Original Article

Do obese children experience more severe fractures than nonobese children? A cross-sectional study from a paediatric emergency department Charisse Kwan MD1, Quynh Doan MD PhD2, John Paul Oliveria BSc1, Melissa Ouyang BNSc1, Andrew Howard MD3, Kathy Boutis MD MSc1 C Kwan, Q Doan, JP Oliveria, M Ouyang, A Howard, K Boutis. Do obese children experience more severe fractures than nonobese children? A cross-sectional study from a paediatric emergency department. Paediatr Child Health 2014;19(5):251-255.

Les enfants obèses subissent-ils des fractures plus graves que les non-obèses? Étude transversale dans un département d’urgence pédiatrique

Objectives: To determine whether there is an association between

OBJECTIFS : Déterminer s’il y a un lien entre l’obésité juvénile et les graves fractures des membres. Examiner également les associations entre l’obésité et les complications liées à la fracture ou à sa prise en charge. MÉTHODOLOGIE : La présente étude transversale et rétrospective a été menée au département d’urgence d’un centre de soins tertiaires pour enfants. Y étaient admissibles les enfants de deux à 17 ans s’étant cassé un membre. Les graves fractures des membres se définissaient comme celles qui exigeaient une manipulation sous anesthésie, une chirurgie ouverte ou une hospitalisation. L’issue primaire était la proportion de graves fractures des membres et l’issue secondaire, la proportion de complications. RÉSULTATS : Les chercheurs ont examiné 1 340 dossiers d’enfants qui ont consulté à cause d’une fracture d’un membre entre janvier 2008 et décembre 2010. La population à l’étude, dont 62,1 % étaient de sexe masculin, avait un âge moyen (± ÉT) de 9,1±4,0 ans. Dans l’ensemble, 19,9 % (95 % IC 17,8 % à 22,0 %) étaient obèses et 39,9 % (95 % IC 36,7 % à 39,1 %) avaient subi une fracture grave. Comparativement aux enfants non obèses, le rapport de cote (RC) des graves fractures d’un membre chez les enfants obèses était de 1,00 (95 % IC 0,76 à 1,32), rajusté selon l’âge, le sexe et le mécanisme de la blessure. De plus, le RC des complications chez les enfants obèses s’élevait à 1,12 par rapport aux enfants non obèses (95 % IC 0,68 à 1,85). CONCLUSIONS : Les résultats de la présente étude démontrent que les enfants obèses ne risquent pas de subir une fracture d’un membre plus grave ou de présenter des complications plus importantes que les enfants non obèses.

childhood obesity and severe extremity fractures. Associations between obesity and complications related to the fracture and/or fracture management were also examined. Methods: The present study was a retrospective, cross-sectional study conducted at a tertiary care children’s emergency department. Eligible cases for review were children (two to 17 years of age) with an extremity fracture. Severe extremity fractures were defined as those requiring manipulation under anesthesia, open operative repair and/or admission to hospital. The primary outcome was the proportion of severe extremity fractures and the secondary outcome was the proportion of complications. Results: A total of 1340 charts of children who presented with extremity fracture from January 2008 to December 2010 were reviewed. The mean (± SD) age of the study population was 9.1±4.0 years and 62.1% were male. Overall, 19.9% (95% CI 17.8% to 22.0%) were obese and 39.6% (95% CI 36.7% to 39.1%) sustained a severe extremity fracture. The OR of severe extremity fractures among obese versus nonobese children was 1.00 (95% CI 0.76 to 1.32), adjusted for age, sex and mechanism of injury. In addition, the OR of experiencing complications among obese relative to nonobese children was 1.12 (95% CI 0.68 to 1.85). Conclusions: The results of the present study demonstrated that in children with extremity fractures, obese children were not at increased risk for sustaining more severe extremity fractures or subsequent complications compared with nonobese children. Key Words: Child; Emergencies; Fracture; Obesity; Prevention

