The epidemiology of fractures in adolescents with reference to social deprivation

Paediatric open fractures presenting to a level 1 trauma centre: a 10 year epidemiological study

PURPOSE

The epidemiology of paediatric fractures has been previously described, however there is limited data available on open fractures in this population. The purpose of this study was to investigate trends, mechanism of injury (MOI) and severity of paediatric open fractures and undertake an epidemiological study.

METHODS

All children ≤ 16.0 years presenting with open fractures were identified between 01/04/2013 and 01/04/2023. Those with craniofacial, thoracic and distal phalangeal fractures were excluded. Incidence was calculated based on those presenting within the local geographical region. Social deprivation was measured using the Index of Multiple Deprivation (IMD).

RESULTS

There were 208 open fractures with a median age of 11.0(q1 7.4-q3 13.4) years, and 153(74.6%) were in males. The MOIs were road traffic collisions 73(35.1%), sports/play 45(21.6%), fall > 2m 29(13.9%), simple fall 25(12.0%), crush 16(7.7%), bites 8(3.8%), assault 6(2.9%), and other 6(2.9%). Nineteen children (9.1%) presented with polytrauma. Gustilo-Anderson grade for long bone fractures were I-61(29.3%), II-24(11.5%), IIIa-36(17.3%), IIIb-30(14.4%) and IIIc-7(3.4%). There were 129 children presenting within the local geographical region providing an annual incidence of 8.0/100,000. Radius and ulna were the most frequently injured 49(38.0%) followed by tibia and fibula 44(34.1%). There were 69(53.5%) children presenting from an IMD quintile 1 with open fractures.

CONCLUSION

Paediatric open fractures are commonly seen in the adolescent male and affect those who are from a more socially deprived background. These injuries account for 3.2% of fractures admitted to a MTC. Data suggests children principally sustain open fractures through two distinct injury patterns and ten-year trends suggests that there is a gradual decline in the annual incidence.

Impact of Socioeconomic Factors on Time to Surgery for Distal Radius Fractures

Background

Delay in care secondary to socioeconomic status (SES) and demographic factors represents an area for potential improvement. Reducing time to surgery in distal radius fracture (DRF) fixation may improve outcomes while reducing cost. The purpose of this study is to investigate the effect of SES on time to surgery in our study population.

Methods

Patients undergoing outpatient DRF surgery within an academic healthcare system during a 4-year period were reviewed. Time to surgery and demographic factors were analyzed. The US Census Bureau was used to determine median household income (MHI) for a patient's ZIP code; patients were stratified into three groups based on MHI.

Results

A total of 413 patients met inclusion criteria. SES (14.7 d in the low-SES group, 14.0 d in the mid-SES group, and 11.1 d in the high-SES group, P = 0.00063), insurance (11.7 d for insured versus 16.3 d for Medicaid/uninsured, P < 0.0001), race (non-White group: 15.2 d versus White group: 10.9 d, P < 0.0001), and treatment facility (16.2 d at county hospital versus 10.9 d at university hospital, P < 0.0001) were associated with time to surgery in univariate analysis. Multivariate analysis found that only treatment facility was associated with time to surgery.

Conclusions

Non-White, uninsured/Medicaid individuals residing in low-SES areas may be more likely to receive care at a safety-net facility and are at greatest risk for delay in time to surgery. Measures aimed to reduce barriers to care, increase healthcare coverage, and improve patient education should be initiated to mitigate these disparities.

Health Disparities in Hand and Upper Extremity Surgery: A Scoping Review

PURPOSE

Social determinants of health (SDOH) are linked to poor health care outcomes across the different medical specialties. We conducted a scoping review to understand the existing literature and identify further areas of research to address disparities within hand surgery.

METHODS

A systematic search of PubMed, Scopus, and Cochrane was conducted. Inclusion criteria were English studies examining health disparities in hand surgery. The following were assessed: the main SDOH, study design/phase/theme, and main disease/injury/procedure. A previously described health disparities research framework was used to determine study phase: detecting (identifying risk factors), understanding (analyzing risk factors), and reducing (assessing interventions). Studies were categorized according to themes outlined at the National Institute of Health and American College of Surgeons: Summit on Surgical Disparities.

RESULTS

The initial search yielded 446 articles, with 49 articles included in final analysis. The majority were detecting-type (31/49, 63%) or understanding-type (12/49, 24%) studies, with few reducing-type studies (6/49, 12%). Patient factors (31/49, 63%) and systemic/access factors (16/49, 33%) were the most frequently studied themes, with few investigating clinical care/quality factors (4/49, 8%), clinician factors (3/49, 6%), and postoperative/rehabilitation factors (1/49, 2%). The most commonly studied SDOH include insurance status (13/49, 27%), health literacy (10/49, 20%), and social deprivation (6/49, 12%). Carpal tunnel syndrome (9/49, 18%), upper extremity trauma (9/49, 18%), and amputations (5/49, 10%) were frequently assessed. Most investigations involved retrospective or database designs (29/49, 59%), while few were prospective, cross-sectional, or mixed-methods.

CONCLUSIONS

Despite an encouraging upward trend in health disparities research, existing studies are in the early phases of investigation.

CLINICAL RELEVANCE

Most of the literature focuses on patient factors and systemic/access factors in regard to insurance status. Further work with prospective, cross-sectional, and mixed-method studies is needed to better understand health disparities in hand surgery, which will inform future interventions.

Social and environmental determinants of health among children with long-term movement impairment

The healthcare research community increasingly recognizes the need to address social (SDOH) and environmental determinants of health (EDOH) to optimize health and healthcare. This is particularly relevant to disability and functioning and to those with child onset conditions that impair mobility and impact functioning and participation. Using the World Health Organization (WHO)'s International Classification of Functioning, Disability, and Health (ICF) as a comprehensive framework, this paper aims to discuss our understanding of the relationships between social and EDOH and outcomes among people with impaired mobility that impacts functioning. This paper offers suggestions for future developments and guidance to use SDOH and EDOH in research and clinical practice.

Predictors of falls and fractures leading to hospitalisation in 36 101 people with affective disorders: a large representative cohort study

OBJECTIVES

To investigate predictors of falls and fractures leading to hospitalisation in people with affective disorders.

