American Journal of Emergency Medicine 33 (2015) 250–253

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Original Contribution

Upper extremity fractures among hospitalized road traffic accident adults☆,☆☆ Guy Rubin, MD a,b,⁎, Kobi Peleg, PhD, MPH c, Adi Givon, BSc c, Israel Trauma Group 1, Nimrod Rozen, MD, PhD a,b a b c

Orthopaedic Department, Ha'Emek Medical Center, Afula, Israel Faculty of Medicine, Technion, Haifa, Israel National Center for Trauma & Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, Israel

a r t i c l e

i n f o

Article history: Received 9 November 2014 Received in revised form 23 November 2014 Accepted 24 November 2014

a b s t r a c t Background: Upper extremity fractures (UEFs) associated with road traffic accidents (RTAs) may result in longterm disability. Previous studies have examined UEF profiles with small patient populations. The objective of this study was to examine the injury profiles of UEFs in all mechanisms of injury related to RTAs. Methods: Data on 71231 RTA adult patients between 1997 and 2012 whose records were entered in a centralized country trauma database were reviewed. Data on UEFs related to mechanism of injury (car, motorcycle, bicycle, and pedestrian) including associated injuries, multiple UEFs, and frequency of UEF were analyzed. Results: Of 71,231 adult RTA cases recorded in 1997–2012, 12,754 (17.9%) included UEFs. Motorcycle (27%) and bicycle riders (25%) had the greater risk for UEF (P b .0001). Of 12754 patients with UEFs, 9701 (76%) had other injuries. Pedestrians (86%) and car occupants (81%) had the greater risk for associated injuries (P b .0001). Most of the injuries were head/face/neck (52%), lower extremities (49%), and chest (46%) injuries (P b .0001). Twenty-two percent of all cases had multiple UEFs. The motorcycle riders (27%) had the greater risk for multiple UEFs (P b .0001). Of 12754 patients with UEFs we found 16371 UEFs. Most of the fractures were in the radius (22%), humerus (19%), and clavicle (17%) (P b .0001). Conclusions: This study contributes the largest database on reported adult UEFs related to all mechanisms of injury in RTAs and finds the comparative epidemiology of associated injuries, multiple UEFs, and frequency of UEFs. It is important that the treating surgeon is aware of the complexity of the UEF patient, the strong possibility for associated injury, the possibility for multiple fractures in the upper limbs, and the most common fractures associated with each mechanism of accident. © 2014 Elsevier Inc. All rights reserved.

1. Introduction Every year 1.2 million people are known to die in road accidents worldwide. Millions of others sustain injuries, with some suffering permanent disabilities. Upper extremity fractures (UEFs) account for up to 13% of injuries requiring admission to health facilities [1]. To date, few studies have evaluated the epidemiology of UEFs related to road traffic accidents (RTAs) in adults, most of them related to car accidents [2–8] and only a few related to motorcycle accidents [8–10], pedestrian accidents [8,11–14], and bicycle accidents [15,16]. The aim of this study is to identify the epidemiology of RTA UEFs and define any commonly occurring patterns. This study focuses on all ☆ No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. ☆☆ This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. ⁎ Corresponding author at: Orthopaedic Department, Haemek Medical Center, Afula, Israel. Tel.: +972 4 649 4300. E-mail address: [email protected] (G. Rubin). 1 Israel Trauma Group: R. Alfici, J.H. Bahouth, A. Becker, A. Hadary, M. Jeroukhimov, I. Karawani, B. Kessel, Y. Klein, G. Lin, O. Merin, B. Miklosh, Y. Mnouskin, A. Rivkind, G. Shaked, D. Simon, G. Sivak, D. Soffer, M. Stein and M. Weiss. http://dx.doi.org/10.1016/j.ajem.2014.11.048 0735-6757/© 2014 Elsevier Inc. All rights reserved.