C

hildhood obesity has become a global epidemic, with more than 155 million overweight children worldwide (1). Between 2009 and 2011 in Canada, 31.5% of children were classified as overweight (19.9%) or obese (11.7%) (2). Childhood obesity poses a significant health care concern and studies have demonstrated that overweight children may be at increased risk for many common medical problems including injuries (3-11). Previous studies have supported an increased risk for fractures in obese versus nonobese children (12-17). A recent systematic review found a small association between overweight children and fractures (RR 1.12 [95% CI 1.00 to 1.25]) (18). In another study, increased weight status was associated with an increased upper extremity fracture risk (12). A relative increased risk for forearm fractures (13-16) and increased risk for repeat forearm fractures has also been demonstrated in obese children (17). In other studies,

obesity was associated with an increased odds of lower extremity injuries and fractures (6,9,10). Furthermore, there is some evidence that demonstrates that obesity is a risk factor for severe fractures such as those requiring hospitalization and/or operative stabilization (19-21). In adults, obesity has been shown to be a factor in sustaining severe lower extremity fractures (19-21). In children, a higher body mass index has also been associated with severe fractures for specific injuries and in the setting of major trauma (9,20,22,24). However, these results may not be generalizable to all types of extremity fractures and/or lower-energy mechanisms of injury. Among children with isolated extremity fractures resulting from low-energy mechanisms of injury, the main objective of the present study was to determine whether obese children have increased odds of sustaining a severe fracture relative to their nonobese

1Division

of Emergency Medicine, Department of Paediatrics,The Hospital for Sick Children, University of Toronto, Toronto, Ontario; 2Division of Emergency Medicine, Department of Paediatrics, British Columbia Children’s Hospital and University of British Columbia; 3Department of Orthopaedic Surgery, The Hospital for Sick Children, and University of Toronto, Toronto, Ontario Correspondence: Dr Kathy Boutis, 555 University Avenue, Toronto, Ontario M5G 1X8. Telephone 416-813-8982, fax 416-813-5043, e-mail [email protected] Accepted for publication December 12, 2013

Paediatr Child Health Vol 19 No 5 May 2014

©2014 Pulsus Group Inc. All rights reserved

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counterparts. The association between obesity and complications related to the fracture and/or fracture management was also examined. If obese children have a greater predisposition for severe extremity fractures and/or complications relative to their nonobese counterparts with fractures, health care providers caring for these children may need to anticipate that obese children’s fractures carry greater risks.

METHODS Study design and setting The present retrospective cross-sectional study was conducted in an urban university-affiliated tertiary care children’s emergency department (ED), The Hospital for Sick Children, in Toronto, Ontario. The present study was approved by The Hospital for Sick Children Research Ethics Board. Study population Study subjects were children between two and 17 years of age who were evaluated and treated at the institutional ED with an extremity fracture. Children with no recorded weight or fracture clinic follow-up were excluded, as were children with risk factors for pathological fractures and/or delayed healing, high-energy trauma (motor vehicle collisions, falls from height, falls down stairs) or with multisystem trauma. Multisystem traumas were excluded because other injuries may have confounded the results. Definitions Obesity was defined as having a weight-for-age percentile ≥95% based on the Centers for Disease Control and Prevention (Georgia, USA) values (8,25,26). Weight-for-age was used to define obesity rather than body mass index because height is not routinely recorded in the ED. This strategy has been adopted in similar studies limited by the absence of height data (8,20,23). A fracture was defined as a break or buckling of the cortex of a bone visible on radiographs. In cases for which the radiograph report was inconclusive, an injury was labelled as fracture/no fracture based on available clinical correlation, fracture clinic records, and the consensus opinion by an attending orthopedic surgeon and paediatric emergency physician. Extremity fractures included any fracture located in the hand, arm, shoulder, leg or foot. Severe extremity fractures included those that were open, required reduction, operative intervention and/or hospitalization. The definition of ‘severe extremity fracture’ was based on available literature in this field (11,21,22,24) and the concept that these injuries generally require surgical intervention and/or put the child at risk for shortor long-term complications. Complications included those related to the fracture, treatment and/or anesthetic. Fracture-related complications included nerve palsies, vascular injuries, mal-union, functional loss, limb shortening and/or long-term deformity. Treatment-related complications included those from the casting or an operation. Anesthetic related complications included allergic reaction, desaturation/apnea with need for oxygen/positive pressure ventilation, hypotension and cardiac arrhythmias. Data collection and review Potentially eligible children were identified through the sitespecific database of the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) (27). This national governmentfunded reporting program prospectively collects data on paediatric injuries that are seen at the 10 paediatric and four general EDs in Canada. The CHIRPP surveillance forms collect information that includes but is not limited to the type and location of injury and management of the injury in the ED. A site administrator reviews these forms for accuracy and completeness and fills in any missing 252

