union, malunion, nonunion, and surgical site infection. All statistical analysis was performed using an αof 0.05.

RESULTS

One hundred forty one patients (81.8% males) were included in the final analysis. Patients treated with flexible nailing took an average of 7 weeks ( P <0.001) longer than patients treated with CRC to achieve radiographic healing. The average time to full weight-bearing activities was longer by 1 week in the patients treated nonoperatively with CRC ( P =0.001). There was no statistically significant difference in the malunion rates between the 2 groups ( P =0.067), but delayed union and nonunion were exclusively seen in the flexible nailing group. There was a total of 40 complications among 33 (23.4%) patients, most of whom were in the CRC cohort (60.6%, n=20), but there was no statistically significant difference in complication rates between the 2 cohorts.

DISCUSSION

Most adolescents presenting with closed diaphyseal tibial fractures of moderate severity can be successfully treated both nonoperatively with CRC and operatively with flexible intramedullary nailing. However, we recommend an initial attempt at nonoperative treatment be performed in these patients due to the association of more severe complications with flexible nailing.

LEVEL OF EVIDENCE

Level III.

Fracture Risk in Pediatric Patients With MEN2B

CONTEXT

The skeletal phenotype of patients with MEN2B has been described but fracture risk in these patients has not yet been evaluated.

OBJECTIVE

This work aims to better delineate fracture risk in patients with multiple endocrine neoplasia type 2B (MEN2B).

METHODS

This case series with chart review was conducted at the National Institutes of Health, Pediatric Oncology Branch. A total of 48 patients with MEN2B were identified, with an age range of 5 to 36 years, median of 19; 24 of 48 (50%) patients were female. Medical records, demographic information, available imaging, and laboratory results were reviewed. History up to age 19 was included in the statistical analyses.

RESULTS

Of the 48 patients with MEN2B, 20 patients experienced at least one fracture. The majority (n = 18) experienced their first fracture at or before age 19. The observed frequency of fracture occurrence throughout childhood (0-19 years) was 38%, with very little difference between males and females. This frequency is higher than the 9.47 to 36.1 fractures per 1000 persons per year that has been reported in healthy pediatric cohorts in the United States. Less common sites of fracture including vertebral compression fracture and pelvic fractures were observed in patients with MEN2B.

CONCLUSION

In this group of patients with MEN2B, there was an increased overall risk of fracture compared to general pediatric cohorts in the United States. Less common sites of fracture were also observed. This suggests a possible effect of an activating RET mutation on bone physiology and warrants further investigation.

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.

"You're O.K. Anesthesia": Closed Reduction of Displaced Pediatric Forearm and Wrist Fractures in the Office Without Anesthesia

BACKGROUND

Angulated wrist and forearm fractures are among the most common pediatric fractures, and they often require closed reduction with anesthesia. There are several issues associated with pediatric anesthesia including the low but non-zero risk of significant complications, increased physician and staff time and effort, and increased cost. Despite these issues, there have not been any studies to prove that using anesthesia results in better outcomes or higher caregiver satisfaction in comparison to performing closed reductions without anesthesia. The purpose of this study was to evaluate the quality of closed reductions of angulated pediatric wrist and forearm fractures and to determine caregiver satisfaction with an anesthesia-free reduction technique.

METHODS

This study included 54 pediatric patients with closed, angulated fractures of the radius or combined radial and ulnar shafts. All closed reductions were performed by a single pediatric fellowship-trained orthopaedic surgeon in the office setting without any anesthesia. Radiographs were obtained to assess the quality of the reduction. At the first follow-up visit, caregivers were asked about their interim use of pain medications. Caregivers were later surveyed about patient use of analgesics and their satisfaction with an anesthesia-free reduction technique.

RESULTS

The average age of the 54 patients in this study was 9 years (1.8 to 16.8 y). Thirty-three fractures were combined radial and ulnar forearm shaft fractures, 18 were distal radius fractures, and 3 were radial shaft fractures. ≤10 degrees of residual angulation was achieved in 98% of patients. Nine percent (5/54) of the patients used ibuprofen or acetaminophen for pain control. Seventy eight percent (42/54) of the caregivers responded to the telephone and email surveys. All responding caregivers stated that the patients returned to full function and had satisfactory outcomes. Ninety eight percent (41/42) of the caregivers stated they would choose the same anesthesia-free reduction technique again.

