Rise of extremity fractures and sport accidents in children at 8–12 years and increase of admittance via the resuscitation room over a decade

This study was performed retrospectively at the Hospital of the J. W. Goethe University, Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, Frankfurt am Main, Germany, with the approval of the institutional ethics committee (130/15, amendment from 07/2019) and in accordance with the Declaration of Helsinki and STROBE guidelines (Strengthening the Reporting of OBservational studies in Epidemiology) [11].

All patients in the age of 0 to 17 years presenting to our emergency department (ED) at University Hospital, Goethe University Frankfurt, Frankfurt am Main, Germany, following trauma in the period from 01/2009 to 12/2018 were enrolled. Patients presenting to our ED with contact to a doctor got a recording protocol and so the patients could be identified retrospectively.

Exclusion parameters were an age ≥ 18 years, the absence of an acute trauma mechanism, presentation in our outpatient department and conditions after surgery and infections.

Trauma mechanisms were defined as following: “fall” (from standing height), fall from great height (≥ 1,5 m) (“fall great height”), traffic crashes (“traffic”), injuries caused by sport activities (“sports”), injuries caused on playground (“playground”), injuries following assaults (“violence”), injuries caused by contusions, distorsions or impacts by striking against or being struck unintentionally by objects or persons (“impact”) and injuries caused by pathologic causes (“pathologic”).

Amputations, fractures, dislocations, and visceral organ injuries as well as significant head injuries (skull fractures, intracerebral, epidural or subdural hematomas) were considered as “major injury”. “Minor injuries” were defined as a contusion, distorsion, burns or simple wounds.

Concussions and head contusions as well as skin/scalp lacerations and little wounds were considered as “minor head injuries”.

Multiply injured patients were defined by an Injury Severity Score (ISS) ≥ 16 pts [12].

A surgical intervention in the ED is defined for every treatment which was conducted in local anesthesia or short anesthetic (for example: suture of little wounds, suture of extensor tendons, reconstruction of nail beds, reposition of dislocations or fractures etc.). Surgeries in the OR (operation room) were for example: osteosynthesis of fractures, amputations, suture of nerves, and procedures that needed general anesthesia.

The cohort of pediatric trauma patients was divided by time period of admittance to our ED: group A (A) with an admittance between 01/2009 and 12/2013 and group B (B) with an admittance between 01/2014 and 12/2018. For further analysis group A and B were divided into four subgroups according to age: group 1 (0–3 years, “toddler”), group 2 (4–7 years, “pre-school”), group 3 (8–12 years, “school-age”), and group 4 (13–17 years, “teenager”).

The patient’s characteristics and injury mechanism, injury pattern, admission to the resuscitation room (RR, “shock room”)—for the hemodynamic stabilization and diagnosing of the patient—as well as the need for surgery were obtained from the patient´s electronic files using the medical protocols. A computerized spreadsheet (Microsoft Excel 2010; Microsoft Corporation, Redmond, WA) was created to abstract the variables. Chi-squared or Fisher’s exact test was used to compare categorical variables depending on sample size; Mann–Whitney U test was used to compare continuous variables (median and IQR [interquartile range]). A p value of < 0.05 was considered statistically significant. All analyses were performed using Bias 11.04 © (Epsilon Verlag GbR 1989–2016, Germany) or GraphPad Prism 3.02 © (GraphPad Software Inc. San Diego, CA).

The demographic results and injury characteristics in pediatric trauma patients stratified by time period of admission are presented in Table 1.

Overall, 23,582 patients were included. Over time, there was a slight increase in the number of patients comparing groups A (n = 11,557) and B (n = 12,025) though this finding is not significant, p = 1.0.

The gender distribution was evident in both groups with nearly 60% male to 40% female patients (ratio 3:2), p = 0.48. The median age in both groups was 8.2 years (A: IQR (interquartile range): 3.8–12.5 years; B: IQR: 3.9–12.4 years; p = 0.37).

No significant difference in the number of patients with multiple injuries (A: n = 44; 0.4% and B: n = 54; 0.5%; p = 0.42) and in the Injury Severity Score (ISS) was found (A: ISS 22 pts. [IQR = 16.8–29 pts.] vs. B: ISS 25 pts. [IQR = 20–32 pts.]; p = 0.23). Nevertheless, in group B (n = 294; 2.4%), significantly more patients were admitted to the resuscitation room (RR) compared to A (n = 217; 1.9%), p < 0.05.

Overall, 6184 patients (26.2%) suffered a major and 17,398 patients (73.8%) a minor injury.

