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ORIGINAL ARTICLE
Adv Biomed Res 2022,  11:100

The effect of COVID-19 pandemic on the characteristics of pediatric supracondylar fracture: A retrospective cohort study


1 Physiotherapy Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences; Clinical Research Development Unit, Akhtar Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Foreign Languages, Urmia University, Urmia, Iran
3 Clinical Research Development Unit, Akhtar Shahid Beheshti University of Medical Sciences, Tehran, Iran
4 Skin Reserch Center, Shahid Beheshti University of Medical Science, Tehran, Iran

Date of Submission28-Feb-2021
Date of Acceptance29-Jun-2021
Date of Web Publication28-Nov-2022

Correspondence Address:
Dr. Morteza Gholipour
Shahid Beheshti University of Medical Sciences, Tehran
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/abr.abr_49_21

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  Abstract 


Background: Environmental factors play a key role in the occurrence of pediatric supracondylar humerus (SH) fracture which has been widely affected by the COVID-19 pandemic and the measures taken to curb its spread. In this study, we aim to investigate the ultimate impact coronavirus pandemic has had on SH fractures in children.
Materials and Methods: This retrospective cohort study compares SH fractures which occurred during the pandemic with their prepandemic counterpart in a pediatric trauma public hospital. Patient's data, submitted from February to July 2020 and 2019, were collected and divided into two groups based on fractures' time of occurrence, i.e., during or before the pandemic.
Results: There was no significant difference in terms of gender, type of fracture, injury location, and time of admission during a day between the aforementioned groups. However, in the pandemic group, patients were transferred to the operating room significantly quicker (odds ratio; 2.13 vs. 0.607, P = 0.01) and the surgery duration was shorter (40.17 ± 12.28 min vs. 49.11 ± 15.48 min, P = 0.011). It was found that the location of injury (home, school, etc.) varied between the two groups (P = 0.01) and the proportion of domestic injuries during the pandemic grew significantly (53.6% vs. 19.8%).
Conclusion: Although the incidence of pediatric SH fractures has decreased due to the closure of schools and sports clubs during the pandemic, domestic occurrence of the same fracture type has grown disproportionately. To prevent this trend, pediatric centers should educate parents on child safety measures and fracture risks during the lockdown.

Keywords: Coronavirus, COVID-19, epidemiology, pediatric, supracondylar humerus fractures


How to cite this article:
Sabaghzadeh A, Bonakdar S, Ebrahimpour A, Khoshkholghsima M, Gorji M, Soufiabadi K, Gholipour M. The effect of COVID-19 pandemic on the characteristics of pediatric supracondylar fracture: A retrospective cohort study. Adv Biomed Res 2022;11:100

How to cite this URL:
Sabaghzadeh A, Bonakdar S, Ebrahimpour A, Khoshkholghsima M, Gorji M, Soufiabadi K, Gholipour M. The effect of COVID-19 pandemic on the characteristics of pediatric supracondylar fracture: A retrospective cohort study. Adv Biomed Res [serial online] 2022 [cited 2023 Feb 6];11:100. Available from: https://www.advbiores.net/text.asp?2022/11/1/100/362025




  Introduction Top


Coronavirus infection is an acute respiratory syndrome caused by the Severe Acute Respiratory Syndrome Coronavirus-2 virus, which originated in Wuhan, China in December 2019, and spread rapidly to other parts of the world.[1] On March 11, 2020, the World Health Organization characterized the disease as a pandemic.[2] The clinical pattern of COVID-19 is not clear, especially in children and the symptoms are different in children compared to adults;[3],[4] in a study conducted in Wuhan, China, 15% of the children who were diagnosed with COVID-19 were clinically asymptomatic with normal radiological findings, despite laboratory confirmation of the disease.[4] The incidence of COVID-19 is lower in children compared to adults due to their high resistance against the disease. As reports suggest, children transmit the virus mostly through person-to-person contact.[5] Given these differences, more consideration should be given to pediatric orthopedic surgical systems. Recent studies on the pandemic have indicated a reduction in total number of pediatric fractures, as well as the characteristics associated with them.[6] SH supracondylar humerous fracture is still the most common fracture among children[7] and constitutes 60%–80% of pediatric humeral fractures.[8],[9],[10] The average age of SH fracture incidence has been reported in various studies to be between 3 and 8 years.[11],[12] Gartland classification is widely used to categorize SH fractures, according to which Type I is a nondisplaced fracture, Type II is an incomplete fracture with an intact posterior cortex, and Type III is a fracture with a complete displacement.[13] Complications are highly probable in nonsurgical treatment of Types II and III, which renders it inefficient.[14] Therefore, in this study, we objective to investigate the ultimate impact coronavirus pandemic has had on SH fractures in children.


