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Children at risk of residual physical problems after public road traffic injuries—A 1-year follow-up study
Injury, Int. J. Care Injured 43 (2012) 84–90
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Children at risk of residual physical problems after public road traffic injuries—A 1-year follow-up study Eva Olofsson a,b,d,*, Olle Bunketorp b,d, Anna-Lena Andersson b,c,d a
Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden c Hospital Social Worker Division, Department of Medicine 2, Uddevalla Hospital, NU Hospital Organization, Uddevalla, Sweden d The Traffic Injury Register, Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 14 July 2010
Objectives: To describe the residual physical problems 1 year after traffic injuries in children with respect to age, gender, extraction (Swedish or foreign), type of care, type of accident and use of protective equipment, type of injury, and the impact on daily living activities. Methods: Hospital data were analysed for children, aged 15 or under, after road traffic accidents in the Gothenburg region in 2000. Age, gender, type of road user, counterpart, use of protective equipment, type and severity of each injury, and type of care were related to follow-up data obtained by a selfcompleted questionnaire answered 1 year after the accident. The AIS90 was used for injury classification. Residual physical problems were specified, graded, and mapped on anatomical pictures of the body by the respondents. Logistic regression was used to explore independent factors for residual problems. Results: A total of 341 children (81%) fulfilled the study. Cyclists dominated, 60%, followed by moped users, car occupants and pedestrians. The mean age was 11 years, 61% were boys, 16% were of foreign extraction, 26% were treated as inpatients, and 11% had at least one serious (AIS3+) injury. Residual problems were reported for 16% of the study group (n = 53), and of these 31% were located to the lower extremities (mostly knee problems), upper extremities in 20%, face in 14%, neck in 14%, upper trunk in 8%, lower trunk in 8%, and skull/brain in 3%. Significant permanent impairment was reported in one case. Cyclists reported problems significantly less frequently than others. Children reporting problems tended to be older and were most often injured as moped users. Problems to the neck and the upper trunk were reported to a higher rate than the injury rate in these regions. Children with residual problems reported limitations in daily living activities after the accident more often than those without residual physical problems. Conclusions: Residual physical problems were reported in about one sixth of the study group, few with serious problems. The risk of residual problems should be recognised in older children, especially after moped accidents, and also in children with neck problems. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Traffic accidents Children Follow-up Risk factors Disability Injury circumstances Physical consequences Long-term Sequel
Introduction Road traffic injuries (RTIs) are a leading cause of morbidity, disability and mortality. Without adequate intervention, RTIs could rank third of all major causes of morbidity and mortality globally by 2020.15 The World Report on Road Traffic Injury Prevention emphasizes the role of public health in the prevention of RTIs. Among other things, the role is to describe the magnitude of the problem by collecting data on fatal and non-fatal injuries, the resulting disabilities and the psychological consequences, and to
* Corresponding author at: The Traffic Injury Register, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden. Tel.: +46 31 3435126; fax: +46 31 258307. E-mail address: [email protected] (E. Olofsson). 0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2010.07.319
ensure appropriate pre-hospital and hospital care and rehabilitation for all injured persons.15 Children are a particularly vulnerable group in traffic, and society has a great responsibility for their protection. In Sweden, more than 92 000 persons attended accident and emergency departments because of accidents during transport in 2007. Children accounted for 31% of this total.18 The number of children in Sweden, 15–17 years old, treated as inpatients for at least one day, has increased significantly during 1998–2006; from 217 to 264 per 100 000 inhabitants.13 The number also increased in the age group 7–14 years; from 123 to 141 per 100 000 inhabitants. The numbers decreased for other age groups. The number of children treated as inpatients, was about 2500 in 2006 and about 22 000 children were treated as outpatients after road traffic accidents (RTAs).19
E. Olofsson et al. / Injury, Int. J. Care Injured 43 (2012) 84–90
In Gothenburg, a hospital-based registration of traffic accident casualties was introduced in the 1970s. The main purpose was to complement the official traffic accident statistics, and to create a base for road safety measures in the community. Since then, continuing improvements in road and vehicle safety have played a vital role in reducing the frequency of RTAs and the severity of road traffic injuries (RTIs) sustained. However, attention also needs to be paid to the long-term consequences of such accidents. Sequels and disability among injured children and adolescents after unintentional injuries, not only RTIs, are common.1,7,16,21 In addition, these are not always associated with major traumas and a long stay in hospital, but also with injuries that are treated fully in the emergency department.16 Burns and traffic crashes were associated with higher proportions of disabilities than other causes.7 Information about the long-term consequences of RTIs, investigations of specific primary circumstances associated with RTAs and the whole spectrum of the injury characteristics may help to identify children who are at risk of disability. The study aims to describe the residual physical problems 1 year after RTAs with respect to age, gender, Swedish or foreign extraction, type of care (outpatient or inpatient), type of accident (road-user category and counterpart) and use of protective equipment, injury localisation and severity, and the impact on daily living activities.
Patients and methods Study sample The study sample was based on 633 children, aged 0–15 years, who were registered with a Traffic Injury Form (TIF) at the emergency department of Queen Silvia Children’s Hospital at Sahlgrenska University Hospital (SUH) after transport accidents in the Gothenburg region, in 2000 (Table 1). In 2000, one boy, without a helmet, died in a bicycle accident. A total of 213 cases were excluded, the vast majority because they were injured in places not intended for public road traffic, and a few without a diagnosed injury (Table 1). Many children, mostly cyclists, were injured in their own garden or yard or other places without traffic but were still registered with a TIF. Other children excluded involved those in accidents that had no diagnosed primary injuries. These children (mostly car occupants) were examined at the parents’ request and therefore had a TIF. In the remaining 420 cases, data from the TIF and the medical records were planned to be complemented by follow-up data, obtained by a self-completed questionnaire, sent by post at least 1 year after the accident together with information about the study. The child and/or its parents were asked to describe the residual problems in a structured way. Two reminder letters were sent within a month, and two weeks after this, attempts were made to telephone non-responders. Some parents agreed to a telephone interview rather than complete the questionnaire. The study was approved by The Ethics Committee of the Sahlgrenska Academy. The Traffic Injury Form, medical records, and injury severity The TIF includes structured information on the date, time, and site of the accident, the type of road user, counterpart, the type of Table 1 Study sample. Total number registered at QSCH year 2000 Excluded (not in traffic environment, or no diagnosed injury) Selected, group for follow-up Refused to participate (drop-outs) Study group
633 213 420 79 341
85
