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Why do children break their arms?
Injury (1988) 19,9-10
Printed in GreatBritain
9
Why do children break their arms? D. M. Williamson
and I. M. R. Lowdon
John Radcliffe Hospital, Oxford
Summary Over a l-year period the mode of fracture of the long bones of children’s upper limbs was analysed. There were 277 fractures and 4 dislocations recorded. The most common fractures were of the distal radius and ulna. Most injuries were due to falls from a low height but those from a high fall necessitated hospital admission most frequently. Preventative measures are discussed. INTRODUCTION
FRACTURESand dislocations of the arm and forearm are among the most common injuries necessitating hospital treatment during childhood and adolescence. The current study documenting the nature and cause of upper limb injuries was undertaken to identify particular activities, avoidance or modification of which might result in fewer accidents. METHODS The hospital records of all patients under 16 years of age who attended the Accident Service at the John
Radcliffe Hospital, Oxford, in 1983 with a fracture or dislocation of the long bones of the upper limb were studied. In particular the aetiology of the injury and the mode of treatment were noted. The mechanisms of injury were classified as a low fall (e.g. a trip, roller skates, skateboard, dancing or a fall on ice), a high fall (e.g. climbing frame, swing, horse, tree, wall, stairs), sports injury, road traffic accident, direct blow or other mechanism. Statistical analysis was by x2 testing.
12 +l
-2
dislocations
disloc
RESULTS
There were 277 fractures and 4 dislocations during the 1Zmonth period with a distribution as shown in Fig. 1. The sex and ages of the children sustaining these injuries are depicted in Fig. 2. They were slightly more common in boys (56 per cent) and the average age was 9-2 years. The prevalence and sex distribution of each mechanism of injury is shown in Table 1. ‘High falls’ tended to occur in younger patients (average age 8.2 years, N.S.) with falls from climbing frames (6.7 years) and swings (7.4 years) having the !owest mean ages. There were 161 greenstick fractures, 92 complete fractures and 24 physeal injuries. The physeal injuries were all of the distal radius, apart from 3 of the proximal humerus, and occurred in children of average age 11.3 years. Almost half (47 per cent) of the children with physeal injuries were admitted to hospital and required manipulation. Children with complete fractures had an average age of 9.3 years with just over one-half (53 per 0 IYXX Butterworth & Co (Publishers) Ltd 002~~1383/XX/0I~WH~‘)-02 $0340
Fig. 1.
Distribution, of fractures and dislocations in the upper
limb. cent) necessitating intervention-including 8 per cent undergoing internal fixation. Supracondylar fractures of the humerus were seen in younger children (average age 7-5 years, P
IO
Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 1 F cl M tB#!
a
40
: I
30
1 2
20 10
I O-1
I
I
I
I
1
4-5
1
8-9
2-3
6-7 AGE
I
1
I
I
1
12-13
10-11
14-15
[Y e a r ~1
Fig. 2. Distribution of fractures by age and sex.
Table 1. Prevalence of the various mechanisms of injury and their sex distribution.
Low Fall High Fall sports RTA Violence Other
No.
