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Long-term disability after trauma in children
Long-Term Disability After Trauma in Children By Saulius Valadka, Dan Poenaru, and Andrew Dueck Kingston, Ontario
Purpose: The aim of this study was to assess long-term disability after pediatric trauma and identify predicting factors. Methods: A phone survey was conducted of all pediatric trauma patients with an Injury Severity Score (ISS) $4 seen over 6 years at a regional trauma center. The questionnaire was a modification of the Rand Health Insurance Study scales. Results: Of 218 eligible trauma registry patients, 19 were deceased, 64 unreachable, 19 declined, and 116 interviewed. There were no demographic differences between respondents and nonrespondents. Sixty-three percent of the respondents were boys, mean age at injury was 13, ISS 16.7, and mean interval since injury was 4.4 (range, 1 to 7) years. Sixty-three children (54%) had no limitations on follow-up;
T
RAUMATIC INJURIES are the leading cause of death in children. Various factors contribute to trauma-related mortality and short-term morbidity.1 Little is known, however, regarding the long-term effects of trauma on children. Do children possess a resiliency that allows them to fully recover from injury, or are there long-term effects that have an impact on their lives? In the current study, we looked for predictors of long-term functional sequelae of pediatric trauma. For this purpose, we modified the questionnaire developed for the Rand Health Insurance Study2 and used it in the form of a telephone interview as an outcome measure to assess disability. We sought to determine if trauma scores, age at time of injury, number and identity of body regions injured, mechanism of injury, or interval since the injury occurred correlated with the long-term presence of a disability. MATERIALS AND METHODS This study forms the second phase of a retrospective clinical study of pediatric patients included in the trauma registry at Kingston General
From the Department of Surgery, School of Medicine, Queen’s University, Kingston, Ontario, Canada. Presented at the 31st Annual Meeting of the Canadian Association of Paediatric Surgeons, Montreal, Quebec, Canada, September 23-26, 1999. Address reprint requests to Dan Poenaru, MD, Kingston General Hospital, Kingston, Ontario, Canada K7L 2V7. Copyright r 2000 by W.B. Saunders Company 0022-3468/00/3505-0007$03.00/0 doi:10.1053/js.2000.5943 684
the remainder had either limitations in physical or role activities (28%), mobility (16%), or self-care ability (2%). Significant correlations were found between the presence of disability and trauma scores and number of body regions injured. Stepwise logistic regression identified number of regions injured, mechanism of injury, and ISS as the main determinants for presence of long-term disability.
Conclusions: Half of injured children do have long-term sequelae. Their occurrence can be predicted from trauma scores, mechanism of injury, and number of regions injured. J Pediatr Surg 35:684-687. Copyright r 2000 by W.B. Saunders Company. INDEX WORDS: Trauma, complications, long-term deficits, trauma scores.
Hospital from January 1991 to June 1997. The first phase correlated the cost of hospital care and the length of hospital stay with trauma scores as well as other injury-time variables.3 The current phase of the study is focusing on the long-term functional outcome of these same pediatric trauma patients in relation to their trauma scores, age at injury, body regions injured, and length of time since the injury occurred. The Injury Severity Score (ISS) is a trauma score developed to describe the overall severity of the injury in persons who have sustained injury to more than 1 body region. It is defined as the sum of the squares of the highest Abbreviated Injury Scale (AIS) grade in each of the 3 most severely injured body areas.4 The Pediatric Trauma Score (PTS) is a combined anatomic and physiological trauma scoring system developed for triage purposes for use in the pediatric population. It is calculated by examining 6 clinical variables graded 21 for major or life-threatening injury, 1 for minor or potentially major injury, or 2 for minimal or no injury—thus giving a range for any injured child of 26 to 12, with severity inversely related to the corresponding PTS value.5,6 The study population was the same for both phases. A total of 218 consecutive patients from the Kingston General Hospital trauma registry met the inclusion criteria below and were reviewed. Of these, 19 were deceased, which left a database of 199 patients meeting the criteria for inclusion in this study. Inclusion criteria were age #18 years at time of injury, and an ISS $4. Exclusion criteria were incomplete charts or death of the patient within the study period. Charts were reviewed for