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The increasing incidence of paediatric diaphyseal both-bone forearm fractures and their internal fixation during the last decade
Injury, Int. J. Care Injured 43 (2012) 362–366
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
The increasing incidence of paediatric diaphyseal both-bone forearm fractures and their internal fixation during the last decade Juha-Jaakko Sinikumpu *, Anu Lautamo, Tytti Pokka, Willy Serlo Division of Paediatric Surgery and Orthopaedics, Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 8 November 2011
Background: The incidence of children’s forearm fractures is increasing worldwide. This is different from the declining trend observed in the overall injury rate, and the reason for the increase is not known. Diaphyseal forearm fractures comprise 3–6% of all paediatric fractures, and they offer a challenge to their treatment. The purpose of this study was to evaluate the incidence of diaphyseal both-bone forearm fractures in children during the last decade in Northern Finland. Another objective was to study the background factors, treatment, and re-displacement of these fractures. Materials and methods: All 168 children (<16 years) admitted to our paediatric trauma centre due to diaphyseal both-bone forearm fractures during 2000–2009 were included. The type of injury, background factors, radiographics, treatments and re-dislocations were reviewed. The age-related incidence rates were evaluated. Results: The incidence of diaphyseal both-bone forearm fractures increased 4.4-fold (95% CI 2.0–10.8; P < 0.001) between 2000 (8.2/100 000) and 2009 (35.9/100 000). The increase in the incidence was accelerating (P < 0.001) and the overall increase was 338%. The incidence of surgical treatment for diaphyseal fractures increased 4.2-fold (95% CI 1.9–10.4, P = 0.001), which is in relation to increasing number of fractures. However, internal fixation increased from 13.3% in 2000–2001 to 52.7% in 2008– 2009 (P = 0.015), as an alternative to conservative treatment. The re-displacement rate was high (29.9%) amongst the patients with conservative treatment compared to those who were invasively operated (1.4%) (P < 0.001). The mean age of the patients increased by 2.4 years in the study period (P = 0.019). Trampoline was the most important and still increasing reason for the fractures. At the beginning of the study, there were no trampoline-related fracture, but towards the end of the study 30–41% of the fractures were caused by a trampoline injury (P = 0.004). Conclusions: There was an accelerating increase in the incidence of paediatric diaphyseal both-bone forearm fractures during the last decade. Trampoline was the most important and still increasing reason for these fractures. The mean age of the patients was increasing. Increasing proportion of diaphyseal both-bone forearm fractures was treated operatively. Re-displacement was unusual amongst operated cases. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Forearm fracture Diaphyse Operative treatment Surgery Incidence Paediatrics Children and Adolescents
Background About one-fourth of all children are injured each year.1 Fractures account for 10–25% of these injuries.2 Before the age of 16, about one-third of children will get a fracture.3 Children have almost twice the incidence of fractures compared to the incidence in adults.3 There has been differing reports of the change in the incidence of paediatric fractures worldwide: some have reported
* Corresponding author at: Division of Paediatric Surgery and Orthopaedics, Department of Children and Adolescents, Oulu University Hospital, PL 29/90029 OYS, Finland. Tel.: +358 8 3155835; fax: +358 8 3154499. E-mail addresses: juha-jaakko.sinikumpu@fimnet.fi (J.-J. Sinikumpu), [email protected].fi (A. Lautamo), tytti.pokka@oulu.fi (T. Pokka), willy.serlo@oulu.fi (W. Serlo). 0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.11.006
decreasing numbers of the incidence of paediatric fractures.4–6 On the other hand, the total incidence of paediatric fractures increased by 13.5% between 1997 and 2006 in Finland.7 The fracture rates in children vary between countries.8 Forearm fractures are the most common fractures in children and adolescent. Including distal part of radius and ulna, they cover up to 36–45% of all fractures in children and adolescent.9 Multiple studies have shown that the incidence of paediatric forearm fractures is increasing.7,10,11 The treatment of paediatric forearm fracture is controversial and the management is still evolving.12 Recently, there has been a trend towards operative management of forearm fractures in children and adolescents.12 The incidence of invasive surgery in forearm fractures has increased from 1.8% to 22% between 1985 and 1995, as an alternative to closed reduction and cast
J.-J. Sinikumpu et al. / Injury, Int. J. Care Injured 43 (2012) 362–366