CONCLUSIONS

Closed reduction of angulated pediatric wrist and forearm fractures in the office without anesthesia can achieve satisfactory reductions and high caregiver satisfaction while eliminating the risks and complications associated with pediatric anesthesia.

LEVEL OF EVIDENCE

Level IV Case series.

Fractures of limbs specific to children: the experience of a Senegalese tertiary hospital

Introduction

Fractures specific to the pediatric age group represent a particular injury due to their pattern, diagnosis, management, and outcomes. In sub-Saharan Africa, studies on this particular injury are scarce. This study reports sociodemographic, diagnostic, and therapeutic aspects and outcomes of these fractures.

Methods

We conducted a descriptive cross sectional study at the pediatric surgery department of Aristide Le Dantec University Teaching Hospital in Dakar, Senegal, from January 2012 to December 2015.

Results

A fracture specific to children was diagnosed in 180, of whom 47.7% were school-aged, with 59.4% of males. The mean time from injury to the attendance of our department was 48.2 h. Domestic accidents occurred in 51.1%. A total of 243 fractures occurred, mainly on the upper limbs (75.3%), as the most affected bones were the radius (47.3%), ulna (22.6%), and tibia (13.6%). Greenstick fractures represented 46.9%, buckle fractures, 42.8%, plastic deformations 9%, and subperiosteal fractures 0.7%. In all patients, management was orthopedic, with associated analgesic treatment. No sequel nor other complication was registered.

Conclusion

Fractures proper to the child are a particular entity in children’s trauma, frequently happening in boys, with greenstick and buckle fractures being the most common. Their treatment is exclusively orthopedic, with excellent outcomes.

Fracture incidence in children and adolescents 0-19 years old in Mexico: a 12-year cross-sectional analysis

The objective was to know the behavior of fractures in Mexican children and adolescents. According to our study, fractures in Mexican male children and adolescents seem to be decreasing; however, we still need more national studies to know the possible causes of these fractures.

PURPOSE

To describe the trends of fractures in Mexican children and adolescents across a 12-year period (2007 to 2019), and to analyze if these trends have changed over time between sexes and age groups.

METHODS

We identified all fracture cases registered in children and adolescents (0 to 19 years) at the emergency rooms and surgical departments of the Mexican Institute of Social Security between January 2007 and December 2019. We used ICD-10 to classify the fractures. The population was divided into two age groups: children (0 to 9 years) and adolescents (10 to 19 years). Additional information regarding sex and age was gathered up as well. We calculated annual incidence; incidence rates are presented per 10,000 population at risk. Changes in fracture trends were calculated using the average annual percentage change (AAPC).

RESULTS

Over 12 years, 1,400,443 fractures were registered. The most frequent site of fracture was forearm in 37.1% followed by shoulder (18.1%). The overall rates of fractures have remained similar over 12 years (86.5, IQR 81.0-94.2); however, a significant decrease in fractures was observed the last 3 years (2017-2019). According to the AAPC, only in men, in both age groups, a significant decrease in fractures was observed.

CONCLUSION

This is the first study in Mexico to follow the behavior of fractures in the pediatric population over 12 years. Fractures seem to be decreasing in children and adolescents. An epidemiological follow-up of childhood fractures is necessary to understand the causes of fractures to generate better prevention and treatment strategies.

Nonoperative Management of Closed Displaced Tibia Shaft Fractures in Patients Under 18 Years of Age: Low Failure Rate

BACKGROUND

Tibial shaft fractures are the third most common pediatric long bone fracture pattern. Historically, these fractures have been initially treated with closed reduction and casting (CRC). Recently, there has been an increasing trend toward surgical intervention as an initial treatment for these injuries. In an effort to better understand whether this trend is warranted, this study seeks to characterize the clinical and radiographic outcomes of a large number of children who underwent nonoperative treatment with CRC as their initial treatment for pediatric tibial shaft fractures at a single tertiary care center.

METHODS

Outcomes measured included final alignment, other procedures performed, length of time to full radiographic healing, and length of time in each method of immobilization before progressing to full weight-bearing status. Patients were separated by ages into the following cohorts during statistical analysis: 4 to 8 years, 9 to 12 years, and 13+ years. Differences between continuous variables were analyzed with independent-samples t tests. χ 2 tests were used to analyze differences in categorical variables. An α<0.05 was considered statistically significant.