demographic data (age at time of injury, present age, sex, mechanism of injury, body region injured, and number of body regions injured); ISS; and the data required to calculate PTS (blood pressure, patient size, airway status, neurological status, presence of an open wound, and presence of fractures). The assessment of functional outcome was done via a telephone interview based on the physical health scales developed for the Rand Health Insurance Study (HIS; Table 1). There were 2 sets of questions, 1 for ages 0 to 4 years, and 1 for ages 5 and older as used by Wesson et al.7 A child was considered ‘‘disabled’’ if the parent or guardian responded positively to any of the questions in the questionnaire. Interviewees were asked whether the functional limitation was a result of the injury or Journal of Pediatric Surgery, Vol 35, No 5 (May), 2000: pp 684-687
LONG-TERM DISABILITY AFTER TRAUMA
685
Table 1. Functional Limitations Assessment Age Group
0-4 yr
Category
Physical activity Self-care activity Role activity
5 yr and older
Physical activity
Role activity
Mobility
Self-care activity
Limitations Assessed
Is this child unable to walk, unless assisted by an adult or by crutches, artificial limb, or braces? Because of health, does this child need more help than usual for a child this age in eating, dressing, bathing, or using the toilet? Does this child’s health keep him or her from taking part in ordinary play? Does this child’s health limit the kind or amount of ordinary play he or she can do? Does health limit this child in any way from doing anything he or she wants to do? Is this child unable to walk, unless assisted by an adult or by a cane, crutches, artificial limb, or braces? Does this child have trouble bending lifting or stooping because of health? Because of health, does this child have trouble either walking one block or climbing one flight of stairs? Does this child have trouble either walking several blocks or climbing a few flights of stairs because of health? Does this child’s health limit the kind or amount of vigorous activities he or she can do, such as running, lifting heavy objects, or taking part in strenuous sports? Does this child’s health keep him or her from going to school? Is this child unable to do certain kinds or amounts of schoolwork because of health? Does health limit this child in any way from doing anything he or she wants to do? Is this child in bed or a chair most or all of the day because of health? Does this child have to stay indoors most or all of the day because of health? Does this child need help in getting around the neighborhood because of health? Does this child’s health limit him or her in any way in using public transportation or a bicycle? Because of health, does this child need help with eating, dressing, bathing, or using the toilet?
Additional Questions Asked Age Group
All ages
Category
General health Parent concern Child pain or distress Treatment
Question
In general, would you say your child’s health is excellent, good, fair, or poor? During the past 3 months, would you say you’ve worried about your child’s health a great deal, somewhat, a little, or not at all? During the past 3 months, how much pain or distress would you say your child’s health has caused him/her? A great deal, some, a little, or none at all? After his/her initial release from the hospital, did your child require any additional surgeries, hospitalizations, or did he/she have to see a specialist for problems related to the accident?
Data from Wesson et al.7
as a result of another condition. Severity of disability was determined by placing each patient into 1 of 4 mutually exclusive groups, in increasing order of severity: 1, no limitations; 2, physical or role activity limitations only; 3, limitations in mobility; and 4, limitations in self-care activity.8 Also asked in the questionnaire were 4 additional questions regarding general health, parental worry, child pain or distress during the last 3 months, and additional hospitalizations, surgeries, or specialist visits required since the initial injury. The interviewees consisted of the parent or guardian of the child or, where applicable, the spouse of the individual. The phone interview was conducted in a standardized fashion.9 Informed consent was obtained before conducting each interview. The data were collected in Microsoft Excel 97 and analyzed using both Microsoft Excel 97 and SPSS 8.0. Cases were divided into 3 groups: ‘‘respondents,’’ ‘‘declined,’’ and ‘‘unreachable by reasonable means.’’ An unpaired Student’s t test assuming unequal variances was performed to test for significant differences between groups of patients. The statistical analysis on the respondent data included descriptive statistics, analysis of variance, correlative statistics, and logistic regression analysis. The significance level was set at P , .05.