accident, the type of traffic environment, the purpose of the transport and the use of protective equipment. The medical records describe the diagnoses according to the ICD10.20 The severity of each injury is classified according to the AIS90-version.5 The maximum AIS (MAIS) in each body region was identified, and the overall injury severity was calculated according to ISS.4 In this study, we used MAIS as the primary descriptor of the injury severity. The type of medical care was defined as inpatient or outpatient. Study questionnaire The questionnaire included 14 main questions on residual physical and psychological problems, social factors and extraction (Swedish or foreign). A child was defined as being of foreign extraction if at least one of the parents was not born in Sweden. In addition, 30 subsidiary questions could also be answered. In this study, only the residual physical problems were analysed. The questionnaire included the following primary question about residual physical problems: ‘‘Does your child still have problems in any part of the body because of the accident?’’ The question could be answered by ‘yes’ or ‘no’. If there were problems, the respondent was asked to mark the localization of the residual problems on a diagram of the body showing the frontal, dorsal and sides view. The problems were ranked depending on the severity (A = worst, B = second worst, etc.) according to the respondent, described in words by the respondents and categorised independently by the authors for pain, stiffness, discomfort, functional loss, and cosmetic complaints. The questionnaire also included questions as to whether the accident influenced activities such as school work, sports and other activities, whether they hampered the parent’s work, and whether there was a need for a service to transport the child to and from school. Statistical analysis Statistical analysis was carried out using SPSS version 15 (SPSS, Chicago, IL, USA). Comparisons of age distributions and MAIS scores were made using the Mann–Whitney U-test. Differences between proportions for categorical variables were analysed with x2-tests or Fisher’s exact test (FET). Binary logistic regressions were performed to explore the effects of more than one variable with residual physical problems. Statistical significance was determined where p < 0.05. Results Study group A total of 341 children (81%) and/or their parents completed the questionnaire (Table 1). The questionnaire was completed by a parent in 293 cases, by another relative in ten cases, by the child together with at least one of the parents in ten cases, and by the child itself in one case. In 27 cases, we did not know who had answered the questionnaire. The mean follow-up time was 15 months (SD 1.4, range 12–20). There were some differences between those who responded and those who did not. The study group had a lower proportion of pedestrians (7% vs. 14%) and a lower proportion of injuries to the lower extremities (26% vs. 35%). Characteristics and injury locations by road-user category in the study group are present in Table 2 and Fig. 1. Overall, single accidents dominated, 61%. Cars were the most common counterpart of the non-single accidents. Thirty-seven (11%) of the children sustained at least one serious (AIS3+) injury, mostly in the upper
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Table 2 Study group, characteristics and injury locations by road-user category. Pedestrian n = 24
Cyclist n = 203
Moped usera n = 67
Car occupant n = 45
Other n = 2
Total n = 341
n
n
%
%
n
%
n
%
n
%
n
%
Female
10
42
82
40
20
30
22
49
–
–
134
39
Age, median 3 years 4–6 years 7–9 years 10–12 years 13–15 years
11 1 4 2 9 8
4 17 8 38 33
10 5 41 50 61 46
3 20 25 30 23
15 – 1 1 1 64
– 2 2 2 96
9 4 6 13 14 8
9 13 29 31 18
– 1 – – 1 –
– – – – –
11 11 52 66 86 126
3 15 19 25 37
Foreign originb
5
21
30
15
11
16
8
18
2
–
55
16
Helmet usec Girls Boys With Swedish origin With foreign origin
– – – – –
– – – – –
120 56 64 111 8
63 73 57 70 27
43 12 31 39 4
72 63 76 80 36
– – – – –
– – – – –
– – – – –
– – – – –
– – – – –
– – – – –
Car safety device used With Swedish extraction With foreign extraction
– – –
– – –
– – –
– – –
– – –
– – –
37 31 5
88 89 83
– – –
– – –
– – –
– – –
Inpatients
8
33
57
28
21
31
4
9
–
–
90
26
5 9 2 8 1 2 13
21 38 8 33 4 8 54
45 59 3 105 7 15 45
22 29 1 52 3 7 22
11 10 1 22 1 5 47
16 15 1 33 1 7 70
8 5 18 4 6 4 10
18 11 40 9 13 9 22
1 – – 1 – – 1
– – – – – – –
70 83 24 140 15 26 116
21 24 7 41 4 8 34
e
Injury location Skull/brain Face Neck Upper extremity Upper trunk Lower trunk Lower extremity MAIS (mean, SD, range) a b c d e
1.3(0.6)1–3
1.6(0.75)1–4
1.5(0.7)1–3
1.1(0.25)1–2
–
1.5(0.7)1–4
Moped users included 2 motorcycle drivers. The origin was unknown among cyclists in one case and among car occupants in one case. Helmet use was unknown in 14 cyclists and 7 moped users. Use of seat belt and or infant-booster seat was unknown in 3 cases. The numbers shown are the number of cases with at least one injury in the specified regions of the body.
and lower extremities. No differences were found for gender or age (<10 years; 10 years) regarding MAIS. The MAIS scores were significantly higher in inpatients (p 0.001). No significant differences were found between children of foreign extraction and those of Swedish extraction with regard to gender, age, roaduser category, counterpart, injury location, injury severity, or type of care. Bicycle helmets were used significantly more by girls than by boys (FET p = 0.03). A significant trend was also seen with regard to age in that older children were more likely to not wear a helmet (OR 0.80 for every year increase; CI 0.7–0.9; p < 0.001). There was also a significant difference in bicycle helmet use between children of Swedish extraction and those of foreign extraction (OR 5.76; CI 2.26–14.67; p < 0.001). The proportion of MAIS2+ and MAIS3+ head injuries did not differ between cyclists of Swedish extraction and those of foreign extraction. Helmet use was known for 189 of the cyclists. AIS2+ skull/brain injuries were noted in 6% of the cyclists with helmets and in 22% of the cyclists without helmets (OR 3.73; CI 1.60–8.70; p = 0.001). Moped helmets were used with a significant difference between children of Swedish extraction and those of foreign extraction (OR 6.83; CI 1.66–27.99; FET p = 0.008). No significant difference was seen in helmet use between boys and girls.
injured in a collision with a car, had serious problems with significant permanent impairment. Children with residual problems reported limitations in daily living activities after the accident more often than those without residual physical problems (Table 4). Children reporting residual physical problems tended to be older (Fig. 2), significantly so for cyclists and car occupants (Table 5), and were more often girls, but this difference was not statistically significant (Fig. 2). Children of foreign extraction reported residual physical problems more often than children of Swedish extraction, but the difference was not statistically significant (24% vs. 14%, p = 0.08). In cyclists and pedestrians, those treated as outpatients more often reported residual physical problems, but the difference was
Residual physical problems Of the 341 children, 53 (16%) reported 91 different residual physical problems. Table 3 summarises the types of physical problems for different road-user categories. One moped driver,
Fig. 1. Gender and age distribution in the study group.
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Table 3 Number and proportion of children with different types of residual physical problems by road-user category. Total
Pain
Functional loss
Cosmetic
n
%
Stiffness n
%
Discomfort n
%
n
%
n
%
Pedestrian Cyclist Moped user Car occupant Other
24 203 67 45 2
2 15 14 9 –
8 7 21 20 –
– 2 2 3 –
– 1 3 7 –
– – 4 1 –
– – 6 2 –
1 11 8 1 –
4 5 12 2 –
2 5 4 – –
8 2 6 – –
Total
341
40
12
7
2
5
1
21
6
11
3
Table 4 Impact on daily living activities in 341 children, injured in road traffic accidents in Gothenburg, with and without residual physical problems. Impact on daily living activities
p (x2)
Residual physical problems No
School problems, at least temporary School problems, still Ended sport or other activity Parents care days for sick children >7 days Transportation service to school, temporary
Yes
n
%
n
%
30 0 5 5 5
11 0 2 6 1.7
19 4 11 9 4
36 8 23 38 7.5
not statistically significant. Only 9% of car occupants were treated as inpatients, but most of them (about 75%) reported residual physical problems (p = 0.021). Fig. 3 shows the frequency of all injured and the percentages of these cases with residual physical problems by road-user category. Moped users reported residual problems significantly more often than cyclists (28% vs. 10%; p < 0.001). There was no significant difference in reported residual physical problems between those in single accidents (14%) and those in collisions (19%). Only five cyclists reported residual head (skull/brain/face) problems. Four of them had worn a helmet. Helmet use was known in 60 moped users. Three of them reported residual head problems. None of them had worn a helmet. The residual problems were located to the lower extremities in 31%, upper extremities in 20%, face in 14%, neck in 14%, upper trunk (including the thoracic spine) in 8%, lower trunk (including the lumbar spine) in 8%, and skull/brain in 3%. Residual neck problems were reported by 13 children, 8 of them without a diagnosed neck injury. Eight of the children with residual neck problems were injured as car occupants, 3 of them without a primary diagnosed neck injury. Knee problems dominated in the lower extremities, 16 of 28. Fig. 4 shows the percentages of children with at least one injury in specific body regions and the percentages of these children with residual physical problems in the same regions.