immobilisation.13 During 1997–2006, the incidence of open surgery of forearm fractures increased by 182% in a Finnish registry-based nationwide study.7 In this study our purpose was to evaluate the incidence of the challenging diaphyseal both-bone forearm fractures and their surgical treatment. Little is known about the change in the incidence of paediatric forearm fractures at different anatomic locations (distal, middle third and proximal). Another objective was to study the rate of re-displacement according to the type of treatment. We also aimed to determine the background factors of the fractures. Materials and methods We performed a population-based epidemiologic research in Northern Finland. All the children under the age of 16 years who were admitted to our paediatric trauma centre for diaphyseal middle third both-bone fracture in a forearm during 2000–2009 were included in the study. Shaft fractures with associated disruption of the radiocapitellar joint (Monteggia fracture and equivalents) and the distal radioulnar joint (Galeazzi fracture and equivalents) were excluded. Both the patients who were hospitalised for operation and those treated on demand in the emergency room were included. There are no other paediatric trauma units in our hospital district and all paediatric diaphyseal forearm fractures have been treated in the same unit during the study period. The cohort was inclusive. To get valid incidence rate in relation to the population in risk, nonresidents were excluded. A comprehensive review on injuries, hospitalisation and the details of treatment and following was entered in the computerised database. All the radiographs were
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re-analysed twice by a radiologist and a clinician. The final include of the cases was made according to the review of the primary radiographs. The operative summaries were reviewed as well as clinical notes. We determined >158 of malalignment, >308 of malrotation and >100% of displacement as the indicators of unacceptable position postoperatively or during the conservative treatment. However, despite the numbers, all the patients who underwent an unplanned operation due to loss of position were classified as unacceptable. The surgical procedures were classified as a closed treatment (closed reduction and application of a cast under general anaesthesia) and an invasive treatment (closed or open reduction and internal fixation). The age-matching population-in-the-risk in the district of our institute during the study was achieved by the comprehensive national database by Official Statistics of Finland. It varied between 84.562 and 86.385. The annual incidences per 100 000 age-related persons are given as well as other descriptive frequencies. Independent t-test was used to test differences between group means, x2 statistic was used to investigate whether distributions of the gategorical variables differed from one another, the differences between two proportions were tested by the binomial SND test and a change in time was tested by the linear trend test. The Poisson distribution-based x2 test was used to test the difference in the annual incidence densities between the first and the last follow-up year. The amount of annual diaphyseal fracture increase was estimated by exponential regression analysis. A statistical significance was preset at the P-value < 0.05. The data were analysed using IBM SPSS Statistic, version 19, and StatsDirect Statistical Software, version 2.7.2. Insitutional Ethics committee approval was not required. Results Descriptives There were 168 included paediatric diaphyseal both-bone forearm fractures during 2000–2009. Males (69.6%) predominated over the whole period (P < 0.001). According to radiographics most fractures were angulated (81.5%). Eight of them were multifragmented, and shortening was observed in 21 (12.5%) cases. Fifteen of all fractures were open. The mean age of the patients was 8.6 years (SD 3.9) for both genders. A notable elevation in the mean age was observed (from 6.4 years in 2000–2001 to 8.8 years in 2002–2009, P = 0.019). This was obvious in both genders, but reached statistical significance only amongst boys (P = 0.016) (Fig. 1). Incidence There was a 4.4-fold (95% CI 2.0–10.8; P < 0.001) increase in the incidence of diaphyseal both-bone forearm fractures during the study time (from 8.2/100 000 in 2000 to 35.9/100 000 in 2009). The increase was 11.7% yearly (95% CI 10.5–12.9%, P < 0.001). The overall increase was 338% (Fig. 2). Injury mechanism
Fig. 1. The mean age of the paediatric patients with a diaphyseal forearm fracture.
Trampoline was the most important reason for the rising incidence of diaphyseal forearm fractures. During the follow-up, 25% of all fractures were caused by a trampoline injury. There was a notable increase in the trampoline-related injuries from 0% to 30– 41% during the study time (trend test, P = 0.004) (Fig. 3). About 10% of all injuries were sports related. There was a slight decreasing incidence of the injuries in organised sports, but it did not reach statistical significance (P = 0.26). No change was observed in the
J.-J. Sinikumpu et al. / Injury, Int. J. Care Injured 43 (2012) 362–366
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Fig. 2. The age-related incidence of the paediatric diaphyseal forearm fractures (bars) and the incidence of surgical procedures for them (line).
incidence of tumbling (22%), falling between planes (21%), injury in a playground device other than trampoline (14%) or in traffic accidents (7%). (Table 1)
Fig. 3. The trampoline related diaphyseal forearm fractures related to all diaphyseal forearm fractures in children and adolescents.
2000–2001 to 29, 52.7% in 2008–2009, P = 0.015). At the end of the study phase (2008–2009), no differences in the proportions of invasive treatment (52.7%) and non-invasive treatment were noted (P = 0.57) (Table 2).
Surgical treatment Re-displacement rate As many as 159 cases of all (94.6%) diaphyseal both-bone forearm fractures were treated in the operating room under general anaesthesia. There was a significant increase in the incidence of open reduction during the study time (from 2, 13.3% in
The incidence of the loss of reduction and the need of unplanned reduction was 29.9% (N = 29/97) amongst the cases that were treated non-invasively primarily. By contrast, the
Table 1 Injury mechanisms and recreational causes of the paediatric diaphyseal forearm fractures.
