The present study revealed many salient findings. A) First, more boys than girls were hospitalized for pediatric fractures, and the highest number of fractures occurred in children aged 3-6 years. B) Second, the most common fractures involved the distal humerus and resulted from falls; moreover, the most common epiphyseal injury involved the distal radius. C) Third, the most common concomitant nerve injury was radial nerve injury; furthermore, the most common concomitant multisystem injury was nervous system injury. D) Fourth, 11.40% of pediatric patients had two or more concomitant fracture sites, and 2.46% had multisystem injuries, including 23 patients with concomitant shock. E) Fifth, the treatment of fractures mainly involved surgical treatment by closed reduction. F) Sixth, of the 9191 patients in the surgical treatment group, 5584 received surgical treatment within 12 h of admission. G) Lastly, fractures occurred more frequently between July and November, and on Saturdays and Sundays. The peak hours of admission were from 20:00 to 00:00, and 7.30% of patients visited our hospital visit > 72 h post-injury. Between 20:00 and 00:00, 86.06% of patients were referred to our hospital after their initial visit at a local hospital.
More educational programs on safety measures should be organized
A study by Rennie et al. [
7] found that fractures in children aged 0-16 years occurred most frequently between the ages of 5-11 years, which accounted for 51.3% of fractures in all age groups. However, the Chinese scholars Chen et al. [
12] found that the highest incidence of fractures occurred at approximately 3 years of age. This is consistent with our findings on the age distribution of pediatric fractures wherein fractures occurred most frequently between the ages of 3-6 years (41.77%), followed by 7-11 years (34.54%). The discrepancy in the peak age group for fractures between China and other countries may be related to differences in the use of sports protective equipment and health education. Our findings suggest the need for improvements in the abovementioned areas for children in fracture-prone age groups.
Landin [
13] showed that during the period from birth to 16 years, the incidence of fractures was 42% for boys and 27% for girls. Our study also found a significantly higher proportion of boys than girls. Hedström et al. [
3] and Cooper et al. [
14] found that the peak age for fractures in girls was 11-12 years, whereas that for boys was 13-14 years; however, the peak for fractures in our study, for both boys and girls, was 3-6 years. Rennie et al. [
7] showed that the incidence of fractures increased with age in both boys and girls before the age of 11 years; nonetheless, the incidence in girls began to decline after the age of 5 years, whereas that in boys continued to increase and was about twice that of girls by the age of 13 years. Our findings corroborated with those of Rennie et al., as we found that the number of fractures increased in boys but decreased in girls after 11 years, with a male to female ratio of 5.7: 1 at 11 years. Thus, despite their larger and stronger bones, boys have a higher incidence of fractures than girls, which may be attributed to their preference for more intense, competitive, and confrontational activities. Therefore, health education should place more emphasis on safety education for boys, especially those who are active and like to participate in high-risk sports that can lead to serious injuries; in addition, more attention should be placed on children aged 3-6 years.
Some studies have suggested that major pediatric fracture sites vary with age. More specifically, clavicular, distal humeral, distal radial, and metacarpal fractures are the most common in children aged < 1 year, 1-3 years, 4-14 years, and 15-16 years, respectively [
9]. However, in the present study, distal humeral and distal radial fractures were most common in children aged < 11 years and 12-18 years, respectively.
Brudvik et al. [
15] showed that pediatric fractures occur primarily in the upper limbs with the distal forearm as the most common fracture site. Children have a habit of extending their arms to protect themselves when they fall, which is the main reason why they are more prone to having upper limb fractures [
11]. Among the 13,982 fracture sites in this study, there were 10,269 long bone fractures of the upper limb, accounting for 73.44% of all fracture sites. The distal humerus was the most common fracture site (3843 cases, 27.50%); however, the number of distal forearm fractures was 3327 cases, accounting for 23.79% of all fracture sites. Thus, our conclusions differ from the abovementioned reports in the literature on the common sites for upper limb fractures. In addition, elbow fractures account for 40-48% of upper limb fractures [
16]. Behdad et al. [
17] reported an epidemiological study of elbow fractures in Iranian children wherein supracondylar humeral fractures were the most common (58.0%). Similarly, our study included 4466 cases of elbow fractures, accounting for 43.50% of long bone fractures of the upper limbs.