DESIGN

Cohort study.

SETTING

The South London and Maudsley National Health Service (NHS) Foundation Trust (SLaM) Biomedical Research Centre (BRC) Case Register.

PARTICIPANTS

A large cohort of people with affective disorders (International Classification of Diseases- 10th version [ICD-10] codes F30-F34) diagnosed between January 2008 and March 2016 was assembled using data from the SLaM BRC Case Register.

PRIMARY AND SECONDARY OUTCOME MEASURES

Falls and fractures leading to hospitalisation were ascertained from linked national hospitalisation data. Multivariable Cox proportional hazards analyses were administrated to identify predictors of first falls and fractures.

RESULTS

Of 36 101 people with affective disorders (mean age 44.4 years, 60.2% female), 816 (incidence rate 9.91 per 1000 person-years) and 1117 (incidence rate 11.92 per 1000 person-years) experienced either a fall or fracture, respectively. In multivariable analyses, older age, analgesic use, increased physical illness burden, previous hospital admission due to certain comorbid physical illnesses and increase in attendances to accident and emergency services following diagnosis were significant risk factors for both falls and fractures. Having a history of falls was a strong risk factor for recurrent falls, and a previous fracture was also associated with future fractures.

CONCLUSIONS

Over a mean 5 years' follow-up, approximately 8% of people with affective disorders were hospitalised with a fall or fracture. Several similar factors were found to predict risk of falls and fracture, for example, older age, comorbid physical disorders and analgesic use. Routine screening for bone mineral density and fall prevention programmes should be considered for this clinical group.

Evaluating the Impact of Social Deprivation on Mid-Term Outcomes Following Distal Radius Open Reduction Internal Fixation

Purpose

Although baseline biopsychosocial factors are associated with short-term patient-reported outcomes following distal radius fracture open reduction internal fixation (ORIF), their effect on mid-term outcomes is unclear. We aimed to evaluate the effect of social deprivation, previously established as a surrogate for depression, pain interference, and anxiety, on quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores >1 year following distal radius ORIF.

Methods

Adult patients (≥18 years) with an isolated distal radius fracture treated with ORIF by orthopedic trauma and hand surgeons at a single tertiary academic center over a 3-year period were included. Outcomes at ≥1 year postoperatively were evaluated using QuickDASH. Age, follow-up duration, area deprivation index (ADI; a measure of social deprivation), subspecialty (hand vs trauma), and postoperative alignment were assessed using linear regression with 95% confidence intervals after bootstrapping and a permutation test for P values to test for their association with the final QuickDASH score.

Results

Follow-up data were obtained for 98 of 220 (44.5%) patients at a mean of 3.1 ± 1.0 years after surgery. Mean age and ADI were 53.2 ± 15.4 years and 26.8 ± 18.7, respectively. Most fractures were intra-articular (67.3%), and 72.4% had acceptable postoperative alignment parameters, as defined by the American Academy of Orthopaedic Surgeons clinical practice guidelines. The mean QuickDASH score was 13.0 ± 16.5. There were no significant associations between the final QuickDASH score and any studied factor, including ADI, as determined using univariable analysis. Multivariable analysis showed no association between ADI and the final QuickDASH score, independent of age, sex, treating service, follow-up duration, and fracture alignment or pattern.

Conclusions

At mid-term follow up after distal radius ORIF, ADI did not correlate with QuickDASH scores, and the QuickDASH scores of the patients did not differ from those of the general population. However, our cohort mostly comprised patients with levels of deprivation below the national median. Although studies have shown that the short-term outcomes of distal radius ORIF are influenced by biopsychosocial factors, outcomes at the time of final recovery may not be associated with social deprivation.

Type of study/level of evidence

Prognostic IV.

Socioeconomic variables and fracture risk in children and adolescents: a population-based study from northern Sweden

OBJECTIVES

Previous studies have investigated the association between socioeconomic characteristics and fractures among children, producing different results. In a population-based study, we previously found an increased risk of fractures among children living in an urban municipality compared with rural municipalities. This study aimed to evaluate the importance of socioeconomic variables for the incidence of fractures among 0-17 year olds.

SETTING, DESIGN AND OUTCOME MEASURE

We present a longitudinal, observational study of a population 0-17 years of age. Data from an injury database were linked with additional socioeconomic data for the population at risk. These were 55 758 individuals residing within the primary catchment area of a regional hospital in northern Sweden. Using the number of fractures as the outcome, we fitted a generalised linear mixed model for a Poisson response with socioeconomic variables at the family level as independent variables while controlling for age, sex and place of residence.

RESULTS

We found a significant association between higher levels of family income and the risk of fracture, rate ratio 1.40 (1.28-1.52) p<0.001 when comparing the highest income quintile to the lowest as well as the number of siblings and the risk of fracture. Children with one or two siblings had a rate ratio of 1.28 (1.19-1.38) p<0.001 when compared with children with no siblings. Parents' educational level and having a single parent showed no significant association with fractures. The previously observed association between municipalities and fracture risk was less pronounced when taking family-level socioeconomic variables into account.

CONCLUSION

Our results indicate that children from families with higher income and with siblings are at greater risk of sustaining fractures.

Area Deprivation Index and Magnitude of Scoliosis at Presentation to a Tertiary Referral Scoliosis Clinic in Massachusetts

BACKGROUND

There is growing interest in identifying predictors of large scoliosis curves at initial presentation, but few data to guide such preventive efforts. The association of neighborhood socioeconomic deprivation with curve magnitude in this context has not been previously evaluated. The purpose of our study was to determine the correlation of socioeconomic deprivation with scoliosis curve magnitude at initial presentation. Secondarily, we assessed the correlation of body mass index (BMI) with curve severity.

METHODS

We retrospectively identified 202 patients presenting with adolescent idiopathic scoliosis to a single tertiary care center in Massachusetts from January 2015 to August 2018. The Area Deprivation Index (ADI), a validated composite measure of neighborhood socioeconomic deprivation, was calculated for each patient. Curve magnitude, age, sex, BMI, race, and insurance status were recorded. Pearson correlation was used to determine the association of the ADI and BMI with scoliosis severity.