Injury mechanism Fall on the same plane Fall between planes Fall on the ice Fall at playground Traffic injury Other injury Recreational causes Organised sport (soccer, ice hockey, etc.) Slalom, cross-country skiing, snowboarding Bicycling, skating, skateboarding Other playground device, swing, etc. Trampoline Indoor play Falling, not more defined Motor vehicle Falling from ladder, roof, etc. Falling when running * **
2000–1
2002–3
2004–5
2006–7
2008–9
All*
P-value**
25% (4) 31.3% (5) 0% (0) 25% (4) 12.5% (2) 6.3% (1)
33.3% (11) 18.2% (6) 6.1% (2) 30.3% (10) 3% (1) 9.1% (3)
20% (6) 13.3% (4) 6.7% (2) 33.3% (10) 20% (6) 6.7% (2)
18.8% (6) 18.8% (6) 3.1% (1) 50% (16) 3.1% (1) 6.3% (2)
17.9% (10) 25% (14) 1.8% (1) 44.6% (25) 3.6% (2) 7.1% (4)
22.2% (37) 21% (35) 3.6% (6) 38.9% (65) 7.2% (12) 7.2% (13)
0.16 0.84 0.58 0.47 0.22 0.88
18.8% (3) 0% (0) 6.3% (1) 6.3% (1) 0% (0) 12.5% (2) 25% (4) 6.3% (1) 25% (4) 25% (4)
15.2% (5) 6.1% (2) 15.2% (5) 9.1% (3) 15.2% (5) 9.1% (3) 24.2% (8) 0% (0) 6.1% (2) 24.2% (8)
3.3% (1) 6.7% (2) 20.0% (6) 10.0% (3) 23.3% (7) 6.7% (2) 20.0% (6) 0% (0) 6.7% (2) 20.0% (6)
9.4% (3) 3.1% (1) 0% (0) 9.4% (3) 40.6% (13) 9.4% (3) 15.6% (5) 9.4% (3) 3.1% (1) 15.6% (5)
8.9% 1.8% 9.0% 12.5% 30.4% 8.9% 12.5% 3.6% 8.9% 12.7%
(5) (1) (5) (7) (17) (5) (7) (2) (5) (7)
10.2% 3.6% 10.2% 10.2% 25.1% 9.0% 18.0% 3.6% 8.4% 18.0%
(17) (6) (17) (17) (42) (15) (30) (6) (14) (30)
0.26 0.58 0.35 0.46 0.004 0.83 0.1 0.52 0.26 0.28
Total number of cases 167 (one cases missing data). Trend test.
Table 2 Operative activity and surgical procedures for the paediatric diaphyseal forearm fractures.
Operative activity (% of all patients and number) Procedure at OR* (operated) Not admitted to OR (not operated) Surgical procedure (% of all operated and number) Closed or open reduction and internal fixation Closed treatment * **
Operating room. Trend test.
2000–1
2002–3
2004–5
2006–7
2008–9
All
P-value
93.8% (15) 6.3% (1)
93.9% (31) 6.1% (2)
96.7% (29) 3.3% (1)
90.6% (29) 9.4% (3)
96.5% (55) 3.5% (2)
94.6% (159) 5.4% (9)
0.74**
13.3% (2) 86.7% (13)
45.2% (14) 54.8% (17)
34.5% (10) 65.5% (19)
55.2% (16) 44.8% (13)
52.7% (29) 47.3% (26)
44.7% (71) 55.3% (88)
0.015**
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worsening of the reduction was observed in one case with internal fixation (1.4%, N = 1/71) (P < 0.001). Discussion In our study the paediatric diaphyseal both-bone forearm fractures increased about 12% yearly. The total increase in the incidence was 4.4-fold (95% CI 2.0–10.8; P < 0.001). This is an alarming finding. There is a variation in a way to report forearm fractures: Some authors have included single or both-bone fractures in every site of a forearm, whereas others have analysed proximal, distal, and middle third diaphyseal fractures separately.14 Diaphyseal middle third fractures differ from distal or proximal forearm fractures. Our study confirmed the increase in the incidence of just challenging diaphyseal both-bone middle third forearm fractures. In our study, the mean age of the male patients with a fracture was increasing. To our knowledge, this has not been reported before. Controversially, the mean age of children with a fracture has been postulated to diminish following the descending trend of pubertal onset.4,15 Our finding may be associated with the changing pattern of recreational activities. The change in the mean age needs to be studied further. In the study, almost every child was treated under general anaesthesia in the OR. The surgical operations for diaphyseal forearm fractures increased 4.2-fold (95% CI 1.9–10.4) between 2000 and 2009 (from 8.2/100 000 to 34.7/100 000, P < 0.001) but it was in relation to the increasing number of the fractures: there was no change in the surgery rate as related to the injury rate (Fig. 2). This means that the indications to treat the patient in the operation room have been stable. Instead, there was increasing trend of internal fixation from 13.3% in 2000–2001 to 52.7% in 2008–2009 (P = 0.015) as an alternative to closed reduction and casting under general anaesthesia. So, we found that the number of internal fixation procedures in diaphyseal both-bone forearm fractures increased 14.5-fold (from 2 to 29) between 2000–2001 and 2008– 2009. It is in relation with a recent trend toward invasive management in treatment of paediatric fractures.12,16 Different kinds of operative fixations have been advocated17 and the management of forearm fractures is evolving.12,18 The risk of re-displacement and the need of unplanned operation were much higher amongst the cases that were treated non-invasively compared to those that were invasively operated, according to presumption. The finding may be an essential reason for the recent increase in internal fixations. An unplanned operation under general anaesthesia is a needless risk for a child. Re-operations cause costs and they load the resources of operating units. A high incidence of displacement, malunion and consequent limitations of function after conservative treatment supports the increase of surgery in forearm fractures.19 Nevertheless, the results of operative methods over the results of closed treatment in forearm fractures have not been reported as superior.12 The problems of surgical trauma in operation are not marginal17 and most implants have to be removed later in a re-operation. The guidelines for acceptable alignment and the indications for operation remain mysterious,18,20 and closed treatment and casting have been a standard for the treatment of diaphyseal forearm fractures.12,21 It is especially reasonable in children younger than 8 or 9 years of age because of a rapid healing time of a bone injury and a predictable remodelling of a fracture.12 A total bayonet apposition and up to 158 of angulation are suggested to be acceptable in older children and adolescence.12 A remarkable increase in the trampoline injuries during the study time was observed (Fig. 3). Forearm fractures have been linked to recreational activities.10 Daily physical activity has been shown to increase amongst school children in this millennium.22