Fractures of the phalanges of fingers are a common type of pediatric fractures resulting from trauma in emergency departments and outpatient clinics, with a high annual incidence [
18‐
21]. A survey found a very low annual incidence of hand fractures among toddlers in the United Kingdom (34/100,000 children); nevertheless, this figure increases by approximately 20-fold after the age of 10 years, reaching 663/100,000 in children aged 11-18 years [
21]. Many previous studies revealed that hand fractures were more common in boys than in girls, with 65-75% of fractures occurring in boys and a peak occurring around 9-14 years [
22‐
24]. However, among the 1112 cases of fractured phalanges of fingers in this study, which included 696 boys and 416 girls, the peak and trough ages of fracture occurrence were 3-6 years (469 cases) and 12-19 years (120 cases), respectively. This finding differed from that previously reported in the literature in other countries.
Epiphyseal fractures are a unique type of pediatric fractures, accounting for 15-30% of all pediatric fractures. The incidence of epiphyseal fractures is higher in boys than in girls, and is more common in the upper limbs [
25,
26]. Komura et al. [
27] found that, of all epiphyseal fractures, those of the distal radius are relatively common. Steinberg et al. [
28] showed that about 50% of epiphyseal fractures occurred in the proximal radius. Peterson et al. [
29] found that the most common site of epiphyseal fracture was the phalanges of the fingers. In the present study, epiphyseal fractures occurred in 1209 cases, accounting for 8.65% of the total number of fractures; moreover, 73.20% of all epiphyseal fractures occurred in the upper limb. The most common type of epiphyseal fracture was that of the distal radius, which occurred in 405 cases and accounted for 33.50% of all epiphyseal fractures. This was followed by epiphyseal fractures of the phalanges of fingers. Therefore, in terms of the location and type of epiphyseal fractures, we should focus on the prevention of upper limb pediatric fractures, especially those of the distal humerus and phalanges of fingers. Fractures of the distal radius should be examined in detail for concomitant epiphyseal injuries. In children with suspected epiphyseal plate injuries, it is important to prevent serious complications such as bone discontinuity and growth disorders due to delayed diagnosis and treatment, misdiagnosis, or missed diagnosis.
Cheng et al. found an increase in the frequency of closed reduction and percutaneous pinning in pediatric fractures, a corresponding decrease in open reduction, and a significant reduction in the length of hospital stay [
11]. In the present study, the number of closed reductions peaked in 2017 (1719 cases), and subsequently decreased to its trough in 2019 (1409 cases). The number of open reductions peaked in 2018 (558 cases), and then decreased subsequently. In this study, 12.35% of patients with pediatric fractures underwent conservative treatment.
Although there are multiple causes of pediatric fractures, falls during normal playing and sports represent a major cause. Both Gouiding et al. [
30] and Mansoor et al. [
31] identified play-related falls as a primary cause of injury. Similarly, our study identified falls as the most common cause of injury, accounting for 67.77% of all causes. It is also the most common cause of injury in all age groups, with the highest number of reported cases of injury in children aged 3-6 years. Children in this age group are able to move independently, and often trip and fall while playing.
A study conducted by Osmond et al. [
32] concluded that road traffic injuries represented a common cause of severe trauma in children, and this also varied across age groups. In this study, road traffic injuries included 650 and 211 cases involving car accidents and bicycle falls, respectively. Car accidents peaked at 3-6 years (328 cases), whereas bicycle falls peaked at 7-11 years (85 cases). Such high-energy traumas often lead to open fractures, polytrauma, and shock, which pose a serious threat to children’s health. Therefore, parents, the community, and schools, should be educated on traffic safety, including the use of car safety seats, wearing protective gear while riding bicycles, and increased supervision [
33,
34].
