Risk Factors For Traumatic Open Fracture in Children and Adolescents Presenting With Traumatic Fractures

Background: To investigate the risk factors for open fractures in children and adolescents ( ≤ 18 years old) presenting with traumatic fractures. Methods: We retrospectively reviewed the records of 2418 children and adolescents who presented with traumatic fractures and were admitted to our university-aliated hospitals, among which 206 patients (8.5%) presented with open fractures. Results: This study enrolled 1789 males (74.0%) and 629 females (26.0%) with an average age of 11.2±5.0 years. There were 206 patients (8.5%) who presented with open fractures. The ve most common fracture sites were the tibia (31.1%, 64/206), bula (20.9%, 43/206), phalanx (15.5%, 32/206), humerus (11.2%, 23/206) and ulna (9.7%, 20/206). Univariate logistic regression analysis showed that the aetiology (P (cid:0) 0.001) and fracture site (P (cid:0) 0.001) were risk factors for open fracture. Multivariate logistic regression analysis indicated that mechanical trauma (OR=64.229, P (cid:0) 0.001), being hurt/cut by others (OR=26.757, P (cid:0) 0.001), and being struck by an object (OR=15.345, P (cid:0) 0.001) were stronger risk factors for open fracture than were low falls; additionally, lower limb fractures (OR=5.970, P (cid:0) 0.001), upper limb fractures (OR=5.865, P (cid:0) 0.001) and multiple fractures (OR=5.414, P (cid:0) 0.001) were stronger risk factors than craniofacial fractures for open fractures. Conclusions: Aetiology (especially being injured by a machine or being hurt/cut by others) and the fracture site (including lower limb fractures, upper limb fractures and multiple fractures) were independent risk factors for open fractures.


Introduction
Fractures account for 10% to 25% of paediatric injuries 1,2 . The patterns of fractures vary between countries and even between regions within a country, depending on the local climate, culture, and leisuretime activities [3][4][5][6][7][8][9][10][11][12][13][14][15] . The epidemiology of open paediatric fractures is still not completely understood. The incidence varies from centre to centre; most authors agree that open fractures comprise 2% to 9% of all paediatric fractures, but the estimates vary from 0.7% to 25% [16][17][18] . In India, researchers have reported that the incidence of open fractures was 2.8% among a total of 500 paediatric fractures 19 . Data about the risk factors and hospital fees for open fracture in children and adolescents (≤18 years old) presenting with traumatic fractures are scarce.
In the present study, we reviewed a multicentre (two tertiary hospitals in Chongqing, China) database of traumatic fractures that occurred between 2003 and 2010 in a population of children and adolescents ≤ 18 years of age to address these de ciencies and to provide comprehensive information on this important childhood public health problem in China. The risk factors for open fracture in children and adolescents (≤18 years old) presenting with traumatic fractures were investigated.

Study population
Our study included 2418 patients from a population of children and adolescents (≤18 years old) who had acute traumatic fractures between January 2003 and December 2010 and who were admitted to our university-a liated hospitals. We used X-rays, computed tomography (CT) and magnetic resonance imaging (MRI) to make de nitive diagnoses of traumatic fractures in patients who were children or adolescents (≤18 years old). The medical records were reviewed and assessed by two independent persons who did not participate in treating any of the patients.
The patients were classi ed into three age groups: ≤6 years old (neonatal period, infancy stage, toddler period, and preschool period), 6-12 years old (junior middle school stage) and 12-18 years old (senior high school stage). The patients were also classi ed into 7 groups based on the aetiology of the trauma: motor vehicle collisions (MVCs), high fall (fall from a high height ≥2 m unrelated to MVCs), low fall (fall from a high height <2 m unrelated to MVCs), injured by a machine, struck by an object, hurt/cut by others and other aetiology. The sites of the traumatic upper limb fractures (TULFs) were classi ed as the humerus, radius, ulna, clavicle, scapula and hand. The sites of the traumatic lower limb fractures (TLLFs) were classi ed as the femur, tibia, bula, pelvis and foot. Nerve injuries (NIs) included central nervous system injury (traumatic brain injury and spinal cord injury) and peripheral nerve injury (cranial nerve injury and spinal nerve injury). Associated injuries (ASOIs) include head injury, lung injury, renal injury, haemorrhagic shock, osteofascial compartment syndrome, retroperitoneal haematoma and so on.
Complications included fracture malunion, fracture nonunion, delayed union, fracture site infection, decubitus ulcers, traumatic arthritis, deep vein thrombosis and so on. The study protocol and this manuscript were approved by the ethics committee and the institutional review board of our institution.