RESULTS

A total of 137 patients met our inclusion criteria. The median age was 10.19 years (4.03 to 17.43). The average initial displacement among all age groups was 27.42% (±15.05%). After the initial intervention with CRC, all age groups demonstrated an average of <5 degrees of residual angulation and <20% of residual displacement. Complete radiographic healing was seen in 127 (92.7%) patients by 3 months. Loss of reduction requiring additional clinical intervention was seen in 30 (21.9%) patients with only 5% requiring surgical intervention, whereas malunion was seen in a total of 16 (11.7%) patients at the final visit. There were no cases of compartment syndrome or deep wound infection. Male and initial angulation were the only factors predictive of loss of reduction.

CONCLUSION

Initial intervention with CRC is a safe and effective treatment for the majority of children in all age groups presenting with tibial shaft fractures demonstrating minimal angulation and displacement with surgical intervention being required in only 5% of patients. Further studies are warranted to elucidate the characteristics of patients who may benefit most from initial surgical intervention.

LEVEL OF EVIDENCE

Level III-retrospective study.

Epidemiology of pediatric fractures before versus during the coronavirus disease 2019 pandemic

Several studies have reported changes in the prevalence of childhood fractures between the prepandemic and coronavirus disease 2019 pandemic periods considering the overall decrease in activity during the latter. This review aimed to organize and summarize the global trends in pediatric fracture incidence. Our findings should help predict fracture patterns in the postpandemic period by identifying changes in the past and present, thus aiding patient management.

Pediatric Fracture Epidemiology and US Emergency Department Resource Utilization

OBJECTIVE

Fractures are common childhood injuries that result in emergency department (ED) visits. National trends in pediatric fracture epidemiology and resource utilization are not well described. Our objective is to analyze national trends in pediatric fracture epidemiology, ED disposition, and ED resource utilization from 2010 to 2015.

METHODS

This is an epidemiological study of fracture care in US EDs from 2010 to 2015 for children 0 to 18 years old using the Nationwide Emergency Department Sample. We calculated frequencies and national rates using weighted analyses and census data. We used the test for linear trend to analyze incidence, hospital admission, transfer, and procedural sedation over time. Multivariate logistic regression analyses identified encounter- and hospital-level predictors of transfer, admission, operative care, and use of procedural sedation.

RESULTS

During the study period, from 2010 to 2015, a total of 5,398,827 children received ED care for fractures. The pediatric fracture rate was 11.5 ED visits/1000 persons (95% confidence interval [CI], 10.6-12.5) and decreased over time. The admission rate for pediatric fracture patients was 5% and stable over time. The transfer rate increased from 3.3 to 4.1/100 fracture visits (linear trend: odds ratio, 1.06; 95% CI, 1.03-1.09). Utilization of procedural sedation increased from 1.5% to 2.9% of fracture visits (linear trend: odds ratio, 1.17; 95% CI, 1.09-1.25). Predictors associated with disposition and resource utilization include patient age, fracture location, insurance type, hospital type, and region.

CONCLUSIONS

The national incidence rate of pediatric fractures decreased slightly. Emergency department resource utilization increased over time. With high national volume, understanding pediatric fracture epidemiology and resource utilization is important to the health care system.

Children’s distal forearm fractures: a population-based epidemiology study of 4,316 fractures

Aims

The aim of this study was to report a complete overview of both incidence, fracture distribution, mode of injury, and patient baseline demographics of paediatric distal forearm fractures to identify age of risk and types of activities leading to injury.

Methods

Population-based cohort study with manual review of radiographs and charts. The primary outcome measure was incidence of paediatric distal forearm fractures. The study was based on an average at-risk population of 116,950. A total number of 4,316 patients sustained a distal forearm fracture in the study period. Females accounted for 1,910 of the fractures (44%) and males accounted for 2,406 (56%).

Results

The overall incidence of paediatric distal forearm fractures was 738.1/100,000 persons/year (95% confidence interval (CI) 706/100,000 to 770/100,000). Female incidences peaked with an incidence of 1,578.3/100,000 persons/year at age ten years. Male incidence peaked at age 13 years, with an incidence of 1,704.3/100,000 persons/year. The most common fracture type was a greenstick fracture to the radius (48%), and the most common modes of injury were sports and falls from ≤ 1 m. A small year-to-year variation was reported during the five-year study period, but without any trends.

Conclusion

Results show that paediatric distal forearm fractures are very common throughout childhood in both sexes, with almost 2% of males aged 13 years sustaining a forearm fracture each year.