% Male
124 56 33 47 12 5
44 70 73 62 67 80
cases, whereas other injuries tended to result predominantly from low falls. DISCUSSION The John Radcliffe Hospital, Oxford, has a catchment population of approximately 400000 with the only Casualty Department within a 20 mile radius of Oxford. Thus, all important fractures of children’s arms occurring in the district would be included in this study. Children display a different spectrum of injuries to the upper limb from that in adults. There were only 4 dislocations in a total of 281 injuries; only one open fracture; and only one intra-articular fracture. The weaker bone (Alffram and Bauer, 1962) means that fractures occur more commonly than dislocations, and the flexibility of the bone allows the higher percentage
Reyuestsfor
reprints should be addressed to: D. M. Williamson,
of greenstick fractures with correspondingly fewer open injuries. The peak incidence of fractures in this study was from 6-13 years of age, with a lower prevalence in the under-fives. This is in contrast to the pattern of other accidents in children where the peak incidence is from l-3 years (Blicars and Savage, 1973). These younger children have more flexible skeletons and also probably do not fall from such heights, or at such speed, as older children. In this age group in particular, therefore, fractures of the arm should alert the physician to the possibility of non-accidental injury. Up to the age of 10 years, the sex incidence is equal but above this age it is approximately 2 to 1 in favour of boys, in whom sport (22 per cent) and cycling (20 per cent) injuries are more frequent. A high proportion (25 per cent) of fractures in older girls were caused by roller skating. Low falls were common at all ages and were the only mechanism more common in girls (56 per cent). As might be expected from the low impact force, these injuries were generally of a more minor nature. High falls, however, required admission to hospital in 46 per cent of children. In the younger children, the falls were from climbing frames, swings, stairs and furniture, while in the older children, trees, walls and horses were the main causes. Prevention in this group is difficult without being restrictive to adventurous youngsters but softer surfaces such as rubber matting or sand beneath swings and climbing frames, rather than concrete, may reduce the severity of injury. Of the road traffic accident group, the great majority (92 per cent) were caused by cycling accidents. The proportion of these actually occurring on the road as opposed to play areas is not known, although a recent publication stresses the latter (Soysa, et al., 1984). As nearly one-fifth of all broken arms were caused by falls from bicycles, the need for improved cycling proficiency in this age group is important, as is the compulsory use of safety equipment for ‘trick’ cyclists.
REFERENCES Alffram P. A. and Bauer G. C. H. (1962) Epidemiology of fractures of the forearm: biochemical investigation of bone strength. J. Bone Joint Surg. 44A, 105. Blicars G. and Savage J. P. (1973) Childhood accidents. Med. J. Amt. 1, 1039. Soysa S. M., Grover M. L. and McDonald P. J. (1984) BMX bike injuries: the latest epidemic. Br. Med. J. 280, 960. Paper accepted 10 June 1987.
Senior Registrarin
Orthopaedics,
Nuffield
Orthopaedic
Centre,
Oxford.
Printed in GreatBritain
9
Why do children break their arms? D. M. Williamson
and I. M. R. Lowdon
John Radcliffe Hospital, Oxford
Summary Over a l-year period the mode of fracture of the long bones of children’s upper limbs was analysed. There were 277 fractures and 4 dislocations recorded. The most common fractures were of the distal radius and ulna. Most injuries were due to falls from a low height but those from a high fall necessitated hospital admission most frequently. Preventative measures are discussed. INTRODUCTION
FRACTURESand dislocations of the arm and forearm are among the most common injuries necessitating hospital treatment during childhood and adolescence. The current study documenting the nature and cause of upper limb injuries was undertaken to identify particular activities, avoidance or modification of which might result in fewer accidents. METHODS The hospital records of all patients under 16 years of age who attended the Accident Service at the John
Radcliffe Hospital, Oxford, in 1983 with a fracture or dislocation of the long bones of the upper limb were studied. In particular the aetiology of the injury and the mode of treatment were noted. The mechanisms of injury were classified as a low fall (e.g. a trip, roller skates, skateboard, dancing or a fall on ice), a high fall (e.g. climbing frame, swing, horse, tree, wall, stairs), sports injury, road traffic accident, direct blow or other mechanism. Statistical analysis was by x2 testing.
12 +l
-2
dislocations
disloc
RESULTS
There were 277 fractures and 4 dislocations during the 1Zmonth period with a distribution as shown in Fig. 1. The sex and ages of the children sustaining these injuries are depicted in Fig. 2. They were slightly more common in boys (56 per cent) and the average age was 9-2 years. The prevalence and sex distribution of each mechanism of injury is shown in Table 1. ‘High falls’ tended to occur in younger patients (average age 8.2 years, N.S.) with falls from climbing frames (6.7 years) and swings (7.4 years) having the !owest mean ages. There were 161 greenstick fractures, 92 complete fractures and 24 physeal injuries. The physeal injuries were all of the distal radius, apart from 3 of the proximal humerus, and occurred in children of average age 11.3 years. Almost half (47 per cent) of the children with physeal injuries were admitted to hospital and required manipulation. Children with complete fractures had an average age of 9.3 years with just over one-half (53 per 0 IYXX Butterworth & Co (Publishers) Ltd 002~~1383/XX/0I~WH~‘)-02 $0340
Fig. 1.