mechanisms of injury related to RTAs, car, motorcycle, bicycle, and pedestrian, with comparison between them and the epidemiology of associated injuries, multiple fractures, and frequency of UEF. 2. Material and methods RTA adult (over age 18) patients (car, motorcycle, bicycle, and pedestrian) in Israel between 1997 and 2012 were reviewed. Data were obtained from the Israel National Trauma Registry (ITR), maintained by Israel’s National Center for Trauma and Emergency Medicine Research at the Gertner Institute for Epidemiology and Health Policy Research. The ITR does not collect data on individuals who were dead at the scene or upon arrival at the emergency department, nor does it follow patients after discharge to home from the emergency department. Data are recorded by trained medical registrars at each hospital and electronic files are transferred to the ITR. During this period, the ITR included trauma patients admitted to all six level I trauma centers and up to 13 regional trauma centers in Israel. Medical diagnosis classifications were from the International Classification of Diseases, 9th Revision, Clinical Modification and Abbreviated Injury Scale (AIS) coding. Associated injuries were

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Table 1 Percentage of patients with UEF from total patients in each type of RTA

No. (%) Total

Car

Motorcycle Bicycle

Pedestrian Other

Total

5275 (14.25) 37011

2933 (27.18) 10793

2615 (19.15) 13655

12754 (17.9) 71231

1291 (24.64) 5239

640 (14.12) 4533

considered for each of the nine body regions coded by the AIS. Face was included with head and neck. Data included age, type of UEF, and other associated body injury. These characteristics were compared between the types of the RTA patients. Statistical analysis was performed using SAS statistical software version 9.2 (SAS, Cary, NC). Statistical tests performed included χ2 test and binomial proportions test. P b .05 was considered statistically significant. Source of Funding: there was no external funding source. 3. Results Of 71231 adult RTA cases recorded in the ITR in 1997 to 2012, 12754 (17.9%) included UEFs (Table 1). Motorcycle (27%) and bicycle riders (25%) had the greater risk for UEFs (P b .0001). 3.1. Multiple fractures in the upper extremities Of 12 754 patients with UEFs, 2805 (22%) had multiple UEFs. Motorcycle riders (27%) had the greater risk for multiple fractures (P b .0001); car occupants (22%), bicycle riders (19%), and pedestrians (18%) came next (Fig. 1). 3.2. Associated injuries Of 12 754 patients with UEFs, 9701 (76%) also had other injury. The pedestrians (86%) and the car occupants (81%) had the greater risk for associated injuries (P b .0001) (Fig. 2). Most of the injuries were head/ face/neck (52%), lower extremities (49%), and chest (46%) injuries (P b .0001) (Table 2). This pattern was the same for each type of accident (P b .0001) (Fig. 3). 3.3. Fracture type Of 12 754 patients with UEFs we found 16 371 UEFs. Most of the fractures were in the radius (22%), humerus (19%), and clavicle (17%) (P b .0001) (Fig. 4). The risk for each fracture according to mechanism

Fig. 2. Percentage of patients with associated injuries from total UEF patients in each type of RTA.

of injury is presented in Fig. 5. In car occupants the most frequent fractures were radius (21%), humerus (19%), and clavicle (18%) (P b .0001). In motorcycle riders the most frequent fractures were radius (26%), clavicle (16.5%), and ulna (14%) (P b .0001). In bicycle riders the most frequent fractures were radius (24%), clavicle (21%), and ulna (17%) (P b .0001), and in pedestrians the most frequent fractures were humerus (32%), clavicle (17%), and radius (16%) (P b .0001).