Cite this article: Bone Jt Open 2022;3(6):448–454.

Postmortem and Antemortem Forensic Assessment of Pediatric Fracture Healing from Radiographs and Machine Learning Classification

Simple Summary

Being able to estimate from X-rays alone how long ago a child’s bone was fractured is important for prosecuting suspected child abuse of living or dead children. This estimate can also help identify a child when all that remains are bones. Experts use various indicators to make these estimates of the age of healing and fully healed fractures, in living and deceased persons, even years after the injury occurred. However, it is not a precise science. We proposed a method using a new combination of indicators to classify fracture healing in children and adolescents. We tested its accuracy with a public database of X-rays of children’s fractures taken during the treatment and healing process. We used part of the X-ray database for training artificial intelligence (AI, or machine learning) programs to classify stages of bone healing when using our new system. We used another portion of the same database to test the performance of the AI system that had been trained with our new classification system. Our new system addresses certain classification ambiguities of a currently used system and is similar in accuracy.

Abstract

A timeline of pediatric bone healing using fracture healing characteristics that can be assessed solely using radiographs would be practical for forensic casework, where the fracture event may precede death by days, months, or years. However, the dating of fractures from radiographs is difficult, imprecise, and lacks consensus, as only a few aspects of the healing process are visible on radiographs. Multiple studies in both the clinical and forensic literature have attempted to develop a usable scale to assess pediatric bone healing on radiographs using various healing characteristics. In contrast to the orthopedic definition, a fracture in forensic casework is only considered to be healed when the area around the fracture has been remodeled to the point that the fracture is difficult to detect on a radiograph or on the surface of the bone itself, a process that can take several years. We subjectively assessed visible characteristics of healing in radiograms of fractures occurring in 942 living children and adolescents. By dividing these assessments into learning and test (validation) sets, the accuracy of a newly proposed fracture healing scale was compared to a previous study. Two machine learning models were used to test predictions of the new scale. All three models produced similar estimates with substantial imprecision. Results corroborate the Malone model with an independent dataset and support the efficacy of using less complex models to estimate fracture age in children.

Epidemiology of Pediatric Musculoskeletal Trauma Patients Admitted to the Trauma Center of King George’s Medical University (KGMU) During COVID-19-Induced Lockdown

Purpose: This retrospective study aims to document the epidemiology of pediatric musculoskeletal trauma patients admitted over a one and half year period to the trauma center of King George's Medical University (KGMU) and the effect of COVID-19-induced lockdown on the timeliness of care.

Methods: We analyzed data of 174 patients for demography, types of injuries, mechanism of injuries, the site where the injury was sustained, the severity of injuries, nature of the injury, and the regions involved by the injuries.

Results: Mean age was 12.44±4.4. One hundred and twelve (67.46%) were males and 62 were females (32.54%). When compared with the period prior to lockdown, significantly higher times were recorded during the lockdown for time to a reception at the trauma center (p=0.028) and the time spent in receiving area of the trauma center (p<0.001). The most common mode of injury was low energy falls (n=68; 40.96%). The most commonly involved region was the lower limb (n=156; 51.82%). The region involved by the injury and the frequency of fracture types varied with the age of the subjects. The frequency distribution of injuries in males and females was almost similar till the age of nine years. The most common injuries of the lower extremity and upper extremities were fracture shaft of the femur and supracondylar fracture of the humerus, respectively.

Conclusion: Our study presents a precise estimate of demography and injury characteristics of pediatric musculoskeletal injuries, which may be helpful in planning and policymaking. The effect of the pandemic on the timeliness of care can be used for improving the infrastructure required to handle future waves of the pandemic.

Health-Related Quality of Life after Adolescent Fractures of the Femoral Shaft Stabilized by a Lateral Entry Femoral Nail