  Materials and Methods Top


Study design

With the approval of the Institutional Review Board of Shahid Beheshti University of Medical Sciences, This retrospective study was performed within a 6-month time span from February to July 2020 and in the same period in 2019 on children with SH fracture at the Pediatric Orthopedic Trauma Center (Akhtar Public Hospital - Iran). We selected 137 patients and divided them into two groups to evaluate their fracture characteristics. All surgeries were performed by an orthopedic surgeon and all patients were operated on with closed reduction and percutaneous fixation with k-wires and a long splint applied after surgery. Inclusion criteria included (1) children aged 2–12 years, (2) without previous history of surgery around the same elbow, (3) without neurologic disorder, and (4) diagnosed with Gartland Type II and III fractures. Exclusion criteria included (1) patients with multiple fractures or open fractures, (2) patients with incomplete medical records, or (3) patients with previous elbow deformity. Demographic information was extracted from patients' electronic files. Digital Picture Archiving and Communication System and Gartland system were used to diagnose the type of fracture and classify it, respectively. Patients' data included demographic characteristics, type of fracture, time of hospital admission (daytime, i.e., between 8:00 a.m. and 8:00 p.m./nighttime, i.e., later than 8:00 p.m.), duration of surgery (total time of anesthesia and surgery), urgency of surgery (urgent for under 8 h/emergent for above 8 h), and location of the injury (home/street/school/kindergarten/playground, etc.). The aim of this study was to compare, retrospectively, the characteristics of supracondylar fractures which occurred during the pandemic with a prepandemic record.

Statistical methods

Following the coding of data, the qualitative variables were evaluated using the Chi-squared (χ2) test or Fisher's exact test, whereas quantitative variables were assessed by Student's t-test and odds ratio obtained from univariate logistic regression. We used the Statistical Package for the Social Sciences version 16.0 software (SPSS Inc., Chicago, IL, USA) for all statistical analyses. Our data were presented as either (mean ± standard deviation), median (range), or n (%), and the significance level was set to P = 0.05 with a confidence interval of 95%.


  Results Top


In our study, 137 patients (below 12 years of age and diagnosed with SH fracture) were selected out of 250 pediatric fracture cases. Patients were then grouped (based on whether the fractures occurred during the pandemic or not) and evaluated in various aspects [Table 1]. The pandemic and the prepandemic groups did not differ significantly by gender (P = 0.123) and by the average age of patients (4.14 ± 2.02 years vs. 5.06 ± 2.61 years, P = 0.055). The pandemic had no significant effect on the side of injury as the left side was more frequently injured in both groups (67.9% vs. 56.8%, P = 0.191). Furthermore, the fracture pattern did not vary significantly between the two groups (P = 0.854).
Table 1: General demographic information of supracondylar fractures in children

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Although hospital admission time for SH fractures did not change significantly during the pandemic (daytime vs. nighttime, P = 0.590), transferring patients to the operating room was quicker (odds ratio; 2.13 vs. 0.607, P = 0.01), and surgeries were of shorter duration (40.17 ± 12.28 min vs. 49.11 ± 15.48 min, P = 0.011(. As for SH fractures during the pandemic, the proportion of domestic injuries significantly increased (53.6% vs. 19.8%) and the most common fracture type was Gartland II [Table 2].
Table 2: Analysis of fracture demographic information in pandemic and prepandemic groups

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  Discussion Top


The spread of the COVID-19 has created a major challenge for the health care system; it has altered the treatment pattern of trauma and has also brought emergency patients into more focus. The nationwide restrictions imposed by governments (e.g., social distancing, schools' closure, etc.) have substantially influenced pediatric fractures,[15] especially supracondylar ones. SH fracture is one of the most common pediatric fractures for which a large number of patients undergo surgery every year.[9],[16] The characteristics of SH fracture have changed during the pandemic, and so have the methods to approach them as a consequence. As indicated by this study, COVID-19 restrictions reduced the total number of fractures in children, especially the SH fracture compared to the prepandemic period (40.9% vs. 59.1%). Such changes are evident as a result of reduced outdoor activities (e.g., school, sports, etc.) since the restrictions came into effect. Despite this overall decrease, on account of more time being spent at home, domestic SH injuries have increased by 33.8%. According to our findings, patients, once admitted, were transferred to the operating room within a significantly shorter time span during the pandemic. This is due to the health system pandemic policies which were implemented to reduce patients' length of stay. The operating time has also decreased during the pandemic. As a preventive measure, more effort should be taken to inform parents of the potential fractures risks and encourage them to boost the safety level of children's play environment.

