Lennart Landin

Fracture Patterns in Children: Analysis of 8,682 Fractures with Special Reference to Incidence, Etiology and Secular Changes in a Swedish Urban Population 1950–1979.

Age, sex, type of fracture and the circumstances causing the injury were studied in altogether 8,682 fractures in children, aged 0 - 16, which had occurred 1950, 1955, 1960, 1965, 1970 and 1975 - 1979. For studies of incidence, the years 1975 - 1979 were chosen and for secular trend studies 1950, 1955, 1960, 1965, 1970 and 1975 - 1979. The following conclusions may be drawn: 1. The risk of fracture increased with age up to age 11 - 12 in girls and 13 - 14 in boys. 2. The accumulated risk of fracture was 27 per cent in girls and 42 per cent in boys. 3. Fractures were more common in boys of all age groups. 4. Over the last three decades the risk of fracture was doubled in boys as well as in girls. 5. Over the years more and more fractures were caused by slight trauma whereas the more severe trauma - even if increasing somewhat in risk - contributed a smaller fraction of the injuries. 6. For the various types of fracture the pattern of change could differ - some increased in incidence, whereas some remained unchanged or even decreased. 7. All types of trauma - horse riding accidents excluded - were more frequent in boys. 8. The most commonly fractured region was the distal end of the forearm followed by the phalanges of the hand and the bones of the carpal-metacarpal region. 9. Playing, sports and traffic, in that order contributed 24, 21 and 12 per cent of those fractures in which the circumstances of the accident could be analysed. 10. Traffic accidents increased with one third in boys as well as in girls. 11. The passive participants in traffic - pedestrians and passengers in motor vehicles - were not more frequently injured during the latter part of the period under observation - a tendency of increase in girls was compensated for by a decrease in boys. 12. Sports and various playing activities as a cause of fracture increased with a factor of five. 13. In the upper limb, the left side was most frequently fractured. 14. The occurrence of fractures varied with the seasons with peak values in May and August and low values in July and December. 15. No fracture type in children could completely meet the criteria of a fragility fracture such as seen in old age. 16. Sustaining one fracture carried an increased risk of an additional fracture especially in the very young children. 17. Fractures not requiring reduction increased the most over the years. 18. The subset of children with various diseases suspected to interfere with skeletal development carried an increased risk of fracture. 19. Some age-related fracture patterns could be traced but they were not very distinct.

Elbow fractures in children. An epidemiological analysis of 589 cases

The radiographs of 589 elbow fractures in children under the age of 16 years were reviewed. The most common fractures were: supracondylar fracture of the humerus -55 per cent, fracture of the radial neck -14 per cent, and fracture of the lateral humeral condyle -12 per cent. One fifth of all fractures of the olecranon were associated with another elbow fracture; most often a fracture of the medial epicondyle. The average annual incidence of elbow fractures in the age group studied was 12 per 10.000 (10.0-14.7) without a significant change of the incidence between 1950 and 1979. Supracondylar and lateral condylar fracture of the humerus and fracture of the olecranon occurred more often in boys. Fractures of the lateral humeral condyle were more often caused by higher energy levels than the other fracture groups.

Bone Mineral Content in Children with Fractures

Bone mineral content was measured in the forearms of 90 children who had recent fractures. The data were compared with those of age-matched healthy children. Bone mineral content was significantly reduced in children in whom fractures were caused by low-energy trauma. Bone mineral content in children in whom fractures were caused by high-energy trauma was also reduced, but the difference was not significant. Correction for other parameters of growth and maturation, e.g., height and weight, did not eliminate the difference in bone mineral content. These findings indicate that endogenous factors contribute to fracture not only in the elderly but also in children.

Bone Mineral Content in Preterm Infants at Age 4 to 16

Using photon absorptiometry the forearm bone mineral content (BMC) was determined in 75 children aged 4 to 16, who all had a low birth weight. Forty‐five of them were born preterm AGA (27 boys, 18 girls, mean weight 1580 g; range 920‐2060 g) and 30 preterm SGA (17 boys, 13 girls, mean weight 1510; range 940‐2130 g). The results were compared with a control group of children of the same age, and analyses of covariance with age, height and weight as the covariant factors were performed. The BMC, weight and height did not differ between the children born AGA or SGA. Irrespective of AGA or SGA, the BMC was significantly decreased in boys but the difference was less pronounced and less significant when height and weight were used as covariant factors. Boys who had been born preterm had a less BMC than the control boys for their age but the were also somewhat shorter and lighter than expected with regard to their age.

FOREARM BONE MINERAL CONTENT IN CHILDREN Normative Data

Abstract. Landin, L. and Nilsson, B. E. (Department of Orthopedic Surgery, University of Lund, Malmö General Hospital, Malmö, Sweden). Forearm bone mineral content in children‐Normative data. Acta Paediatr Scand, 70: 919, 1981.‐The bone mineral content in the forearm was measured by gamma‐absorptiometry in 131 normal children. The bone mineral content was closely related to age, height and weight, to the size of forearm and to the force of the forearm muscles. By correcting for the dimensions of the bones a parameter of density (mass/volume) was calculated. This variable also increased with age. Knowing the necessary corrections factors gamma‐absorptiometry could be a useful and harmless method for bone mineral assessment in children with various diseases.