(1) Background: In adolescents, fractures of the femoral shaft that are not suitable for elastic-stable-intramedullary-nailing (ESIN), are challenging. We aimed to evaluate the health-related quality of life (HRQoL) and complications in adolescents treated with intramedullary rodding using the adolescent lateral trochanteric entry femoral nail (ALFN), and to assess if HRQoL was associated with additional injuries. (2) Methods: We followed-up on 15 adolescents with a diaphyseal femoral fracture who were treated with an ALFN from 2004 to 2017. Patients were asked to fill in a questionnaire that includes the iHOT, Peds-QL, and the Pedi-IKDC. (3) Results: The ALFN was used as a primary method of fixation in 13 patients, and as a fixation for failed ESIN in two cases. All 15 fractures healed radiographically. One distal locking screw broke. After a mean follow-up of 2.8 years, the mean iHOT-12 was 14.0 (SD 15.4), PedsQL-function was 85.7 (SD 19.3), PedsQL-social-score was 86.2 (SD 12.5), and the mean Pedi-IKDC was 77.2 (SD 11.3). In patients where the femoral fracture was an isolated injury, the HRQoL-scores were consistently higher compared with patients who sustained additional injures. (4) Conclusions: Treating diaphyseal fractures in adolescents with an ALFN resulted in good radiographic outcomes in all our cases. HRQoL, as measured by the iHOT, PedsQL, and Pedi-IKDC, was good to excellent; but it was consistently inferior in patients with additional injuries. These results suggest that the ALFN is a good alternative when patients are not suitable for ESIN, and that the HRQoL of adolescents who were treated with an ALFN is mainly influenced by the presence of additional injures, and less by the fracture of the femur itself.

Bruise Location in Supracondylar Humerus Fractures Predicts Specific Neurovascular Injuries

PURPOSE

The presence of soft tissue injury in pediatric supracondylar humerus fractures (SCHFs) has been shown to be an independent predictor of any neurovascular injury. Potentially expanding this concept, the specific neurovascular structure injured around the elbow is thought to be dependent upon the direction and magnitude of fracture displacement and subsequent soft tissue injury. Therefore, it was hypothesized that the bruise location following SCHF is indicative of the anatomic location of maximal soft tissue injury and therefore is a specific prognosticator of which neurovascular structure may be injured.

METHODS

Retrospective chart review of all SCHFs treated at a tertiary pediatric hospital from 2007 to 2017 collected information on bruise location, neurovascular injury patterns, and outcomes. Bruise location was classified as anterior, anterolateral, anteromedial, or posterior. Injury radiographs were reviewed by a blinded pediatric orthopaedic surgeon to neurovascular structure injured.

RESULTS

Of 2845 SCHFs identified, 267 (9.4%) had concomitant neurovascular injury-of which 128 (47.9%) met inclusion criteria. Among the vascular injuries, all bruising was anteromedial (28/45, 62.2%, P<0.05) or anterior (17/45, 37.8%, P>0.05). Fractures with anteromedial bruising correlated with median nerve injury (24/27, 88.9%, P<0.05), whereas fractures with anterolateral bruising correlated with radial nerve injuries (24/25, 96.0%, P<0.05). Bruising or radiographic evaluation correctly identified 60.2% and 64.1% of neurovascular injuries, respectively, whereas the combination identified 82.0% of neurovascular injuries correctly. Bruise location identified 23 neurovascular injuries not predicted by radiographic evaluation alone.

CONCLUSION

Bruise location is an important physical examination finding that can be used as an adjunct to improve the diagnostic accuracy of neurovascular injury in SCHFs in conjunction with neurovascular physical examination and radiographic evaluation. SCHFs with anterior or anteromedial bruising should raise concern for vascular injury. In addition, anteromedial bruising is predictive of a median nerve injury and anterolateral bruising is predictive of radial nerve injury. This adjunct diagnostic is particularly helpful in a noncooperative child or if performed by a clinician with limited experience in diagnosing neurovascular injuries or interpreting pediatric elbow radiographs.

LEVEL OF EVIDENCE

Level IV, case series.

Levels of Physical Activity in Children with Extremity Fractures a Dutch Observational Cross-Sectional Study

Background: Fractures are common in children and a frequent cause of emergency department (ED) visits. Fractures can cause long-term complications, such as growth problems. Research on fractures can reveal useful areas of focus for injury prevention. Objective: To assess the role of physical activity in the occurrence of fractures, this study investigates physical activity among children with extremity fractures based on the Global Recommendations on Physical Activity for Health. Methods: A multi-center, cross-sectional study was performed at two EDs in Nijmegen, the Netherlands. Patients between 4 and 18 years of age visiting these EDs with a fracture were asked to complete a validated questionnaire. Results: Of the 188 respondents, 51% were found to adhere to the recommendations. Among participants between 13 and 18 years of age, 43% were adequately physically active, compared to participants between 4 and 12 years of age among whom 56% were adequately physically active (p = 0.080). Additionally, more males were found to meet the recommendations (60% versus 40%). The most common traumas were sports-related (57%). Sports-related traumas were cited more often among youth between 13 and 18 years of age, compared to those between 4 and 12 (p < 0.001). Conclusions: A relatively high prevalence of adherence to the Global Recommendations on Physical Activity for Health was observed among children with fractures. Most respondents obtained their fractures during participation in sports. This study emphasizes the need for more injury prevention, especially among youth between 13 and 18 years of age and children participating in sports.