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The trampoline is known to be a high-risk activity with a potential for orthopaedic injuries.23 There are many backyard trampolines in our hospital district. There are some other factors that have been assumed to explain the paediatric fractures. A transient increase in the cortical porosity of the bone during the growth in early adolescence may contribute to the risk of forearm fractures.10,24 The forearm, in particular, may represent a fracture location that is likely to reflect the bone health deficits.25 Overweight children are reported to be at increased risk of sustaining fractures.26,27 Obesity may increase the mechanical loads when falling as the bone strength is not relative to the body mass.28,29 Obesity is increasing in children.30 The participation in organised sports amongst teenagers has increased by 5% in Sweden between 1998 and 2005.31 Most sportsrelated fractures involve the upper extremity, radius and ulnae.32 However, sports-related injuries vary between countries and between different regions in one country.3 So, organised sports did not explain the increasing incidence of the diaphyseal forearm fractures in this population. Poor nutrition has been associated with low bone mineralisation.33 Association between vitamin D status and fracture risk in children has not been reported.4 Finally, there does not seem to be any single explaining factor for the significant increase in the paediatric diaphyseal both-bone forearm fractures. Paediatric forearm fractures offer significant therapeutic challenges to orthopaedic surgeons.12 The increasing incidence rates and descending threshold for performing internal fixation in a forearm fracture in our region are certain. All the cases were included in this population-based study. There are no other paediatric trauma centres in the geographic catchment area. The increased interest of invasive surgery is supported by the higher re-displacement rate amongst the cases that are treated with close reduction compared to the cases with internal fixation. This study was a complete epidemiologic study in the natural geographical district. The findings are certain. However, the reasons for the increasing incidence of forearm fractures and surgery remain unclear due to study design. The reason for the increase of the mean age of the male patients also remains uncertain. These are the major limitations of our study. So, there is a need for a wide prospective cohort study to investigate the causative background factors of increasing paediatric forearm fractures. The fast increase of these fractures and their invasive treatment load the operation room resources and have economical effects, too. Conclusion Our results show accelerating increase in the incidence of paediatric diaphyseal both-bone forearm fractures in the last decade. A trampoline was the most important cause for these injuries. Open surgery increased and closed reduction decreased as a treatment of paediatric diaphyseal both-bone forearm fractures. Internal fixation prevented re-displacement in our cohort. High rate of re-displacement (29.9%) was observed during the conservative treatment. Conflict of interest Authors do not have any conflict of interest in relation to this work. References 1. Scheidt PC, Harel Y, Trumble AC, et al. The epidemiology of nonfatal injuries among US children and youth. Am J Public Health 1995;85:932–8. 2. Landin LA. Epidemiology of children’s fractures. J Pediatr Orthop B 1997;6: 79–83.
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3. Rennie L, Court-Brown CM, Mok JY, Beattie TF. The epidemiology of fractures in children. Injury 2007;38:913–22. 4. Ryan LM, Teach SJ, Searcy K, et al. Epidemiology of pediatric forearm fractures in Washington DC. J Trauma 2010;69:S200–5. 5. Rivara FP, Grossman DC, Cummings P. Injury prevention, first of two parts. N Engl J Med 1997;337:543–8. 6. Mayranpaa MK, Makitie O, Kallio PE. Decreasing incidence and changing pattern of childhood fractures: a population-based study. J Bone Miner Res 2010;25:2476–83. 7. Helenius I, Lamberg TS, Kaariainen S, et al. Operative treatment of fractures in children is increasing. A population-based study from Finland. J Bone Joint Surg Am 2009;91:2612–6. 8. Lyons RA, Sellstrom E, Delahunty AM, et al. Incidence and cause of fractures in European districts. Arch Dis Child 2000;82:452–5. 9. Lyons RA, Delahunty AM, Kraus D, et al. Children’s fractures: a population based study. Inj Prev 1999;5:129–32. 10. Khosla S, Melton 3rd LJ, Dekutoski MB, et al. Incidence of childhood distal forearm fractures over 30 years: a population-based study. JAMA 2003;290:1479–85. 11. Jonsson B, Bengner U, Redlund-Johnell I, Johnell O. Forearm fractures in Malmo, Sweden. Changes in the incidence occurring during the 1950s, 1980s and 1990s. Acta Orthop Scand 1999;70:129–32. 12. Zionts LE, Zalavras CG, Gerhardt MB. Closed treatment of displaced diaphyseal both-bone forearm fractures in older children and adolescents. J Pediatr Orthop 2005;25:507–12. 13. Cheng JC, Ng BK, Ying SY, Lam PK. A 10-year study of the changes in the pattern and treatment of 6493 fractures. J Pediatr Orthop 1999;19:344–50. 14. Cooper C, Dennison EM, Leufkens HG, et al. Epidemiology of childhood fractures in Britain: a study using the general practice research database. J Bone Miner Res 2004;19:1976–81. 15. Herman-Giddens ME. Recent data on pubertal milestones in United States children: the secular trend toward earlier development. Int J Androl 2006;29:241–6. 16. Flynn JM, Jones KJ, Garner MR, Goebel J. Eleven years experience in the operative management of pediatric forearm fractures. J Pediatr Orthop 2010;30:313–9. 17. Yung PS, Lam CY, Ng BK, et al. Percutaneous transphyseal intramedullary Kirschner wire pinning: a safe and effective procedure for treatment of