RESULTS
Of the 199 eligible patients (61% boys), 135 (67.5%) could be contacted. Of these, 116 agreed to be inter-
viewed, resulting in a response rate of 86%. The 3 populations (respondents, declined, and unreachable) were found to be equivalent by two-tailed t test in age at injury, ISS, PTS, and time since injury. Table 2 gives a summary of the patient characteristics of our study population. It shows the mean, range, and the standard deviation for the age, interval since injury, ISS, and PTS of the respondent population. The table also gives a description of the injuries received by the study population broken down by location of injury and number of regions injured. The patients were grouped according to the type of injury they had received: (0) isolated extremity injury, (1) isolated body injury, (2) body plus extremity injury, (3) isolated head injury, and (4) head plus other injury (in anticipated order of increasing severity). There was no significant correlation between the type of injury as classified above and the outcome. The mechanism of injury was divided into 4 categories: (1) MVA, (2) sports, (3) falls, and (4) other (including abuse, gunshot, kicked by cow). The distribu-
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Table 2. Characteristics of the Injured Patients Patient Characteristics
Mean (SD)
Age (yr) Interval since injury (yr) ISS PTS Distribution of Injuries, N (%) Head Truncal Extremity Upper Lower Number of injured regions 1 2 3 4
13 (5) 4.4 (1.7) 16.8 (11.2) 8.2 (2.9) 78 (67.2) 51 (44) 46 (39.7) 27 (23.3) 30 (25.9)
Fig 1.
Breakdown of long-term disability by severity.
regression equation obtained therefore was as follows:
69 (59.6) 27 (23.3) 16 (13.8) 4 (3.5)
p 0 death 0 5
tion of injuries and their average trauma scores are shown in Table 3. Analysis of mechanism of injury and trauma scores showed that MVAs caused, on average, more severe injuries than the other categories. Figure 1 shows the distribution of respondent disability levels. The total percentage of disabled individuals was 47%. Six variables (ISS, PTS, age at injury, interval since injury, body regions injured, and mechanism of injury) were tested for significance by analysis of variance (ANOVA) and correlation against 7 outcome measures (general health, concerns during past 3 months, pain or distress during past 3 months, additional treatment required since injury, presence of any disability, total number of identified health issues, and type of disability). The relationships between the significant variables are shown in Table 4. Stepwise logistic regression analysis was carried out using the presence of any disability as the dependent outcome variable. Seventy-eight percent of outcomes were correctly predicted by 3 factors: truncal injury (P 5 .0045), leg injury (P 5 .0006), and ISS (P 5 .0071). Although PTS was significant in the stepwise process, ISS was more significant, and accounted for the same variation that was explained by the PTS. The logistic
Table 3. Patient and Injury Characteristics by Trauma Mechanism Injury Type
No. (%) of Injuries
Mean Age (SD)
Mean No. of Regions Injured
Mean ISS (SD)
Mean PTS (SD)
MVA Sports Falls Other Total
78 (67.2) 15 (12.9) 14 (12.1) 9 (7.8) 116 (100)
14 (4) 12 (4) 10 (6) 11 (6) 13 (5)
1.9 1.1 1.2 0.9 1.6
18.3 (11.9) 14.9 (12.3) 14.7 (6.1) 9.7 (5.8) 16.8 (11.2)
7.8 (3.1) 9.1 (3.2) 9.9 (1.6) 9 (1.7) 8.2 (2.9)
exp[0.89 1 0.069*ISS 2 1.90*(leg) 2 1.29*(trunk)] 1 1 exp[0.89 1 0.069*ISS 2 1.90*(leg) 2 1.29*(trunk)]
where ‘‘trunk’’ and ‘‘leg’’ 5 1 if truncal or leg injury was present and 0 if not. DISCUSSION
For this study we, as others,6,7 have defined disability as a limitation in any age-appropriate activity according to HIS measures. It is apparent from the current study that almost half (47%) of injured children have long-term functional sequelae after trauma. The incidence and severity of the disability increases as the severity of the injuries, as measured by trauma scores, increases. This finding underscores the magnitude of the problem presented by childhood trauma, and the lasting impact that it can have on the individuals, their families, and society in general. The occurrence of long-term functional limitation could be predicted in our study using trauma scores, the number and identity of the body regions injured, and the mechanism of injury. Of the 2 trauma scores used in this Table 4. Correlations Between Injury Factors and Disability (Spearman’s rho) Additional Presence No. of Positive Disability General Treatment of Type Health Required Disability Answers
ISS PTS No. of injured regions Head injury Truncal injury Arm injury Leg injury Age at injury Interval since injury Mechanism of injury *P , .05. †P , .01. ‡P , .001.
