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Fractures of the Femoral Shaft in Children. Incidence, Mechanisms, and Sociodemographic Risk Factors*

RICHARD Y. HINTON, M.D., M.P.H., M.ED., P.T., ANDREW LINCOLN, M.S., MICHELE M. CROCKETT, B.S., PAUL SPONSELLER, M.D. and GORDON SMITH, M.B., CH.B., M.P.H., BALTIMORE, MARYLAND

Investigation performed at The Johns Hopkins School of Hygiene and Public Health, The Union Memorial Hospital, and The Johns Hopkins Medical Institutions, Baltimore

	Abstract

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Background: Fractures of the femoral shaft in children are caused by major musculoskeletal trauma and result in high direct and indirect medical costs. To date, the American literature has focused on treatment options and outcomes, but the epidemiology of these injuries has been generalized from Scandinavian studies reported in the 1970s and early 1980s. The goals of the current study were (1) to determine the age, gender, and race-specific rates and mechanisms of fractures of the femoral shaft in children in a large United-States-based population and (2) to identify associations between the rates of these fractures and multiple sociodemographic indicators. Such information is vital for preventive efforts. Methods: The Hospital Discharge Database of the Maryland Health Services Cost Review Commission for the years 1990 through 1996 was used to obtain demographic data on 1485 cases of acute fracture of the femoral shaft in patients who were less than eighteen years old, and data from the United States Bureau of the Census for the state of Maryland for the year 1990 were used to obtain denominator data. Reliable external-cause data were available from the 1995 and 1996 databases for 472 patients. Small-area analysis was performed at the zip-code level to determine associations between numerous sociodemographic indicators and the rate of femoral shaft fracture. Results: The annual rate of femoral shaft fracture in children was 19.15 per 100,000. With regard to age, there was a bimodal distribution, with peaks at two and seventeen years. Boys had higher rates of fracture than did girls at all ages, and blacks had higher rates than did whites. The primary mechanisms of fracture were age-dependent and included falls, for children less than six years old; motor vehicle-pedestrian accidents, for those six to nine years old; and motor-vehicle accidents, for teenagers. Firearm-related injuries accounted for 15 percent of the fractures among black adolescents. Adverse socioeconomic conditions were significantly associated with higher rates of fracture. Conclusions: The rates and mechanisms of femoral shaft fractures in children depend on age, gender, and race. For children living in the United States today, the epidemiology of these fractures is different than that described in earlier, Scandinavian reports.

	Introduction

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Trauma is the leading cause of death of children in the United States, and major sociodemographic variations in the rates of fatal injury in this population have been reported^{2,11,25,31,32,39}. However, there have been fewer studies of more common, nonfatal injuries in children. The incidence and mechanisms of such injuries cannot be reliably extrapolated from the existing mortality data^8,25; thus, a greater understanding of their epidemiology is required to guide preventive efforts.

Fractures of the femur in children are caused by major musculoskeletal trauma and result in high direct and indirect medical costs^7,18,26. Throughout childhood, changes in physical and social maturation place children at varying risk for femoral shaft fractures due to different mechanisms. Although investigators from a few institutions have reported on the frequency and mechanisms of these fractures^1,14, the United States-based literature has focused largely on treatment options and complications⁴. To date, the epidemiology of femoral shaft fractures in children in the United States has been generalized from Scandinavian studies reported in the 1970s and early 1980s^15,22,40.

The goals of the current study were to determine the age, gender, and race-specific rates and mechanisms of femoral shaft fractures in children in a large United States-based population and to identify, with use of small-area analysis, associations between the rates of fracture and multiple sociodemographic indicators.

	Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
The Hospital Discharge Database of the Maryland Health Services Cost Review Commission²³ for the years 1990 through 1996 was used to obtain diagnostic and demographic data on patients with a principal or secondary diagnosis of fracture of the femoral shaft who had been less than eighteen years old when they had been discharged from a nonfederal hospital in Maryland. Unlike most childhood fractures, almost all femoral shaft fractures necessitate hospitalization of some duration, for medical and often social reasons. A few patients in the youngest age-groups may have been managed on a strictly outpatient basis and would not have been included in the discharge database; however, we believe that this small percentage of unaccounted-for outpatients would affect the rates of femoral shaft fracture only slightly.

