Abstract
Childhood fractures are different from adult fractures in many ways, both mechanical and biological. Fractures in children usually recover rapidly because their growing bones are more vascular than adult bones. Correspondingly, the inflammatory response needed in healing is stronger in children. Incidentally, body temperatures as high as 40 °C have been measured as a response of long bone fractures in children. Osteoblast activity, that is vital in bone formation, is already high in children due to normal growth. Furthermore, spontaneous remodeling of growing bones is potentially enough to correct significant deformities: as high as 8° of monthly correction can occur in the metaphysis (1).
Despite their advantages, bone fractures of the growing skeleton are a significant cause of morbidity in children and can be a social burden on families. With that in mind, it is important to recognize that there are several upcoming trends in pediatric trauma research, concerning both epidemiology and clinical treatment. First, fracture patterns are changing. Upper extremity fractures are increasing in many countries. Exceptionally high increases are reported in forearm shaft fractures; a fourfold increase was shown in the population-based study over the last decade in Finland (2). Despite a short 10-year period and relatively small study population, the increase appeared to be exponential. A parallel increase was recognized using the nationwide hospital admission registry in 1997–2006 as well (3). Overall incidence of childhood fractures has been relatively stable. Fractures account for 25% of all pediatric injuries, and the incidence is about 1.6 per 100 children yearly (4).
Focusing on the increasing incidence of forearm shaft fractures, many reasons have been found. Recreational activities have changed. In 2000, no forearm shaft fractures were caused by a trampoline injury in the Oulu region of Finland, while 10 years later, a trampoline was the cause for one in three fractures (2). Scooting, skating, and other playground injuries remain to be the leading causes for fractures, as well as conventional falling, traffic injury, and horseback riding. Sunny days are found to increase the fracture risk by 50% (5). Modern technology and increased screen time lead to decreased physical activity in children. This, again, may diminish the strengthening of growing bones. Obesity is also increasing in children in the developed countries (6). Obese children have higher energy when falling, compared to regular individuals. Nutrition plays a role in fracture risk, but the role of vitamin D and calcium is not as widely understood in children as in adults.
Another trend of forearm shaft fractures in children is the increasing tendency for surgical fixation. The incidence of stabilization has increased from 13% to 53% between 2000 and 2009 (2). The incidence of non-operative care has correspondingly decreased. Elastic stable intramedullary nailing (ESIN) has revolutionized the treatment since 1980 when the method was introduced for children. There is no doubt that there are many advantages in ESIN, compared with non-operative treatment. They include lower risk for re-reduction and faster mobilization. Cosmetic results are mostly good due to the minimally invasive approach. Furthermore, despite no conclusive evidence (7), it is becoming more common not to routinely remove the elastic nails from every patient.
In clinics, deciding on the right treatment is a crucial task for the surgeon. There are recent guidelines that outline the treatment options in forearm shaft fractures to assist clinicians in practice (8). However, despite the increasing popularity of surgical fixation, the best approach remains uncertain, in particular when clear indications for operative care are excluded (e.g. evidently unstable fracture or open fracture with concomitant neurovascular complications). It is challenging to compare the different treatments because the specific benefits of each treatment are seen at different times. In the short term, ESIN prevents worsening of the alignment. This complication and consequent need of re-reduction are common (37%) in non-operative care (9). However, despite limited short-term outcomes, non-operative treatment results in excellent long-term outcomes 12 years after a fracture (10). Which one should have a greater effect on choice of treatment: short-term or long-term results?
In order to better understand the biologic and mechanical basis of changing fractures, more basic science studies are needed. To understand the changing trends in fracture incidence, large epidemiologic studies are warranted. Furthermore, to support the clinical decision making, more comparative trials of different treatments are needed to enhance evidence-based practice in children’s trauma surgery. We in the international peer-review journals encourage further high-standard research in pediatric trauma. It seems clear that multi-center collaboration and networking are needed in order to get comprehensive prospective designs.
Juha-Jaakko Sinikumpu
Assistant editor