In group A (n = 2942, 25.5%), major injuries occurred significantly less frequently than in group B (n = 3242; 27.0%), p < 0.05. There was no significant difference in the frequency of minor injuries between the two groups (A: n = 8615 [74.5%] vs. B: n = 8783 [73%]), p = 0.3.

A total of 2540 patients (10.8%) required a surgical treatment. Of these, 1549 patients (6.6%) were operated in the operation room (OR) and 991 (4.2%) patients underwent a surgical intervention in the ED.

Comparing the two groups, in group B there were a slightly increase of surgeries in the OR (B: n = 828, 6.9% > A: n = 721, 6.2%; p = 0.06) and a significant increase of surgical interventions in the ED (B: n = 612, 5.1% > A: n = 379, 3.3%; p < 0.05).

Figure 4 shows the injury mechanism of all patients in groups A and B.

The most common trauma mechanism in both groups for all injuries was impact (A: 40.2%; B: 38.7%), followed by falls from standing height (A: 24.4%; B: 20.2%) and sports injuries (A: 13.6%; B: 18.6%).

The number of patients with falls (from standing height) or violence was significantly lower in B (20.2% and 2.6%, respectively) compared to A (24.4% and 3.3%, respectively). Otherwise, the number of patients suffering from sports accidents or injuries caused on playgrounds was significantly higher in B (18.6% and 6.3%, respectively) compared to A (13.6% and 4.9%, respectively). There was no significant difference between A and B concerning impact, fall from great height and traffic crashes. 1.4% of all fractures were pathological and similarly distributed between both patient groups.

The analyzes for major or minor injuries concerning trauma mechanism were the same like above mentioned and followed the same changes over time (data not shown).

In subgroup analysis, the incidence of injuries caused by falls (from standing height) and falls from great height was highest in group 1 (0–3 years) and 2 (4–7 years) in both main cohorts (A and B). In groups 3 (8–12 years) and 4 (13–17 years), injuries from violence, traffic accidents and sports had the highest incidence in both main groups. The highest incidence of injuries caused on playgrounds was found in groups 2 and 3 of both main groups. Injuries caused by impact had the highest incidence in groups 1 and 3 [data not shown].

Interestingly, in particular sports, injuries showed a high and significant increase at the age of 8–12 years (group 3) compared A (n = 596, 5.1%) to B (n = 984, 8.2%), p < 0.05.

Overall, 2540 patients (10.8%) required a surgical treatment. Of these, 1549 patients (6.6%) were operated in the OR and 991 (4.2%) patients underwent a surgical intervention in the ED.

Comparing both groups, the number of operations in the OR was slightly higher in B (n = 828, 6.9%) compared to A (n = 721, 6.2%) without statistical significance (Fig. 5), p = 0.06.

Of all patients in group A undergoing surgery in the OR, 649 patients (90.0%) had a major injury and 72 patients (10.0%) had a minor injury. This is comparable to the 764 patients (92.3%) with a major injury and the 64 patients (7.7%) with minor injury in group B.

On the other hand, there also was a significant increase of surgical interventions in the ED compared group A (n = 379, 3.3%) to B (n = 612, 5.1%), p < 0.05. These surgical interventions in the ED were caused by major injuries (A: n = 45, 1.5% and B: n = 85, 2.6%)—like repositions of fractures or dislocations, reconstruction of nail beds, and suture of extensor tendons—as well as by minor injuries (A: n = 334, 3.9% and B: n = 527, 6.0%).

Multiple trauma in children accounts for only 5% of all severely traumatized patients [5]. In the present study, 2.2% of all children were admitted to the resuscitation room (RR). This is markedly higher than recently reported by another trauma center in Germany (0.4%) [8]. In the present study, the number of patients admitted to the RR increased significantly over time. However, the number of multiple injured patients (ISS ≥ 16) did not differ over time.

This supports published data by Marzi et al. from 2019 which showed that the number of patients admitted to the RR increased over time, but the number of multiply traumatized patients is still the same [15]. So this shows an increasing “over-triage” of pediatric patients over the last years due to the changes of the prehospital algorithms. But it remains a matter of critical discussion whether this is not better than missing a relevant and life-threatening injury.

Nearly 75% of the patients included suffered a minor injury, which is comparable to the literature [8, 16, 17]. In the present study, the number of patients with minor injuries did not increase significantly. But there was a trend to an increase of major injuries over time. The predominating injuries were extremities fractures, mainly of the upper extremity, followed by Chassaignac lesions, luxations and injuries to nerves, tendons or ligaments. These results are comparable to data from all over the world. [8, 10, 18‐20]

The number of fractures increased, with a consistent ratio of fractures of the upper to the lower extremity as well as most frequent fracture site. This contrasts with a recently published study from Körner et al., 2019, which showed a decrease in the absolute number of upper extremity fractures from 2002 to 2017 [13].