Definition of the Injury
The International Classification of Diseases, Ninth Revision, codes 821.00, 821.01, 821.10, and 821.11 were used to define fracture of the femoral shaft²⁴. This yielded narrowly defined diagnoses because there are separate codes for fracture of the femur involving the hip, the supracondylar region, the distal part of the femur, and the epiphyseal plates. The inclusion of nonacute fractures and readmissions was minimized with use of discharge database codes to exclude patients who had been seen initially at one hospital and had subsequently been admitted to a specialty center or another hospital. Diagnoses that had been made with use of codes 733.81 (malunion), 733.82 (nonunion), 958 (early complications), and 905–909 (late complications)²⁴ also were not included.

Mechanism of Injury
External-cause (E-code) data were obtained from the Hospital Discharge Database file for each case of femoral shaft fracture for the two years (1995 and 1996) for which reliable data were available. A total of 472 acute fractures were identified. On the basis of the recommendations of the Centers for Disease Control and Prevention⁵, individual mechanism codes were grouped into nine functionally descriptive categories (Fig. 3).

View larger version (48K): [in this window] [in a new window]   Fig. 3 Bar graph showing external causes of femoral shaft fracture, according to age-group, from 1995 through 1996 for children living in Maryland (total number of cases, 472). MVA = motor-vehicle accident.

Demographic Data
Information on age, race, gender, and zip code of residence was obtained from the discharge database file. The thirty-four zip-code areas that make up the metropolitan Baltimore area³⁸ (those that are totally or partially within Baltimore city limits) were included in the analysis²⁸. The 1990 United States Census Data^36,37 (Database STF3B) for Maryland were used for population estimates and for sociodemographic profiling of the zip-code areas. Information that was gathered for each zip-code area included the median household income; the percentages of children living below the federal poverty level, of blacks and whites in the population (as defined in the 1990 Census CP-1-22 General Population Characteristics³⁶ [because of small numbers, other racial groups were not included]), of households headed by a single mother, of the population between the ages of sixteen and nineteen years that was not enrolled in or had not graduated from high school, of the population that was more than twenty-five years old and had attended college for some period of time, of housing units that were not single and detached, and of housing structures with more than twenty units; and the number of persons per room.

On the basis of developmental levels and possibly unique mechanisms of femoral shaft fractures, five age-groups were delineated. Group I comprised children who were less than two years old; group II, those two to five years old; group III, those six to nine years old; group IV, those ten to thirteen years old; and group V, those fourteen to seventeen years old.

Data gathered from administrative databases have potential flaws regarding migration of patients within and out of the state, reliability of the diagnoses, patient transfers from other hospitals, and readmissions. These problems have been discussed fully in previous reports^16,17,33 and are unlikely to have had any major effect on the rates presented in this report.

Statistical Analysis
Gender, race, age, and age-group-specific rates of femoral shaft fracture were calculated with use of hospital-discharge data (as the numerator) and 1990 census data (as the denominator). The rates of fracture were calculated in terms of 100,000 person-years, with 95 percent confidence intervals determined with use of the Cornfield approximation³⁵ (Table I). The level of significance was set at p < 0.05. Stata data-analysis software³⁵ was used to determine incidence-rate ratios and corresponding 95 percent confidence intervals for each stratum. The incidence-rate ratio represents the risk of femoral shaft fracture relative to the stratum with the lowest incidence.

	Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
Use of the Hospital Discharge Database of the Maryland Health Services Cost Review Commission for the years 1990 through 1996²³ led to the identification of 1647 individuals less than eighteen years of age who had a fracture of the femoral shaft. One hundred and sixty-two were excluded from the study because they had had a nonacute fracture or had been admitted to the hospital more than once; this left 1485 children.

The annual rate of femoral shaft fracture was 19.15 per 100,000 (95 percent confidence interval, 18.18 to 20.12). Boys had a higher risk of fracture than did girls (relative risk, 2.49; 95 percent confidence interval, 2.22 to 2.79), and black children had a higher risk than did white children (relative risk, 1.30; 95 percent confidence interval, 1.17 to 1.45) (Table I). Among girls, the rate of fracture was highest in infants less than two years of age, and it decreased between the ages of two and five years. Among boys, the highest rate of fracture was in the two to five-year age-group. Both genders had similar escalating rates from the ages of fourteen through seventeen years (Fig. 1). The higher rates of fracture among blacks were driven by the disproportionately higher relative risk for black male patients compared with their white counterparts. The single highest-risk group was black male patients between the ages of fourteen and seventeen years (relative risk compared with that for whites, 1.68; 95 percent confidence interval, 1.21 to 2.33). Although a significant difference was not detected with the numbers available, black female teenagers had a lower relative risk of fracture than did their white counterparts (relative risk, 0.87; 95 percent confidence interval, 0.44 to 1.32) (Fig. 2).