Statistical analysis
All statistical analyses were performed using SPSS version 22.0 (SPSS, Inc., Chicago, IL). We used Pearson chi-square tests to assess differences in age, sex distribution and clinical characteristics between the two groups of patients with and without open fractures. Continuous variables such as current age were examined using the one-sample Kolmogorov-Smirnov test for normally distributed variables; these variables are expressed as the mean ± standard deviation (SD). Differences in the continuous variables between the two groups were evaluated using independent samples t-tests. Univariate and multivariate logistic regression analyses were used to evaluate associations between the clinicopathological features and the prevalence of open fractures.
Univariate logistic regression analysis showed that aetiologies (P 0.001) and fracture sites (P 0.001) were risk factors for open fractures (Table 1). Multivariate logistic regression analysis indicated that mechanical trauma (OR=64.229, P 0.001), being hurt/cut by others (OR=26.757, P 0.001), and being struck by an object (OR=15.345, P 0.001) were stronger independent risk factors for open fracture than low fall; moreover, lower limb fracture (OR=5.970, P 0.001), upper limb fracture (OR=5.865, P 0.001) and multiple fractures (OR=5.414, P 0.001) were stronger independent risk factors for open fracture than craniofacial fractures (Table 4). involved the tibia/ bula and 32% involved the forearm, followed by the hand (10%), femur (6.7%) and humerus (6.5%) [21]. In the current study, the most common open fracture sites were the tibia (31.6%), bula (22.8%), radius (13.6%), ulna (13.1%) and humerus (13.1%). We believe that the pattern of traumatic fractures among children is partly explained by differences in the activity patterns of children.

Discussion
Children around the world are routinely engaged in paid and unpaid forms of work that are not harmful to them. However, they are classi ed as child labourers when they are either too young to work or are involved in hazardous activities that may compromise their physical, mental, social or educational development. In China, child labor refers to children or young workers under the age of 16. In the current study, one person (6.7%) was injured by a machine during working in the 0-16 age group. Two person (2.9%) was struck by object during working in the 6-16 age group. We presume that the main causes of child labour are high level poverty and lack of access to good education. In the current study, nine persons (24.3%) was cut by others in the 6-16 age group, 15 persons (40.5%) were cut by others in the 16-18 age group. We should tighten up law enforcement to crack down on all kinds of violations and protect the children. In the current study, univariate logistic regression analysis indicated that aetiologies and fracture sites were risk factors for open fractures. Multivariate logistic regression analysis indicated that mechanical trauma, being hurt/cut by others, and being struck by an object were independent risk factors for open fracture. Multivariate logistic regression analysis indicated that lower/upper limb fractures and multiple fractures were independent risk factors for open fractures. Therefore, we should maintain and enhance a safe work environment for younger adolescents and provide a safe and comfortable place for children to rest and play to avoid mechanical trauma and being struck by objects. We should also strengthen schoolbased moral education to effectively prevent crimes such as being hurt/cut by others.

Availability of data and material
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Authors' contributions
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Jun Liu, Deluo Wu, Lan Ou. The rst draft of the manuscript was written by Hongwei Wang and all authors commented on previous versions of the manuscript. All authors read and approved the nal manuscript.

Ethics approval and consent to participate
The procedure was approved by the ethics committee of Xinqiao Hospital, and patients provided written informed consent to participate in this study.

Consent for publication
Not applicable.