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displaced diaphyseal forearm fracture in children. J Pediatr Orthop 2004;24: 7–12. Price CT. Acceptable alignment of forearm fractures in children: open reduction indications. J Pediatr Orthop 2010;30:82–4. Yung SH, Lam CY, Choi KY, et al. Percutaneous intramedullary Kirschner wiring for displaced diaphyseal forearm fractures in children. J Bone Joint Surg Br 1998;80:91–4. Ortega R, Loder RT, Louis DS. Open reduction and internal fixation of forearm fractures in children. J Pediatr Orthop 1996;16:651–4. Smith VA, Goodman HJ, Strongwater A, Smith B. Treatment of pediatric bothbone forearm fractures: a comparison of operative techniques. J Pediatr Orthop 2005;25:309–13. Raustorp A, Ludvigsson J. Secular trends of pedometer-determined physical activity in Swedish school children. Acta Paediatr 2007;96:1824–8. Hurson C, Browne K, Callender O, et al. Pediatric trampoline injuries. J Pediatr Orthop 2007;27:729–32. Parfitt AM. The two faces of growth: benefits and risks to bone integrity. Osteoporos Int 1994;4:382–98. Cuddihy MT, Gabriel SE, Crowson CS, et al. Forearm fractures as predictors of subsequent osteoporotic fractures. Osteoporos Int 1999;9:469–75. Goulding A, Cannan R, Williams SM, et al. Bone mineral density in girls with forearm fractures. J Bone Miner Res 1998;13:143–8. Taylor ED, Theim KR, Mirch MC, et al. Orthopedic complications of overweight in children and adolescents. Pediatrics 2006;117:2167–74. Wetzsteon RJ, Petit MA, Macdonald HM, et al. Bone structure and volumetric BMD in overweight children: a longitudinal study. J Bone Miner Res 2008;23:1946–53. Goulding A, Jones IE, Taylor RW, et al. More broken bones: a 4-year double cohort study of young girls with and without distal forearm fractures. J Bone Miner Res 2000;15:2011–8. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999–2000. JAMA 2002;288:1728–32. Hedstrom EM, Svensson O, Bergstrom U, Michno P. Epidemiology of fractures in children and adolescents. Acta Orthop 2010;81:148–53. Soprano JV. Musculoskeletal injuries in the pediatric and adolescent athlete. Curr Sports Med Rep 2005;4:329–34. Goulding A. Risk factors for fractures in normally active children and adolescents. Med Sport Sci 2007;51:102–20.
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
The increasing incidence of paediatric diaphyseal both-bone forearm fractures and their internal fixation during the last decade Juha-Jaakko Sinikumpu *, Anu Lautamo, Tytti Pokka, Willy Serlo Division of Paediatric Surgery and Orthopaedics, Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 8 November 2011
Background: The incidence of children’s forearm fractures is increasing worldwide. This is different from the declining trend observed in the overall injury rate, and the reason for the increase is not known. Diaphyseal forearm fractures comprise 3–6% of all paediatric fractures, and they offer a challenge to their treatment. The purpose of this study was to evaluate the incidence of diaphyseal both-bone forearm fractures in children during the last decade in Northern Finland. Another objective was to study the background factors, treatment, and re-displacement of these fractures. Materials and methods: All 168 children (<16 years) admitted to our paediatric trauma centre due to diaphyseal both-bone forearm fractures during 2000–2009 were included. The type of injury, background factors, radiographics, treatments and re-dislocations were reviewed. The age-related incidence rates were evaluated. Results: The incidence of diaphyseal both-bone forearm fractures increased 4.4-fold (95% CI 2.0–10.8; P < 0.001) between 2000 (8.2/100 000) and 2009 (35.9/100 000). The increase in the incidence was accelerating (P < 0.001) and the overall increase was 338%. The incidence of surgical treatment for diaphyseal fractures increased 4.2-fold (95% CI 1.9–10.4, P = 0.001), which is in relation to increasing number of fractures. However, internal fixation increased from 13.3% in 2000–2001 to 52.7% in 2008– 2009 (P = 0.015), as an alternative to conservative treatment. The re-displacement rate was high (29.9%) amongst the patients with conservative treatment compared to those who were invasively operated (1.4%) (P < 0.001). The mean age of the patients increased by 2.4 years in the study period (P = 0.019). Trampoline was the most important and still increasing reason for the fractures. At the beginning of the study, there were no trampoline-related fracture, but towards the end of the study 30–41% of the fractures were caused by a trampoline injury (P = 0.004). Conclusions: There was an accelerating increase in the incidence of paediatric diaphyseal both-bone forearm fractures during the last decade. Trampoline was the most important and still increasing reason for these fractures. The mean age of the patients was increasing. Increasing proportion of diaphyseal both-bone forearm fractures was treated operatively. Re-displacement was unusual amongst operated cases. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Forearm fracture Diaphyse Operative treatment Surgery Incidence Paediatrics Children and Adolescents
Background About one-fourth of all children are injured each year.1 Fractures account for 10–25% of these injuries.2 Before the age of 16, about one-third of children will get a fracture.3 Children have almost twice the incidence of fractures compared to the incidence in adults.3 There has been differing reports of the change in the incidence of paediatric fractures worldwide: some have reported
