Surgery: Current Research
Tariq et al., Surgery Curr Res 2019, 8:3
Research Article
Open Access
Pattern of Bone Fractures in Paediatric Population Presenting in Tertiary Care Hospital Maham Tariq1, Raheel Ahmad1*, Sara Malik1, Mehwish Changeez1, Anum Iftikhar2 and Usman Akram1 1Surgical 2Fazaia
Unit-I, Holy Family Hospital, Rawalpindi, Pakistan
Medical College, Islamabad, Pakistan
*Corresponding author: Raheel Ahmad, Surgical Unit-I, Holy Family Hospital, Rawalpindi, Pakistan, Tel: 9203345417436; E-mail: raheelsun89@hotmail.com Received date: March 15, 2019; Accepted date: April 2, 2019; Published date: April 9, 2019 Copyright: © 2019 Tariq M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract Introduction: Fractures are a leading cause of emergency presentation in pediatric age group and comprise 9% cause of healthcare presentation in children. About 1/3rd fractures in young age occur before 7 years of age 3, but are particularly prevalent in ages between 10-14 years and especially involve the male gender. Growing bone has the remarkable tendency of being able to correct underlying displacement as well as the risk of growth disturbance. Patients and Methods: A Cross-sectional study was carried at Benazir Bhutto Hospital and Holy Family Hospital, Rawalpindi, which are affiliated with Rawalpindi Medical University. All children older than 6 months and younger than fourteen years of age presenting between January 2017 and June 2017 were included in the study. All concerned data was collected on a predesigned questionnaire. Results: Total two hundred pediatric patients were enrolled in the study, out of which 139 (69.5%) were males and 61 (30.5%) were females, with a mean age of 8.9 ± 2.7 years. The most vulnerable group was between 6 to 10 years and the most common cause was fall. 97.5% of patients had closed fractures and only 2.5% had open fractures. 143 (71.5%) were from the urban area and only 57 (28.5%) were from rural areas. Conclusion: Long bone fractures in children are very common. Early detection and timely management of these fractures is the key to better outcomes and preventing disabilities in young people.
Keywords: Fractures; Pediatric age group; Urban and rural areas
Introduction Fractures are a leading cause of emergency presentation in pediatric age group and comprise 9% cause of healthcare presentation in children [1]. Fractures are prevalent in young as well as old age when the skeleton is soft and porous [2]. In pediatric age group, physis or growth plate is most commonly affected while in elderly mostly the metaphysis bears the brunt of a majority of fractures [3]. About 1/3rd fractures in young age occur before 7 years of age 3, but are particularly prevalent in ages between 10-14 years and especially involve the male gender. This predisposition is explained by the active involvement of boys of this age group in sports and their thrill-seeking behavior [4]. Differentiating fractures caused by abuse from those caused by other factors is mandatory despite being difficult. To effectively differentiate between the two, both the radiologist as well as the orthopedic surgeons should have full access to both the clinical and social information. Growing bone has the remarkable tendency of being able to correct underlying displacement as well as the risk of growth disturbance [5]. With reference to fracture management children are not to be treated as miniature adults. Confirmed errors while dealing with pediatric fractures include faulty physical assessment, imprecise radiological assessment, not making the right treatment choice i.e. operative versus conservative, and inadequacy or complete loss of follow up [6].
Surgery Curr Res, an open access journal 2161-1076
Treatment of fractures in every age group is aimed at providing effective analgesia and provision of best possible treatment (whether in a healthcare facility or on OPD basis) to ensure a good outcome, keeping the cost of treatment and effort to a bare minimum.
Figure 1: Management of pediatric fractures.
Volume 8 • Issue 3 • 1000324
Citation:
Tariq M, Ahmad R, Malik S, Changeez M, Iftikhar A, et al. (2019) Pattern of Bone Fractures in Paediatric Population Presenting in Tertiary Care Hospital. Surgery Curr Res 8: 324.
Page 2 of 3 Knowledge about child specific pattern, bone maturity and extent of displacement caused by a fracture govern treatment and prognosis hence the management differs markedly ranging from conservative treatment to simply immobilize the bone via pop casts and application of skin tractions and polyslings to operative intervention [7]. In this, we are going to find out causes, patterns and treatment of pediatric appendicular bone fractures presenting in a tertiary care hospital (Figure 1).
Material and Methods A Cross-sectional study was carried out in the trauma departments, Orthopedic indoors and fracture clinics at Benazir Bhutto Hospital and Holy Family Hospital, Rawalpindi, which are affiliated with Rawalpindi Medical University. All children older than 6 months and younger than fourteen years of age presenting between January 2017 and June 2017 were included in the study. The data was collected regarding the age of the patient, gender, injury mechanism of, anatomic site, open or closed fracture, place of occurrence of an accident, history of previous fractures, the time interval between the incident and seeking medical help and their management. All information was collected on predesigned perform. All statistical analyses were carried out using the SPSS (Statistical Package of Social Sciences USA).
