Pediatric Fractures Shift During Pandemic

Maureen Salamon

October 07, 2020

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Pediatric fractures dropped by 2.5-fold during the early months of the COVID-19 pandemic, but more breaks happened at home and on bicycles, and younger kids were more affected, new research indicates.

The study of 1745 patients also found that those with distal radius torus fractures were more likely to receive a Velcro splint during the pandemic. Experts said this key trend points toward widespread shifts to streamline treatment, which should persist after the pandemic.

"We expected to see a drop in fracture volume, but what was a bit unexpected was the proportional rise in at-home injuries, which we weren't immediately aware of," said senior author Apurva Shah, MD, MBA, of Children's Hospital of Philadelphia (CHOP) and the University of Pennsylvania Perelman School of Medicine in Philadelphia.

"As time went on, it became more apparent that trampoline and bicycle injuries were on the rise, but at the beginning of the pandemic, we didn't intuitively expect that," he added.

"Whenever there's a major shift in how the world is working, we want to understand how that impacts child safety," Shah told Medscape Medical News. "The message to get out to parents is that it's obviously difficult to supervise kids while working from home" during the pandemic, "and that supervision obviously is not always working as well as intended."

Joshua T. Bram, a medical student, presented the study at the virtual American Academy of Pediatrics (AAP) 2020 National Conference.

Bram, Shah, and colleagues compared patients with acute fractures who presented at CHOP between March and April 2020 with those who presented during the same months in 2018 and 2019.

Overall, the number of patients with pediatric fractures who presented to CHOP fell to an average of just under 10 per day, compared with more than 22 per day in prior years (P < .001). In addition, the age of the patients fell from an average of 9.4 years to 7.5 years (P < .001), with fewer adolescents affected in 2020.

"I think when you cancel a 14-year-old's baseball season" because of the pandemic, "unfortunately, that lost outdoor time might be substituted with time on a screen," he explained. "But canceling a 6-year-old's soccer season might mean substituting that with more time outside on bikes or on a trampoline."

As noted, because of the pandemic, a higher proportion of pediatric fractures occurred at home (57.8% vs 32.5%; P < .001) or on bicycles (18.3% vs 8.2%; P < .001), but there were fewer organized sports–related (7.2% vs 26.0%; P < .001) or playground-related injuries (5.2% vs 9.0%; P < .001).

In the study period this year, the researchers saw no increase in the amount of time between injury and presentation. However, data suggest that in more recent months, "kids are presenting with fractures late, with sometimes great consequences," Shah said.

"What has changed is that a lot of adults have lost their jobs, and as a consequence, a lot of children have lost their access to private insurance," he said. "But fracture is really a major injury, and this is a reminder for pediatricians and primary care physicians to recognize that families are going through these changes and that delays in care can really be detrimental to children."

Velcro Splints More Common

A potential upside to shifts seen during the pandemic, Shah said, is the finding that distal radius torus fractures were more likely to be treated with a Velcro splint than in previous years (44.2% vs 25.9%; P = .010).

"This is hitting on something important ― that sometimes it's crisis that forces us as physicians to evolve," he said. "This is something I think is here to stay.

"Although research had already been there suggesting a close equivalent between splints and casting, culturally, a lot of surgeons hadn't made that shift when historically the gold standard had been casting," Shah added. "But with the pandemic, the shift to minimize contact with the healthcare system to keep families safe in their COVID bubble helped [usage of] splints take off.

"I suspect ― and we'll only know when we're on the other side of this ― when physicians see good results in splints in their own patients, they're going to adopt those strategies more permanently," he said.

Benjamin Shore, MD, MPH, of Boston Children's Hospital, agreed with Shah's prediction that fracture care will be more streamlined after the pandemic. Shore, who wasn't involved in the study, said not only are more orthopedic providers treating patients with Velcro splints and bivalve casts, but they are also monitoring patients via telehealth.

"All of these are great examples of innovation, and one of the unique parts of the pandemic is it created a lot of rapid change across healthcare because it caused us to scrutinize the ways we practice and make a change," Shore told Medscape Medical News.

"It wasn't a very fancy study, but it's very important in terms of demonstrating a change in practice," Shore said. "The research here basically validated what many of us are seeing and hopefully will help us in future pandemics ― which hopefully won't happen ― to tell families what to be proactive about."

Shah and Shore agreed that because fewer fractures are occurring in kids during the pandemic, there is an opportunity to redeploy orthopedic providers to other clinical areas on the basis of volume and need.

Shah and Shore have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2020 National Conference: Abstract P0862, presented October 3, 2020.

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