Problems to the neck and the upper trunk were reported to a higher rate than the injury rate in these regions. Injuries to the neck and the upper trunk (including the thoracic spine) caused residual physical problems to a higher rate than the injury rate in these regions. Of the 11 boys, aged 13–15 years, injured on mopeds, who reported residual physical problems, besides from problems in other regions in some of them, all had problems from the lower extremities. The number of primary diagnosed injuries did not significantly affect the occurrence of residual physical problems. There were no significant differences in reported residual physical problems when serious (AIS3+) and minor or moderate (MAIS2) injuries were compared (Table 6). Factors affecting residual physical problems Logistic regression analyses were carried out for each road-user category in order to explore which factors influenced the likelihood of residual physical problems using age, gender, care MAIS, and extraction (Table 7). These showed that only age in cyclists was a Table 5 Median age of children by residual physical problems and road-user category. Physical problems n Cyclist No 182 Yes 21 Pedestrian No 20 Yes 4 Car occupant No 36 Yes 9 Moped user No 48 Yes 19 b Total No 286 Yes 53 a
Median
Minimum
Maximum
pa
10 12
2 5
15 15
0.016
11 14
3 6
15 15
0.18
9 12
0 7
15 15
0.047
15 15
6 11
16 15
0.36
11 13
0 5
16 15
<0.001
p-Values from Mann–Whitney U-test. The road-user category ‘‘Other’’ were excluded because this group included only two cases. b
Fig. 2. Percentage of residual physical problems by gender and age group.
<0.001 <0.001 <0.001 <0.001 0.015
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Fig. 3. Frequency of all injured and the percentages of these cases with residual physical problems by road-user category (2 cases ‘‘Other’’ excluded).
Fig. 4. Frequency distribution of injuries by body region and percentages of these cases with residual physical problems in the same region.
significant factor. When using age and injury location with all children in the study group, age and neck injuries were also significant factors affecting residual physical problems (Table 8). Helmet use by cyclists and moped users, and seat belts for car occupants did not affect the likelihood of residual physical problems in logistic regressions adjusted for age and sex. Discussion In this study we have been able to describe residual physical problems after traffic accidents in children with respect to age, Table 6 Physical problems by injury severity and road-user category.
Cyclist MAIS 2 MAIS 3+ Pedestrian MAIS 2 MAIS 3+ Car occupant MAIS 2 MAIS 3+ Moped user MAIS 2 MAIS 3+ Totalc MAIS 2 MAIS 3+ a b c
n
Physical problems
%
pa
174 29
20 1
11 3
0.32
23 1
3 1
13 –b
0.17
43 –
9 –
21 –
–
60 7
16 3
27 43
0.40
302 37
48 5
16 14
0.45
p-Values from Fisher’s exact tests. Too few cases for calculation. MAIS not known in 2 cases.
gender, Swedish or foreign extraction, type of care, type of accident and use of protective equipment, injury, and the impact on daily living activities. There were satisfactory rates of completion of questionnaires and residual physical problems were reported in about one sixth of the study group, few with serious problems. Nevertheless, there was a significant difference in impact on daily living activities between those with residual problems and those without. As far as we know, sequels of traffic-related injuries in children in general, related to specific primary circumstances associated with RTAs and the whole spectrum of the injury characteristics, have not been reported in this way before. Earlier reports have been based on subgroups and they show various rates, depending on selection criteria such as age, type of accident, type of injury, injury severity, etc. Maraste et al.11 provided information from serious RTIs in Sweden in the 1990s in terms of loss of health. The study was based on 476 road traffic casualties (73 under 15 years of age) treated as inpatients at four hospitals in Sweden in the period 1991–1992. In questionnaire data from 200 adults and 30 children, 13% of the children and 38% of the older casualties reported some disability, pain or distress at the 1-year follow-up. At the finalfollow-up, 3.7 years after the accident, 10% of the children and 23% of the adults suffered from long-term consequences. Sturms et al.17 noted a reduced health-related quality of life (HRQoL) reported by parents 2 years after traffic accidents in 23% of 211 children (4–13 years of age when injured) who attended a hospital in Groningen in 1996–1997. Older children reported residual physical problems more often than younger ones in this study. Using material based on motor vehicle accident data obtained from insurance claims in Bloomington, IL, USA, Greenspan et al.8 reported an overall 3.3% rate of (one or more) physical limitations in children who had been involved in car accidents (43% of which were injured). They also noticed an increased rate with age in this respect, from 0.7% in those who were under or equal to 3 years of age to 7.6% in those aged 13–15 years. In a study of 432 children, hospitalized after all kinds of unintentional injuries in Jerusalem (20% in road traffic), Gofin et al.7 found an increasing short- and long-term disability with age (43% in the age group 15–17 years after traffic accidents). Tursz and Crost21 reported from a prospective study on unintentional injuries in children in a health care district near Paris comprising 448 216 inhabitants (104 212 under 15 years). Of the injured children, 704 were followed, and the median follow-up time was 14.8 months. ‘‘Major sequels’’ (i.e. with limitations of daily activities according to the reports by the children and/or the parents) were noted in 10% of the traffic accident victims as a whole, the rate increasing significantly with age. Age is also the most important prognostic factor of residual problems in this study. Problems reported by teenagers, however, may have many causes. Some of them may be related to developmental factors,10 or post-traumatic reactions similar to those in adults.11,2 Zatzick et al.22 investigated the association between Post-traumatic Stress Disorder (PTSD), depressive symptoms, and functional and quality-of-life outcomes among 108 injured youths, aged 12–18, admitted to a trauma centre in Washington. They concluded early PTSD and depressive symptoms are associated with a broad spectrum of functional impairment during the year after physical injury. A systematic review14 showed that about one third of children injured in traffic accidents, fulfilled diagnostic criteria of PTSD and PTSD symptoms (PTSS) after one month and about half of that proportion after 3–6 months. Any child will be at risk, not just those with serious injuries.14 Residual physical problems were significantly less reported in cyclists, however, cyclists had the highest proportion of serious (AIS3+) injuries (14%). These injuries were more concentrated to
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Table 7 Potential risk factors for residual physical problems by road-user category. Factor
Road-user category Cyclist n = 203
Pedestrian n = 24
Car occupant n = 45
Moped user n = 67
Age
OR 1.26 CI (1.06–1.50) p = 0.008
OR 1.55 CI (0.83–2.90) p = 0.17
OR 1.17 CI (0.86–1.60) p = 0.32
OR 1.08 CI (0.73–1.58) p = 0.71
Gender
OR 2.11 CI (0.79–5.65) p = 0.14
OR 2.37 CI (0.10–56.22) p = 0.59
OR 1.90 CI (0.27–13.24) p = 0.52
OR 2.12 CI (0.62–7.19) p = 0.23
Care
OR 1.48 CI (0.41–5.37) p = 0.55
OR 0.57 CI (0.03–10.52) p = 0.71
–a –a
OR 3.17 CI (0.74–13.63) p = 0.12
MAIS
OR 0.57 CI (0.25–1.30) p = 0.18
OR 5.44 CI (0.43–68.72) p = 0.19
–a –a
OR 0.88 CI (0.31–2.49) p = 0.82
Extraction
OR 1.24 CI (0.37–4.21) p = 0.73
OR 3.46 CI (0.08–143.59) p = 0.51
OR 3.71 CI (0.52–26.38) p = 0.19
OR 2.12 CI (0.50–8.93) p = 0.13
a
Too few cases for calculation.