0.35‡ 20.3† 0.35‡ 20.21* 0.37‡ 0.11 0.37‡ 0.17 20.12 20.39‡
0.35‡ 20.32† 0.35‡ 20.24* 0.38‡ 0.11 0.36‡ 0.2* 20.1 20.38‡
0.36‡ 0.24* 20.32‡ 20.25† 0.34‡ 0.24† 20.21* 20.27† 0.36‡ 0.37‡ 0.11 0.13 0.34‡ 0.19* 0.17 0.25† 20.13 0.09 20.38‡ 20.27†
0.32† 20.25† 0.22* 20.06 0.17 0.08 0.2* 0.09 20.04 20.26†
LONG-TERM DISABILITY AFTER TRAUMA
687
study, the ISS was correlated more strongly with the presence of long-term disability than the PTS. The age at the time of injury was significantly correlated with the total number of limitations but not with the presence of a disability. This association was maintained regardless of the specific age group looked at. The time interval since the injury occurred did not correlate significantly with any of our outcome measures. We may have expected to see a plateau in the amount of functional limitation over time. This was not found however, probably because of the retrospective nature of our study. Further studies using a cohort design may indeed show this plateau. Two studies related to the current topic use the Rand Health Insurance Study as an outcome measure. Hu et al7 examined the relation between 2 trauma scores (AIS and ISS) and functional outcome in 92 injured children. The study found limitations in 94% of patients at discharge, in 73% at 6 months, and in 55% 1 year after discharge. Unlike the current study, the investigators did not find an association between ISS and functional limitation. Wesson et al7 correlated 3 scores (AIS, ISS, and Glasgow Coma Score) to functional outcome in 250 pediatric patients. At discharge 88% of patients were recorded disabled, the percentage decreasing to 54% at a 6-month follow-up.
Our study looked at a time frame longer than previously reported and identified correlations between timeof-injury factors and long-term functional outcome. We have shown that the limitations existing 1 year after discharge tend to be long term and possibly permanent. Our data concur with the literature in identifying a significant extent of long-term disability.6,7 There are several limitations to the current study. First, the survey was conducted from a distance, and therefore did not allow direct evaluation of functional outcome. Secondly, this retrospective study did not allow the measurement of individual changes from the time of discharge. Other limitations include regional variations in trauma demographics and management, and possibly the inclusion of minor injuries through the selected inclusion criteria. The current study shows and characterizes the significant long-term consequences of trauma in children. It also identifies the time-of-injury factors predictive of such long-term disability. Further work is needed, however, to fully clarify the subject. This may include a prospective study following children from the time of injury for up to 5 to 10 years, with regular multidisciplinary follow-up visits.