RESULTS

There was no correlation between the ADI and the magnitude of scoliosis at presentation (r=0.055; P=0.43). Greater BMI was moderately correlated with increased scoliosis curve magnitude (r=0.28; P<0.001). There was no association between curve magnitude and patient age, sex, race, or insurance status.

CONCLUSIONS

The finding that neighborhood socioeconomic deprivation did not correlate with greater scoliosis severity at presentation may be suggestive of equitable access to specialized scoliosis care. Future research should determine whether this reassuring finding is unique to Massachusetts--a state with high rates of health insurance coverage--or generalizable to other US states. In addition, our study further corroborates the notion that greater BMI is associated with larger scoliosis curves, and calls for targeted interventions to facilitate early scoliosis detection in the growing childhood obese population.

LEVEL OF EVIDENCE

Level II-prognostic study and retrospective study.

The association of socioeconomic deprivation and paediatric open tibia fractures

The primary aim of this study is to test the association of open tibial fractures (OTF), in a paediatric age group, with socioeconomic deprivation. The secondary objectives are to more clearly define the epidemiological characteristics of these high-energy injuries. A consecutive series of patients with OTF presenting to a major trauma centre at a children's hospital in Liverpool had age, gender, fracture pattern, mechanism, timing of the injury and their postcode of residence recorded. Those cases outside Liverpool, Sefton and Knowsley local authorities were excluded from incidence calculations. Postcodes were used to generate deprivation scores (Index of Multiple Deprivation, 2010) based on census data (2011). Cases were ranked and allocated to deprivation quintiles. A comparison to the normal population within Merseyside was undertaken using regression analysis. There were 71 cases over a 9-year period. Fifty cases resided within the geographical limits of Merseyside and were included in the incidence calculations. The annual incidence of paediatric OTF is 3.09 per 100 000 children (0-16 years). The median age at injury was 11 years (range 2-16) and this occurred most usually during term-time between 3 and 5 p.m. from road traffic collisions. Paediatric OTFs are strongly associated with socioeconomic deprivation. The association with deprivation reflects an exposure to unsafe roads in busy urban areas with limited access to safe playing spaces. Socioeconomically deprived men are most at risk from this injury. The links between deprivation and outcomes of treatment or long-term prospects are unclear.

Is Social Deprivation Associated with PROMIS Outcomes After Upper Extremity Fractures in Children?

BACKGROUND

We previously found that social deprivation was associated with worse perceived function and pain among children presenting with upper extremity fractures. We performed the current study to determine whether this differential in outcome scores would resolve after children received orthopaedic treatment for their fractures. This was needed to understand whether acute pain and impaired function were magnified by worse social deprivation or whether social deprivation was associated with differences in health perception even after injury resolution.

QUESTIONS/PURPOSES

Comparing patients from the least socially deprived national quartile and those from the most deprived quartile, we asked: (1) Are there differences in age, gender, race, or fracture location among children with upper extremity fractures? (2) After controlling for relevant confounding variables, is worse social deprivation associated with worse self-reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores before and after the treatment of pediatric upper extremity fractures? (3) Is social deprivation associated with PROMIS score improvements as a result of fracture treatment?

METHODS

In this this retrospective, comparative study, we considered data from 1131 pediatric patients (aged 8 to 17 years) treated nonoperatively at a single tertiary academic medical center for isolated upper extremity fractures between June 2016 and June 2017. We used the Area Deprivation Index to define the patient's social deprivation by national quartiles to analyze those in the most- and least-deprived quartiles. After excluding patients with missing zip codes (n = 181), 18% (172 of 950) lived in the most socially deprived national quartile, while 31% (295 of 950) lived in the least socially deprived quartile. Among these 467 patients in the most- and least-deprived quartiles, 28% (129 of 467) were excluded for lack of follow-up and 9% (41 of 467) were excluded for incomplete PROMIS scores. The remaining 297 patients were analyzed (107 most-deprived quartile, 190 least-deprived quartile) longitudinally in the current study; they included 237 from our initial cross-sectional investigation that only considered reported health at presentation (60 patients added and 292 removed from the 529 patients in the original study, based on updated Area Deprivation Index quartiles). The primary outcomes were the self-completed pediatric PROMIS Upper Extremity Function, Pain Interference, and secondarily PROMIS Peer Relationships computer-adaptive tests. In each PROMIS assessment, higher scores indicated more of that domain (such as, higher function scores indicate better function but a higher pain score indicates more pain), and clinically relevant differences were approximately 3 points. Bivariate analysis compared patient age, gender, race, fracture type, and PROMIS scores between the most- and least-deprived groups. A multivariable linear regression analysis was used to determine factors associated with the final PROMIS scores.

RESULTS

Between the two quartiles, the only demographic and injury characteristic difference was race, with Black children being overrepresented in the most-deprived group (most deprived: white 53% [57 of 107], Black 45% [48 of 107], other 2% [2 of 107]; least deprived: white 92% [174 of 190], Black 4% [7 of 190), other 5% [9 of 190]; p < 0.001). At presentation, accounting for patient gender, race, and fracture location, the most socially deprived quartile remained independently associated with the initial PROMIS Upper Extremity (β 5.8 [95% CI 3.2 to 8.4]; p < 0.001) scores. After accounting for patient gender, race, and number of days in care, we found that the social deprivation quartile remained independently associated with the final PROMIS Upper Extremity (β 4.9 [95% CI 2.3 to 7.6]; p < 0.001) and Pain Interference scores (β -4.4 [95% CI -2.3 to -6.6]; p < 0.001). Social deprivation quartile was not associated with any differential in treatment impact on change in PROMIS Upper Extremity function (8 ± 13 versus 8 ± 12; mean difference 0.4 [95% CI -3.4 to 2.6]; p = 0.79) or Pain Interference scores (8 ± 9 versus 6 ± 12; mean difference 1.1 [95% CI -1.4 to 3.5]; p = 0.39) from presentation to the conclusion of treatment.