This study revealed consistent findings with the previous literature; the mean age of patients (which remained nearly constant across pandemic and prepandemic groups) corresponded to similar studies[17],[18] and the left side was consistently reported as the most frequent fracture side.[11] Lack of access to patients' objective data in the prepandemic period (2019) and exclusive use of electronic records posed limitations to the study. Patients who referred to private hospitals instead due to their insurance coverage and those who did not seek medical help due to COVID-19 concerns were not included in this study for their information was unobtainable for public hospitals.


  Conclusion Top


Although the incidence of pediatric SH fractures has decreased due to the closure of schools and sports clubs during the pandemic, domestic occurrence of the same fracture type has grown disproportionately. To prevent this trend, pediatric centers should educate parents on child safety measures and fracture risks during the lockdown.

Limitations of the study

The limitations of this study included: Small number of patients, lack of access to pediatric orthopedic trauma centers, and lack of timely referral due to fear of coronavirus, which in future studies should be given special attention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, et al. A novel coronavirus from patients with pneumonia in China, 2019. N Engl J Med 2020;382:727-33.  Back to cited text no. 1
    
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Lu X, Zhang L, Du H, Zhang J, Li YY, Qu J, et al. SARS-CoV-2 infection in children. N Engl J Med 2020;382:1663-5.  Back to cited text no. 3
    
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Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA 2020;323:1239-42.  Back to cited text no. 4
    
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Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al. Epidemiology of COVID-19 among children in China. Pediatrics 2020;145:e20200702.  Back to cited text no. 5
    
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Bram JT, Johnson MA, Magee LC, Mehta NN, Fazal FZ, Baldwin KD, et al. Where have all the fractures gone? The epidemiology of pediatric fractures during the COVID-19 pandemic. J Pediatr Orthop 2020;40:373-9.  Back to cited text no. 6
    
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Cheng JC, Ng BK, Ying SY, Lam PK. A 10-year study of the changes in the pattern and treatment of 6,493 fractures. J Pediatr Orthop 1999;19:344-50.  Back to cited text no. 7
    
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Aydoğmuş S, Duymuş TM, Keçeci T, Adiyeke L, Kafadar AB. Comparison of daytime and after-hours surgical treatment of supracondylar humeral fractures in children. J Pediatr Orthop B 2017;26:400-4.  Back to cited text no. 8
    
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McRae B, Nusem I. Temporal characteristics of paediatric supracondylar humerus fractures. Trauma 2018;20:208-16.  Back to cited text no. 9
    
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Sinikumpu JJ, Pokka T, Hyvönen H, Ruuhela R, Serlo W. Supracondylar humerus fractures in children: The effect of weather conditions on their risk. Eur J Orthop Surg Traumatol 2017;27:243-50.  Back to cited text no. 10
    
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Anjum R, Sharma V, Jindal R, Singh TP, Rathee N. Epidemiologic pattern of paediatric supracondylar fractures of humerus in a teaching hospital of rural India: A prospective study of 263 cases. Chin J Traumatol 2017;20:158-60.  Back to cited text no. 11
    
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Mitchelson AJ, Illingworth KD, Robinson BS, Elnimeiry KA, Wilson CJ, Markwell SJ, et al. Patient demographics and risk factors in pediatric distal humeral supracondylar fractures. Orthopedics 2013;36:e700-6.  Back to cited text no. 12
    
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Alton TB, Werner SE, Gee AO. Classifications in brief: The Gartland classification of supracondylar humerus fractures. Clin Orthop Relat Res 2015;473:738-41.  Back to cited text no. 13
    
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Vaquero-Picado A, González-Morán G, Moraleda L. Management of supracondylar fractures of the humerus in children. EFORT Open Rev 2018;3:526-40.  Back to cited text no. 14
    
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Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet 2020;395:931-4.  Back to cited text no. 15
    
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Holt JB, Glass NA, Shah AS. Understanding the epidemiology of pediatric supracondylar humeral fractures in the United States: Identifying opportunities for intervention. J Pediatr Orthop 2018;38:e245-51.  Back to cited text no. 16
    
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Okubo H, Nakasone M, Kinjo M, Onaka K, Futenma C, Kanaya F. Epidemiology of paediatric elbow fractures: A retrospective multi-centre study of 488 fractures. J Child Orthop 2019;13:516-21.  Back to cited text no. 17
    
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Barr LV. Paediatric supracondylar humeral fractures: Epidemiology, mechanisms and incidence during school holidays. J Child Orthop 2014;8:167-70.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2]



 

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