REFERENCES 1. Tepas JJ, Ramenofsky ML, Barlow B, et al: National pediatric trauma registry. J Pediatr Surg 24:156-158, 1989 2. Eisen M, Donald CA, Ware JE, et al: Conceptualization and Measurement of Health for Children in the Health Insurance Study. Santa Monica, CA, Rand Corporation, 1980 3. Dueck A, Poenaru D, Pichora D: Cost factors in Canadian pediatric trauma. Abstract presented at the 29th meeting of the Canadian Association of Pediatric Surgeons, Toronto, 1998 4. Baker SP, O’Neill B, Haddon W, et al: The Injury Severity Score: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14:187-196, 1974
5. Kaufmann CR, Maier RV, Rivara FP, et al: Evaluation of the Pediatric Trauma Score. JAMA 263:69-72, 1990 6. Eichelberger MR, Gotschall CS, Sacco WJ, et al: A Comparison of the Trauma Score, The Revised Trauma Score, and the Pediatric Trauma Score. Ann Emerg Med 18:1053-1058, 1989 7. Wesson DE, Williams JI, Spence LJ, et al: Functional outcome in pediatric trauma. J Trauma 29:589-592, 1989 8. Hu X, Wessen DE, Logsetty S, et al: Functional limitations and recovery in children with severe trauma: A one-year follow-up. J Trauma 37:209-213, 1994 9. Dillman DA: Mail and Telephone Surveys: The Total Design Method. New York, NY, Wiley, 1978
Purpose: The aim of this study was to assess long-term disability after pediatric trauma and identify predicting factors. Methods: A phone survey was conducted of all pediatric trauma patients with an Injury Severity Score (ISS) $4 seen over 6 years at a regional trauma center. The questionnaire was a modification of the Rand Health Insurance Study scales. Results: Of 218 eligible trauma registry patients, 19 were deceased, 64 unreachable, 19 declined, and 116 interviewed. There were no demographic differences between respondents and nonrespondents. Sixty-three percent of the respondents were boys, mean age at injury was 13, ISS 16.7, and mean interval since injury was 4.4 (range, 1 to 7) years. Sixty-three children (54%) had no limitations on follow-up;
T
RAUMATIC INJURIES are the leading cause of death in children. Various factors contribute to trauma-related mortality and short-term morbidity.1 Little is known, however, regarding the long-term effects of trauma on children. Do children possess a resiliency that allows them to fully recover from injury, or are there long-term effects that have an impact on their lives? In the current study, we looked for predictors of long-term functional sequelae of pediatric trauma. For this purpose, we modified the questionnaire developed for the Rand Health Insurance Study2 and used it in the form of a telephone interview as an outcome measure to assess disability. We sought to determine if trauma scores, age at time of injury, number and identity of body regions injured, mechanism of injury, or interval since the injury occurred correlated with the long-term presence of a disability. MATERIALS AND METHODS This study forms the second phase of a retrospective clinical study of pediatric patients included in the trauma registry at Kingston General
From the Department of Surgery, School of Medicine, Queen’s University, Kingston, Ontario, Canada. Presented at the 31st Annual Meeting of the Canadian Association of Paediatric Surgeons, Montreal, Quebec, Canada, September 23-26, 1999. Address reprint requests to Dan Poenaru, MD, Kingston General Hospital, Kingston, Ontario, Canada K7L 2V7. Copyright r 2000 by W.B. Saunders Company 0022-3468/00/3505-0007$03.00/0 doi:10.1053/js.2000.5943 684
the remainder had either limitations in physical or role activities (28%), mobility (16%), or self-care ability (2%). Significant correlations were found between the presence of disability and trauma scores and number of body regions injured. Stepwise logistic regression identified number of regions injured, mechanism of injury, and ISS as the main determinants for presence of long-term disability.
Conclusions: Half of injured children do have long-term sequelae. Their occurrence can be predicted from trauma scores, mechanism of injury, and number of regions injured. J Pediatr Surg 35:684-687. Copyright r 2000 by W.B. Saunders Company. INDEX WORDS: Trauma, complications, long-term deficits, trauma scores.