the upper extremities and the head, but the occurrences of residual problems from these body regions were in a lower rate. Residual problems were most often reported by moped users. Moped users (and cyclists) had the highest proportion of serious injuries. However, in this study, we have not found any relationship between the injury severity and residual physical problems. This is not unexpected, because the AIS grade is primarily a classification of the threat to life for specific injuries, and the disability risk also depends on other factors, such as the localisation of the injuries.9 In the larger study on children under the age of 15, treated as inpatients after all types of accidents (not only traffic), Tursz et al.,21 however, found a correlation between MAIS and long-term functional prognosis. They did not find a good correlation between the ISS-scores and disability. In this study, helmet use amongst cyclists did not affect the likelihood of residual physical problems or residual head problems but did significantly protect against skull/brain injuries. Helmet use did not significantly affect the likelihood of residual physical problems in moped users either, although residual head problems were noted in three of 17 moped users, all three without helmets. Seventy percent of the pedestrians reported residual physical problems. However, these 24 pedestrians constituted only 7% of the study group and were twice as frequent among the nonresponders. Long-term physical sequels among children up to 16 years of age injured in car-pedestrian collisions in the Graz region in Germany were studied by Mayr et al.12 Based on a questionnaire, Table 8 Effect of age and injury location on residual physical problems. Factor
Study group n = 341
Age
OR 1.25 CI (1.11–1.40) p < 0.001
Skull/brain injury
OR 0.70 CI (0.28–1.72) p = 0.44
Face injury
OR 1.99 CI (0.92–4.27) p = 0.079
Neck injury
OR 3.51 CI (1.21–10.16) p = 0.021
Upper extremity injury
OR 0.71 CI (0.35–1.44) p = 0.35
Upper trunk injury
OR 1.90 CI (0.52–6.91) p = 0.33
Lower trunk injury
OR 0.75 CI (0.19–2.92) p = 0.68
Lower extremity injury
OR 1.29 CI (0.62–2.68) p = 0.50
59 of 217 (27%) children reported physical sequels 3–6 months after the accident in their study. Neck injuries caused residual physical problems to a higher rate in the same body region as did injuries in other regions (Fig. 4) and was a significant factor affecting residual problems (Table 7). However, a majority of the children who reported residual neck problems had no primary diagnosed neck injury. Neck problems and whiplash-associated disorders (WAD) have almost only been reported in adults and the time delay before the onset of symptoms in adults is well known. Boyd et al.3 have studied the incidence and clinical course of WAD in children aged 4–16 years involved as passengers in car crashes. 105 children were identified and 47% experienced symptoms of WAD. Twenty-nine developed symptoms within 24 h and 20 became symptomatic the following day. No children in the study reported pain lasting more than two months and the clinical course would seem to be more favourable than in adults. Greenspan et al.8 reported residual physical limitations in children after whiplash trauma in 47% (medium length of time between the date of the crash and the completion of the interview was 23 days). However, they did not report which body region caused the limitation. Our data showed long-term neck problems in children with and without a diagnosed neck injury. We have not found any other long-term study on this matter and we recommend further studies. Traffic accidents vary with respect to the age and gender of those involved, road-user category, type of accident, accident circumstances, and use of protective devices for example. Many factors also influence the risk for long-term consequences such as location, type and severity of the injuries, diagnostic qualities, and routines for medical follow-up (not studied in this paper). In the present study, the influence of extraction, age, gender, road-user category, counterpart, use of protective devices, injury severity, location of injury, type of medical care (outpatient or inpatient), and impact on daily living activities were studied. As the study sample is quite small, we did not expect to identify more than a few prognostic factors independently related to the outcome. It would be interesting to carry out a future prospective and multi-centre study to evaluate this result. This study was based on an extensive questionnaire with no promise of any reward. We could not estimate the severity or the validity of the reported consequences. However, we think serious physical consequences are rare. Only one child reported serious problems with significant permanent impairment. We think overreporting is not a major issue, because detailed information was given about the study. Some results reported by parents not born in Sweden may be due to language difficulties and misunderstandings. We have not been able to evaluate what influence illiteracy and cultural differences may have.
90
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In most cases, the questionnaire was answered by a parent. In 27 cases, we did not know who had answered the questionnaire. However, as the letter was sent to the custodians in all cases, we think it was probably they who replied. There are strong arguments for obtaining information from both parents and children whenever possible, but a systematic overview has shown that parents can rate their child’s health-related quality of life,6 and agreement between the children and their parents in this respect was greatest for observable functioning (e.g. physical HRQoL), and less for non-observable functioning (e.g. emotional or social HRQoL). Conclusions Residual physical problems were reported in about one sixth of the study group and children at risk tend to be those who are older, those injured as moped users, and those with neck injuries. Even if the long-term consequences in this study were seldom of a serious grade, improvements in road and vehicle safety and medical care should continue to be made, and treatment should take account of older children, with procedures for early recognition and follow-up potential problems, especially in moped users and children with neck injuries and neck problems. Future prospective and multi-centre study would be interesting to carry out to evaluate this result. Conflict of interest statement There are no financial interests or other relationships with people or organisations that could inappropriately be of interest for any of the authors. Acknowledgments This study was supported by grants from La¨nsfo¨rsa¨kringar Alliance, Research and Development, Sweden, and the Swedish Society against Cancer and Traffic Injuries. We would like to thank Tom Marlow, a statistician at University of Gothenburg, for help with data analysis. References 1. Aitken M, Tilford J, Barrett K, et al. Health status of children after admission for injury. Paediatrics 2002;110:337–42.
2. Andersson, Anna-Lena. Psychosocial factors and traffic injuries. Gothenburg, Sweden: Diss. University of Gothenburg. Digitaltryck & Bunden, Vasastadens Bokbinderi AB; 2003. 3. Boyd R, Massey R, Duane L, Yates DW. Whiplash associated disorder in children attending the emergency department. Emerg Med J 2002;19:311–3. 4. Bull JP. The injury severity score of road casualties in relation to mortality, time of death, hospital treatment time and disability. Accid Anal Prev 1975;7:249–55. 5. Committee on Injury Scaling. The abbreviated injury scale: 1985 and 1990 revision. Des Plaines, IL, USA: Association for the Advancement of Automotive Medicine; 1990. 6. Eiser C, Morse R. Can parents rate their childs health-related quality of life? Results of a systematic review. Qual Life Res 2001;10:347–57. 7. Gofin R, Adler B, Hass T. Incidence and impact of childhood and adolescent injuries: a population-based study. J Trauma 1999;47(1):15–21. 8. Greenspan A, Durbin D, Kallan M. Short-term physical limitations in children following motor vehicle crashes. Accid Anal Prev 2008;40:1949–54. 9. Gustafsson H, Nygren A˚, Tingvall C. Rating system for serious consequences (RSC) due to traffic accidents—risk of death or permanent disability. In: Proceedings of the 10th int. technichal conference on experimental safety vehicles; 1985. p. 556–60. 10. Kail RV, Wicks-Nelson R. Developmental psychology, 5th ed., Engelwood Cliffs, NJ: Prentice Hall; 1993. p. 17. 11. Maraste P, Persson U, Berntman M. Long-term follow up and consequences for severe road traffic injuries—treatment, costs and health impairment in Sweden in the 1960s and the 1990s. Health Policy 2003;66:147–58. 12. Mayr J, Eder C, Berghold A, et al. Causes and consequences of pedestrian injuries in children. Eur J Pediatr 2003;162:184–90. 13. National Institute for Transport and Communications Analysis (SIKA). Road traffic injuries in health care. Statistics on medical care given to road traffic casualties 1998–2006. In: SIKA statistics. Stockholm: SIKA; 2008. p. 23. 14. Olofsson E, Bunketorp O, Andersson AL. Children and adolescents injured in traffic, associated psychological consequences: a literature review. Acta Paediatr 2009;98:17–22. 15. Peden M, Scurfield R, Sleet D, et al. World report on road traffic injury prevention. Gene`ve: WHO; 2004. 16. Polinder S, Meerding WJ, Toet H, et al. Prevalence and prognostic factors of disability after childhood injury. Pediatrics 2005;116:810–7. 17. Sturms LM, van der Sluis CK, Groothoff JW, et al. The health-related quality of life of paediatric traffic victims. J Trauma 2002;52:88–94. 18. The National Board of Health and Welfare. Damage events that led to emergency room visits—statistics from the injury database (IDB), Sweden, 2007. Article nr. 2009-125-11. Stockholm: The National Board of Health and Welfare; 2009. 19. The National Board of Health and Welfare. Injury statistics among children in Sweden—intentional and unintentional. Stockholm: The National Board of Health and Welfare; 2007. 20. The National Board of Health and Welfare. Klassifikation av sjukdomar och ha¨lsoproblem 1997. In: Swedish version of international classification of diseases and related health problems, tenth revision (ICD-10) WHO. Stockholm: Socialstyrelsen; 1996. 21. Tursz A, Crost M. Sequelae after unintentional injures to children: an exploratory study. Inj Prev 2000;6:209–13. 22. Zatzick D, Jurkovich G, Fan M-Y, et al. Association between posttraumatic stress and depressive symptoms and functional outcomes in adolescents followed up longitudinally after injury hospitalization. Arch Pediatr Adolesc Med 2008;162:642–8.
