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CHAPTER 1 • Epidemiology of Fractures in Children

leading cause of death in youths. In considering the prevalence of firearms in the United States, it has been estimated that there are about 200 million privately owned guns in the United States and that approximately 40% of US households contain firearms of some type. 17 Two recent epidemiologic reports from pediatric trauma centers, orthopedic injuries related to firearms, demonstrated varying rates of complications and need for operative interven- tion (35% and 54%) in gunshot wound–related injuries and complications. 72,76 Perkins et al. 76 found that in 46 patients with 50 injuries, gunshot-related fractures had an increased incidence of permanent neurologic deficits, infection (11%), and fracture non-union rates (9%). The two most common complications associated with firearm-related injuries are growth arrest and infection. Other complications included delayed union and malunion. The treatment of fractures associated with gunshot wounds in chil- dren is never simple. Bone defects, associated peripheral nerve injuries, and involvement of the joint can negatively influence outcomes. 4 Firearm-related injury and safety have received much atten- tion nationally and internationally in the wake of the events over the last decade. Rather than modifying behavioral or envi- ronmental issues, which are more complex, strategies to reduce firearm-related injuries and deaths among the youth include reducing the number of guns in the environment through restrictive legislation, gun buy-back programs, gun taxes, phy- sician counseling, and modifying the design of guns to make them more childproof and prevent unauthorized and unin- tended use. PREVENTIVE PROGRAMS While studying the epidemiology of fractures, it is important to focus on the etiology of fractures and the settings in which they occur. Fractures do not occur in a vacuum, and well-re- searched studies that analyze the physical and social environ- ment in which they occur are extremely valuable. Efforts can be made toward creating a safer environment for play and recre- ation. It is hoped that by targeting these areas, programs can be designed to decrease the risk factors. NATIONAL CAMPAIGNS Several national organizations have developed safety programs. The foremost is the American Academy of Pediatrics, which has committees on injury and poison prevention and sports medi- cine and fitness that has produced guidelines for athletics, 15 play- grounds, trampolines, 20 ATVs, 18 and skateboards. 19 The AAOS has also produced a program designed to decrease the inci- dence of playground injuries. These programs offer background data and guidelines for various activities, but their effectiveness has not been fully studied. In addition, the AAOS, the Ortho- paedic Trauma Association (OTA), and Pediatric Orthopaedic EVOLVING EPIDEMIOLOGY OF FRACTURES IN CHILDREN

Society of North America (POSNA) have issued updated posi- tion statements regarding the safe use of ATVs, trampolines, skateboards, and in-line skating.

EXPANDED OPPORTUNITIES TO EXAMINE THE EPIDEMIOLOGY OF PEDIATRIC TRAUMA

Several sources of administrative, national, and regional data have recently become available, providing significantly improved investigation into various areas within pediatric trauma. The Healthcare Cost and Utilization Project (HCUP) is a family of databases including the State Inpatient Databases (SID), the Nationwide Inpatient Sample (NIS), and the KID. Although administrative data may lack clinical detail for cer- tain purposes, these datasets provide a comprehensive overview of health care utilization in the United States and are available without purchase (http://www.ahrq.gov/research/data/hcup/ index.html). 104 The KID database has been increasingly used to examine the incidence of pediatric trauma as well as prac- tice patterns in pediatric trauma. Data for KIDS are collected and published every 3 years. In 2011 study, using the 2006 HCUP KID dataset, Gao 27 reported on lower-extremity fractures requiring hospitalization and found there were about 11,500 admission records for children aged 0 to 20 with lower-ex- tremity fractures. Urban hospitalizations accounted for 93% of cases and 66% of admissions were to teaching hospitals in Gao’s study. There was an increased mortality risk among patients cared for in nonteaching hospitals and hospitals located in a rural region. An additional study using this dataset, Nakaniida et al. 70 found femur and humerus fractures as the most common injuries requiring hospitalization, with pelvic and vertebral frac- tures largely due to MVAs representing the most costly injuries. Trauma registries are another source for injury data that doc- ument clinical and demographic information regarding acute care delivered to hospitalized patients with injuries at trauma centers. These databases are designed to provide information that can be used to study the effectiveness and quality of trauma care, collect information on rare injuries, 81,109 and identify areas for quality improvement. Although the amount of informa- tion available through regional and national databases allowed is immense, the creation and maintenance of these registries require a significant amount of time and financial resources. Several limitations of these databases include the focus on adult over pediatric injuries and the data that do not always reflect population-based samples. Currently, the American College of Surgeons National Trauma Data Bank serves as the largest database, producing annual reports on pediatric injury from trauma centers from the United States and Canada (http://www. ntdb.org). In the future, databases such as these may provide the infrastructure needed to study pediatric musculoskeletal trauma care.

ACKNOWLEDGMENT

With appreciation to Kaye Wilkins for work on previous edi- tions of this chapter.

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