Hospital from January 1991 to June 1997. The first phase correlated the cost of hospital care and the length of hospital stay with trauma scores as well as other injury-time variables.3 The current phase of the study is focusing on the long-term functional outcome of these same pediatric trauma patients in relation to their trauma scores, age at injury, body regions injured, and length of time since the injury occurred. The Injury Severity Score (ISS) is a trauma score developed to describe the overall severity of the injury in persons who have sustained injury to more than 1 body region. It is defined as the sum of the squares of the highest Abbreviated Injury Scale (AIS) grade in each of the 3 most severely injured body areas.4 The Pediatric Trauma Score (PTS) is a combined anatomic and physiological trauma scoring system developed for triage purposes for use in the pediatric population. It is calculated by examining 6 clinical variables graded 21 for major or life-threatening injury, 1 for minor or potentially major injury, or 2 for minimal or no injury—thus giving a range for any injured child of 26 to 12, with severity inversely related to the corresponding PTS value.5,6 The study population was the same for both phases. A total of 218 consecutive patients from the Kingston General Hospital trauma registry met the inclusion criteria below and were reviewed. Of these, 19 were deceased, which left a database of 199 patients meeting the criteria for inclusion in this study. Inclusion criteria were age #18 years at time of injury, and an ISS $4. Exclusion criteria were incomplete charts or death of the patient within the study period. Charts were reviewed for demographic data (age at time of injury, present age, sex, mechanism of injury, body region injured, and number of body regions injured); ISS; and the data required to calculate PTS (blood pressure, patient size, airway status, neurological status, presence of an open wound, and presence of fractures). The assessment of functional outcome was done via a telephone interview based on the physical health scales developed for the Rand Health Insurance Study (HIS; Table 1). There were 2 sets of questions, 1 for ages 0 to 4 years, and 1 for ages 5 and older as used by Wesson et al.7 A child was considered ‘‘disabled’’ if the parent or guardian responded positively to any of the questions in the questionnaire. Interviewees were asked whether the functional limitation was a result of the injury or Journal of Pediatric Surgery, Vol 35, No 5 (May), 2000: pp 684-687
LONG-TERM DISABILITY AFTER TRAUMA
685
Table 1. Functional Limitations Assessment Age Group
0-4 yr
Category
Physical activity Self-care activity Role activity
5 yr and older
Physical activity
Role activity
Mobility
Self-care activity
Limitations Assessed
Is this child unable to walk, unless assisted by an adult or by crutches, artificial limb, or braces? Because of health, does this child need more help than usual for a child this age in eating, dressing, bathing, or using the toilet? Does this child’s health keep him or her from taking part in ordinary play? Does this child’s health limit the kind or amount of ordinary play he or she can do? Does health limit this child in any way from doing anything he or she wants to do? Is this child unable to walk, unless assisted by an adult or by a cane, crutches, artificial limb, or braces? Does this child have trouble bending lifting or stooping because of health? Because of health, does this child have trouble either walking one block or climbing one flight of stairs? Does this child have trouble either walking several blocks or climbing a few flights of stairs because of health? Does this child’s health limit the kind or amount of vigorous activities he or she can do, such as running, lifting heavy objects, or taking part in strenuous sports? Does this child’s health keep him or her from going to school? Is this child unable to do certain kinds or amounts of schoolwork because of health? Does health limit this child in any way from doing anything he or she wants to do? Is this child in bed or a chair most or all of the day because of health? Does this child have to stay indoors most or all of the day because of health? Does this child need help in getting around the neighborhood because of health? Does this child’s health limit him or her in any way in using public transportation or a bicycle? Because of health, does this child need help with eating, dressing, bathing, or using the toilet?
Additional Questions Asked Age Group
All ages
Category
General health Parent concern Child pain or distress Treatment
Question
In general, would you say your child’s health is excellent, good, fair, or poor? During the past 3 months, would you say you’ve worried about your child’s health a great deal, somewhat, a little, or not at all? During the past 3 months, how much pain or distress would you say your child’s health has caused him/her? A great deal, some, a little, or none at all? After his/her initial release from the hospital, did your child require any additional surgeries, hospitalizations, or did he/she have to see a specialist for problems related to the accident?
Data from Wesson et al.7
as a result of another condition. Severity of disability was determined by placing each patient into 1 of 4 mutually exclusive groups, in increasing order of severity: 1, no limitations; 2, physical or role activity limitations only; 3, limitations in mobility; and 4, limitations in self-care activity.8 Also asked in the questionnaire were 4 additional questions regarding general health, parental worry, child pain or distress during the last 3 months, and additional hospitalizations, surgeries, or specialist visits required since the initial injury. The interviewees consisted of the parent or guardian of the child or, where applicable, the spouse of the individual. The phone interview was conducted in a standardized fashion.9 Informed consent was obtained before conducting each interview. The data were collected in Microsoft Excel 97 and analyzed using both Microsoft Excel 97 and SPSS 8.0. Cases were divided into 3 groups: ‘‘respondents,’’ ‘‘declined,’’ and ‘‘unreachable by reasonable means.’’ An unpaired Student’s t test assuming unequal variances was performed to test for significant differences between groups of patients. The statistical analysis on the respondent data included descriptive statistics, analysis of variance, correlative statistics, and logistic regression analysis. The significance level was set at P , .05.