Distribution, of fractures and dislocations in the upper
limb. cent) necessitating intervention-including 8 per cent undergoing internal fixation. Supracondylar fractures of the humerus were seen in younger children (average age 7-5 years, P
IO
Injury: the British Journal of Accident Surgery (1988) Vol. 19/No. 1 F cl M tB#!
a
40
: I
30
1 2
20 10
I O-1
I
I
I
I
1
4-5
1
8-9
2-3
6-7 AGE
I
1
I
I
1
12-13
10-11
14-15
[Y e a r ~1
Fig. 2. Distribution of fractures by age and sex.
Table 1. Prevalence of the various mechanisms of injury and their sex distribution.
Low Fall High Fall sports RTA Violence Other
No.
% Male
124 56 33 47 12 5
44 70 73 62 67 80
cases, whereas other injuries tended to result predominantly from low falls. DISCUSSION The John Radcliffe Hospital, Oxford, has a catchment population of approximately 400000 with the only Casualty Department within a 20 mile radius of Oxford. Thus, all important fractures of children’s arms occurring in the district would be included in this study. Children display a different spectrum of injuries to the upper limb from that in adults. There were only 4 dislocations in a total of 281 injuries; only one open fracture; and only one intra-articular fracture. The weaker bone (Alffram and Bauer, 1962) means that fractures occur more commonly than dislocations, and the flexibility of the bone allows the higher percentage
Reyuestsfor
reprints should be addressed to: D. M. Williamson,
of greenstick fractures with correspondingly fewer open injuries. The peak incidence of fractures in this study was from 6-13 years of age, with a lower prevalence in the under-fives. This is in contrast to the pattern of other accidents in children where the peak incidence is from l-3 years (Blicars and Savage, 1973). These younger children have more flexible skeletons and also probably do not fall from such heights, or at such speed, as older children. In this age group in particular, therefore, fractures of the arm should alert the physician to the possibility of non-accidental injury. Up to the age of 10 years, the sex incidence is equal but above this age it is approximately 2 to 1 in favour of boys, in whom sport (22 per cent) and cycling (20 per cent) injuries are more frequent. A high proportion (25 per cent) of fractures in older girls were caused by roller skating. Low falls were common at all ages and were the only mechanism more common in girls (56 per cent). As might be expected from the low impact force, these injuries were generally of a more minor nature. High falls, however, required admission to hospital in 46 per cent of children. In the younger children, the falls were from climbing frames, swings, stairs and furniture, while in the older children, trees, walls and horses were the main causes. Prevention in this group is difficult without being restrictive to adventurous youngsters but softer surfaces such as rubber matting or sand beneath swings and climbing frames, rather than concrete, may reduce the severity of injury. Of the road traffic accident group, the great majority (92 per cent) were caused by cycling accidents. The proportion of these actually occurring on the road as opposed to play areas is not known, although a recent publication stresses the latter (Soysa, et al., 1984). As nearly one-fifth of all broken arms were caused by falls from bicycles, the need for improved cycling proficiency in this age group is important, as is the compulsory use of safety equipment for ‘trick’ cyclists.
REFERENCES Alffram P. A. and Bauer G. C. H. (1962) Epidemiology of fractures of the forearm: biochemical investigation of bone strength. J. Bone Joint Surg. 44A, 105. Blicars G. and Savage J. P. (1973) Childhood accidents. Med. J. Amt. 1, 1039. Soysa S. M., Grover M. L. and McDonald P. J. (1984) BMX bike injuries: the latest epidemic. Br. Med. J. 280, 960. Paper accepted 10 June 1987.
Senior Registrarin
Orthopaedics,
Nuffield
Orthopaedic
Centre,
Oxford.