CONCLUSION

Delivering upper extremity fracture care produces substantial improvement in pain and function that is consistent regardless of a child's degree of social deprivation. However, as social deprivation is associated with worse perceived health at treatment initiation and conclusion, prospective interventional trials are needed to determine how orthopaedic surgeons can act to reduce the health disparities in children associated with social deprivation. As fractures prompt interaction with our health care system, the orthopaedic community may be well placed to identify children who could benefit from enrollment in proven community health initiatives or to advocate for multidisciplinary care coordinators such as social workers in fracture clinics.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Social Deprivation and Congenital Upper Extremity Differences-An Assessment Using PROMIS

PURPOSE

Social deprivation, a measure of socioeconomic status, has been shown to negatively affect perceptions of orthopedic conditions and outcomes of treatment. The objective of this study was to assess whether social deprivation correlates with subjective assessment of function in pediatric patients with congenital hand differences.

METHODS

Patients enrolled in the Congenital Upper Limb Differences (CoULD) registry were assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS). The PROMIS scores for Pain Interference, Peer Relations, Anxiety, Depression, and Upper Extremity (UE) function were obtained for all patients 5 years and older at initial presentation. Social deprivation was determined by the Area Deprivation Index (ADI); the index ranges from 0 to 100 with higher scores being the most deprived. The PROMIS scores were correlated with the ADI for all patients.

RESULTS

Three hundred seventy-five pediatric patients with congenital UE differences were evaluated. Average age was 11 years, 56% were female, and 55% had bilateral involvement. Overall, PROMIS scores were within 1 SD of normal for Peer Relations, Pain, Depression, and Anxiety. However, child-reported scores for UE function (39) were more than 1 SD below the national average (50). The mean ADI for the cohort was lower than the national average, indicative of less deprivation, with 14% of patients in the most deprived national quartile. Children in the highest ADI quartile reported PROMIS scores that reflected higher Pain Interference (41 vs 45), lower Peer Relations (55 vs 50), higher Anxiety (44 vs 49), and higher Depression (43 vs 47) than children in the lowest ADI quartile.

CONCLUSIONS

The PROMIS scores were normal for psychosocial measures in children with congenital hand differences when evaluated as an entire cohort. However, child self-reported PROMIS scores for Pain Interference, Peer Relations, Anxiety, and Depression were worse in more socially deprived areas, suggesting more psychosocial challenges in these children.

CLINICAL RELEVANCE

Pediatric patients with congenital upper extremity differences in areas of higher social deprivation report lower psychosocial well-being. The care of these individuals must be considered within the context of their environment because they may be more at risk for negative outcomes secondary to environmental and societal stressors.

Socioeconomic Deprivation and Its Adverse Association with Adolescent Fracture Care Compliance

Background:

Socioeconomic deprivation increases fracture incidence in adolescents, but its impact on fracture care is unknown. The area deprivation index (ADI), which incorporates 17 factors from the U.S. Census, measures socioeconomic deprivation in neighborhoods. This investigation aimed to determine the impact of socioeconomic deprivation and other socioeconomic factors on fracture care compliance in adolescents.

Methods:

This study included patients who were 11 to 18 years of age and received fracture care at a single urban children’s hospital system between 2015 and 2017. Demographic information (sex, race, caregiver status, insurance type) and clinical information (mechanism of injury, type of treatment) were obtained. The ADI, which has a mean score of 100 points and a standard deviation of 20 points, was used to quantify socioeconomic deprivation for each patient’s neighborhood. The outcome variables related to compliance included the quantity of no-show visits at the orthopaedic clinic and delays in follow-up care of >1 week. Risk factors for suboptimal compliance were evaluated by bivariate analysis and multivariate logistic regression.

Results:

The cohort included 457 adolescents; 75.9% of the patients were male, and the median age was 16.1 years. The median ADI was 101.5 points (interquartile range, 86.3 to 114.9 points). Bivariate analyses demonstrated that higher ADI, black race, single-parent caregiver status, Medicaid insurance, non-sports mechanisms of injury, and surgical management are associated with suboptimal fracture care compliance. Adolescents from the most socially deprived regions were significantly more likely to have delays in care (33.8% compared with 20.1%; p = 0.037) and miss scheduled orthopaedic visits (29.9% compared with 7.1%; p < 0.001) compared with adolescents from the least deprived regions. ADI, Medicaid insurance, and initial presentation to the emergency department were independent predictors of suboptimal care compliance, when controlling for other variables.

Conclusions:

Socioeconomic deprivation is associated with an increased risk of suboptimal fracture care compliance in adolescents. Clinicians can utilize caregiver and insurance status to better understand the likelihood of fracture care compliance. These findings highlight the importance of understanding differences in each family’s ability to adhere to the recommended follow-up and of implementing measures to enhance compliance.

Geospatial Analyses of Pain Intensity and Opioid Unit Doses Prescribed on the Day of Discharge Following Orthopedic Surgery

OBJECTIVE

Inappropriate opioid prescribing after surgery contributes to opioid use disorder and risk of opioid overdose. In this cross-sectional analysis of orthopedic surgical patients, we examined the role of patient location on postoperative pain intensity and opioids prescribed on hospital discharge.

METHODS

We used geospatial analyses to characterize spatial patterns of mean pain intensity on the day of discharge (PiDoD) and opioid units prescribed on the day of discharge (OuPoD), as well as the effect of regional social deprivation on these outcomes.

RESULTS

At a 500-km radius from the surgery site, the Global Moran's I for PiDoD (2.71 × 10-3, variance = 1.67 × 10-6, P = 0.012) and OuPoD (2.19 × 10-3, SD = 1.87, variance = 1.66 × 10-6, P = 0.03) suggested significant spatial autocorrelation within each outcome. Local indicators of spatial autocorrelation, including local Moran's I, Local Indicator of Spatial Autocorrelation cluster maps, and Getis-Ord Gi* statistics, further demonstrated significant, specific regions of clustering both OuPoD and PiDoD. These spatial patterns were associated with spatial regions of area deprivation.

CONCLUSIONS

Our results suggest that the outcomes of pain intensity and opioid doses prescribed exhibit varying degrees of clustering of patient locations of residence, at both global and local levels. This indicates that a given patient's pain intensity on discharge is related to the pain intensity of nearby individuals. Similar interpretations exist for OuPoD, although the relative locations of hot spots of opioids dispensed in a geographic area appear to differ from those of hot spots of pain intensity on discharge.