With respect to bicycle-related fractures, attention should also be given to bicycle-spoke injuries, which occur when the limb comes into contact with the spokes of the bicycle wheel, thereby leading to entanglement of the limb in the spokes and crushing of the limb against the bicycle frame. Injuries are usually sustained by children who are bicycle passengers, and involve mainly lower limb soft tissue damage, followed by lower limb fractures [
35,
36]. In this study, 103 cases of bicycle-spoke injury were observed, predominantly in children aged 3-6 years, and the most common fracture site was the distal tibia. Although bicycle-spoke injuries are usually not life-threatening, the resulting socioeconomic damage is substantial. We believe that, in order to prevent bicycle-spoke injuries, safety education for guardians should be vigorously promoted, as this enhances supervision and prevention. With the growing popularity of bicycle sharing, bicycle manufacturers should improve the design and structural defects of the bicycle itself. This can be done by installing protective equipment (for instance, protective nets) to preventing toes from getting caught between spokes and designing special safety child backseats.
In this study, falls from height affected 114 patients, and peaked in children aged 3-6 years (50 cases). We believe that emphasis should be placed on the protection of high-rise buildings, and promoting safety education for guardians of children in the peak age group of 3-6 years. For example, in New York, a program themed “Children Can’t Fly” was organized to prevent fall injuries. Through extensive public safety health education, the installation of guardrails on high-rise windows, and the installation of protective nets, remarkable results were achieved in the number of fall injury victims, which dropped by 50% after 3 years, and by 96% after 7 years [
37].
The third leading cause of injury in this study was clipping (465 cases). Door-clipping were observed in 403 patients, which primarily resulted in fractures of the phalanges of fingers. Al-Anazi [
38] and Doraiswamy [
39] concluded that door-related finger crush injury is the leading cause of finger injury in children. These injuries frequently occur at home, where the affected fingers are often crushed against the hinged side of the door, and are more likely to occur in younger children. The majority of door-clipping occur in the presence of an adult, thus highlighting the need for preventive measures. We should increase guardians’ awareness of these injuries and provide more educational programs on safety measures. Moreover, since fingers are most likely crushed in the hinged side of the door, finger guards can be installed to prevent finger entrapment. Furthermore, triangular rubber and plastic or wooden door wedges can be inserted into the bottom of the door to prevent its automatic closure.
There is a distinct seasonal pattern in the occurrence of pediatric fractures. Sinikumpu et al. [
40] showed, in a study on fractures and weather, that most fractures occurred on dry days (79.7%) as opposed to rainy days, with a 3.5-fold higher risk of fracture on dry days. In a study conducted in Ireland, Masterson et al. [
41] also showed a significant positive correlation between the number of sunshine hours per month and the corresponding number of hospital admissions for fractures, as well as a weak negative correlation between the number of fractures and the amount of rainfall per month; similar studies have been conducted in countries with summer holiday customs [
42]. Fractures predominantly occurred in the afternoon, possibly due to the after-class or after-school hours during which schoolchildren are prone to fractures [
43]. The high incidence of fractures in summer and autumn, and the lower incidence in winter, were also confirmed in the present study. This may be related to the favorable climate and temperature in summer and autumn, the long sunshine hours, the increased outdoor activity of children, and the use of thinner and fewer clothing that neither absorbs collision energy nor provides cushioning in the event of an accident. In addition, our study showed that July to November were the peak months for fractures. Apart from the aforementioned reasons, this may also be related to the National Day holiday and summer vacation in China, during which children spend more time outdoors and are exposed to accidental injuries and fractures. Therefore, on the one hand, medical resources need to be increased to ensure the priority and quality of care for children with fractures during this peak period. On the other hand, health education and promotion should be carried out in conjunction with schools and communities prior to this peak period.