fields that are available from the medical record. All ED records are reviewed by the site CHIRPP administrator for chief complaints of injury. The CHIRPP data collection form is then completed for all patients for whom an injury was the presenting complaint to the ED. Access to the site’s injury database was approved by the central CHIRPP office in Ottawa (Ontario). For January 2008 to December 2010, via CHIRPP standardized coding, the study institution’s administrator identified all children two to 17 years of age with extremity injuries excluding high-energy and multisystem trauma. From the list of identified patients, two research assistants trained in the methods of chart review and chart abstraction accessed the patient’s corresponding hospital records to identify children who met eligibility criteria. Data were specifically abstracted from the following electronic patient records: ED visit(s), fracture clinic visit(s), admission records, discharge summary(ies) and/or surgery/anesthesia report(s). For children who met eligibility criteria, the following data were entered into data collection forms: patient demographic data; weight at ED visit; mechanism of injury; body part and features of fracture (open, angulated, comminuted, displaced) based on the official radiology report; ED management; diagnosis at orthopedic fracture clinic; complications; number of follow-up visits to the orthopedic fracture clinic; and other ED visits at the study institution. If a complication was not recorded, it was assumed not to have occurred. Throughout the data collection process, to ensure data extraction accuracy and reliability, the principal author repeated and reviewed the data extraction and recording for 20% of included subjects. After data collection was complete, each field in the database was also quality checked by a senior team member for consistency and omissions; any errors in data collection/data entry were identified and corrected. Outcome measures The primary outcome was the proportion of extremity fractures that met the study definition of ‘severe’ in obese versus nonobese children. Because severe extremity fractures include procedures and potentially carry greater risks for poorer functional recovery, this was considered to be the most important clinical outcome. The secondary outcome was the proportion of extremity fractures with fracture, treatment and/or anesthetic-related complications. Data analyses Based on hospital data, it was assumed that 20% of the study population would be obese and that 35% of extremity fractures in the nonobese group would be severe. Thus, the estimated sample size required to detect, with 80% power, a statistically significant increased OR of 1.5 among obese subjects at an alpha of 0.05 was 1228. Normally distributed variables were compared between obese and nonobese children using an independent Student’s t test and proportions were compared using the χ2 test. Multiple logistic regression analysis was used to estimate the odds of sustaining a severe extremity fracture in obese versus nonobese children, adjusted for the confounders of age, sex and mechanism of injury. This analytical method was also used to estimate the odds of complications in obese children versus nonobese children, and to determine the association(s) of clinical variables (mean age, male sex, sport-related injury) with a severe extremity fracture or complications. Variables of age and obesity were tested for colinearity. Goodness-of-fit of the final model to the data was tested using the Hosmer-Lemeshow test. Significance levels for tests involving secondary outcomes were set at 0.01 to account for multiple testing. All analyses were performed using SAS version 9.2 (SAS Institute Inc, USA). Paediatr Child Health Vol 19 No 5 May 2014

Fracture severity and obese children

Table 1 Demographic characteristics of obese versus nonobese children Characteristic Age, years, mean ± SD Male sex, n (%) Sport-related fracture, n (%)

Obese (n=267) Nonobese (n=1073)

P

8.8±4.1

9.2±4.0

0.22

181 (67.8)

651 (60.7)

0.03

53 (19.9)

222 (20.7)

0.69

Table 2 Location of fractures in obese versus nonobese children Obese (n=267)†

Nonobese (n=1073)†

39 (14.6)

154 (14.4)

113 (42.3)

414 (38.6)

Humerus

52 (19.5)

215 (20.0)

Clavicle

20 (7.5)

117 (10.9)

Foot

14 (5.2)

40 (3.7)

Tibia/fibula

24 (9.0)

103 (9.6)

5 (1.9)

25 (2.3)

Variable Hands/fingers Radius/ulna

Figure 1) Patient enrollment. †n>358 because some patients had more than one exclusion criteria