The incidence of childhood fractures peaks fairly consistent across the literature, with a peak around the age of 14 years for boys and 11 years for girls; thereafter, a decline is observed [21‐25]. In our study, the peak of childhood fractures was around the age of 8 to 12 years. Furthermore, there was a significant increase in the occurrence of fractures in this age over the last 10 years. Thus, it seems that pediatric patients living in an urban setting such as ours suffer fractures in younger years (8–12 years) compared to those patients in countries in the cited studies. Furthermore, the increase of fractures in our study could be explain by an growing interest among children of extreme sports, such as skateboarding, snowboarding, and mountain biking, which are associated with an increased risk of fractures [26].

In the present study, there was a significant increase in injuries of nerves/tendons/ligaments over time in almost all age groups, except the age of 0–3 years. In particular, there was an increase of injuries of ligaments. Reasons for this could be, on the one hand, the well-known anatomical particularities in childhood such as higher elasticity of ligaments in early childhood and a decrease of this with increasing age, and, on the other hand, the increasing participation in road traffic and sport activities with increasing age.

Concerning minor injuries, the most frequently found minor injury in this study was the head injury followed by injuries of the finger and ankle. Our previous study showed, that injuries to the head are the most common minor injury in all patient subgroups with a decrease observed from the age of 8 with increasing age because of the disproportionately large head in infants and toddlers combined with the still weak muscles and the lack of coordination.[6]

In contrast, minor injuries of the finger, hand or ankle increased with age, explained by increasing sport activities such as ballsports [8, 16].

In this study (major and minor), head injuries significantly decreased over the period of 10 years. A reason for this could be the prevention of falls in the age of infant and toddler (for minor head injuries) and the better accident prevention in the last years, e.g., in traffic accidents by wearing a helmet (for major head injuries) [1].

Minor ankle injuries increased in this study over time caused by the increased participation in sport activities with increasing age.

In our study, the number of patients with sport accidents or injuries caused on playground was significantly increased. Interestingly, sport injuries showed a sharp and significant increase over time at the age of 8–12 years.

As previously described, this could be the reason for the increase in fractures and ligament injuries as well as minor injuries to the ankle at this age.

Concerning the other trauma mechanism, the most common injury mechanism was “impact”, followed by falls from standing height and sport accidents, which is comparable to Albert et al., 2014.[7]

Over time, there was no difference in the number of injuries caused by impact, fall from great height and traffic crashes in our study. Ellsäßer et al., 2019 showed, that there is a decrease of deadly injuries in children by a successful traffic accident prevention with a continuous reduction in fatal and serious injuries from traffic accidents but without varying the number of injuries caused by traffic crashes [2]. Reasons for the better outcome of children could be the better accident prevention, e.g., by wearing a helmet, the above-mentioned “over-triage” of the pediatric patients and the improved in-hospital treatment [1].

In addition, this study showed a significant reduction in injuries caused by falls or violence over a period of 10 years.

10.8% of our patients required surgical treatment, with almost 7% needing surgery in the OR. This is much higher than previously reported by Ruffing et al. with only 3.1% patients requiring surgery but similar to our previous study [6, 8]. Since our level I trauma center covers hand and children´s orthopedic and general surgery, we are a primary referral center for pediatric patients with hand injuries and for multiply injured pediatric patients in particular.

This study found a slight increase in the number of operations over a 10-year period with a significant increase in the surgical treatment of major forearm injuries. With advancing age the bony spontaneous correction capability decreases, leading to a higher rate of operative interventions in older children. As previously shown, the number of fractures of the forearm increased with age, especially in the age of 8–12 years. This could possibly caused by a higher incidence of sports accidents in this age over time like previously shown. This could, therefore, be the reason for the increase in surgically treatment of major injuries of the forearm.

Furthermore, this study showed a significant increase of surgical interventions in the ED of major injuries—especially repositions of fractures or dislocations, reconstruction of nail beds and suture of extensor tendons—as well as of minor injuries over time. These findings are comparable to Schlegel et al. who also showed an increase of operative interventions in general [27].

The present study has several limitations. First of all, it is a retrospective study. Furthermore, it is not a real epidemiological study because only patients treated in our ED were included and other pediatric trauma patients, treated in non-emergency health care facilities or in our outpatient clinic, are not included. Otherwise, pediatric trauma patients were included who were sent in our ED from established doctors` practices.