An evaluation of the characteristics of orthopedic pediatric traumas during the COVID-19 pandemic lockdown period

BACKGROUND

The purpose of this study is to investigate the effects of implemented social isolation measures on the characteristics of orthopedic pediatric traumas during this COVID-19 pandemic lockdown period.

METHODS

Patients who were admitted at our center between two time periods: April 3, 2019-May 31, 2019 (no lockdown period) and April 3, 2020-May 31, 2020 (lockdown period) were included to the study. Group 1 comprised 743 patients who were treated during no lockdown period, whereas Group 2 comprised 615 patients who were treated during lockdown period. Patients' medical records and radiographs were reviewed through our hospital's computer database. In addition, we recorded each patients' age and gender, their definite diagnosis, the anatomic location of the trauma, the type of trauma (fracture, dislocation, tendon injury, ligament injury, fracture dislocation, open fracture, etc.), the type of pediatric fracture (displaced fracture, torus fracture, epiphyseal fracture, pathological fracture, etc.), and the treatment method (non-operative/operative).

RESULTS

The mean age of the patients was significantly lower in Group 2 (p<0.001). There were significant differences between the groups in terms of anatomic locations of the traumas (p<0.001). The types of the traumas, pediatric traumas, and treatment were significantly different between the groups (p<0.001, p<0.001, and p<0.001, respectively). The frequency of operative treatment was significantly higher in Group 2 (p<0.001).

CONCLUSION

Our results demonstrated significant differences in patients' demographics as well as trauma characteristics during COVID-19 pandemic.

Accurately assessing children's asthma study

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The Impact of Cast Immobilization on Return to Daycare

BACKGROUND

Children who are prohibited from returning to daycare (RTD) after treatment with cast immobilization place an increased burden on parents and caregivers. The purpose of this study was to assess the impact of cast immobilization on RTD. Specifically, we sought to determine the prevalence of RTD after orthopaedic immobilization based on daycare facility policy.

METHODS

This was a survey study of randomly selected daycare facilities servicing a total of 6662 children within 10 miles of a major metropolitan city center. The 40-question survey included information on daycare policies and experience caring for children treated with orthopaedic immobilization. The survey also included questions about daycare type, enrollment, and geographic location. Photographs of the types of immobilization were embedded in the survey to facilitate understanding. Daycare facilities were randomly selected based on a power analysis to estimate a 50% prevalence of RTD after spica casting within 10% margin of error.

RESULTS

Seventy-three daycare facilities completed the survey study. The average child-staff ratio was 5:1 and most daycare facilities (78%) did not have a nurse on staff. Predetermined policies regarding RTD after injury were available at 81% of daycares. Twenty-eight (38.5%) facilities had encountered a child with a cast in the previous year. The rate of RTD for children with upper limb injuries was 90.5% compared with 79% for lower limb injuries (P=0.003). Spica casts showed the lowest RTD rate: single leg (22.5%), 1 and a half leg (18%), and 2 leg (16%) (P<0.0001). Experienced daycare facilities (>5 y) had a higher RTD rate compared with less experienced facilities (P=0.026).

CONCLUSIONS

The ability to RTD is dependent on immobilization type. Children with long leg and spica casts are disproportionately restricted when compared with other cast types. At minimum, surgeons should consider the socioeconomic implications of orthopaedic immobilization. There is also a need for orthopaedic involvement in policy formation at the local level to provide standardized guidelines for re-entry into childcare facilities following orthopaedic immobilization.

LEVEL OF EVIDENCE

Level IV.

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.