* Corresponding author at: Division of Paediatric Surgery and Orthopaedics, Department of Children and Adolescents, Oulu University Hospital, PL 29/90029 OYS, Finland. Tel.: +358 8 3155835; fax: +358 8 3154499. E-mail addresses: juha-jaakko.sinikumpu@fimnet.fi (J.-J. Sinikumpu), [email protected].fi (A. Lautamo), tytti.pokka@oulu.fi (T. Pokka), willy.serlo@oulu.fi (W. Serlo). 0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.11.006
decreasing numbers of the incidence of paediatric fractures.4–6 On the other hand, the total incidence of paediatric fractures increased by 13.5% between 1997 and 2006 in Finland.7 The fracture rates in children vary between countries.8 Forearm fractures are the most common fractures in children and adolescent. Including distal part of radius and ulna, they cover up to 36–45% of all fractures in children and adolescent.9 Multiple studies have shown that the incidence of paediatric forearm fractures is increasing.7,10,11 The treatment of paediatric forearm fracture is controversial and the management is still evolving.12 Recently, there has been a trend towards operative management of forearm fractures in children and adolescents.12 The incidence of invasive surgery in forearm fractures has increased from 1.8% to 22% between 1985 and 1995, as an alternative to closed reduction and cast
J.-J. Sinikumpu et al. / Injury, Int. J. Care Injured 43 (2012) 362–366
immobilisation.13 During 1997–2006, the incidence of open surgery of forearm fractures increased by 182% in a Finnish registry-based nationwide study.7 In this study our purpose was to evaluate the incidence of the challenging diaphyseal both-bone forearm fractures and their surgical treatment. Little is known about the change in the incidence of paediatric forearm fractures at different anatomic locations (distal, middle third and proximal). Another objective was to study the rate of re-displacement according to the type of treatment. We also aimed to determine the background factors of the fractures. Materials and methods We performed a population-based epidemiologic research in Northern Finland. All the children under the age of 16 years who were admitted to our paediatric trauma centre for diaphyseal middle third both-bone fracture in a forearm during 2000–2009 were included in the study. Shaft fractures with associated disruption of the radiocapitellar joint (Monteggia fracture and equivalents) and the distal radioulnar joint (Galeazzi fracture and equivalents) were excluded. Both the patients who were hospitalised for operation and those treated on demand in the emergency room were included. There are no other paediatric trauma units in our hospital district and all paediatric diaphyseal forearm fractures have been treated in the same unit during the study period. The cohort was inclusive. To get valid incidence rate in relation to the population in risk, nonresidents were excluded. A comprehensive review on injuries, hospitalisation and the details of treatment and following was entered in the computerised database. All the radiographs were
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re-analysed twice by a radiologist and a clinician. The final include of the cases was made according to the review of the primary radiographs. The operative summaries were reviewed as well as clinical notes. We determined >158 of malalignment, >308 of malrotation and >100% of displacement as the indicators of unacceptable position postoperatively or during the conservative treatment. However, despite the numbers, all the patients who underwent an unplanned operation due to loss of position were classified as unacceptable. The surgical procedures were classified as a closed treatment (closed reduction and application of a cast under general anaesthesia) and an invasive treatment (closed or open reduction and internal fixation). The age-matching population-in-the-risk in the district of our institute during the study was achieved by the comprehensive national database by Official Statistics of Finland. It varied between 84.562 and 86.385. The annual incidences per 100 000 age-related persons are given as well as other descriptive frequencies. Independent t-test was used to test differences between group means, x2 statistic was used to investigate whether distributions of the gategorical variables differed from one another, the differences between two proportions were tested by the binomial SND test and a change in time was tested by the linear trend test. The Poisson distribution-based x2 test was used to test the difference in the annual incidence densities between the first and the last follow-up year. The amount of annual diaphyseal fracture increase was estimated by exponential regression analysis. A statistical significance was preset at the P-value < 0.05. The data were analysed using IBM SPSS Statistic, version 19, and StatsDirect Statistical Software, version 2.7.2. Insitutional Ethics committee approval was not required. Results Descriptives There were 168 included paediatric diaphyseal both-bone forearm fractures during 2000–2009. Males (69.6%) predominated over the whole period (P < 0.001). According to radiographics most fractures were angulated (81.5%). Eight of them were multifragmented, and shortening was observed in 21 (12.5%) cases. Fifteen of all fractures were open. The mean age of the patients was 8.6 years (SD 3.9) for both genders. A notable elevation in the mean age was observed (from 6.4 years in 2000–2001 to 8.8 years in 2002–2009, P = 0.019). This was obvious in both genders, but reached statistical significance only amongst boys (P = 0.016) (Fig. 1). Incidence There was a 4.4-fold (95% CI 2.0–10.8; P < 0.001) increase in the incidence of diaphyseal both-bone forearm fractures during the study time (from 8.2/100 000 in 2000 to 35.9/100 000 in 2009). The increase was 11.7% yearly (95% CI 10.5–12.9%, P < 0.001). The overall increase was 338% (Fig. 2). Injury mechanism
Fig. 1. The mean age of the paediatric patients with a diaphyseal forearm fracture.
