Accident Prevention, Risk, and the Evolving Epidemiology of Fractures

Dennis Wenger

James Bomar

INTRODUCTION

The late Mercer Rang was a leader in promoting the concept of safer playgrounds, better sports equipment, and auto safety issues (for both passengers and pedestrians). Over time many orthopedic organizations (AAOS, POSNA, others) have joined this effort in promoting accident prevention to minimize musculoskeletal injury. Also, these organizations have expanded their efforts into areas such as the need for exercise in childhood development, avoidance of obesity, and efforts to promote bone density (avoid osteopenia/osteoporosis).

“It takes as much energy to wish as it does to plan”

—Eleanor Roosevelt

Figure 20-1 Helmet wear is fortunately becoming the standard for many sports. Efforts to prevent head injury have been a huge success. (Photo courtesy of R. Knudson.)

Figure 20-2 Children love the thrill of riding motorized vehicles. (Photo courtesy of R. Knudson.)

ACCIDENT FREQUENCY AND THE NEED FOR PREVENTION

Vitale and colleagues at Columbia University, through the International Center for Health Outcomes and Innovation Research, provide data on children’s musculoskeletal injuries. A paper from their center clarifies pediatric trauma as the leading cause of death and disability in children, accounting for 11 million hospitalizations, 100,000 permanent disabilities, and 15,000 childhood deaths each year in the United States. Clearly this calls for a focus on preventing childhood injuries.

Tremendous progress has been made in accident prevention. Automobiles are now much safer (better design [structural “cage”], air-bags [front, side, head protection], better brakes [ABS], and better seat belts—plus laws that mandate their use). The routine (and usually legally mandated) requirement for helmet use in bicycling and other sports (Fig. 20-1) has been important in reducing head injuries. In many neighborhoods, playgrounds are safer, because of better design with soft surfaces replacing asphalt or compacted dirt to minimize injury related to a fall (such as from monkey bars).

Furthermore, in developed countries, the establishment of effective trauma systems including, in many cases, pediatric trauma centers has helped reduce the morbidity and mortality associated with severe musculoskeletal injury. Also, the rapid growth of pediatric orthopedics as a subspecialty has reduced fracture morbidity because of research produced by the major pediatric orthopedic centers that has led to better treatment methods (as have been presented in this 4th edition).

A concentration of experience in treating severe fractures has greatly improved the quality of children’s fracture care in North America. The methods learned by pediatric orthopedic fellows, who have trained in major centers, are now available in hundreds of communities, not only in large centers but also in medium-sized cities (e.g., Fargo, North Dakota; Wichita, Kansas; Jackson, Mississippi, others).

Despite this progress, not all the news is good regarding risks to children and fracture incidence/prevalence.

ACCIDENT OR CULTURAL CONSEQUENCE?

We continue to marvel at how the North American culture uses the term “accident” in reference to children’s fractures (Fig. 20-2). Parents will bring in their 6-year-old boy who was driving a mini-racing motorcycle in the desert with a large number of family members (with some family members enjoying “a few beers” while riding their off-road vehicles). The child has multiple fractures (one open) with the parents distraught over the “accident.” In some cases, the term “accident” has become a euphemism for failure to provide appropriate
guidance and supervision for children. When small children and powerful machines are involved, this failure may border on neglect.

Vitale and colleagues suggest that the incidence of fractures is increasing in North America (rather than decreasing) because of cultural patterns that will be discussed later in this chapter (Galano et al.—see Suggested Readings).

As sports become safer (helmets, pads, etc.), children are more likely to push themselves to attempt more difficult maneuvers. The constant progression of aggressive sports increases the risk for injury. As an example of this progression, in 2005 (when the previous edition of this text was released), the X Games (Extreme Games) were largely unknown. Since then, X Game alumni such as Tony Hawk and Shaun White have become mainstream athletes and traditional X Game sports (such as the snowboard half pipe competition) have become Olympic events.

The unbelievable “musculoskeletal genius” required to perform their most difficult maneuvers does not safely transfer to an awkward 8-year-old who just received a skateboard for his or her birthday. The concept of “risk homeostasis,” in which those who wear protective equipment or use vehicles with advanced “safety features,” then attempt more extreme stunts or drive faster, will be discussed later.

Brent and Weitzman presented a comprehensive analysis of the environmental risks of childhood in North America. They noted that accidents are the leading cause of death in children under age 15 years, and that many are preventable with safety education. Although leaders in pediatric orthopedics have made a concerted effort to work on developing methods that might prevent fracture, the prevalence of fractures appears to be increasing in our culture.