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Children at risk of residual physical problems after public road traffic injuries—A 1-year follow-up study Eva Olofsson a,b,d,*, Olle Bunketorp b,d, Anna-Lena Andersson b,c,d a
Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden c Hospital Social Worker Division, Department of Medicine 2, Uddevalla Hospital, NU Hospital Organization, Uddevalla, Sweden d The Traffic Injury Register, Department of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 14 July 2010
Objectives: To describe the residual physical problems 1 year after traffic injuries in children with respect to age, gender, extraction (Swedish or foreign), type of care, type of accident and use of protective equipment, type of injury, and the impact on daily living activities. Methods: Hospital data were analysed for children, aged 15 or under, after road traffic accidents in the Gothenburg region in 2000. Age, gender, type of road user, counterpart, use of protective equipment, type and severity of each injury, and type of care were related to follow-up data obtained by a selfcompleted questionnaire answered 1 year after the accident. The AIS90 was used for injury classification. Residual physical problems were specified, graded, and mapped on anatomical pictures of the body by the respondents. Logistic regression was used to explore independent factors for residual problems. Results: A total of 341 children (81%) fulfilled the study. Cyclists dominated, 60%, followed by moped users, car occupants and pedestrians. The mean age was 11 years, 61% were boys, 16% were of foreign extraction, 26% were treated as inpatients, and 11% had at least one serious (AIS3+) injury. Residual problems were reported for 16% of the study group (n = 53), and of these 31% were located to the lower extremities (mostly knee problems), upper extremities in 20%, face in 14%, neck in 14%, upper trunk in 8%, lower trunk in 8%, and skull/brain in 3%. Significant permanent impairment was reported in one case. Cyclists reported problems significantly less frequently than others. Children reporting problems tended to be older and were most often injured as moped users. Problems to the neck and the upper trunk were reported to a higher rate than the injury rate in these regions. Children with residual problems reported limitations in daily living activities after the accident more often than those without residual physical problems. Conclusions: Residual physical problems were reported in about one sixth of the study group, few with serious problems. The risk of residual problems should be recognised in older children, especially after moped accidents, and also in children with neck problems. ß 2010 Elsevier Ltd. All rights reserved.
Keywords: Traffic accidents Children Follow-up Risk factors Disability Injury circumstances Physical consequences Long-term Sequel
Introduction Road traffic injuries (RTIs) are a leading cause of morbidity, disability and mortality. Without adequate intervention, RTIs could rank third of all major causes of morbidity and mortality globally by 2020.15 The World Report on Road Traffic Injury Prevention emphasizes the role of public health in the prevention of RTIs. Among other things, the role is to describe the magnitude of the problem by collecting data on fatal and non-fatal injuries, the resulting disabilities and the psychological consequences, and to
* Corresponding author at: The Traffic Injury Register, Sahlgrenska University Hospital, 416 85 Gothenburg, Sweden. Tel.: +46 31 3435126; fax: +46 31 258307. E-mail address: [email protected] (E. Olofsson). 0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2010.07.319
ensure appropriate pre-hospital and hospital care and rehabilitation for all injured persons.15 Children are a particularly vulnerable group in traffic, and society has a great responsibility for their protection. In Sweden, more than 92 000 persons attended accident and emergency departments because of accidents during transport in 2007. Children accounted for 31% of this total.18 The number of children in Sweden, 15–17 years old, treated as inpatients for at least one day, has increased significantly during 1998–2006; from 217 to 264 per 100 000 inhabitants.13 The number also increased in the age group 7–14 years; from 123 to 141 per 100 000 inhabitants. The numbers decreased for other age groups. The number of children treated as inpatients, was about 2500 in 2006 and about 22 000 children were treated as outpatients after road traffic accidents (RTAs).19
E. Olofsson et al. / Injury, Int. J. Care Injured 43 (2012) 84–90
In Gothenburg, a hospital-based registration of traffic accident casualties was introduced in the 1970s. The main purpose was to complement the official traffic accident statistics, and to create a base for road safety measures in the community. Since then, continuing improvements in road and vehicle safety have played a vital role in reducing the frequency of RTAs and the severity of road traffic injuries (RTIs) sustained. However, attention also needs to be paid to the long-term consequences of such accidents. Sequels and disability among injured children and adolescents after unintentional injuries, not only RTIs, are common.1,7,16,21 In addition, these are not always associated with major traumas and a long stay in hospital, but also with injuries that are treated fully in the emergency department.16 Burns and traffic crashes were associated with higher proportions of disabilities than other causes.7 Information about the long-term consequences of RTIs, investigations of specific primary circumstances associated with RTAs and the whole spectrum of the injury characteristics may help to identify children who are at risk of disability. The study aims to describe the residual physical problems 1 year after RTAs with respect to age, gender, Swedish or foreign extraction, type of care (outpatient or inpatient), type of accident (road-user category and counterpart) and use of protective equipment, injury localisation and severity, and the impact on daily living activities.
Patients and methods Study sample The study sample was based on 633 children, aged 0–15 years, who were registered with a Traffic Injury Form (TIF) at the emergency department of Queen Silvia Children’s Hospital at Sahlgrenska University Hospital (SUH) after transport accidents in the Gothenburg region, in 2000 (Table 1). In 2000, one boy, without a helmet, died in a bicycle accident. A total of 213 cases were excluded, the vast majority because they were injured in places not intended for public road traffic, and a few without a diagnosed injury (Table 1). Many children, mostly cyclists, were injured in their own garden or yard or other places without traffic but were still registered with a TIF. Other children excluded involved those in accidents that had no diagnosed primary injuries. These children (mostly car occupants) were examined at the parents’ request and therefore had a TIF. In the remaining 420 cases, data from the TIF and the medical records were planned to be complemented by follow-up data, obtained by a self-completed questionnaire, sent by post at least 1 year after the accident together with information about the study. The child and/or its parents were asked to describe the residual problems in a structured way. Two reminder letters were sent within a month, and two weeks after this, attempts were made to telephone non-responders. Some parents agreed to a telephone interview rather than complete the questionnaire. The study was approved by The Ethics Committee of the Sahlgrenska Academy. The Traffic Injury Form, medical records, and injury severity The TIF includes structured information on the date, time, and site of the accident, the type of road user, counterpart, the type of Table 1 Study sample. Total number registered at QSCH year 2000 Excluded (not in traffic environment, or no diagnosed injury) Selected, group for follow-up Refused to participate (drop-outs) Study group
633 213 420 79 341
85