RESULTS

A total of 1698 charts were reviewed and 1340 children were included in the present study (Figure 1). Of these, 267 (19.9% [95% CI 17.8% to 22.0%]) patients were classified as obese and 530 (39.6% [95% CI 36.7% to 39.1%]) sustained severe extremity fractures. There were no significant differences in the obese versus nonobese groups with regard to demographics (Table 1), the distribution of anatomical location of injuries or mechanism of injury (Table 2). Of note, 1124 (83.3%) involved the upper extremities; 187 (13.9%) underwent fracture reduction performed in the ED and 265 (19.6%) underwent operative repair (Table 3). The OR of an obese child sustaining a severe extremity fracture compared with their nonobese counterparts, adjusted for age, sex and mechanism of injury, was 1.00 (95% CI 0.76 to 1.32) (Table 4). The OR (0.61 [95% CI 0.49 to 0.91]) for severe extremity fracture in children 13 to 17 years of age relative to children two to five years of age, and in females relative to males was significantly lower (Table 4). A significant association was not observed between the location of the injury (upper versus lower extremities) and the presence of severe fractures. Overall, 116 (8.7%) patients experience at least one complication (21 [7.9%] in the obese group and 95 [8.9%] in the nonobese group). Table 3 details the percentages of children in each group who had open fractures, required reduction, admission, surgery, and/or had fracture or treatment related complications (Table 3). There was no significant association between obesity and fracturerelated complications (OR 1.12 [95% CI 0.68 to 1.85]; Table 5). The ORs for the odds of complications related to the fracture among boys relative to girls, nonobese versus obese and fractures sustained during sport versus recreation were not significant. Similarly, older children (13 to 17 years of age versus two to five years of age) and upper versus lower extremity fractures had a nonsignificant lower OR of sustaining complications (Table 5).

DISCUSSION

Our study did not find an association between childhood obesity and severe extremity fractures. Furthermore, the odds of complications from severe extremity fractures were not significantly greater in the obese versus nonobese children. These data support that health care providers caring for children with extremity fractures need not treat obese children differently under the assumption that their fractures may be more severe or more susceptible to complications. Some studies have found that obese children were more likely to sustain severe fractures (11,20,22-24), while others have not (4,28). Specifically, Fornari et al (11) reviewed 992 children with Paediatr Child Health Vol 19 No 5 May 2014

Femur

Data presented as n (%). †P value for difference in distribution between the groups = 0.58

elbow fractures and concluded that obese children were at greater risk for sustaining lateral condyle fractures, a fracture that requires surgical reduction. Other studies examined paediatric major trauma cohorts and found that obese children were more likely to have extremity fractures requiring operative intervention and/or scored relatively higher on the Abbreviated Injury Scale relative to nonobese children (20,22-24). Although these results contrast with our study findings, the studies involved different populations: Fornari et al (11) included a specific body part (ie, elbow) while our research examined all types of extremity fractures, and the second set of studies (20,22,23) included patients with a highenergy mechanism and/or multisystem trauma, which were excluded from the current study. Alternatively, Bazelmans et al (4) included a population more comparable with ours and did not find an association between severe fractures and childhood obesity. Similarly, Alselaim et al (28) found no difference among obese and nonobese children with respect to severity of extremity fractures in a large cohort of paediatric patients who had sustained an injury. Therefore, while studies that included high-energy mechanisms and/or specific fracture types demonstrated increased risk for severe fractures in obese children, our data demonstrated that the latter results should not necessarily be overinterpreted and generalized to extremity fractures sustained by low-energy mechanisms and/or all types of extremity injuries. While our study did not find an association between obesity and complications in the setting of an extremity fracture, Leet et al (23) found that obese versus nonobese children with femoral fractures were more likely to experience postoperative complications. Adult obese patients have also been found to have a relatively higher predisposition for complications such as loss of fracture reduction requiring subsequent surgery (29), compartment syndrome, nerve injuries and pressure ulcers (30). Similar to above, the difference in study findings is likely due to the specific fracture type examined in the latter studies compared with our population, which included all fracture types, of which only 2% were femur fractures. Furthermore, approximately 40% of our study population sustained fractures of the distal radius/ulna, and these types of injures are generally at lower risk for complications compared with those of the femur and may have diluted any increased complication rates in obese versus nonobese children for rarer fracture types (31-33). We found that specific patient demographics significantly increased the odds of sustaining a severe extremity fracture. First, 253

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Table 3 Extremity injury outcomes in obese versus nonobese children Variable Severe extremity fractures Emergency department fracture reduction Open fractures

Table 5 Odds of a fracture, anaesthetic and/or treatment related complication

Obese (n=267)

Nonobese (n=1073)

P

107 (40.0)

423 (39.4)

0.42

35 (13.1)

152 (14.2)

0.49

1 (0.4)

15 (1.4)

0.14

Admitted to hospital

66 (24.7)

222 (20.7)

0.23

Operative repair of fracture

54 (20.2)

211 (19.7)