Sports-related acute shoulder injuries in an urban population

Objectives

More than a third of sports injuries involve the upper extremity. The primary aim was to quantify and describe sports-related shoulder injuries in a general population cohort. A secondary aim was to compare aspects of these injuries to those that were not sports-related.

Methods

We performed a prospective registration of the activity at the time of shoulder injury in all cases admitted during 1 year in a combined primary care and orthopaedic emergency department serving a defined population. The electronic patient records and patient reported questionnaires were reviewed.

Results

Twenty-nine per cent (n=781) of 2650 registered shoulder injuries were reported to be sports-related, with the highest proportion in acromioclavicular injuries (>50%). Patients with sports injuries were younger than those injured during other activities (median age 28 and 43 years, respectively, p<0.001), and more often male (78% and 52%, respectively, p<0.001). There was a strong gender disparity in incidence of sports-related shoulder injuries in adolescents and young adults, which was not observed in non-sports shoulder injuries. Football (soccer) (6–29 years), cycling (30–49 years), skiing (50–69 years) and martial arts were the dominating sports activities. Fractures were more common in skiing and cycling than in other major sports in the study.

Conclusions

Almost a third of the shoulder injuries occurred during sports. The types of sports involved varied with age and gender. The comparison of sport to non-sport shoulder injury incidence rates suggests that the increased risk of shoulder injuries in young males is mainly attributable to sports injuries.

Trends in paediatric distal radius fractures: an eight-year review from a large UK trauma unit

INTRODUCTION

This observational study investigated the incidence of distal radius fractures in children, to determine whether the rate is rising, the effect of seasonal variation on incidence and whether fracture type and rate of surgical intervention has changed, to help in determining costs for secondary care and to aid resource allocation.

MATERIALS AND METHODS

All paediatric patients(n = 6529) who sustained a distal radius fracture over an eight-year period (2007-2014) were identified. Poisson regression modelling was used to identify change in trends.

RESULTS

There was no change in distal radius fracture incidence, rate of surgical intervention (P = 0.36) or fracture type (P = 0.70). Overall incidence was 337 fractures per 100,000 patient/years. The highest fracture incidence was seen in older school boys (708 per 100,000 patient/years, P < 0.005). Overall fracture rate was lower in winter (P < 0.005). Incidence is highest in summer and the main variation is related to season.

DISCUSSION

These data can help to predict accurately the number of children presenting to the emergency department with wrist fractures depending on the time of year.

The Impact of Social Deprivation on Pediatric PROMIS Health Scores After Upper Extremity Fracture

PURPOSE

Although social deprivation is acknowledged to influence physical and mental health in adults, it is unclear if and how social deprivation influences perceived health in children. This study was conducted to evaluate the impact of social deprivation on Patient-Reported Outcomes Measurement Information System (PROMIS) scores in children presenting for treatment of upper extremity fractures.

METHODS

This cross-sectional evaluation analyzed data from 975 new pediatric patients (8-17 years old) with upper extremity fractures presenting to a tertiary orthopedic center between June 1, 2016, and June 1, 2017. They completed self-administered PROMIS Computer Adaptive Tests (CATs). The Area Deprivation Index was used to quantify social deprivation. Bivariate statistical analysis determined the effect of disparate area deprivation (based on most and least deprived national quartiles) for the entire population.

RESULTS

A total of 327 children (34%) lived in areas categorized as the most socially deprived quartile of the United States, whereas 202 (21%) arrived from homes in the least socially deprived quartile. Children in the most deprived quartile had significantly worse mean PROMIS Upper Extremity Function, Mobility, Pain Interference, and Peer Relations scores than those in the least deprived quartile. Significantly more children from the most socially deprived areas were black. Patient age, sex, and fracture type were not significantly different between patients from the least and the most socially deprived quartiles.

CONCLUSIONS

Children living in areas of greatest social deprivation report worse Upper Extremity Function, Mobility, Pain Interference, and Peer Relations scores on self-administered PROMIS CATs than children from areas of least social deprivation at presentation for care of upper extremity fractures. The impact of social deprivation on perceived health and function is evident before adulthood and, therefore, interventions to mitigate this effect should be offered to children as well as adults.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Socioeconomic inequalities in injuries treated in primary care in Madrid, Spain

Background

Socioeconomic inequalities in injury morbidity are an important yet understudied issue in Southern Europe. This study analysed the injuries treated in primary care in the Community of Madrid, Spain, by socioeconomic status (SES), sex and age.

Methods

This was a cross-sectional study of injuries registered in the primary care electronic medical records of the Madrid Health Service in 2012. Incidence stratified by sex, SES and type of injury were calculated. Poisson regression was performed.

Results

A statistically significant upward trend in global injury incidence was observed with decreasing SES in all age groups. By type of injury, the largest differences were observed in injuries by foreign body in men aged 15-44 and in poisonings in girls under 15 years of age. Burns risk also stood out in the group of girls under 15 years of age with the lowest SES. In the group above 74 years of age, wounds, bruises and sprains had the lowest SES differences in both sexes, and the risk of fractures was lower in the most socioeconomically advantaged group.

Conclusion

People with lower SES were at a greater risk of injury. The relationship between SES and injury varies by type of injury and age.

Consultation patterns of children and adolescents with knee pain in UK general practice: analysis of medical records

BACKGROUND

Knee problems are common in children and adolescents. Despite this, little is known about the epidemiology of knee problems in children and adolescents who consult in general practice. The aim of this study was to describe consultations by children and adolescents about knee problems in general practice, and examine patterns of patient presentations and consultations by age group, sex and area of socio-economic deprivation.

METHODS

Consultations records specific to the knee region were extracted from a general practice consultation database (CiPCA) over a one year period. Knee consultation codes were organised into 'symptom' or 'diagnosis' (sub-categorised: 'trauma', 'non-trauma') categories. Descriptive statistics were used to describe patient presentations and number of consultations overall, and stratified analysis carried out on age group, sex, and area of socio-economic deprivation.