Trampoline was the most important reason for the rising incidence of diaphyseal forearm fractures. During the follow-up, 25% of all fractures were caused by a trampoline injury. There was a notable increase in the trampoline-related injuries from 0% to 30– 41% during the study time (trend test, P = 0.004) (Fig. 3). About 10% of all injuries were sports related. There was a slight decreasing incidence of the injuries in organised sports, but it did not reach statistical significance (P = 0.26). No change was observed in the
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Fig. 2. The age-related incidence of the paediatric diaphyseal forearm fractures (bars) and the incidence of surgical procedures for them (line).
incidence of tumbling (22%), falling between planes (21%), injury in a playground device other than trampoline (14%) or in traffic accidents (7%). (Table 1)
Fig. 3. The trampoline related diaphyseal forearm fractures related to all diaphyseal forearm fractures in children and adolescents.
2000–2001 to 29, 52.7% in 2008–2009, P = 0.015). At the end of the study phase (2008–2009), no differences in the proportions of invasive treatment (52.7%) and non-invasive treatment were noted (P = 0.57) (Table 2).
Surgical treatment Re-displacement rate As many as 159 cases of all (94.6%) diaphyseal both-bone forearm fractures were treated in the operating room under general anaesthesia. There was a significant increase in the incidence of open reduction during the study time (from 2, 13.3% in
The incidence of the loss of reduction and the need of unplanned reduction was 29.9% (N = 29/97) amongst the cases that were treated non-invasively primarily. By contrast, the
Table 1 Injury mechanisms and recreational causes of the paediatric diaphyseal forearm fractures.
Injury mechanism Fall on the same plane Fall between planes Fall on the ice Fall at playground Traffic injury Other injury Recreational causes Organised sport (soccer, ice hockey, etc.) Slalom, cross-country skiing, snowboarding Bicycling, skating, skateboarding Other playground device, swing, etc. Trampoline Indoor play Falling, not more defined Motor vehicle Falling from ladder, roof, etc. Falling when running * **
2000–1
2002–3
2004–5
2006–7
2008–9
All*
P-value**
25% (4) 31.3% (5) 0% (0) 25% (4) 12.5% (2) 6.3% (1)
33.3% (11) 18.2% (6) 6.1% (2) 30.3% (10) 3% (1) 9.1% (3)
20% (6) 13.3% (4) 6.7% (2) 33.3% (10) 20% (6) 6.7% (2)
18.8% (6) 18.8% (6) 3.1% (1) 50% (16) 3.1% (1) 6.3% (2)
17.9% (10) 25% (14) 1.8% (1) 44.6% (25) 3.6% (2) 7.1% (4)
22.2% (37) 21% (35) 3.6% (6) 38.9% (65) 7.2% (12) 7.2% (13)
0.16 0.84 0.58 0.47 0.22 0.88
18.8% (3) 0% (0) 6.3% (1) 6.3% (1) 0% (0) 12.5% (2) 25% (4) 6.3% (1) 25% (4) 25% (4)
15.2% (5) 6.1% (2) 15.2% (5) 9.1% (3) 15.2% (5) 9.1% (3) 24.2% (8) 0% (0) 6.1% (2) 24.2% (8)
3.3% (1) 6.7% (2) 20.0% (6) 10.0% (3) 23.3% (7) 6.7% (2) 20.0% (6) 0% (0) 6.7% (2) 20.0% (6)
9.4% (3) 3.1% (1) 0% (0) 9.4% (3) 40.6% (13) 9.4% (3) 15.6% (5) 9.4% (3) 3.1% (1) 15.6% (5)
8.9% 1.8% 9.0% 12.5% 30.4% 8.9% 12.5% 3.6% 8.9% 12.7%
(5) (1) (5) (7) (17) (5) (7) (2) (5) (7)
10.2% 3.6% 10.2% 10.2% 25.1% 9.0% 18.0% 3.6% 8.4% 18.0%
(17) (6) (17) (17) (42) (15) (30) (6) (14) (30)
0.26 0.58 0.35 0.46 0.004 0.83 0.1 0.52 0.26 0.28
Total number of cases 167 (one cases missing data). Trend test.
Table 2 Operative activity and surgical procedures for the paediatric diaphyseal forearm fractures.
Operative activity (% of all patients and number) Procedure at OR* (operated) Not admitted to OR (not operated) Surgical procedure (% of all operated and number) Closed or open reduction and internal fixation Closed treatment * **
Operating room. Trend test.