4. Discussion In a review of 71,231 adult RTA cases recorded in the ITR in 1997–2012, UEFs were found in 12,754 (17.9%) of cases, suggesting this is a common injury following such events. Data from the Global Burden of Disease Project show that 13% of injuries requiring admission to a health facility are attributed to UEFs [1]. In other previously described samples of RTAs, Conroy et al described 24.8% upper extremity injury out of 607 car occupants [3]. Richter et al. found 5.5% of 3620 restrained front seat occupants sustained UEFs [7]. Goldman et al. found 22% to 31% of occupants, depending upon their safety system use, had upper extremity injuries [5]. Chan et al found about 20% UEFs in RTA patients [8]. We found 14% UEFs in car occupants. Motorcycle riders are exposed to severe injuries during accidents; Wick et al reported 20% of 86 patients suffering from UEFs [9], Zetta et al. reported 20% out of 260 patients suffering from UEFs [10], we found 27% UEFs in motorcycle riders. Bicycle versus car accidents are common but little has been written about UEF-associated injuries. Guichon et al reported 19% UEF in a group of 107 patients [15] and Juhra et al reported only 13% UEFs in all age groups [16]. In our study we found 24.6% UEFs in this group. Pedestrian UEF epidemiology studies are rarely reported. Landy et al. described UEFs in 25% out of 393 pedestrian patients [11]. Siram et al reported 11.6% UEFs [12] and Kong et al reported 28% UEFs [14]. We found 19% UEFs in pedestrian patients. Multiple fractures in the same upper limb or in both upper limbs are usually considered to be related to high energy injury. Where there are co-existing injuries one or more may be overlooked. Epidemiology of multiple UEFs may be able to identify the demographic information Table 2 Percent of associated injury in RTA

Fig. 1. Percentage of patients with Multiple UEF from total UEF patients in each type of RTA.

Type of injury

No. (%)

Other upper extremity injury Head/face/neck Chest Abdomen Spinal cord/column Lower extremity Burn/overall skin

1482 (15) 5035 (52) 4501 (46) 1844 (19) 1763 (18) 4778 (49) 226 (2)

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*Each patient can have more than one associated injury. Fig. 3. Percentage of patients with associated injuries from total UEF patients in each type of RTA by body region.

Fig. 4. Distribution of fracture type among upper extremities fractures.

that indicates the possibility of multiple fractures being present and identify patterns of injury that should raise suspicion that other injuries may be present in the same limb. Landy et al described multiple UEFs in 18% of 86 UEFs in pedestrian patients [11]. Broadbent et al described multiple UEFs in 8.4% of UEFs in pedestrian patients and 6% in car accident patients [2]. Our study has shown that multiple UEFs in the same patient can occur in 22% of RTAs admitted to hospital and that

motorcycle accident patients are at greater risk for multiple UEFs, with up to 27% having multiple UEFs. Associated injuries to UEFs were found in most of our patients (76%). The pedestrians and the car occupants had greater risk for associated injuries compared to the other groups. Most of the injuries in all the groups were head/face/neck, lower extremities, and chest. Hall and Fisher noticed that when a pedestrian is involved in an accident he will receive on average about 2 injuries. These injuries will most likely be to the limbs, especially the legs, and to the head. They did not specify the incidence of fractures [13]. Landy et al. found associated lower extremity injuries in 67% of pedestrian patients with UEFs [11]. We found a similar result of 63%. Data from the Global Burden of Disease Project show that the most frequent UEF fractures requiring admission to a health facility are attributed to radius or ulna and account for 6.3%, followed by clavicle, scapula, or humerus with 4.8%, and hand fractures 2%. The most frequent UEFs described for car occupants are forearm, humerus, and clavicle and were similar to our results [3,4,6–8]. The most frequent UEFs described for motorcycle riders are forearm, humerus, and clavicle and were similar to our results [8–10]. The most frequent UEFs described for pedestrians are forearm and humerus, and were similar to our results [8,11,14]. The most frequent UEFs for bicycle riders are forearm and clavicle, and were similar to our results [15].

Fig. 5. Distribution of fracture type among upper extremities fractures in each type of RTA.

G. Rubin et al. / American Journal of Emergency Medicine 33 (2015) 250–253

It is important that the emergency physicians are aware of the complexity of the UEF patient, the strong possibility for associated injury, the possibility for multiple fractures in the upper limbs, and the most common fractures associated with each mechanism of accident.

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Upper extremity fractures among hospitalized road traffic accident adults.

Upper extremity fractures (UEFs) associated with road traffic accidents (RTAs) may result in long-term disability. Previous studies have examined UEF ...
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