Results Total two hundred pediatric patients were enrolled in the study, out of which 139 (69.5%) were males and 61 (30.5%) were females, with a mean age of 8.9 ± 2.7 years. The most vulnerable group was between 6 to 10 years and the most common cause was fall (Table 1). Cause of Injury
Age in years
RTA
Other
up to 1 year
8
0
1
9
1-5year
53
5
2
6-10year
78
11
11-14 year
24
Total
163
Segment
Bone Involved
Total
Percentage %
Proximal End Shaft
Distal End
Humerus
3
3
42
48
24.0%
Radius
0
13
10
23
11.5%
Ulna
3
9
4
16
8.0%
Radius+ulna
2
30
5
37
18.5%
Tibia
1
5
0
6
3.0%
Tibia+fibula
0
16
2
18
9.0%
Clavicle
0
9
1
10
5.0%
Metacarpal
1
1
1
3
1.5%
Metatarsal
2
1
2
5
2.5%
Phalanx
2
1
2
5
2.5%
Femur
3
22
4
29
14.5%
Total
17 (8.5%)
110 (55%) 73 (36.5%) 200
100%
Table 3: Bone and the respective segments involved in fracture (n=200).
Percentage
Total
Fall
Table 3 illustrates the different bones and their respective segments fractured. In regard to the type of fracture, the transverse fracture was most common (Table 4). 97.5% of patients had closed fractures and only 2.5% had open fractures.
Pattern
Frequency
Percentage %
4.5%
Linear
6
3%
60
30%
Transverse
161
80.5%
2
91
45.5%
Oblique
25
12.5%
16
0
40
20%
Spiral
4
2%
32
5
200
100%
Wedge
1
0.5%
Torus
3
1.5%
Total
200
100%
Displaced
88
44%
Table 1: Cross tabulation showing the age and causes of bone fractures (n=200). Table 1 shows a detailed description of causes of bone fractures in relation to age groups and the time interval between trauma and hospital presentation is depicted in Table 2.
Displacement
Time of Presentation
Frequency
Percentage %
Non displaced
112
56%
within 24 hrs
155
77.5
Total
200
100%
24-48 hrs
13
6.5
48-72 hrs
10
5.0
more than 72 hours
22
11.0
Total
200
100.0
Table 2: Time interval between trauma and hospital presentation (n=200). Surgery Curr Res, an open access journal 2161-1076
Table 4: Fracture patterns and displacement. Out of 200 patients, 143 (71.5%) were from the urban area and only 57 (28.5%) were from rural areas. Only about 1% had preexisting osteoporosis and 0.5% had rickets while rest of the 98.5% had no risk factors. Neurovascular status was intact in 98.5% and compromised in 1.5%. 99.5% of the patients were diagnosed on plain X-ray films while 0.5% needed CT scan for diagnosis.
Volume 8 • Issue 3 • 1000324
Citation:
Tariq M, Ahmad R, Malik S, Changeez M, Iftikhar A, et al. (2019) Pattern of Bone Fractures in Paediatric Population Presenting in Tertiary Care Hospital. Surgery Curr Res 8: 324.
Page 3 of 3
Discussion Fractures have a remarkable physical, psychosocial and financial strain on both the kids and their parents. Children with multiple disabilities are prone to develop low Bone Mineral Density (BMD). The underlying pathophysiology in these patients is complex, and several risk factors for the development of low BMD, such as immobility, low calcium intake, low vitamin D status and anticonvulsant use, are frequently observed in this group. Low BMD is a serious problem in children and significant determinants of low BMD are limited ambulation feeding difficulties, previous fracture, anticonvulsant use, and lower fat mass. Fracture management is governed by age, BMI, NVB status, fracture characteristics, surgeon’s choice, institutional protocol, and social factors. In a study conducted in Italy on pediatric bone fractures, there were 261 boys (68.3%) and 121 girls (31.7%) and this gender distribution are almost similar to our study [8]. Male being more hyperactive and indulge in more physical activities are more prone to trauma. Many studies have shown that the falls are a most common cause to physical trauma leading to fractures in young people (77.8% and 57.9%), but in a Nigerian study road traffic accidents were the main culprit (51%) [9,10]. Petridou along with their colleagues proved a higher turnover of pediatric fractures in the rural population [11], whereas Gilbride and Hedstrom reported an increased turnover in the urban community [12]. This is consistent with our study which shows that 71.5% of patients belonged to urban areas and 28.5% from rural areas. A major problem in our social setup is delayed presentation along with poor surgical outcomes associated with quack treatment. 