2000–1
2002–3
2004–5
2006–7
2008–9
All
P-value
93.8% (15) 6.3% (1)
93.9% (31) 6.1% (2)
96.7% (29) 3.3% (1)
90.6% (29) 9.4% (3)
96.5% (55) 3.5% (2)
94.6% (159) 5.4% (9)
0.74**
13.3% (2) 86.7% (13)
45.2% (14) 54.8% (17)
34.5% (10) 65.5% (19)
55.2% (16) 44.8% (13)
52.7% (29) 47.3% (26)
44.7% (71) 55.3% (88)
0.015**
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worsening of the reduction was observed in one case with internal fixation (1.4%, N = 1/71) (P < 0.001). Discussion In our study the paediatric diaphyseal both-bone forearm fractures increased about 12% yearly. The total increase in the incidence was 4.4-fold (95% CI 2.0–10.8; P < 0.001). This is an alarming finding. There is a variation in a way to report forearm fractures: Some authors have included single or both-bone fractures in every site of a forearm, whereas others have analysed proximal, distal, and middle third diaphyseal fractures separately.14 Diaphyseal middle third fractures differ from distal or proximal forearm fractures. Our study confirmed the increase in the incidence of just challenging diaphyseal both-bone middle third forearm fractures. In our study, the mean age of the male patients with a fracture was increasing. To our knowledge, this has not been reported before. Controversially, the mean age of children with a fracture has been postulated to diminish following the descending trend of pubertal onset.4,15 Our finding may be associated with the changing pattern of recreational activities. The change in the mean age needs to be studied further. In the study, almost every child was treated under general anaesthesia in the OR. The surgical operations for diaphyseal forearm fractures increased 4.2-fold (95% CI 1.9–10.4) between 2000 and 2009 (from 8.2/100 000 to 34.7/100 000, P < 0.001) but it was in relation to the increasing number of the fractures: there was no change in the surgery rate as related to the injury rate (Fig. 2). This means that the indications to treat the patient in the operation room have been stable. Instead, there was increasing trend of internal fixation from 13.3% in 2000–2001 to 52.7% in 2008–2009 (P = 0.015) as an alternative to closed reduction and casting under general anaesthesia. So, we found that the number of internal fixation procedures in diaphyseal both-bone forearm fractures increased 14.5-fold (from 2 to 29) between 2000–2001 and 2008– 2009. It is in relation with a recent trend toward invasive management in treatment of paediatric fractures.12,16 Different kinds of operative fixations have been advocated17 and the management of forearm fractures is evolving.12,18 The risk of re-displacement and the need of unplanned operation were much higher amongst the cases that were treated non-invasively compared to those that were invasively operated, according to presumption. The finding may be an essential reason for the recent increase in internal fixations. An unplanned operation under general anaesthesia is a needless risk for a child. Re-operations cause costs and they load the resources of operating units. A high incidence of displacement, malunion and consequent limitations of function after conservative treatment supports the increase of surgery in forearm fractures.19 Nevertheless, the results of operative methods over the results of closed treatment in forearm fractures have not been reported as superior.12 The problems of surgical trauma in operation are not marginal17 and most implants have to be removed later in a re-operation. The guidelines for acceptable alignment and the indications for operation remain mysterious,18,20 and closed treatment and casting have been a standard for the treatment of diaphyseal forearm fractures.12,21 It is especially reasonable in children younger than 8 or 9 years of age because of a rapid healing time of a bone injury and a predictable remodelling of a fracture.12 A total bayonet apposition and up to 158 of angulation are suggested to be acceptable in older children and adolescence.12 A remarkable increase in the trampoline injuries during the study time was observed (Fig. 3). Forearm fractures have been linked to recreational activities.10 Daily physical activity has been shown to increase amongst school children in this millennium.22
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The trampoline is known to be a high-risk activity with a potential for orthopaedic injuries.23 There are many backyard trampolines in our hospital district. There are some other factors that have been assumed to explain the paediatric fractures. A transient increase in the cortical porosity of the bone during the growth in early adolescence may contribute to the risk of forearm fractures.10,24 The forearm, in particular, may represent a fracture location that is likely to reflect the bone health deficits.25 Overweight children are reported to be at increased risk of sustaining fractures.26,27 Obesity may increase the mechanical loads when falling as the bone strength is not relative to the body mass.28,29 Obesity is increasing in children.30 The participation in organised sports amongst teenagers has increased by 5% in Sweden between 1998 and 2005.31 Most sportsrelated fractures involve the upper extremity, radius and ulnae.32 However, sports-related injuries vary between countries and between different regions in one country.3 So, organised sports did not explain the increasing incidence of the diaphyseal forearm fractures in this population. Poor nutrition has been associated with low bone mineralisation.33 Association between vitamin D status and fracture risk in children has not been reported.4 Finally, there does not seem to be any single explaining factor for the significant increase in the paediatric diaphyseal both-bone forearm fractures. Paediatric forearm fractures offer significant therapeutic challenges to orthopaedic surgeons.12 The increasing incidence rates and descending threshold for performing internal fixation in a forearm fracture in our region are certain. All the cases were included in this population-based study. There are no other paediatric trauma centres in the geographic catchment area. The increased interest of invasive surgery is supported by the higher re-displacement rate amongst the cases that are treated with close reduction compared to the cases with internal fixation. This study was a complete epidemiologic study in the natural geographical district. The findings are certain. However, the reasons for the increasing incidence of forearm fractures and surgery remain unclear due to study design. The reason for the increase of the mean age of the male patients also remains uncertain. These are the major limitations of our study. So, there is a need for a wide prospective cohort study to investigate the causative background factors of increasing paediatric forearm fractures. The fast increase of these fractures and their invasive treatment load the operation room resources and have economical effects, too. Conclusion Our results show accelerating increase in the incidence of paediatric diaphyseal both-bone forearm fractures in the last decade. A trampoline was the most important cause for these injuries. Open surgery increased and closed reduction decreased as a treatment of paediatric diaphyseal both-bone forearm fractures. Internal fixation prevented re-displacement in our cohort. High rate of re-displacement (29.9%) was observed during the conservative treatment. Conflict of interest Authors do not have any conflict of interest in relation to this work. References 1. Scheidt PC, Harel Y, Trumble AC, et al. The epidemiology of nonfatal injuries among US children and youth. Am J Public Health 1995;85:932–8. 2. Landin LA. Epidemiology of children’s fractures. J Pediatr Orthop B 1997;6: 79–83.
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