accident, the type of traffic environment, the purpose of the transport and the use of protective equipment. The medical records describe the diagnoses according to the ICD10.20 The severity of each injury is classified according to the AIS90-version.5 The maximum AIS (MAIS) in each body region was identified, and the overall injury severity was calculated according to ISS.4 In this study, we used MAIS as the primary descriptor of the injury severity. The type of medical care was defined as inpatient or outpatient. Study questionnaire The questionnaire included 14 main questions on residual physical and psychological problems, social factors and extraction (Swedish or foreign). A child was defined as being of foreign extraction if at least one of the parents was not born in Sweden. In addition, 30 subsidiary questions could also be answered. In this study, only the residual physical problems were analysed. The questionnaire included the following primary question about residual physical problems: ‘‘Does your child still have problems in any part of the body because of the accident?’’ The question could be answered by ‘yes’ or ‘no’. If there were problems, the respondent was asked to mark the localization of the residual problems on a diagram of the body showing the frontal, dorsal and sides view. The problems were ranked depending on the severity (A = worst, B = second worst, etc.) according to the respondent, described in words by the respondents and categorised independently by the authors for pain, stiffness, discomfort, functional loss, and cosmetic complaints. The questionnaire also included questions as to whether the accident influenced activities such as school work, sports and other activities, whether they hampered the parent’s work, and whether there was a need for a service to transport the child to and from school. Statistical analysis Statistical analysis was carried out using SPSS version 15 (SPSS, Chicago, IL, USA). Comparisons of age distributions and MAIS scores were made using the Mann–Whitney U-test. Differences between proportions for categorical variables were analysed with x2-tests or Fisher’s exact test (FET). Binary logistic regressions were performed to explore the effects of more than one variable with residual physical problems. Statistical significance was determined where p < 0.05. Results Study group A total of 341 children (81%) and/or their parents completed the questionnaire (Table 1). The questionnaire was completed by a parent in 293 cases, by another relative in ten cases, by the child together with at least one of the parents in ten cases, and by the child itself in one case. In 27 cases, we did not know who had answered the questionnaire. The mean follow-up time was 15 months (SD 1.4, range 12–20). There were some differences between those who responded and those who did not. The study group had a lower proportion of pedestrians (7% vs. 14%) and a lower proportion of injuries to the lower extremities (26% vs. 35%). Characteristics and injury locations by road-user category in the study group are present in Table 2 and Fig. 1. Overall, single accidents dominated, 61%. Cars were the most common counterpart of the non-single accidents. Thirty-seven (11%) of the children sustained at least one serious (AIS3+) injury, mostly in the upper
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86
Table 2 Study group, characteristics and injury locations by road-user category. Pedestrian n = 24
Cyclist n = 203
Moped usera n = 67
Car occupant n = 45
Other n = 2
Total n = 341
n
n
%
%
n
%
n
%
n
%
n
%
Female
10
42
82
40
20
30
22
49
–
–
134
39
Age, median 3 years 4–6 years 7–9 years 10–12 years 13–15 years
11 1 4 2 9 8
4 17 8 38 33
10 5 41 50 61 46
3 20 25 30 23
15 – 1 1 1 64
– 2 2 2 96
9 4 6 13 14 8
9 13 29 31 18
– 1 – – 1 –
– – – – –
11 11 52 66 86 126
3 15 19 25 37
Foreign originb
5
21
30
15
11
16
8
18
2
–
55
16
Helmet usec Girls Boys With Swedish origin With foreign origin
– – – – –
– – – – –
120 56 64 111 8
63 73 57 70 27
43 12 31 39 4
72 63 76 80 36
– – – – –
– – – – –
– – – – –
– – – – –
– – – – –
– – – – –
Car safety device used With Swedish extraction With foreign extraction
– – –
– – –
– – –
– – –
– – –
– – –
37 31 5
88 89 83
– – –
– – –
– – –
– – –
Inpatients
8
33
57
28
21
31
4
9
–
–
90
26
5 9 2 8 1 2 13
21 38 8 33 4 8 54
45 59 3 105 7 15 45
22 29 1 52 3 7 22
11 10 1 22 1 5 47
16 15 1 33 1 7 70
8 5 18 4 6 4 10
18 11 40 9 13 9 22
1 – – 1 – – 1
– – – – – – –
70 83 24 140 15 26 116
21 24 7 41 4 8 34
e
Injury location Skull/brain Face Neck Upper extremity Upper trunk Lower trunk Lower extremity MAIS (mean, SD, range) a b c d e
1.3(0.6)1–3
1.6(0.75)1–4
1.5(0.7)1–3
1.1(0.25)1–2
–
1.5(0.7)1–4
Moped users included 2 motorcycle drivers. The origin was unknown among cyclists in one case and among car occupants in one case. Helmet use was unknown in 14 cyclists and 7 moped users. Use of seat belt and or infant-booster seat was unknown in 3 cases. The numbers shown are the number of cases with at least one injury in the specified regions of the body.
and lower extremities. No differences were found for gender or age (<10 years; 10 years) regarding MAIS. The MAIS scores were significantly higher in inpatients (p 0.001). No significant differences were found between children of foreign extraction and those of Swedish extraction with regard to gender, age, roaduser category, counterpart, injury location, injury severity, or type of care. Bicycle helmets were used significantly more by girls than by boys (FET p = 0.03). A significant trend was also seen with regard to age in that older children were more likely to not wear a helmet (OR 0.80 for every year increase; CI 0.7–0.9; p < 0.001). There was also a significant difference in bicycle helmet use between children of Swedish extraction and those of foreign extraction (OR 5.76; CI 2.26–14.67; p < 0.001). The proportion of MAIS2+ and MAIS3+ head injuries did not differ between cyclists of Swedish extraction and those of foreign extraction. Helmet use was known for 189 of the cyclists. AIS2+ skull/brain injuries were noted in 6% of the cyclists with helmets and in 22% of the cyclists without helmets (OR 3.73; CI 1.60–8.70; p = 0.001). Moped helmets were used with a significant difference between children of Swedish extraction and those of foreign extraction (OR 6.83; CI 1.66–27.99; FET p = 0.008). No significant difference was seen in helmet use between boys and girls.
injured in a collision with a car, had serious problems with significant permanent impairment. Children with residual problems reported limitations in daily living activities after the accident more often than those without residual physical problems (Table 4). Children reporting residual physical problems tended to be older (Fig. 2), significantly so for cyclists and car occupants (Table 5), and were more often girls, but this difference was not statistically significant (Fig. 2). Children of foreign extraction reported residual physical problems more often than children of Swedish extraction, but the difference was not statistically significant (24% vs. 14%, p = 0.08). In cyclists and pedestrians, those treated as outpatients more often reported residual physical problems, but the difference was
Residual physical problems Of the 341 children, 53 (16%) reported 91 different residual physical problems. Table 3 summarises the types of physical problems for different road-user categories. One moped driver,
Fig. 1. Gender and age distribution in the study group.
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87
Table 3 Number and proportion of children with different types of residual physical problems by road-user category. Total
Pain
Functional loss
Cosmetic
n
%
Stiffness n
%
Discomfort n
%
n
%
n
%
Pedestrian Cyclist Moped user Car occupant Other
24 203 67 45 2
2 15 14 9 –
8 7 21 20 –
– 2 2 3 –
– 1 3 7 –
– – 4 1 –
– – 6 2 –
1 11 8 1 –
4 5 12 2 –
2 5 4 – –
8 2 6 – –
Total
341
40
12
7
2
5
1
21
6
11
3
Table 4 Impact on daily living activities in 341 children, injured in road traffic accidents in Gothenburg, with and without residual physical problems. Impact on daily living activities
p (x2)
Residual physical problems No
School problems, at least temporary School problems, still Ended sport or other activity Parents care days for sick children >7 days Transportation service to school, temporary
Yes
n
%
n
%
30 0 5 5 5
11 0 2 6 1.7
19 4 11 9 4
36 8 23 38 7.5
not statistically significant. Only 9% of car occupants were treated as inpatients, but most of them (about 75%) reported residual physical problems (p = 0.021). Fig. 3 shows the frequency of all injured and the percentages of these cases with residual physical problems by road-user category. Moped users reported residual problems significantly more often than cyclists (28% vs. 10%; p < 0.001). There was no significant difference in reported residual physical problems between those in single accidents (14%) and those in collisions (19%). Only five cyclists reported residual head (skull/brain/face) problems. Four of them had worn a helmet. Helmet use was known in 60 moped users. Three of them reported residual head problems. None of them had worn a helmet. The residual problems were located to the lower extremities in 31%, upper extremities in 20%, face in 14%, neck in 14%, upper trunk (including the thoracic spine) in 8%, lower trunk (including the lumbar spine) in 8%, and skull/brain in 3%. Residual neck problems were reported by 13 children, 8 of them without a diagnosed neck injury. Eight of the children with residual neck problems were injured as car occupants, 3 of them without a primary diagnosed neck injury. Knee problems dominated in the lower extremities, 16 of 28. Fig. 4 shows the percentages of children with at least one injury in specific body regions and the percentages of these children with residual physical problems in the same regions.