12% of our cases had a positive quack treatment history whereas 88% had no such history. In respect to the anatomic site, the upper limb is more commonly involved in pediatric fractures [9,13,14]. We found out that isolated humerus is the most commonly fractured bone in kids (24%) while forearm fractures i.e. radius, ulna and radius+ulna combined were found in 11.5%, 8% and 18.5% of our patients respectively. Valerio et al. [8] in their study found that the distal radius was most commonly fractured bone (30%) followed by a radial shaft (24.1%). Humerus shaft fracture was only found in 8.6% of his patients. Radius was also found to be the most commonly fractured bone by Sharat Agarwal [15]. Petridou and coworkers found out that among the fractured bones in the pediatric age group 15.3% were upper limb phalanges, 15.9% other upper limb bones, 24.1% were bones of the lower limb. Preschool children had a greater incidence of face and head injuries while the school going age group was more prone to extremity fractures [16,17]. Riffat Rehman observed that from the fifty-four cases of fractures evaluated, 38 fractures involved the lower limb, 14 occurred in the upper limb, and 2 involved other sites [18]. Not many studies have highlighted the segments of bone fractured. We observed these percentages with regard to fractured segments of bone, metaphysis 5%, diaphysis 67%, epiphysis 7%, diaphysis, and epiphysis 2.5% and supracondylar fractures in 18.5%. We treated 32.5% fractures via surgery while 67.5 cases were managed without surgery with the use of cast, skin traction and poly sling. The neurovascular bundle was intact in 98.5% of our patients and compromised in 1.5% at presentation. In patients undergoing surgery, regular clinical assessment and ICP measurements are mandatory both before and
Surgery Curr Res, an open access journal 2161-1076
after surgery to monitor soft tissue state even if compartment syndrome was initially ruled out. The treatment of these fractures by conservative means give favorable results. This is of great economic interest in our resource-limited setting.
Conclusion Our findings suggest that a better emergency department-based surveillance system needs to be devised for the prevention and treatment of death and disability of children because of fractures. Parents need to be sensitized via involvement of media and home visits on preventable etiologies so as to be more vigilant leading to effective fracture prevention.
References 1. 2. 3.
4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
Hedstrom EM, Svensson O, Bergstrom U, Michno P (2010) Epidemiology of fractures in children and adolescents. Acta Orthop 81: 148-153. Hoytema van Konijnenburg EM, Vrolijk-Bosschaart TF, Bakx R, Van Rijn RR (2016) Paediatric femur fractures at the emergency department: Accidental or not? Br J Radiol 89: 20150822. Meling T, Harboe K, Enoksen CH, Aarflot M, Arthursson AJ, et al. (2013) Reliable classification of children's fractures according to the comprehensive classification of long bone fractures by Muller. Acta Orthop 84: 207-212. Kraus R, Wessel L (2010) The treatment of upper limb fractures in children and adolescents. Dtsch Arztebl Int 107: 903-910. Sinikumpu J, Victorzon S, Antila E, Pokka T, Serlo W (2014) Nonoperatively treated forearm shaft fractures in children show good long-term recovery. Acta Orthop 85: 620-625. Khaji A, Zargar M, Karbakhsh M (2010) Extremity fractures in children: A hospital-based study in Tehran. Chin J Traumatol 13: 217-221. Mayranpaa MK, Makitie O, Kallio PE (2010) Decreasing incidence and changing pattern of childhood fractures: A population-based study. J Bone Miner Res 25: 2752-2759. Valerio G, Galle F, Mancusi C, Di Onofrio V, Colapietro M, et al. (2010) Pattern of fractures across pediatric age groups: Analysis of individual and lifestyle factors. BMC Public Health 10: 656. Rennie L, Court-Brown CM, Mok JY, Beattie TF (2007) The epidemiology of fractures in children. Injury 38: 913-922. Nwadinigwe CU, Ihezie CO, Iyidiobi EC (2006) Fracture in children. Nigerian J Med 15: 81-84. Petridou E, Anastasiou A, Katsiardanis K, Dessypris N, Spyridopoulos T, et al. (2005) A prospective population-based study of childhood injuries: The Velestino town study. Eur J Public Health 15: 9-14. Hedstrom EM, Waernbaum I (2014) Incidence of fractures among children and adolescents in rural and urban communities- analysis based on 9,965 fracture events. Inj Epidemiol 1: 14. Jones G (2004) Growth, children, and fractures. Curr Osteoporos Rep 2: 75-78. Pitone ML, Attia MW (2006) Patterns of injury associated with routine childhood falls. Pediatr Emerg Care 22: 470-474. Agarwal S (2014) A prospective hospital-based study of childhood orthopaedic problems-A case series. J Clin Diagn Res 8: 1-3. Lempesis V, Rosengren BE, Nilsson JA, Landin L, Tiderius CJ, et al. Time trends in pediatric fracture incidence in Sweden during the period 1950-2006. Acta Orthop 88: 440-445. Mathison DJ, Agrawal D (2010) An update on the epidemiology of pediatric fractures. Pediatr Emerg Care 26: 594-603. Rehmani R (2008) Childhood injuries seen at an emergency department. J Pak Med Assoc 58: 114-118.
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