0.22

Number of follow-up fracture clinic visits, mean ± SD

2.4±1.7

2.4±1.5

0.88

Fracture-related complications

20 (7.5)

86 (8.0)

0.74

1 (0.4)

9 (0.8)

0.28

Treatment-related complications

Data presented as n (%) unless otherwise indicated

Table 4 Odds of a severe fracture Variable

Adjusted* OR† (95% CI)

Nonobese (versus obese)

1.00 (0.76–1.32)

Age, years

0.96 (0.93–0.99)

6–12 versus 2–5

0.78 (0.58–1.11)

13–17 versus 2–5

0.61 (0.49–0.91)

Male (versus Female)

1.36 (1.08–1.71)

Sport-related mechanism (versus non-sport related)

0.77 (0.56–1.04)

Upper extremity fracture (versus lower)

1.04 (0.78–1.37)

*ORs are adjusted for age, sex and mechanism of injury; †No significant colinearity between variables age and obesity (P=0.28); Hosmer-Lemeshow P=0.57; Area under the curve of model = 0.61 (95% CI 0.51–0.73)

children 13 to 17 years of age relative to those two to five years of age had lower odds of sustaining a severe extremity fracture. Children are known to fracture more easily and more severely than adults with lower impact mechanisms because the adjoining ligaments are stronger than their bones (34). Our data support that the latter may also be true when younger children are compared with older children because adolescent musculoskeletal physiology approaches that of an adult (35). Second, boys were more likely than girls to sustain severe extremity fractures, and while previous studies have demonstrated that boys are more likely than girls to sustain fractures (36), it may also be true that the types of fractures they sustain are also more severe. There were limitations to the present study. As a retrospective study, we relied on the accuracy of the written record and, as such, it was assumed that if it was not recorded, a specific complication did not occur. While this is consistent with our institution’s policy of documenting the complications that defined our primary outcome, fracture clinic documentation is not systematic and includes free-form text; thus, we could not be certain that there were no missing data from these records. Furthermore, the design of the present study did not enable us to control for unknown confounders. We also defined obesity as weight-for-age ≥95% percentile because height is not routinely measured in the ED. Stettler et al (25) demonstrated that the weight-for-age ≥95% metric for defining obesity is only 82% sensitive relative to body mass index for-age >95% percentile. However, they did recommend that outside the clinical setting in situations for which height is not available, such as research, some weight-for-age percentile cut-off points may be useful to identify groups of children with a high prevalence of being overweight. As such, the weight-for-age metric has been used in similar retrospective ED research (8,20,23,37) for which the prevalence of obesity has been found to be greater 254

Adjusted* OR† (95% CI)

Variable Nonobese (versus obese)

1.12 (0.68–1.85)

Age, years

0.98 (0.93–1.03)

6–12 versus 2–5

1.00 (0.59–1.56)

13–17 versus 2–5

0.72 (0.42–1.39)

Male (versus female)

1.29 (0.87–1.91)

Sport-related mechanism (versus non-sport related)

1.28 (0.77–2.13)

Upper extremity fracture (versus lower)

0.72 (0.46–1.12)

*ORs are adjusted for age, sex and mechanism of injury, †Hosmer-Lemeshow P=0.44; Area under the curve of model = 0.51 (95% CI 0.42–0.64)

than the general population (38). However, due to the potential inaccuracies of our metric, ‘obesity’ in our study more correctly refers to ‘excessive body weight’. Another limitation was the proportion of upper-extremity injuries (approximately 80%) included in the cohort. Therefore, our results may not be valid for lowerextremity injuries. Furthermore, we did not have sufficient power to examine the association between obesity and any one specific type of fracture. The present study was conducted in a tertiary care paediatric ED, and specific management decisions (eg, need for reduction) may vary in other EDs, limiting the generalizability of our findings.

conclusion

The results of the present study did not demonstrate an increase in severe extremity fractures or complications in obese versus nonobese children presenting to a paediatric ED. Thus, once an extremity fracture has occurred, parents and health care providers need not necessarily be concerned that an obese child is at greater risk for a severe extremity fracture and/or subsequent complications from this injury. source of Funding: The Hospital for Sick Children, Residency Training Start-Up Fund. disclosures: The authors have no conflicts of interest to declare.

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Do obese children experience more severe fractures than nonobese children? A cross-sectional study from a paediatric emergency department.

Déterminer s’il y a un lien entre l’obésité juvénile et les graves fractures des membres. Examiner également les associations entre l’obésité et les c...
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