Risperidone versus aripiprazole fracture risk in children and adolescents with autism spectrum disorders

Risperidone and aripiprazole, commonly used antipsychotics in children with autism spectrum disorder (ASD), have previously been associated with elevated fracture risk in other populations. The aim of this study was to evaluate and compare the risk of fracture among children with ASD using risperidone or aripiprazole. This was a retrospective, propensity-score matched cohort study, set between January 2013 and December 2018. We used the MarketScan Medicaid insurance data, which covers multiple states of the United States. We included ASD children aged 2-18 years, who were new users of aripiprazole or risperidone and with no prior history of antipsychotic use or fractures. The main exposure was the continued use of aripiprazole or risperidone. The incidence rates of any fracture during follow-up were evaluated, and the risk between aripiprazole and risperidone was compared via Cox-proportional hazard models. Results were stratified by age, sex, duration of exposure and fracture site. In total, 3312 patients (78% male; mean [SD] age 11.0 [3.7] years) were identified for each cohort. Over the full duration of follow-up, fracture incidence rates per 1000 patient-years were 23.2 for risperidone and 38.4 for aripiprazole (hazard ratio and 95% confidence interval: 0.60 [0.44-0.83]). Risks were similar between cohorts throughout the first 180 days on treatment, but significantly higher in the aripiprazole group thereafter. Extremity fractures drove most of the increased risk, with the biggest differences in lower leg and ankle fractures. Differences widened for children aged 10 years or younger (HR [95% CI]: 0.47 [0.30-0.74]). In conclusion, compared to aripiprazole, risperidone was associated with 40% lower risk of fracture. Further analysis on the mechanism and long-term bone health of antipsychotic-treated children with ASD is warranted. LAY SUMMARY: We compared the risk of bone fractures among 6624 children with autism spectrum disorder (ASD), half of whom used risperidone and half of whom used aripiprazole. Taking other factors into account, risks were similar between the two groups throughout the first 180 days on treatment, but significantly higher in the aripiprazole group thereafter. The biggest differences were in lower leg and ankle fractures. Overall, compared with aripiprazole, risperidone was associated with 40% lower risk of fracture.

Casting in finger trap traction without reduction versus closed reduction and percutaneous pin fixation of dorsally displaced, over-riding distal metaphyseal radius fractures in children under 11 years old: a study protocol of a randomised controlled trial

INTRODUCTION

Distal radius is the most common site of fracture in children, comprising 23%-31% of all paediatric fractures. Approximately one-fifth of these fractures are displaced. Completely displaced distal metaphyseal radius fractures in children have traditionally been treated with closed reduction. Recent evidence suggests that correcting the shortening in over-riding distal metaphyseal radius fractures is not necessary in prepubertal children. To date, no published randomised controlled trial (RCT) has compared treatment of these fractures in children by casting the fracture in bayonet position to reduction and pin fixation.

METHODS AND ANALYSIS

We will conduct an RCT to compare the outcomes of casting the fracture in bayonet position in children under 11 years of age to reduction and percutaneous pin fixation. 60 patients will be randomly assigned to casting or surgery groups. We have two primary outcomes. The first is ratio (injured side/non-injured side) in the total active forearm rotation and the second is ratio (injured side/non-injured side) in total active range of motion of the wrist in the flexion-extension plane at 6 months. The secondary outcomes will include axial radiographic alignment, passive extension of the wrists, grip strength and length of forearms and hands, patient-reported outcome QuickDASH and pain questionnaire PedsQL. Patients not willing to participate in the RCT will be asked to participate in a prospective cohort. Patients not eligible for randomisation will be asked to participate in a non-eligible cohort. These cohorts are included to enhance the external validity of the results of the RCT. Our null hypothesis is that the results of the primary outcome measures in the casting group are non-inferior to surgery group.

ETHICS AND DISSEMINATION

The institutional review board of the Helsinki and Uusimaa Hospital District has approved the protocol. We will disseminate the findings through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT04323410.

PROTOCOL

V.1.1, 29 September 2020.

Supracondylar Humerus Fractures in Older Children: Success of Closed Reduction and Percutaneous Pinning

BACKGROUND

The incidence of supracondylar humerus (SCH) fracture declines and fracture types change as children grow. Optimal treatment method is unclear in older children. The aim of the study was to determine if fracture type and configuration of distal humerus fractures changes as patients approach skeletal maturity, and to assess the success of closed reduction and percutaneous pin (CRPP) in extra-articular SCH fractures in this transitional age group.

METHODS

Inclusion criteria for this retrospective review were (1) distal humerus fractures with extension types 2 and 3, flexion type, T-type; (2) surgically managed, and (3) modified Sauvegrain score ≥1. Reviewed parameters included fracture type and configuration, grade of skeletal maturity, fixation technique, and loss of reduction. Primary analysis was to determine the distribution of fracture type and configuration with age or grade of skeletal maturity. Secondary analysis was used to determine the factors affecting treatment success of CRPP in extra-articular fractures.