RESULTS
Of the 199 eligible patients (61% boys), 135 (67.5%) could be contacted. Of these, 116 agreed to be inter-
viewed, resulting in a response rate of 86%. The 3 populations (respondents, declined, and unreachable) were found to be equivalent by two-tailed t test in age at injury, ISS, PTS, and time since injury. Table 2 gives a summary of the patient characteristics of our study population. It shows the mean, range, and the standard deviation for the age, interval since injury, ISS, and PTS of the respondent population. The table also gives a description of the injuries received by the study population broken down by location of injury and number of regions injured. The patients were grouped according to the type of injury they had received: (0) isolated extremity injury, (1) isolated body injury, (2) body plus extremity injury, (3) isolated head injury, and (4) head plus other injury (in anticipated order of increasing severity). There was no significant correlation between the type of injury as classified above and the outcome. The mechanism of injury was divided into 4 categories: (1) MVA, (2) sports, (3) falls, and (4) other (including abuse, gunshot, kicked by cow). The distribu-
686
VALADKA, POENARU, AND DUECK
Table 2. Characteristics of the Injured Patients Patient Characteristics
Mean (SD)
Age (yr) Interval since injury (yr) ISS PTS Distribution of Injuries, N (%) Head Truncal Extremity Upper Lower Number of injured regions 1 2 3 4
13 (5) 4.4 (1.7) 16.8 (11.2) 8.2 (2.9) 78 (67.2) 51 (44) 46 (39.7) 27 (23.3) 30 (25.9)
Fig 1.
Breakdown of long-term disability by severity.
regression equation obtained therefore was as follows:
69 (59.6) 27 (23.3) 16 (13.8) 4 (3.5)
p 0 death 0 5
tion of injuries and their average trauma scores are shown in Table 3. Analysis of mechanism of injury and trauma scores showed that MVAs caused, on average, more severe injuries than the other categories. Figure 1 shows the distribution of respondent disability levels. The total percentage of disabled individuals was 47%. Six variables (ISS, PTS, age at injury, interval since injury, body regions injured, and mechanism of injury) were tested for significance by analysis of variance (ANOVA) and correlation against 7 outcome measures (general health, concerns during past 3 months, pain or distress during past 3 months, additional treatment required since injury, presence of any disability, total number of identified health issues, and type of disability). The relationships between the significant variables are shown in Table 4. Stepwise logistic regression analysis was carried out using the presence of any disability as the dependent outcome variable. Seventy-eight percent of outcomes were correctly predicted by 3 factors: truncal injury (P 5 .0045), leg injury (P 5 .0006), and ISS (P 5 .0071). Although PTS was significant in the stepwise process, ISS was more significant, and accounted for the same variation that was explained by the PTS. The logistic
Table 3. Patient and Injury Characteristics by Trauma Mechanism Injury Type
No. (%) of Injuries
Mean Age (SD)
Mean No. of Regions Injured
Mean ISS (SD)
Mean PTS (SD)
MVA Sports Falls Other Total
78 (67.2) 15 (12.9) 14 (12.1) 9 (7.8) 116 (100)
14 (4) 12 (4) 10 (6) 11 (6) 13 (5)
1.9 1.1 1.2 0.9 1.6
18.3 (11.9) 14.9 (12.3) 14.7 (6.1) 9.7 (5.8) 16.8 (11.2)
7.8 (3.1) 9.1 (3.2) 9.9 (1.6) 9 (1.7) 8.2 (2.9)
exp[0.89 1 0.069*ISS 2 1.90*(leg) 2 1.29*(trunk)] 1 1 exp[0.89 1 0.069*ISS 2 1.90*(leg) 2 1.29*(trunk)]
where ‘‘trunk’’ and ‘‘leg’’ 5 1 if truncal or leg injury was present and 0 if not. DISCUSSION
For this study we, as others,6,7 have defined disability as a limitation in any age-appropriate activity according to HIS measures. It is apparent from the current study that almost half (47%) of injured children have long-term functional sequelae after trauma. The incidence and severity of the disability increases as the severity of the injuries, as measured by trauma scores, increases. This finding underscores the magnitude of the problem presented by childhood trauma, and the lasting impact that it can have on the individuals, their families, and society in general. The occurrence of long-term functional limitation could be predicted in our study using trauma scores, the number and identity of the body regions injured, and the mechanism of injury. Of the 2 trauma scores used in this Table 4. Correlations Between Injury Factors and Disability (Spearman’s rho) Additional Presence No. of Positive Disability General Treatment of Type Health Required Disability Answers
ISS PTS No. of injured regions Head injury Truncal injury Arm injury Leg injury Age at injury Interval since injury Mechanism of injury *P , .05. †P , .01. ‡P , .001.