RESULTS

Out of all musculoskeletal consultations, knee problems were the fourth most common patient presentation, responsible for the second highest number of consultations. Patient presentations and consultations increased up to age 12-15 years and then stabilised. Symptoms codes e.g. 'knee pain' were used more commonly than diagnosis codes e.g. 'knee sprain' overall. However, symptom code use declined as age increased, more symptom codes were used in girls compared to boys, and more diagnosis codes were used in patients from areas of high socio-economic deprivation.

CONCLUSIONS

This study provides insight into the epidemiology of knee problems in children and adolescents in general practice. Future research is needed to improve our understanding of the knee problems encountered by GPs, and the influence socio-economic deprivation has on consultations.

Impact of Safety Net Hospitals in the Care of the Hand-Injured Patient: A National Perspective

A clear disparity in the pattern and provision of surgical care exists, particularly for patients with vulnerable socioeconomic backgrounds. For hand-injured patients in particular, this discrepancy has been frequently shown in their receiving appropriate care. With the advent of the Affordable Care Act and with Medicaid expansion on the horizon, more patients will be requiring access to care. Safety net programs have been shown to provide equivalent levels of care for patients compared with non-safety net providers, and the survival of these hospitals for the disadvantaged is essential to providing quality care for this growing patient population. In this article, the authors review the factors that affect the barriers to care, the importance of safety net hospitals, the epidemiology of the hand-injured patient, and how the Affordable Care Act will impact these safety net programs.

The epidemiology of fractures of the scaphoid

Aims

This study explores the epidemiology of patients with a fracture of the scaphoid presenting to a regional teaching hospital.

Patients and Methods

All patients with a confirmed fracture of the scaphoid over a retrospective period between January 2010 and May 2013 were included. Their demographics, deprivation status and when the fracture occurred was noted and assessed. There were 415 fractures in 365 males and 50 females.

Results

The incidence of fracture of the scaphoid was 12.4 in 100 000 each year in the general population. The mean age of the patients was 22 years (nine to 35); the highest incidence was in males aged between 15 and 19 years. We calculate the annual incidence in the United Kingdom to be 7265 each year. Patients with the lowest socioeconomic status had an incidence of 18.57 in 100 000 whereas the least deprived patients had an incidence of 9.98 (p < 0.001). There was evidence of a seasonal trend (p = 0.022) with the highest monthly rate found in June (16.96 in 100 000 each year) and the lowest was in December (7.61 in 100 000 each year). There were significantly fewer presentations of fracture at the weekend (p <  0.001), and the highest incidence was on Mondays. Most fractures occurred at the waist (64%) and tubercle (18.1%). Take home message: In this large-scale epidemiological study, we confirmed that young men are most at risk of sustaining a fracture of the scaphoid, and report new factors in relation to social deprivation and seasonality that influence scaphoid fractures. Cite this article: Bone Joint J 2016;98-B:654–9.

The Epidemiology of Upper Extremity Fractures in the United States, 2009

BACKGROUND

No single epidemiological study of upper extremity fractures exists in the United States using data from all payers. Current epidemiological estimates are based on case series, foreign databases, or Medicare data, which are not representative of the entire US population. The objective of this project was to accurately describe the incidence of fractures of the upper extremity in a representative sample of the US population.

METHODS

Using International Classification of Disease, Ninth Edition codes for patient visits reported in the 2009 State Emergency Department Database and the State Inpatient Database, available from the Healthcare Cost and Utilization Project, and 2010 US Census data, we calculated the annual incidence rates per 10,000 persons of upper extremity fractures of all patients, regardless of age or payer type. This was done using a representative national sample from 8 states: Arizona, California, Iowa, Maryland, Massachusetts, New Jersey, and Vermont.

RESULTS

Overall, in this population of over 87 million Americans, there were 590,193 fractures of the upper extremity, yielding an annual incidence of 67.6 fractures per 10,000 persons. Distal radius and ulna fractures were the most common upper extremity fractures (16.2 fractures per 10,000 persons), followed by hand fractures (phalangeal and metacarpal fractures; 12.5 and 8.4 per 10,000, respectively), proximal humerus fractures (6.0 per 10,000), and clavicle fractures (5.8 per 10,000). The most common type of fracture for all age groups was distal radius fractures, except in the 18- to 34-year-old group, in which metacarpal and phalangeal fractures were more common (16.1 and 12.5 per 10,000, respectively) and the 35- to 49-year-old group, in which phalangeal fractures were most common (11.5 per 10,000). The incidence of distal radius fractures was bimodal, with the highest rates in the under 18 and over 65 age groups (30.18 and 25.42 per 10,000, respectively) with lower rates in the middle age groups. The most common type of fracture for males was phalangeal fractures (11.5 per 10,000), and distal radius and ulna fractures were the most common type for females (11.8 per 10,000). Interestingly, phalangeal and metacarpal fractures varied by socioeconomic status (SES), which decreased with increasing SES. No other fracture type varied by SES.

CONCLUSIONS

Epidemiological studies are necessary for research, clinical applications, and public health and health policy initiatives. This study reports national estimates of upper extremity fractures with subgroup analysis.

Social deprivation as a risk factor for fractures in childhood

Paediatric fractures are common and can cause significant morbidity. Socioeconomic deprivation is associated with an increased incidence of fractures in both adults and children, but little is known about the epidemiology of paediatric fractures. In this study we investigated the effect of social deprivation on the epidemiology of paediatric fractures. We compiled a prospective database of all fractures in children aged < 16 years presenting to the study centre. Demographics, type of fracture, mode of injury and postcode were recorded. Socioeconomic status quintiles were assigned for each child using the Scottish Index for Multiple Deprivation (SIMD). We found a correlation between increasing deprivation and the incidence of fractures (r = 1.00, p < 0.001). In the most deprived group the incidence was 2420/100 000/yr, which diminished to 1775/100 000/yr in the least deprived group. The most deprived children were more likely to suffer a fracture as a result of a fall (odds ratio (OR) = 1.5, p < 0.0001), blunt trauma (OR = 1.5, p = 0.026) or a road traffic accident (OR = 2.7, p < 0.0001) than the least deprived. These findings have important implications for public health and preventative measures.

