Epidemiological and radiological patterns of paediatric fractures in an elite community in South West Nigeria

Olubukola T. A. Omidiji; Olasode Israel Akinmokun; Omodele A Olowoyeye

doi:10.4103/jcls.jcls_55_22

Users Online: 113

ORIGINAL RESEARCH REPORT

Year : 2022 | Volume : 19 | Issue : 4 | Page : 136-141

Epidemiological and radiological patterns of paediatric fractures in an elite community in South West Nigeria

Olubukola T. A. Omidiji¹, Olasode Israel Akinmokun², Omodele A Olowoyeye¹
¹ Department of Radiation Biology, Radiotherapy, Radiodiagnosis and Radiography, College of Medicine, University of Lagos, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
² Department of Surgery, College of Medicine, University of Lagos, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria

Date of Submission	09-Jul-2022
Date of Acceptance	01-Sep-2022
Date of Web Publication	09-Nov-2022

Correspondence Address:
Dr. Olubukola T. A. Omidiji
Department of Radiodiagnosis, Lagos University Teaching Hospital, Idi-Araba, Lagos
Nigeria

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jcls.jcls_55_22

Abstract

Background: Fracture remains a common cause of morbidity, mortality, and disability in childhood. The etiology of fractures varies between and within countries and depends on the socioeconomic and environmental conditions. Etiology of fractures from the elite and high socioeconomic class community has not been documented and this study aimed to document such, including the radiographic features. Methods: A prospective, descriptive, cross-sectional study conducted on 38 children below 17 years that presented with injured limb between July 1, 2018, and June 30, 2020, to a private facility located within a highbrow location in Lagos, Nigeria. Ethical approval was obtained from the Health Research and Ethics Committee, Lagos University Teaching Hospital, Idi-Araba. Data were collected with pro forma. Data analysis was done using the Microsoft excel and Statistical Package for the Social Sciences software (SPSS) for Windows version 21. Results: Thirty-eight children were recruited. The mean age was 8.78 ± 4.35 years. The male-to-female ratio was 3.2–1. Fall was the most common cause of the fracture. Injury occurred most within the school environment followed by the home environment. All the injured presented with pain and swelling of the affected parts. The upper limbs were more injured. Transverse fractures were the most common radiographic findings. Moderate-to-severe displacement of fracture edges was seen in 55.3%, with severe angulations of fracture edges in 23.4%. Majority of the fractures were managed conservatively. Conclusion: Majority of the fractures were due to falls. Most are complete and transverse fractures. A higher percentage was displaced. The management was mostly conservative.

Keywords: Epidemiology, fracture, Nigeria, paediatric, radiographs

How to cite this article:
Omidiji OT, Akinmokun OI, Olowoyeye OA. Epidemiological and radiological patterns of paediatric fractures in an elite community in South West Nigeria. J Clin Sci 2022;19:136-41

How to cite this URL:
Omidiji OT, Akinmokun OI, Olowoyeye OA. Epidemiological and radiological patterns of paediatric fractures in an elite community in South West Nigeria. J Clin Sci [serial online] 2022 [cited 2023 Mar 28];19:136-41. Available from: https://www.jcsjournal.org/text.asp?2022/19/4/136/360624

Introduction

A fracture is a break in the structural continuity of the bone.^[1] It may be a partial or complete break in continuity of the bone, resulting in pain, deformity, swelling and sometimes, damage to adjacent structures such as nerves, blood vessels, muscles, fascia, and the skin. Fracture in children constituted 16%−27% of all injuries in children presenting in the emergency room in Nigeria.^[2],[3] This is similar to the documentation by Landin,^[4] in Sweden, who stated that fractures constitute 10%–25% of all pediatric injuries. However, Spady et al.^[5] in Canada documented fractures occurred in 8.5% of all injuries in children that come to the attention of health services.

Fractures are common in childhood, with about one-third in the general population of children sustaining at least one fracture before 17 years of age.^[6] The accumulated risk of sustaining a fracture before 17 years of age is 34%.^[7] In Scotland, for example, the incidence of pediatric fractures is 20.2/1000/year.^[8]

Fractures, therefore, remain a common cause of morbidity, mortality, and disability in childhood. A male predominance is noted in several studies.^{[7],[8],[9],[10],[11]} The risk of sustaining a fracture was higher in boys than girls at 42% and 27%, respectively.^[4] The etiology of fractures varies between and within countries and depends on socioeconomic and environmental conditions, among others. The rate of fractures may be similar in both the affluent and deprived groups, but the causes of fractures usually differ.^[12] Studies from worldwide have documented different etiological factors for pediatric fractures. Most of the studies from Nigeria, a low to middle income country, documented road traffic accidents (RTAs) and falls as the common causes of fractures in children, with RTAs having slight dominance.^{[9],[10],[11],[13],[14]} However, most of the studies from developed countries documented falls as the most common cause of fractures in children.^[4],[7],[8] In a Nigerian study in which majority of the children (58.7%) were from families classified as low socioeconomic status, the most common cause of fracture was RTA.^[9] Studies from elite, high socioeconomic classes have not been documented and this study aimed (aims) to document the fractures in an elite society within Nigeria.

