Upper extremity open fractures in hospitalized road traffic accident patients: adult versus pediatric cases

Background Fractures in pediatrics show epidemiological characteristics which are different from fractures in adults. The objective of this study was to examine the injury profiles of open upper extremity fractures (UEFs) in all modes of injury related to road traffic accidents (RTAs) in adult and pediatric hospitalized patients. Methods Data on 103,465 RTA patients between 1997 and 2013 whose records were entered in a centralized country trauma database were reviewed. Data on open UEFs related to mode of injury (car, motorcycle, bicycle, and pedestrian) was compared between adult (18+ years) and pediatric (0–17 years) RTA patients. Results Of 103,465 RTA cases, 17,263 (16.7%) had UEFs. Of 73,087 adults, 13,237 (18.1%) included UEFs and of 30,378 pediatric cases, 4026 (13.2%) included UEFs (p < 0.0001). Of 17,263 cases with UEFs, we reviewed 22,132 fractures with 2, 743 (12.4%) open fractures. Adults had a greater risk for open fractures (2221, 13%) than the pediatric cases (522, 10.3%) (p < 0.0001). Overall, of a total of 22,132 UEFs, most of the fractures were in the radius (22.8%), humerus (20.3%), clavicle (17.5%), and ulna (15.4%). The adult pedestrian group had a significantly higher risk for open UEFs than the pediatric group (11 vs 8%, p = 0.0012). Conclusions This study demonstrates the difference between adult and pediatric open fractures in hospitalized RTAs. We showed that adults had a greater risk for open UEFs compared to children, and the adult pedestrian group particularly had a significantly higher risk for open UEFs than the pediatric group.


Background
Fractures in children show epidemiological characteristics which are different from fractures in adults. The epidemiology of adult and pediatric fractures was studied in Edinburgh, Scotland, where it was found that the incidence of fractures in children was almost twice that of fractures in adults. Equal numbers of male and female adults were affected, but there is a strong male predominance in pediatric cases. More adults present with multiple and open fractures. Another difference is that children present mainly with upper limb fractures and have relatively few lower limb fractures [1,2].
In recent studies on upper extremity fractures (UEFs) in road traffic accident (RTA) hospitalized adult and pediatric patients [3,4], we found that the fracture rate in children is less than that in adults. Of the total number of pedestrian accidents, about 22% of the children sustained fractures, while 40% of the adults sustained fractures in the same type of accident. The rate of UEFs in the pediatric population was 13.2% compared to 19.9% in the adult group. Multiple UEFs were similar between the groups (23% in the pediatric group and 22% in the adult group). Associated injuries to UEFs were found in about half of our group (56%) but in most of our adult population group (76%). The most frequent UEFs in our pediatric group were similar to our adult group and included the forearm, humerus, and clavicle.
The aim of this study was to identify the epidemiology of RTA open UEFs and to define any commonly occurring patterns. This study focused on all modes of injury related to RTAs (car, motorcycle, bicycle, pedestrian), regarding fracture pattern and age difference.

Methods
RTA patients (car, motorcycle, bicycle, and pedestrian) in Israel between 1997 and 2013 were reviewed. Data were obtained from the Israel National Trauma Registry (ITR), maintained by Israel's National Center for Trauma and Emergency Medicine Research at the Gertner Institute for Epidemiology and Health Policy Research. The ITR does not collect data on individuals who were dead at the scene or upon arrival at the hospital, nor does it include patients discharged to home from the Emergency Department. Data are recorded by trained medical registrars at each hospital, and electronic files are transferred to the ITR. During the study period, the ITR included trauma patients admitted to all six level I trauma centers and up to 13 regional trauma centers in Israel.
Medical diagnosis classifications were from the International Classification of Diseases, Ninth Revision, Clinical Modification.
Data included diagnosis of open UEF and type of UEF among different RTA modes. These characteristics were compared between adult (18+ years) and pediatric (0-17 years) RTA patients.
Statistical analysis was performed using SAS statistical software version 9.2 (SAS, Cary, NC). Statistical tests performed included the chi-square test and binomial proportions test. A p value less than 0.05 was considered as statistically significant.
Ethical approval was not necessary since the data was collected from a national data registry without patient details.

Source of funding
There was no external funding source.

Fracture type
Overall, of a total of 22,132 UEFs, most of the fractures were in the radius (22.8%), humerus (20.3%), clavicle (17.5%), and ulna (15.4%). The adult group had a similar distribution of fracture type, but the pediatric group had more ulna fractures than clavicle fractures (Fig. 1).
The percent of open fracture according to fracture type demonstrated that the risk for open fractures in the phalanges was 41%, followed by the ulna (21%), metacarpals (14%), and the radius (13%) (Fig. 2).  Table 2).

Discussion
Open fractures are relatively uncommon and can be complicated with soft tissue damage and compartment syndrome [5]. A study on fracture epidemiology in Edinburgh, Scotland, in 2007Scotland, in -2008 [5]. Of the total number of pedestrians involved in vehicle accidents, about 22% of the children sustained fractures, while 40% of the adults sustained fractures in the same type of accident. This has been attributed to the fact that children are more likely to "bounce" when hit [8]. We found that the adult pedestrian group had a significantly higher risk for open UEFs than the pediatric group (11 vs 8%, p = 0.0012).
The highest prevalence for an open UEF according to type of bone in the adult general population occurs in the phalanges followed by the forearm [1]. This data has not been studied in the pediatric population. In our study, we demonstrated that the adult group had a similar distribution of fracture type but the pediatric group had more ulna fractures than clavicle fractures.
The limitations of this study are its retrospective nature and the data concerning only hospitalized patients with no data concerning close fractures, other body parts fractures, open fracture classification, or other soft tissue complications. However, the large cohort study and the recommendation for intravenous antibiotic treatment to open fracture inpatients [9] make this study a valuable source of information on the epidemiology of UEFs in adult and pediatric patients.

Conclusions
This study demonstrates the difference between adult and pediatric open fractures in hospitalized RTAs. We showed that adults had a greater risk for open UEFs compared to children, and the adult pedestrian group particularly had a significantly higher risk for open UEFs than the pediatric group.