View larger version (16K): [in this window] [in a new window]   Fig. 1 Graph showing age and gender-specific rates of hospitalization from 1990 through 1996 for children living in Maryland who had a femoral shaft fracture (total number of cases, 1485).

View larger version (25K): [in this window] [in a new window]   Fig. 2 Graph showing the age-group, gender, and race-specific rates of hospitalization from 1990 through 1996 for children living in Maryland who had a femoral shaft fracture (total number of cases, 1485).

Race and gender-specific external-cause data demonstrated, most noticeably, that black children in all age-groups had a higher rate of fractures caused by motor vehicle-pedestrian accidents and a lower rate of fractures secondary to falls (Fig. 4). The rate of fractures that were due to documented abuse was slightly higher among blacks, and firearm-related fractures were found in black teenagers only (15 percent).

View larger version (55K): [in this window] [in a new window]   Fig. 4 Bar graph showing external causes of femoral shaft fracture, according to age-group, gender, and race, from 1995 through 1996 for children living in Maryland (total number of cases, 472). MVA = motor-vehicle accident.

View larger version (16K): [in this window] [in a new window]   Fig. 5 Scatter plot showing correlations between the rate of femoral shaft fracture and the median annual income in the zip-code areas of the Baltimore metropolitan area from 1990 through 1996.

View larger version (16K): [in this window] [in a new window]   Fig. 6 Scatter plot showing correlations between the rate of femoral shaft fracture and the percentage of households headed by a single mother in the Baltimore metropolitan area from 1990 through 1996.

Changes in the order of entry of the variables into the regression model did not alter the paramount position of median income as a predictor of the rates of fracture. Although race and socioeconomic level are highly associated in urban populations, multivariate analysis revealed that the percentage of blacks living within a zip-code area was an important, independent predictor of the rates of fracture among children fourteen to seventeen years of age. Crowding within housing structures, determined by the average number of people per room in a zip-code area, was also a positive predictor that was unique to this age-group.

	Discussion

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Most descriptive epidemiological studies of injuries in children have dealt with fatal trauma^{2,3,12,32,39,41}. Nonfatal injuries have been loosely categorized as serious, as requiring hospitalization, or as requiring medical attention^8,21,29,30. Orthopaedic studies of fractures in children often have lacked the appropriate population denominator and census-based demographic data necessary to generate true rates rather than frequencies or proportions^1,6,14,43. In the current study, we focused on a single, well defined orthopaedic diagnosis. To our knowledge, this is the first United States-based population study of the incidence, mechanisms, and socioeconomic risk factors for femoral shaft fracture in children. Previously, such information was extrapolated from Scandinavian population studies reported in the late 1970s and early 1980s^22,26; however, children living in the United States today are confronted with different situations and socioeconomic risk factors that may predispose them to injury.

The patterns of occurrence of femoral shaft fractures that are reported in the current study closely resemble previously described patterns of fatal childhood injuries with regard to the bimodal age distribution, the significantly higher rates among the socioeconomically disadvantaged, and the shared primary mechanisms of injury in several age-groups^3,39,42. Motor vehicle-pedestrian accidents and accidents involving motor-vehicle occupants are the leading causes of death of children between the ages of six to nine and fourteen to seventeen years, respectively^3,41. These mechanisms were also the primary causes of femoral shaft fractures in these age-groups. Child abuse is a common cause of fatal injury in children less than two years of age⁴¹. Although, in our study, only 14 percent of the fractures in this age-group were secondary to documented abuse (E codes E9670, E9671, E9679, and E9684), many of the falls may have been due to undetected abuse. Previous work has suggested that abuse is a leading cause of fractures in children less than one year old¹⁴. The higher rates of fracture due to abuse among black infants may be related to socioeconomic factors or to bias in the reporting and documentation of cases.