Fractures in children differ from that of the adults and often change with age due to their unique anatomy. Pediatric bones are less dense; more porous with less elasticity, lower mineral content, markedly strong and thick periosteum; hence, they have unique fracture patterns, healing mechanisms, and management.^[15] Younger children often have fractures from playing and falling on an outstretched hand, whereas older children have fractures associated with sports and bicycle/vehicular accidents.^{[7],[15],[16]}

Imaging is vital in the management of fractures, providing objective information on the fracture pattern and extent of injury.^[15] The type of imaging utilized depends on several factors including the age of the patient and anatomic location of injury (skeletal, head, thorax, and abdomen). Plain X-rays are the first line of imaging, whereas other modalities such as computed tomography, magnetic resonance imaging, and scintigraphy are utilized when there is a lack of correlation between clinical and X-ray findings. It is important to compare the contralateral limb while reviewing the radiograph of injured limb of children to avoid mistaking epiphyseal lines for fractures.

This study aimed to assess the epidemiology and radiographic patterns of fractures in children residing in high socioeconomic status community. The etiology, clinical features, site; type of fracture, mechanism of injury, and treatment were also documented.

Methods

This was a prospective descriptive study that was conducted to determine the epidemiology and radiographic patterns of fractures in children living in Ajah, Lagos state is the commercial capital of Nigeria. It is located in South-Western part of the country. It has a population of 15.3 million people within a land mass total of 1171.28 km². Lagos state has a very diverse ethnic population due to migration from other parts of the country as well as the surrounding countries. Lagos state has both highbrow communities and slums, areas which housed the wealthy and poor populace, respectively. This study was set at a Ajah, a highbrow community in Lagos. Injured children, 17 years and below, who presented consecutively at the private facility within this community were recruited into the study after resuscitation. The data collection was done between July 1, 2018 and June 30, 2020. A pretested questionnaire was used to obtain the information. The injured child was resuscitated and stabilized. A thorough clinical evaluation was done to rule out any life-threatening injury before recruitment. Informed consent was also obtained before recruitment of the injured child. The injured child was investigated with radiograph afterward and the findings as reported by the radiologist(s) were documented. Treatment offered was also documented.

The participants recruited were children, 17 years and below, with a history of trauma and radiographic diagnoses of fractures, after obtaining consent from their parents. The exclusion criteria included children with tumors, infections, and those who failed to give consent. Participants were resuscitated and fractured limb splinted before their recruitment.

Variables were fracture diagnosed based on the history of significant trauma, painful swelling with deformity, and inability to use the affected upper limb or inability to bear weight on the affected lower limb. Injuries are the outcomes of exchanges in energy transfer that occurred during a process, for instance, a fall. The radiographic feature of fracture was loss of continuity of the cortex of the affected bones. Displacement of the fracture was defined as the abnormal position of the distal fracture fragment in relation to the proximal fracture fragment of the bone.

The instrument used was a structured pretested pro forma which was used to obtain the data from the parents, injured children, guardians, and witnesses.

The data retrieved included sociodemographic (age, gender, religion, parents' occupation, and their combined estimated monthly income), injury data (date, time, cause, and site of injury), clinical presentation of the child, clinical classification of the fracture (open or closed fracture), the region of the body affected, and associated injuries. The radiograph of the injured limb was done and reviewed by two independent radiologists on the type of fracture, location of fracture, presence and type of displacement, and ancillary findings such as soft tissue and joint involvement.

All the data obtained were entered into an Excel software for analysis. Data analysis was done using the Microsoft excel and IBM SPSS statistics for windows, Version 21.0 IBM Corp, Armonk, NY, USA. The results are presented in tabulated and diagram formats. The mean and standard deviation of the age were documented. Frequencies and distributions of quantitative variables including the etiology of the fractures, places of injury, parts of the body, and the bones affected were calculated and presented.

Ethical approval was obtained from the Health Research and Ethics Committee, Lagos University Teaching Hospital, Idi-Araba before the commencement of the study.

Limitations

General limitation

Larger epidemiological studies may eliminate the bias of chance.

Specific limitation

None.