RESULTS

A total of 142 patients were included (58 males and 84 females). Fracture types revealed significant changes with increased age (P=0.031) and skeletal maturity grade (P<0.005). Skeletal maturity was a better predictor of changing fracture type than chronological age. T-type fractures were only seen in patients with modified Sauvegrain score ≥6 and flexion-type fractures were only seen in patients with modified Sauvegrain score ≤4. Loss of reduction rate after CRPP was 5%. The success of CRPP was not affected by age, sex, modified Sauvegrain score, fracture type, direction of displacement, coronal fracture pattern, number of pins or medial pin use. Fracture obliquity in the sagittal plane (P=0.05), suboptimal pin spread (P<0.01), and lack of bicolumnar fixation (P<0.01) were found as statistically significant factors associated with failed CRPP.

CONCLUSION

The distribution of fracture type changed with increased age and skeletal maturity. CRPP of extra-articular fractures in older children is a reliable option regardless of the stage of skeletal maturity. Determinants of a good outcome include optimal pinning technique with adequate pin spread at the fracture site and bicolumnar fixation.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Randomized Controlled Trial of the Clinical Recovery and Biodegradation of Polylactide-co-glycolide Implants Used in the Intramedullary Nailing of Children's Forearm Shaft Fractures with at Least Four Years of Follow-Up

The preferred surgical fixation of forearm shaft fractures in children is Elastic Stable Intramedullary Nailing (ESIN). Due to known disadvantageous effects of metal implants, a new surgical method using biodegradable polylactide-co-glycolide (PLGA) intramedullary nails has been developed but its long-term outcomes are unclear. The aim of this study was to compare the long-term outcomes of Biodegradable Intramedullary Nailing (BIN) to ESIN and assess the biodegradation of the study implants via magnetic resonance imaging (MRI). The study population of the prospective, randomized trial consisted of paediatric patients whose forearm shaft fractures were treated with BIN (n = 19) or ESIN (n = 16). Forearm rotation at minimally four years’ follow-up was the main outcome. There was no clinically significant difference in the recovery of the patients treated with the BIN as compared to those treated with the ESIN. More than half of the implants (57.7%, n = 15/26) were completely degraded, and the rest were degraded almost completely. The PLGA intramedullary nails used in the treatment of forearm shaft fractures in this study resulted in good function and anatomy. No unexpected disadvantages were found in the degradation of the implants. However, two implant failures had occurred in three months postoperatively.

Long-term outcomes of warfarin versus aspirin after Fontan surgery

OBJECTIVES

Because of the nature of the Fontan physiology, patients are at an increased risk of thromboembolic complications. As such, warfarin or aspirin is generally prescribed lifelong for thromboprophylaxis. This study aimed to compare long-term rates of cerebrovascular injury, thrombosis, bleeding, bone mineral density, and quality of life in people living with Fontan circulation receiving warfarin compared with aspirin.

METHODS

This was a multicenter study of a selected cohort from the Australia and New Zealand Fontan population. Participants underwent cerebral magnetic resonance imaging to detect the presence of cerebrovascular injury (n = 84) and dual-energy X-ray absorptiometry to assess bone mineral density (n = 120). Bleeding (n = 100) and quality of life (n = 90) were assessed using validated questionnaires: Warfarin and Aspirin Bleeding assessment tool and Pediatric Quality of Life Inventory, respectively.

RESULTS

Stroke was detected in 33 participants (39%), with only 7 (6%) being clinically symptomatic. There was no association between stroke and Fontan type or thromboprophylaxis type. Microhemorrhage and white matter injury were detected in most participants (96% and 86%, respectively), regardless of thromboprophylaxis type. Bleeding rates were high in both groups; however, bleeding was more frequent in the warfarin group. Bone mineral density was reduced in our cohort compared with the general population; however, this was further attenuated in the warfarin group. Quality of life was similar between the warfarin and aspirin groups. Home international normalized ratio monitoring was associated with better quality of life scores in the warfarin group.

CONCLUSIONS

Cerebrovascular injury is a frequent occurrence in the Australia and New Zealand Fontan population regardless of thromboprophylaxis type. No benefit of long-term warfarin prophylaxis could be demonstrated over aspirin; however, consideration must be given to important clinical features such as cardiac function and lung function. Furthermore, the association of reduced bone health in children receiving warfarin warrants further mechanistic studies.