0.35‡ 20.3† 0.35‡ 20.21* 0.37‡ 0.11 0.37‡ 0.17 20.12 20.39‡
0.35‡ 20.32† 0.35‡ 20.24* 0.38‡ 0.11 0.36‡ 0.2* 20.1 20.38‡
0.36‡ 0.24* 20.32‡ 20.25† 0.34‡ 0.24† 20.21* 20.27† 0.36‡ 0.37‡ 0.11 0.13 0.34‡ 0.19* 0.17 0.25† 20.13 0.09 20.38‡ 20.27†
0.32† 20.25† 0.22* 20.06 0.17 0.08 0.2* 0.09 20.04 20.26†
LONG-TERM DISABILITY AFTER TRAUMA
687
study, the ISS was correlated more strongly with the presence of long-term disability than the PTS. The age at the time of injury was significantly correlated with the total number of limitations but not with the presence of a disability. This association was maintained regardless of the specific age group looked at. The time interval since the injury occurred did not correlate significantly with any of our outcome measures. We may have expected to see a plateau in the amount of functional limitation over time. This was not found however, probably because of the retrospective nature of our study. Further studies using a cohort design may indeed show this plateau. Two studies related to the current topic use the Rand Health Insurance Study as an outcome measure. Hu et al7 examined the relation between 2 trauma scores (AIS and ISS) and functional outcome in 92 injured children. The study found limitations in 94% of patients at discharge, in 73% at 6 months, and in 55% 1 year after discharge. Unlike the current study, the investigators did not find an association between ISS and functional limitation. Wesson et al7 correlated 3 scores (AIS, ISS, and Glasgow Coma Score) to functional outcome in 250 pediatric patients. At discharge 88% of patients were recorded disabled, the percentage decreasing to 54% at a 6-month follow-up.
Our study looked at a time frame longer than previously reported and identified correlations between timeof-injury factors and long-term functional outcome. We have shown that the limitations existing 1 year after discharge tend to be long term and possibly permanent. Our data concur with the literature in identifying a significant extent of long-term disability.6,7 There are several limitations to the current study. First, the survey was conducted from a distance, and therefore did not allow direct evaluation of functional outcome. Secondly, this retrospective study did not allow the measurement of individual changes from the time of discharge. Other limitations include regional variations in trauma demographics and management, and possibly the inclusion of minor injuries through the selected inclusion criteria. The current study shows and characterizes the significant long-term consequences of trauma in children. It also identifies the time-of-injury factors predictive of such long-term disability. Further work is needed, however, to fully clarify the subject. This may include a prospective study following children from the time of injury for up to 5 to 10 years, with regular multidisciplinary follow-up visits.
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5. Kaufmann CR, Maier RV, Rivara FP, et al: Evaluation of the Pediatric Trauma Score. JAMA 263:69-72, 1990 6. Eichelberger MR, Gotschall CS, Sacco WJ, et al: A Comparison of the Trauma Score, The Revised Trauma Score, and the Pediatric Trauma Score. Ann Emerg Med 18:1053-1058, 1989 7. Wesson DE, Williams JI, Spence LJ, et al: Functional outcome in pediatric trauma. J Trauma 29:589-592, 1989 8. Hu X, Wessen DE, Logsetty S, et al: Functional limitations and recovery in children with severe trauma: A one-year follow-up. J Trauma 37:209-213, 1994 9. Dillman DA: Mail and Telephone Surveys: The Total Design Method. New York, NY, Wiley, 1978