Results

A total of 38 children were recruited with the age range between 9 days (0.025 year) and 17 years with a mean age of 8.78 ± 4.35 years [Table 1]. The male-to-female ratio was 3.2–1. Fall was the most common cause of the fracture. Twenty-two (57.9%) children sustained injury following fall, whereas 7 children (18.1%) sustained injury during sporting activities and 5 (13.1%) children were injured following RTA [Table 1]. Injury occurred most in the school environment (13, 34.2%) followed by the home environment (11, 28.9%) [Figure 1]. Thirty-one children sustained single bone fractures, whereas the remaining 7 sustained multiple bones fractures. All the injured presented with pain and swelling of the affected parts, whereas only 11 patients presented with deformities in addition to the aforementioned symptoms. The upper limbs were injured more (28, 73.7%) than the lower limbs (10, 26.3%) [Table 1].

Figure 1: Pie chart showing the place/location of injury

Click here to view

Table 1: Frequency and cause of fractures in each body region across age groups and gender

Click here to view

Forty-seven fractures were recorded in these 38 children. Majority 37 (98%) of the fractures were closed. More bones of the left side of the body (29, 61.7%) were fractured compared to the right side (18, 38.3%). The humerus (11, 23.4%) and radius (11, 23.4%) were most commonly fractured followed by the ulna (7, 14.9%) and the phalanges of the hand (6, 12.8%) [Figure 2].

Figure 2: Bone affected and their frequency

Click here to view

On the radiographs, transverse fractures were the most common (30, 63.8%) [Figure 3]. Other types of fractures noted in this study were Salter Harris injuries in 4 (8.5%) [Figure 4] and Torus fracture in 2 (4.3%) patients [Figure 5]. Displacement was absent or minimal in 21 (44.7%) of the fractures, whereas moderate-to-severe displacement was seen in 26 (55.3%). Unacceptable angulation reported in 11 fractures (23.4%) and overlapping fractures were seen in 7 fractures (14.9%). Joint involvement was seen in only 3 (6.4%) of the patients [Table 2].

Figure 3: Type of fractures seen

Click here to view

Figure 4: Salter 2 fracture: Radiograph of the left hand shows widening of the physis and metaphyseal corner fracture of the fifth proximal phalanx

Click here to view

Figure 5: Torus fracture: Radiograph of the forearm shows buckling of the cortex and distal third of the radius

Click here to view

Table 2: Other radiographic features of fractures seen

Click here to view

Majority of the fractures (41, 87%) were managed conservatively, whereas others were managed with surgical intervention (6, 13%).

Discussion

Fractures in the pediatric age group remain a health scourge that is yet to receive adequate attention it requires. It affects children from all socioeconomic status. This study, however, documented the findings from the high socioeconomic status subgroup. The age group with the highest number of fracture was the 10–14.9 years' age group. Naranje et al.,^[17] in the United States, documented that the occurrence of fracture peaked at 10–14 years' age group. Report from the study by Lyons et al.^[18] also showed that the age group of 10–14 years sustained more fractures than any other age group. Cooper et al.^[6] noted that the peak incidence for fracture occurred at 14 years of age among boys and 11 years of age among girls, both ages were within the age range with the highest number of fractures documented in this study; but differed from the age group documented from studies within Nigeria, where age group documented were 5–8 years and 4–6 years, respectively.^[9],[10] Nonetheless, children within this age group (10–14.9 years) are involved in outdoor activities and may be prone to sustaining fractures. Fractures occurred more in male children. This is documented in various studies worldwide.^{[4],[6],[7],[8],[9],[10],[11],[13]}

In this study, most of the fractures occurred from falls during leisure or sport activities, at school, home environment, and playground. This finding is in contrast from studies documented in our environment. Many researchers documented RTAs as the most common cause of fractures in children.^{[9],[10],[11],[13]} The contrast may be due to elite community where this study was carried out. The occurrence of fractures during leisure and sporting activities is also documented by Lyons et al.^[18] Falls as the most common cause of fractures were documented by authors in Sweden, Wales, Scotland, and. Norway.^{[4],[7],[8],[18],[19]} These countries are classified as high-income countries. The findings from this elite community seem to mirror the findings from high-income countries.

This study also revealed that upper limb fractures were more common than lower limb fractures and was corroborated by Olatunji and Thanni^[10] where he documented that upper limb fractures were three times more common than lower limb fractures. The humerus and the radius were the most common individual bones fractured with the same frequency. Overall, the forearm bones (radius and ulnar) were commonly fractured. This is similar to the documentation by Ejagwulu et al.,^[13] but Olatunji and Thanni^[10] documented the humerus as the most frequently fractured bone in their study. Most studies from high-income countries documented forearm/distal forearm as the most commonly affected part of the body.^{[2],[4],[7],[8],[17]} Other authors from Nigeria documented femur as the most fractured bone in children.^[9],[11] The disparity can be accounted for by the difference in the etiology of the fractures. In places where the forearm was mostly injured, the most common etiology was falls, unlike RTAs that was documented as the most common cause in studies where the femur was mostly injured.