The overall rate of childhood fracture peaks between the ages of ten and thirteen years^6,40, whereas in the current study the rate of femoral shaft fracture was the lowest during this period. The bimodal age distribution that we noted, with rates that peaked at the ages of two and seventeen years, may be due to a number of factors. Abuse was a mechanism of injury unique to the youngest age-groups. Femoral remodeling is greatest during the first two years of life²⁷. Commonly occurring low-energy mechanisms, such as falls, may not injure an older child but may produce a femoral fracture in an infant or a toddler²⁰. In toddlers, the protective reflexes are not fully developed and physical capabilities outpace judgment skills in assessing potentially dangerous situations and activities¹⁰. Differences between genders with regard to accepted play activities and reinforced behaviors make this relative mismatch more of a problem for boys than for girls⁴². This appears to be reflected by the widened gap in the rates of fracture between boys and girls in the two to five-year age-group.

The second peak in the rate of femoral shaft fracture is probably associated with increased rates of trauma due to motor-vehicle accidents. Although boys have higher rates, the increases in the rates for teenage boys and girls are similar. The finding that the boy:girl ratio for nonfatal motor-vehicle injuries is considerably lower than that reported for fatal accidents suggests that there are gender differences in exposure to injury during vehicular accidents^10,39. For example, girls are more often relatively protected backseat passengers, they use seatbelts more frequently, and they are involved in fewer alcohol-related accidents¹⁰. Although the overall rates of femoral shaft fracture in children in Scandinavian studies are slightly higher than those in our United States-based study (thirty-five per 100,000 compared with twenty-six per 100,000 for boys and fifteen per 100,000 compared with eleven per 100,000 for girls), Scandinavian investigators did not find a second peak among girls¹⁹, suggesting that there are cultural differences in adolescent behavior and exposure to injury.

Black children had a much higher rate of femoral shaft fracture caused by motor vehicle-pedestrian accidents in the present study. Similarly, black children have been reported to have a higher risk than white children for all types of motor vehicle-pedestrian injuries requiring hospitalization^21,29,30. King and Palmisano found an increased risk of such injury among black children even after the implementation of gross controls for socioeconomic status²¹. The differences may have been related to patterns of play, availability of transportation, and housing environments.

Firearm-related violence is another mechanism of injury that disproportionately affects black children, particularly boys. For the black male children between the ages of fourteen and seventeen years in the current study, the rate of fracture due to gun-related violence was nearly half that due to the more common mechanism of motor-vehicular trauma. Racial disparity was greatest in this age-group. This finding is in agreement with those of previous studies on adolescent mortality, which found that black male teenagers were exposed to disproportionately greater risks of injury^2,11,12. Although black female teenagers also had some gun-related fractures, their overall rate of femoral shaft fracture was actually slightly lower than that of their white counterparts (Fig. 2). This protective effect may be due to lower exposure to motor-vehicular trauma or high-energy sports activities. For example, several fractures in the white female teenagers were related to horseback riding, whereas this mechanism was not associated with the fractures in the black children. Baker et al. found that adolescents living in more densely populated, inner-city areas had a substantially lower risk of mortality due to motor-vehicle accidents than did those living in more rural areas³. Black girls also have slightly higher bone density and reach skeletal maturity sooner than do age-matched white girls^9,13. The role of gender-related differences in the rates of injury among black teenagers is an interesting area that deserves additional research in terms of potentially causal behavioral and environmental factors.

In summary, in the current study we detailed the epidemiology of femoral shaft fractures in children as well as the host, agent, and environment-related factors that contribute to increased risk of such fractures. Our findings should serve as the basis for preventive programs aimed at reducing the occurrence and consequences of these common childhood injuries²⁵.

NOTE: The authors thank Monique Sheppard, formerly of the Maryland Department of Health and Mental Hygiene; Gregg Burleyson of the Department of Case Mix Management at The Johns Hopkins Hospital for supplying the databases for this study; and Elaine Bulson for her assistance in project development.

	Footnotes

 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Department of Orthopaedic Surgery, The Union Memorial Hospital, Johnston Professional Building, 3333 North Calvert Street, Suite 400, Baltimore, Maryland 21218. Please address requests for reprints to Dr. Hinton c/o Elaine P. Bulson, Editor.

Center for Injury Research and Policy, The Johns Hopkins School of Hygiene and Public Health, 624 North Broadway, Baltimore, Maryland 21205.

Department of Orthopaedic Surgery, The Johns Hopkins Medical Institutions, 601 North Caroline Street, Baltimore, Maryland 21287.

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