Precision of image-based registration for intraoperative navigation in the presence of metal artifacts: Application to corrective osteotomy surgery

Navigation for corrective osteotomy surgery requires patient-to-image registration. When registration is based on intraoperative 3-D cone-beam CT (CBCT) imaging, metal landmarks may be used that deteriorate image quality. This study investigates whether metal artifacts influence the precision of image-to-patient registration, either with or without intermediate user intervention during the registration procedure, in an application for corrective osteotomy of the distal radius. A series of 3-D CBCT scans is made of a cadaver arm with and without metal landmarks. Metal artifact reduction (MAR) based on inpainting techniques is used to improve 3-D CBCT images hampered by metal artifacts. This provides three sets of images (with metal, with MAR, and without metal), which enable investigating the differences in precision of intraoperative registration. Gray-level based point-to-image registration showed a better correlation coefficient if intraoperative images with MAR are used, indicating a better image similarity. The precision of registration without intermediate user intervention during the registration procedure, expressed as the residual angulation and displacement error after repetitive registration was very low and showed no improvement when MAR was used. By adding intermediate user intervention to the registration procedure however, precision was very high but was not affected by the presence of metal artifacts in the specific application.

Incidence of fractures among children and adolescents in rural and urban communities - analysis based on 9,965 fracture events

BACKGROUND

Previous work has explored the significance of residence on injuries. A number of articles reported higher rates of injury in rural as compared to urban settings. This study aimed to evaluate the importance of residency on the occurrence of fractures among children and adolescents within a region in northern Sweden.

METHODS

In a population based study with data from an injury surveillance registry at a regional hospital, we have investigated the importance of sex, age and place of residency for the incidence of fractures among children and adolescents 0-19 years of age using a Poisson logistic regression analysis. Data was collected between 1998 and 2011.

RESULTS

The dataset included 9,965 cases. Children and adolescents growing up in the most rural communities appeared to sustain fewer fractures than their peers in an urban municipality, risk ratio 0.81 (0.76-0.86). Further comparisons of fracture rates in the urban and rural municipalities revealed that differences were most pronounced for sports related fractures and activities in school in the second decade of life.

CONCLUSION

Results indicate that fracture incidence among children and adolescents is affected by place of residency. Differences were associated with activity at injury and therefore we have discussed the possibility that this effect was due to the influence of place on activity patterns. The results suggest it is of interest to explore how geographic and demographic variables affect the injury pattern further.

Outcome at 12 to 22 years of 1502 tibial shaft fractures

Fractures of the tibial shaft are common injuries, but there are no long-term outcome data in the era of increased surgical management. The aim of this prospective study was to assess the clinical and functional outcome of this injury at 12 to 22 years. Secondary aims were to determine the short- and long-term mortality, and if there were any predictors of clinical or functional outcome or mortality. From a prospective trauma database of 1502 tibial shaft fractures in 1474 consecutive adult patients, we identified a cohort of 1431 tibial diaphyseal fractures in 1403 patients, who fitted our inclusion criteria. There were 1024 men, and mean age at injury was 40.6 years. Fractures were classified according to the AO system, and open fractures graded after Gustilo and Anderson. Requirement of fasciotomy, time to fracture union, complications, incidence of knee and ankle pain at long-term follow-up, changes in employment and the patients’ social deprivation status were recorded. Function was assessed at 12 to 22 years post-injury using the Short Musculoskeletal Function Assessment and short form-12 questionnaires. Long-term functional outcome data was available for 568 of the surviving patients, 389 were deceased and 346 were lost to follow-up. Most fractures (90.7%, n = 1363) united without further intervention. Fasciotomies were performed in 11.5% of patients; this did not correlate with poorer functional outcome in the long term. Social deprivation was associated with a higher incidence of injury but had no impact on long-term function. The one-year mortality in those over 75 years of age was 29 (42%). At long-term follow-up, pain and function scores were good. However, 147 (26%) reported ongoing knee pain, 62 (10%) reported ankle pain and 97 (17%) reported both. Such joint pain correlated with poorer functional outcome.

Cite this article: Bone Joint J 2014;96-B:1370–7.

Sociodemographic factors influence the risk for femur shaft fractures in children: a Swedish case-control study, 1997-2005

AIM

To investigate how sociodemographic factors relate to the risk of femur shaft fractures in children and how the relationship differs by gender and age.

METHODS

Population-based case-control study. Swedish children (n = 1,874), 0-14 years of age, with a femur shaft fracture diagnostic code occurring between 1997 and 2005 were selected from the Swedish national inpatient register and compared with matched controls (n = 18,740). Demographic, socio-economic and injury data were based on record linkage between six Swedish registers.

RESULTS

The risk of femur shaft fracture increased for children with younger parents or those living in low-income households. Having a parent with a university education reduced the risk. Stratifying for gender and age group, the association between parents' age was evident only for older boys (7-14 years of age) (OR = 1.40; 95% CI 1.04-1.45), and the association between living in low-income households and fracture rate was only seen in older girls (7-14 years) (OR = 1.50; 95% CI 1.01-2.22). Family composition, number of siblings, birth order or receiving social welfare did not influence the fracture risk.

CONCLUSION

Sociodemographic variables influence the rate of femur shaft fractures, in older children the influence differs between boys and girls.

[Hand injuries in children]

The hand is one of the most commonly injured locations in children. In the young child, the ignorance of dangers may explain this frequency. In the older child, hand trauma is usually secondary to recreational sports. Most hand injuries in children are treated nonoperatively because of high remodeling potential. Surgical treatments are mandatory in case of open or unstable fracture, displaced intraarticular fractures and displaced phalangeal neck fractures. In phalangeal neck fractures, percutaneous treatment should be preferred. Finger stiffness and non-union are uncommon and are usually in relation with skin or vascular involvement. In case of physis fracture, clinical and radiological follow-up should monitor any growth problems.