Problems to the neck and the upper trunk were reported to a higher rate than the injury rate in these regions. Injuries to the neck and the upper trunk (including the thoracic spine) caused residual physical problems to a higher rate than the injury rate in these regions. Of the 11 boys, aged 13–15 years, injured on mopeds, who reported residual physical problems, besides from problems in other regions in some of them, all had problems from the lower extremities. The number of primary diagnosed injuries did not significantly affect the occurrence of residual physical problems. There were no significant differences in reported residual physical problems when serious (AIS3+) and minor or moderate (MAIS2) injuries were compared (Table 6). Factors affecting residual physical problems Logistic regression analyses were carried out for each road-user category in order to explore which factors influenced the likelihood of residual physical problems using age, gender, care MAIS, and extraction (Table 7). These showed that only age in cyclists was a Table 5 Median age of children by residual physical problems and road-user category. Physical problems n Cyclist No 182 Yes 21 Pedestrian No 20 Yes 4 Car occupant No 36 Yes 9 Moped user No 48 Yes 19 b Total No 286 Yes 53 a
Median
Minimum
Maximum
pa
10 12
2 5
15 15
0.016
11 14
3 6
15 15
0.18
9 12
0 7
15 15
0.047
15 15
6 11
16 15
0.36
11 13
0 5
16 15
<0.001
p-Values from Mann–Whitney U-test. The road-user category ‘‘Other’’ were excluded because this group included only two cases. b
Fig. 2. Percentage of residual physical problems by gender and age group.
<0.001 <0.001 <0.001 <0.001 0.015
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88
Fig. 3. Frequency of all injured and the percentages of these cases with residual physical problems by road-user category (2 cases ‘‘Other’’ excluded).
Fig. 4. Frequency distribution of injuries by body region and percentages of these cases with residual physical problems in the same region.
significant factor. When using age and injury location with all children in the study group, age and neck injuries were also significant factors affecting residual physical problems (Table 8). Helmet use by cyclists and moped users, and seat belts for car occupants did not affect the likelihood of residual physical problems in logistic regressions adjusted for age and sex. Discussion In this study we have been able to describe residual physical problems after traffic accidents in children with respect to age, Table 6 Physical problems by injury severity and road-user category.
Cyclist MAIS 2 MAIS 3+ Pedestrian MAIS 2 MAIS 3+ Car occupant MAIS 2 MAIS 3+ Moped user MAIS 2 MAIS 3+ Totalc MAIS 2 MAIS 3+ a b c
n
Physical problems
%
pa
174 29
20 1
11 3
0.32
23 1
3 1
13 –b
0.17
43 –
9 –
21 –
–
60 7
16 3
27 43
0.40
302 37
48 5
16 14
0.45
p-Values from Fisher’s exact tests. Too few cases for calculation. MAIS not known in 2 cases.
gender, Swedish or foreign extraction, type of care, type of accident and use of protective equipment, injury, and the impact on daily living activities. There were satisfactory rates of completion of questionnaires and residual physical problems were reported in about one sixth of the study group, few with serious problems. Nevertheless, there was a significant difference in impact on daily living activities between those with residual problems and those without. As far as we know, sequels of traffic-related injuries in children in general, related to specific primary circumstances associated with RTAs and the whole spectrum of the injury characteristics, have not been reported in this way before. Earlier reports have been based on subgroups and they show various rates, depending on selection criteria such as age, type of accident, type of injury, injury severity, etc. Maraste et al.11 provided information from serious RTIs in Sweden in the 1990s in terms of loss of health. The study was based on 476 road traffic casualties (73 under 15 years of age) treated as inpatients at four hospitals in Sweden in the period 1991–1992. In questionnaire data from 200 adults and 30 children, 13% of the children and 38% of the older casualties reported some disability, pain or distress at the 1-year follow-up. At the finalfollow-up, 3.7 years after the accident, 10% of the children and 23% of the adults suffered from long-term consequences. Sturms et al.17 noted a reduced health-related quality of life (HRQoL) reported by parents 2 years after traffic accidents in 23% of 211 children (4–13 years of age when injured) who attended a hospital in Groningen in 1996–1997. Older children reported residual physical problems more often than younger ones in this study. Using material based on motor vehicle accident data obtained from insurance claims in Bloomington, IL, USA, Greenspan et al.8 reported an overall 3.3% rate of (one or more) physical limitations in children who had been involved in car accidents (43% of which were injured). They also noticed an increased rate with age in this respect, from 0.7% in those who were under or equal to 3 years of age to 7.6% in those aged 13–15 years. In a study of 432 children, hospitalized after all kinds of unintentional injuries in Jerusalem (20% in road traffic), Gofin et al.7 found an increasing short- and long-term disability with age (43% in the age group 15–17 years after traffic accidents). Tursz and Crost21 reported from a prospective study on unintentional injuries in children in a health care district near Paris comprising 448 216 inhabitants (104 212 under 15 years). Of the injured children, 704 were followed, and the median follow-up time was 14.8 months. ‘‘Major sequels’’ (i.e. with limitations of daily activities according to the reports by the children and/or the parents) were noted in 10% of the traffic accident victims as a whole, the rate increasing significantly with age. Age is also the most important prognostic factor of residual problems in this study. Problems reported by teenagers, however, may have many causes. Some of them may be related to developmental factors,10 or post-traumatic reactions similar to those in adults.11,2 Zatzick et al.22 investigated the association between Post-traumatic Stress Disorder (PTSD), depressive symptoms, and functional and quality-of-life outcomes among 108 injured youths, aged 12–18, admitted to a trauma centre in Washington. They concluded early PTSD and depressive symptoms are associated with a broad spectrum of functional impairment during the year after physical injury. A systematic review14 showed that about one third of children injured in traffic accidents, fulfilled diagnostic criteria of PTSD and PTSD symptoms (PTSS) after one month and about half of that proportion after 3–6 months. Any child will be at risk, not just those with serious injuries.14 Residual physical problems were significantly less reported in cyclists, however, cyclists had the highest proportion of serious (AIS3+) injuries (14%). These injuries were more concentrated to
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89
Table 7 Potential risk factors for residual physical problems by road-user category. Factor
Road-user category Cyclist n = 203
Pedestrian n = 24
Car occupant n = 45
Moped user n = 67
Age
OR 1.26 CI (1.06–1.50) p = 0.008
OR 1.55 CI (0.83–2.90) p = 0.17
OR 1.17 CI (0.86–1.60) p = 0.32
OR 1.08 CI (0.73–1.58) p = 0.71
Gender
OR 2.11 CI (0.79–5.65) p = 0.14
OR 2.37 CI (0.10–56.22) p = 0.59
OR 1.90 CI (0.27–13.24) p = 0.52
OR 2.12 CI (0.62–7.19) p = 0.23
Care
OR 1.48 CI (0.41–5.37) p = 0.55
OR 0.57 CI (0.03–10.52) p = 0.71
–a –a
OR 3.17 CI (0.74–13.63) p = 0.12
MAIS
OR 0.57 CI (0.25–1.30) p = 0.18
OR 5.44 CI (0.43–68.72) p = 0.19
–a –a
OR 0.88 CI (0.31–2.49) p = 0.82
Extraction
OR 1.24 CI (0.37–4.21) p = 0.73
OR 3.46 CI (0.08–143.59) p = 0.51
OR 3.71 CI (0.52–26.38) p = 0.19
OR 2.12 CI (0.50–8.93) p = 0.13
a
Too few cases for calculation.