Greenstick fractures and incomplete fractures are typically more common in children. In this study, greenstick fractures occurred in 6.4% of the total number of fractures, which was similar to the findings by Akinmokun et al.^[9]

The most common radiological type of fracture was transverse fracture (63.8%). Transverse fracture was noted to be most common in this study because the complete and growth fractures occur in children that above 10 years.^[20] It is important to identify displacement on radiographs. They are important in the decision-making, whether to manipulate the fracture or not, need for traction or otherwise and most especially, if operative intervention would be most appropriate. In this study, nonoperative management was the most common method (87%) employed in the treatment of the fractures. This is similar to other documented studies in our environment.^{[9],[11],[14],[21]}

Conclusion

Fractures in the elite community predominated in the 10–14 years' age group. Majority were due to falls during sporting and leisure activities. Most are complete and transverse fractures. Higher percentages were displaced. The management was mostly conservative.

Recommendations

Efforts should be made to make playgrounds safe for children. Legislations should be made to protect the children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Nayagam S. Principles of fractures. In: Solomon L, Warwick D, Nayagam S, editors. Apley's System of Orthopedics Andfractures. 9^th ed. London: Hodder and Arnold; 2010. p. 687.
2.	Adesunkanmi AR, Oginni LM, Oyelami AO, Badru OS. Epidemiology of childhood injury. J Trauma 1998;44:506-12.
3.	Onyemaechi NO, Bisi-Onyemaechi AI, Nduagubam OC. Epidemiology and pattern of paediatric injuries in a developing country: An analysis of 170 injuries. Malawi Med J 2020;32:95-100.
4.	Landin LA. Epidemiology of children's fractures. J Pediatr Orthop B 1997;6:79-83.
5.	Spady DW, Saunders DL, Schopflocher DP, Svenson LW. Patterns of injury in children: A population-based approach. Pediatrics 2004;113:522-9.
6.	Cooper C, Dennison EM, Leufkens HG, Bishop N, van Staa TP. Epidemiology of childhood fractures in Britain: A study using the general practice research database. J Bone Miner Res 2004;19:1976-81.
7.	Hedström EM, Svensson O, Bergström U, Michno P. Epidemiology of fractures in children and adolescents. Acta Orthop 2010;81:148-53.
8.	Rennie L, Court-Brown CM, Mok JY, Beattie TF. The epidemiology of fractures in children. Injury 2007;38:913-22.
9.	Akinmokun OI, Giwa SO, Bode CO. Skeletal injuries in children presenting in a tertiary care facility in Lagos State, Nigeria. Nig J Med 2018;27:20-8.
10.	Olatunji AA, Thanni LO. Radiographic pattern of skeletal trauma in children seen in a tertiary hospital in Sagamu, South West Nigeria. Niger Postgrad Med J 2013;20:14-9. [Full text]
11.	Nwadinigwe CU, Ihezie CO, Iyidiobi EC. Fractures in children. Niger J Med 2006;15:81-4.
12.	Lyons RA, Delahunty AM, Heaven M, McCabe M, Allen H, Nash P. Incidence of childhood fractures in affluent and deprived areas: Population based study. BMJ 2000;320:149.
13.	Ejagwulu FS, Lawal YZ, Maitama MI, Amefule KE, Dahiru IL, Gafar YA. Fractures in children aged 0-12 years and their management as seen in North Central Nigeria. West Afr J Med 2018;35:123-7.
14.	Adewole OA, Kayode MO, ShogaMO, Williams OM, Ikem IC. Pattern and trauma mechanisms of paediatric long bone fractures in Lagos, Nigeria. NJOT 2011;10:100-4.
15.	Jain N. The role of diagnostic imaging in the evaluation of child abuse. BC Med J 2015;57:336-40.
16.	Omoke NI, Ekumankama FO. Incidence and pattern of extremity fractures seen in accident and emergency department of a Nigerian teaching hospital. Niger J Surg 2020;26:28-34. [Full text]
17.	Naranje SM, Erali RA, Warner WC Jr., Sawyer JR, Kelly DM. Epidemiology of pediatric fractures presenting to emergency departments in the United States. J Pediatr Orthop 2016;36:e45-8.
18.	Lyons RA, Delahunty AM, Kraus D, Heaven M, McCabe M, Allen H, et al. Children's fractures: A population based study. Inj Prev 1999;5:129-32.
19.	Kopjar B, Wickizer TM. Fractures among children: Incidence and impact on daily activities. Inj Prev 1998;4:194-7.
20.	Arora R, Fichadia U, Hartwig E, Kannikeswaran N. Pediatric upper-extremity fractures. Pediatr Ann 2014;43:196-204.
21.	Archibong AE, Onuba O. Fractures in children in South Eastern Nigeria. Cent Afr J Med 1996;42:340-3.