Brent and Weitzman grouped environmental risks to children with many of the listed subgroups leading to musculoskeletal injury.

Trauma from falls
Vehicular accidents
Burns
Choking, strangulation
Drowning
Bicycling
Pedestrian injuries
Guns
Sports injuries
Power tools/farm tools
Obesity
Alcohol, smoking, drug use

“As sports become safer (helmets, pads, etc.), children are more likely to push themselves to attempt more difficult maneuvers”

Figure 20-3 The razor scooter has proven to be a great source of new fractures. The tiny wheels and large sidewalk cracks are not a good mix.

“Clearly children’s orthopedists need a balanced view regarding what play is ‘too risky’ for children”

In this chapter, we will focus on the conditions with risk for musculoskeletal injury in children, that is, falls, vehicular accidents, sports injuries, and power tools. A growing, but less easily categorized group (not clearly demarcated in the review by Brent and Weitzman), includes wheeled devices that are not formally considered vehicles (skateboards, rollerblades, “razor” scooters, hoverboards, etc.) (Fig. 20-3) that can be used in very dynamic (even aggressive) ways. Also, the use of gasoline powered mini-bikes and battery-powered scooters has increased “childhood speed.”

Falls

Infants can incur head injuries when falling down stairs, off of beds, or against sharp, pointed furniture. Toddlers and older children often fall from windows, stairs, trees, garage roofs, and ladders. Trampoline injuries produce many fractures (as well as head and neck injuries). Each year thousands of children have emergency room visits for trampoline injuries. When multiple children jump at once, injury is more likely and younger children are at the greatest risk for fracture. However, children really enjoy trampolines (Fig. 20-4). One of our pediatric orthopedic staff recently purchased one for his children (with side netting and flexible rods instead of springs). Clearly children’s orthopedists need a balanced view regarding what play is “too risky” for children.

Figure 20-4 Trampolines provide enjoyment for millions of children. This photo shows a “safer model.”

Vehicular Accidents

Passenger injuries are extremely common in young children, and they should not ride in the front seat of a car. Education and regulations regarding properly installed car and booster seats have improved this circumstance. Government mandated latch systems, which allow a nationally standardized method for attaching child seats to the automobile frame, have made auto travel safer. Legislation-mandated child car seat use also helps. In most states, a parent who fails to properly restrain a child is penalized.

Also, children under age 10 years are at great risk for death from pedestrian accidents including being run over by the family car in their own driveway (lack of vision from the height of the new, taller SUVs have added to the problem). The addition of so-called rear view cameras, mounted on the back of a vehicle, has reduced this risk.

For teenage drivers, impulsive behavior, speeding, and inattentive driving as well as driving after alcohol intake make auto accidents a leading cause of death in this age group. The Europeans may have a better strategy (drink mildly and while with family, drive late—age 18 years).

Also, cell-phone use and texting while driving has become a recent risk for severe auto accidents. Teenagers, who believe that only they have the mental agility to both text and drive, have been a major cause of traffic deaths in the United States. Just a few seconds of one’s eyes “off the road” can be fatal. Many states have developed teen driver education programs to illustrate this risk. Also laws have been developed to severely penalize those who text and drive. A teenager in California, who while texting and driving, causes an accident that kills a pedestrian (or other driver) will time years in detention.

We see many young patients whose parents have aspirations for their children to become professionals in motorcycle racing and/or daredevil motorcycle jumping activities. If children are adequately skilled, they can “get a sponsor” (equipment, etc.), at a very young age (Fig. 20-5). Accidents are very common in these high-risk sports, but parents are willing to accept these risks because those who “rise to the top” in competitive events can earn handsome incomes as “professionals.”

Children riding a bicycle, tricycle, scooter, or skateboard or using a razor scooter should use a well-fitted helmet to reduce the risk for head injury. Bicycling can be risky for children and ideally would be restricted to daylight use, in safe areas, with helmet use.

“Organized Sports”

The prevalence of sports injuries in our culture is “sky-rocketing” as greater numbers of children/adolescents participate in “organized
sports.” The growth of year-round focus on one sport including the development of “travel teams” (who spend each weekend in fiercely competitive tournaments in distant cities) has led to “overuse injuries” in many children.

“Government mandated latch systems, that allow a nationally standardized method for attaching child seats to the automobile frame, have made auto travel safer”