the upper extremities and the head, but the occurrences of residual problems from these body regions were in a lower rate. Residual problems were most often reported by moped users. Moped users (and cyclists) had the highest proportion of serious injuries. However, in this study, we have not found any relationship between the injury severity and residual physical problems. This is not unexpected, because the AIS grade is primarily a classification of the threat to life for specific injuries, and the disability risk also depends on other factors, such as the localisation of the injuries.9 In the larger study on children under the age of 15, treated as inpatients after all types of accidents (not only traffic), Tursz et al.,21 however, found a correlation between MAIS and long-term functional prognosis. They did not find a good correlation between the ISS-scores and disability. In this study, helmet use amongst cyclists did not affect the likelihood of residual physical problems or residual head problems but did significantly protect against skull/brain injuries. Helmet use did not significantly affect the likelihood of residual physical problems in moped users either, although residual head problems were noted in three of 17 moped users, all three without helmets. Seventy percent of the pedestrians reported residual physical problems. However, these 24 pedestrians constituted only 7% of the study group and were twice as frequent among the nonresponders. Long-term physical sequels among children up to 16 years of age injured in car-pedestrian collisions in the Graz region in Germany were studied by Mayr et al.12 Based on a questionnaire, Table 8 Effect of age and injury location on residual physical problems. Factor
Study group n = 341
Age
OR 1.25 CI (1.11–1.40) p < 0.001
Skull/brain injury
OR 0.70 CI (0.28–1.72) p = 0.44
Face injury
OR 1.99 CI (0.92–4.27) p = 0.079
Neck injury
OR 3.51 CI (1.21–10.16) p = 0.021
Upper extremity injury
OR 0.71 CI (0.35–1.44) p = 0.35
Upper trunk injury
OR 1.90 CI (0.52–6.91) p = 0.33
Lower trunk injury
OR 0.75 CI (0.19–2.92) p = 0.68
Lower extremity injury
OR 1.29 CI (0.62–2.68) p = 0.50
59 of 217 (27%) children reported physical sequels 3–6 months after the accident in their study. Neck injuries caused residual physical problems to a higher rate in the same body region as did injuries in other regions (Fig. 4) and was a significant factor affecting residual problems (Table 7). However, a majority of the children who reported residual neck problems had no primary diagnosed neck injury. Neck problems and whiplash-associated disorders (WAD) have almost only been reported in adults and the time delay before the onset of symptoms in adults is well known. Boyd et al.3 have studied the incidence and clinical course of WAD in children aged 4–16 years involved as passengers in car crashes. 105 children were identified and 47% experienced symptoms of WAD. Twenty-nine developed symptoms within 24 h and 20 became symptomatic the following day. No children in the study reported pain lasting more than two months and the clinical course would seem to be more favourable than in adults. Greenspan et al.8 reported residual physical limitations in children after whiplash trauma in 47% (medium length of time between the date of the crash and the completion of the interview was 23 days). However, they did not report which body region caused the limitation. Our data showed long-term neck problems in children with and without a diagnosed neck injury. We have not found any other long-term study on this matter and we recommend further studies. Traffic accidents vary with respect to the age and gender of those involved, road-user category, type of accident, accident circumstances, and use of protective devices for example. Many factors also influence the risk for long-term consequences such as location, type and severity of the injuries, diagnostic qualities, and routines for medical follow-up (not studied in this paper). In the present study, the influence of extraction, age, gender, road-user category, counterpart, use of protective devices, injury severity, location of injury, type of medical care (outpatient or inpatient), and impact on daily living activities were studied. As the study sample is quite small, we did not expect to identify more than a few prognostic factors independently related to the outcome. It would be interesting to carry out a future prospective and multi-centre study to evaluate this result. This study was based on an extensive questionnaire with no promise of any reward. We could not estimate the severity or the validity of the reported consequences. However, we think serious physical consequences are rare. Only one child reported serious problems with significant permanent impairment. We think overreporting is not a major issue, because detailed information was given about the study. Some results reported by parents not born in Sweden may be due to language difficulties and misunderstandings. We have not been able to evaluate what influence illiteracy and cultural differences may have.
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In most cases, the questionnaire was answered by a parent. In 27 cases, we did not know who had answered the questionnaire. However, as the letter was sent to the custodians in all cases, we think it was probably they who replied. There are strong arguments for obtaining information from both parents and children whenever possible, but a systematic overview has shown that parents can rate their child’s health-related quality of life,6 and agreement between the children and their parents in this respect was greatest for observable functioning (e.g. physical HRQoL), and less for non-observable functioning (e.g. emotional or social HRQoL). Conclusions Residual physical problems were reported in about one sixth of the study group and children at risk tend to be those who are older, those injured as moped users, and those with neck injuries. Even if the long-term consequences in this study were seldom of a serious grade, improvements in road and vehicle safety and medical care should continue to be made, and treatment should take account of older children, with procedures for early recognition and follow-up potential problems, especially in moped users and children with neck injuries and neck problems. Future prospective and multi-centre study would be interesting to carry out to evaluate this result. Conflict of interest statement There are no financial interests or other relationships with people or organisations that could inappropriately be of interest for any of the authors. Acknowledgments This study was supported by grants from La¨nsfo¨rsa¨kringar Alliance, Research and Development, Sweden, and the Swedish Society against Cancer and Traffic Injuries. We would like to thank Tom Marlow, a statistician at University of Gothenburg, for help with data analysis. References 1. Aitken M, Tilford J, Barrett K, et al. Health status of children after admission for injury. Paediatrics 2002;110:337–42.
2. Andersson, Anna-Lena. Psychosocial factors and traffic injuries. Gothenburg, Sweden: Diss. University of Gothenburg. Digitaltryck & Bunden, Vasastadens Bokbinderi AB; 2003. 3. Boyd R, Massey R, Duane L, Yates DW. Whiplash associated disorder in children attending the emergency department. Emerg Med J 2002;19:311–3. 4. Bull JP. The injury severity score of road casualties in relation to mortality, time of death, hospital treatment time and disability. Accid Anal Prev 1975;7:249–55. 5. Committee on Injury Scaling. The abbreviated injury scale: 1985 and 1990 revision. Des Plaines, IL, USA: Association for the Advancement of Automotive Medicine; 1990. 6. Eiser C, Morse R. Can parents rate their childs health-related quality of life? Results of a systematic review. Qual Life Res 2001;10:347–57. 7. Gofin R, Adler B, Hass T. Incidence and impact of childhood and adolescent injuries: a population-based study. J Trauma 1999;47(1):15–21. 8. Greenspan A, Durbin D, Kallan M. Short-term physical limitations in children following motor vehicle crashes. Accid Anal Prev 2008;40:1949–54. 9. Gustafsson H, Nygren A˚, Tingvall C. Rating system for serious consequences (RSC) due to traffic accidents—risk of death or permanent disability. In: Proceedings of the 10th int. technichal conference on experimental safety vehicles; 1985. p. 556–60. 10. Kail RV, Wicks-Nelson R. Developmental psychology, 5th ed., Engelwood Cliffs, NJ: Prentice Hall; 1993. p. 17. 11. Maraste P, Persson U, Berntman M. Long-term follow up and consequences for severe road traffic injuries—treatment, costs and health impairment in Sweden in the 1960s and the 1990s. Health Policy 2003;66:147–58. 12. Mayr J, Eder C, Berghold A, et al. Causes and consequences of pedestrian injuries in children. Eur J Pediatr 2003;162:184–90. 13. National Institute for Transport and Communications Analysis (SIKA). Road traffic injuries in health care. Statistics on medical care given to road traffic casualties 1998–2006. In: SIKA statistics. Stockholm: SIKA; 2008. p. 23. 14. Olofsson E, Bunketorp O, Andersson AL. Children and adolescents injured in traffic, associated psychological consequences: a literature review. Acta Paediatr 2009;98:17–22. 15. Peden M, Scurfield R, Sleet D, et al. World report on road traffic injury prevention. Gene`ve: WHO; 2004. 16. Polinder S, Meerding WJ, Toet H, et al. Prevalence and prognostic factors of disability after childhood injury. Pediatrics 2005;116:810–7. 17. Sturms LM, van der Sluis CK, Groothoff JW, et al. The health-related quality of life of paediatric traffic victims. J Trauma 2002;52:88–94. 18. The National Board of Health and Welfare. Damage events that led to emergency room visits—statistics from the injury database (IDB), Sweden, 2007. Article nr. 2009-125-11. Stockholm: The National Board of Health and Welfare; 2009. 19. The National Board of Health and Welfare. Injury statistics among children in Sweden—intentional and unintentional. Stockholm: The National Board of Health and Welfare; 2007. 20. The National Board of Health and Welfare. Klassifikation av sjukdomar och ha¨lsoproblem 1997. In: Swedish version of international classification of diseases and related health problems, tenth revision (ICD-10) WHO. Stockholm: Socialstyrelsen; 1996. 21. Tursz A, Crost M. Sequelae after unintentional injures to children: an exploratory study. Inj Prev 2000;6:209–13. 22. Zatzick D, Jurkovich G, Fan M-Y, et al. Association between posttraumatic stress and depressive symptoms and functional outcomes in adolescents followed up longitudinally after injury hospitalization. Arch Pediatr Adolesc Med 2008;162:642–8.