Children's Ankle Fractures: Classification and Epidemiology

In an investigation of childhood and adolescence fractures (age groups 0-16) occurring in Malmö during 1950, 1955, 1960, 1965, 1970 and 1975-79, a total of 8682 were found. Four per cent or 373 ankle fractures were classified according to their roentgenological appearance. Avulsion fractures of the tip of the lateral malleolus were the most frequent, followed by fractures involving the distal fibular physis. Triplane and Tillaux fractures were the third and fourth most common fracture groups. Tillaux fractures were more common in girls (0.01 greater than P greater than 0.001). There was no statistically significant difference between the sexes in the other fracture groups or in the whole series. Most injuries were caused by low energy trauma. A foot caught in a bicycle wheel resulted more often in an epiphyseal fracture of the lateral malleolus than any other type of fracture. Otherwise no other etiological factor caused a significant number of cases in any fracture group. There was a seasonal variation with twice as many fractures during April and September as compared with July and December. The incidence showed a steady increase during growth which ceased after the early teens due to a lower incidence among girls in the age groups 15-16. The incidence increased significantly during the 30 years covered by this study.

Does a childhood fracture predict low bone mass in young adulthood?—A 27-year prospective controlled study

A fracture in childhood is associated with low bone mineral density (BMD), but it is debated whether a fracture at growth also predicts low BMD in young adulthood. The purpose of this work was to gender‐specifically evaluate whether children with a fracture are at increased risk of low BMD in young adulthood. Distal forearm BMD (g/cm2) was measured with single‐photon absorptiometry (SPA) in 47 boys and 26 girls (mean age 10 years, range 3–16 years) with an index fracture and in 41 boys and 43 girls (mean age 10 years, range 4–16 years) with no fracture. BMD was re‐measured mean 27 years later with the same SPA apparatus and with dual‐energy absorptiometry (DXA), quantitative ultrasound (QUS), and peripheral computed tomography (pQCT). Individual Z‐scores were calculated using the control cohort as reference population. Data are presented as means with 95% confidence intervals (95% CI) within brackets and correlation with Pearsons correlation coefficient. Boys with an index fracture had at fracture event a distal forearm BMD Z‐score of −0.4 (95% CI, −0.7 to −0.1) and at follow‐up −0.4 (95% CI, −0.7 to −0.1). Corresponding values in girls were −0.2 (95% CI, −0.5 to 0.1) and −0.3 (95% CI, −0.7 to 0.1). The deficit in absolute bone mass was driven by men with index fractures in childhood due to low energy rather than moderate or high energy. There were no changes in BMD Z‐score during the follow‐up period. The BMD deficit at follow‐up was in boys with an index fracture verified with all advocated techniques. A childhood fracture in men was associated with low BMD and smaller bone size in young adulthood whereas the deficit in women did not reach statistical significance.

Traumatic hip dislocation with spontaneous reduction and capsular interposition: A report of 2 children

We present 2 cases of posterolateral hip dislocation in children followed by spontaneous reduction and interposition of soft tissue. After reduction of a dislocated hip joint, interposition of soft tissues or fracture fragments must be excluded. When reduction has occurred spontaneously, the condition may be misjudged, correct treatment delayed and the hip joint permanently damaged, as occurred in one of our cases. In the second case, prompt surgery was undertaken and the patient recovered completely.

Late results in 65 physeal ankle fractures

Fifty-nine Salter-Harris III and IV lesions of the medial malleolus, Tillaux fractures, and triplane fractures were examined after 9 (3-32) years to assess the frequency of late symptoms, deformity, joint incongruity, and secondary arthrosis. Six out of 18 Salter-Harris III and IV lesions of the medial malleolus were reduced open, none of which had any signs of growth disturbance, whereas 1 case, left with a 3-mm residual dislocation, had 5 degrees of anterior angulation. Of the 17 Tillaux fractures, ten were not reduced and two of these gave slight symptoms, whereas five openly reduced fractures were asymptomatic at follow-up. Out of 18 triplane fractures, not reduced, two gave slight ankle pain and another had 6 degrees of anterior angulation, whereas three of ten reduced fractures were symptomatic. The overall results were good and no case of arthrosis, defined as reduction of the joint space, was found in any of the fracture groups despite a follow-up of 12 or more years in one third of the cases.

Increasing wrist fracture rates in children may have major implications for future adult fracture burden.

Background and purpose — Childhood fractures are associated with lower peak bone mass (a determinant of osteoporosis in old age) and higher adult fracture risk. By examining time trends in childhood fracture epidemiology, it may be possible to estimate the vector of fragility fracture risk in the future. Patients and methods — By using official inpatient and outpatient data from the county of Skåne in Sweden, 1999–2010, we ascertained distal forearm fractures in children aged ≤ 16 years and estimated overall and age- and sex-specific rates and time trends (over 2.8 million patient years) and compared the results to earlier estimations in the same region from 1950 onwards. Results — During the period 1999–2010, the distal forearm fracture rate was 634 per 105 patient years (750 in boys and 512 in girls). This was 50% higher than in the 1950s with a different age-rate distribution (p < 0.001) that was most evident during puberty. Also, within the period 1999–2010, there were increasing fracture rates per 105 and year (boys +2.0% (95% CI: 1.5–2.6), girls +2.4% (95% CI: 1.7–3.1)). Interpretation — The distal forearm fracture rate in children is currently 50% higher than in the 1950s, and it still appears to be increasing. If this higher fracture risk follows the children into old age, numbers of fragility fractures may increase sharply—as an upturn in life expectancy has also been predicted. The origin of the increase remains unknown, but it may be associated with a more sedentary lifestyle or with changes in risk behavior.