Legg-Calvé-Perthes disease and the risk of injuries requiring hospitalization: a register study involving 2579 patients

BACKGROUND AND PURPOSE

Previous studies have suggested that Legg-Calvé-Perthes disease (LCPD) is associated with repetitive trauma, coagulation problems and anatomical abnormalities of the blood supply to the femoral head. The hypothesis that repetitive trauma can affect the blood supply of the femoral head, leading to LCPD, is supported by an animal model. For evidence of an increased risk of repetitive trauma, we investigated whether patients with LCPD have a higher risk for severe injuries requiring hospitalization.

PATIENTS AND METHODS

We identified 2579 patients with LCPD in Sweden during the period 1964-2005. 13,748 individuals without LCPD were randomly selected from the Swedish general population, matched by year of birth, sex and region (control group). Cox proportional hazard regression estimated the risks.

RESULTS

Compared to the control group, patients with LCPD had a modestly raised hazard ratio (HR) of 1.2 (95% CI 1.1-1.3) for injury requiring hospitalization. The risks were slightly higher for soft tissue injuries (HR = 1.3, 95% CI:1.1-1.4) than for fractures (HR = 1.1, 95% CI: 1.0-1.3) and more pronounced among females. Compared to the control group, the higher risk for injury only applied to the lower extremities (HR = 1.2, 95% CI: 1.0-1.4) in patients with LCPD.

INTERPRETATION

Patients with LCPD are vulnerable to injuries which could be interpreted as a marker of hyperactive behavior. It could also implicate that anatomical changes in the bone formation or blood supply of the femoral head - increasing its sensibility for trauma - contribute to the etiology of LCPD.

Patient-tailored plate for bone fixation and accurate 3D positioning in corrective osteotomy

A bone fracture may lead to malunion of bone segments, which gives discomfort to the patient and may lead to chronic pain, reduced function and finally to early osteoarthritis. Corrective osteotomy is a treatment option to realign the bone segments. In this procedure, the surgeon tries to improve alignment by cutting the bone at, or near, the fracture location and fixates the bone segments in an improved position, using a plate and screws. Three-dimensional positioning is very complex and difficult to plan, perform and evaluate using standard 2D fluoroscopy imaging. This study introduces a new technique that uses preoperative 3D imaging to plan positioning and design a patient-tailored fixation plate that only fits in one way and realigns the bone segments as planned. The method is evaluated using artificial bones and renders realignment highly accurate and very reproducible (d(err) < 1.2 ± 0.8 mm and φ(err) < 1.8° ± 2.1°). Application of a patient-tailored plate is expected to be of great value for future corrective osteotomy surgeries.

The epidemiology of radial head and neck fractures

PURPOSE

The aim of this study was to define the epidemiological characteristics of proximal radial fractures.

METHODS

Using a prospective trauma database of 6,872 patients, we identified all patients who sustained a fracture of the radial head or neck over a 1-year period. Age, sex, socioeconomic status, mechanism of injury, fracture classification, and associated injuries were recorded and analyzed.

RESULTS

We identified 285 radial head (n = 199) and neck (n = 86) fractures, with a patient median age of 43 years (range, 13-94 y). The mean age of male patients was younger when compared to female patients for radial head and neck fractures, with no gender predominance seen. Gender did influence the mechanism of injury, with female patients commonly sustaining their fracture following a low-energy fall. Radial head fractures were associated more commonly with complex injuries according to the Mason classification, while associated injuries were related to age, the mechanism of injury, and increasing fracture complexity.

CONCLUSIONS

Radial head and neck fractures have distinct epidemiological characteristics, and consideration for osteoporosis in a subset of patients is recommended.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

The relationship of fall-related fractures to social deprivation

The relationship between fall-related fractures and social deprivation was studied in 3,843 patients. The incidence of fractures correlated with deprivation in all age groups although the spectrum of fractures was not affected by deprivation. The average age and the prevalence of hip fractures decreased with increasing deprivation.

INTRODUCTION

This study examines the relationship between social deprivation and fall-related fractures. Social deprivation has been shown to be a predisposing factor in a number of diseases. There is evidence that it is implicated in fractures in children and young adults, but the evidence that it is associated with fragility fractures in older adults is weak. As fragility fractures are becoming progressively more common and increasingly expensive to treat, the association between social deprivation and fractures is important to define.

METHODS

All out-patient and in-patient fractures presenting to the Royal Infirmary of Edinburgh over a 1-year period were prospectively recorded. The fractures caused by falls from a standing height were analysed in all patients of at least 15 years of age. Social deprivation was assessed using the Carstairs score and social deprivation deciles, and the 2001 census was used to calculate fracture incidence. The data were used to analyse the relationship between social deprivation and fall-related fractures in all age groups.

RESULTS

The incidence of fall-related fractures correlated with social deprivation in all age groups including fragility fractures in the elderly. The overall spectrum of fractures was not affected by social deprivation although the prevalence of proximal femoral fractures decreased with increasing deprivation. The average age of patients with fall-related fractures also decreased with increasing social deprivation as did the requirement for in-patient treatment.

CONCLUSIONS

This is the first study to show the relationship between fall-related fractures and social deprivation in older patients. We believe that the decreased incidence of proximal femoral fractures, and the lower average age of patients with fall-related fractures, in the socially deprived relates to the relative life expectancies in the different deprivation deciles.

Are extremity musculoskeletal injuries in children related to obesity and social status? A prospective observational study in a district general hospital

BACKGROUND

Obesity is one of the several independent risk factors for the risk of fractures. Major epidemiological studies also suggested the social status of the patients to be a confounding factor. We aimed to look at the influence of obesity on fractures and to determine if the social status of the patients is a confounding factor.

METHODS

This is an observational study of 560 children with musculoskeletal injuries who presented over a period of 8 months and the data were collected prospectively. Obesity status and social deprivation index were estimated.

RESULTS

The prevalence of overweight and obese children was 29.9%. Twenty-four percent of the boys and 31% of the girls were obese (P = 0.2). In the group of most deprived areas, the prevalence of obesity increased to 40% in those needing admission for intervention.

CONCLUSIONS

Although there is a slight increase in obesity, there is no suggestion of increased rate of fractures in deprived areas. Upper limb injuries were more predominant, with distal radius fracture being the most common injury. Boys sustain fractures twice as often as girls. There is a tendency to increasing obesity with increasing age.