Epidemiologic Changes in Pediatric Fractures During the COVID-19 Pandemic

Background: Fractures are a common cause of pediatric injury. The coronavirus disease 2019 (COVID-19) pandemic resulted in significant changes in daily life including social distancing, partial cessation of youth sports, and school closings, all of which could have a major impact on the incidence of pediatric fractures. Prior work has demonstrated a significant reduction in fracture burden during the early pandemic; however, few have examined pediatric fractures in the period after lifted restrictions or on a national level. The purpose of this study was to compare pediatric fracture rates in the United States during the COVID-19 pandemic to previous seasonally-adjusted injury rates using the National Electronic Injury Surveillance System (NEISS) database.

Methods: The NEISS database was queried from 2016 to 2020 for fractures occurring in pediatric (0-17yo) patients. Studied demographic variables included age, sex, body region injured, disposition, and location of injury. Using a quasi-experimental, interrupted time series design, we constructed linear regression models for number of fractures per month that included a linear time trend, month of injury, a binary variable representing whether the fracture occurred after February 2020, and number of months post-March 2020 to allow the effect of restrictions to change over time. The differential impact of COVID-19 on fracture rate by each demographic variable was then tested using interaction terms.

Results: Our sample consisted of 121,803 cases representing 2,959,421±372,337 fractures nationally. Monthly incidences (Figure 1) identified a 32% decrease in fractures per month after February of 2020 (Overall B=-11,400 fractures 95% Credible Interval[-17,600, -5,200]), and the decay of this effect did not reach significance. We found significant effect modification by age, body region, location, and disposition (p < 0.05, Table 1). Children (6-11yo) experienced 44% fewer fractures (-5,070 [-7,590, -2,570]) while adolescent injuries declined 34% (-5,300 [-7,760, -3,020]). A 93% reduction in fractures at school (-5,050 [-6,870, -3,250]) and a 69% decrease in those during sports (-7,570 [-9,380, -5,750]) was identified. Fractures that did not require hospitalization decreased by 35% (-11,200 [-16,890, -5,630]).

Conclusion: A nationally representative injury database demonstrated a 32% decline in monthly pediatric fractures during the COVID-19 pandemic that persisted into the latter half of 2020. These trends were identified to be most attributable to a reduction in less severe, extremity fractures among older children sustained at school and in sports. In contrast, more severe injuries or those in younger children remained relatively unaffected. Our findings provide unique insight into the epidemiology of pediatric fractures and demonstrate a baseline need for musculoskeletal care among young children and orthopaedic injuries necessitating hospitalization, even in the setting of a national shutdown.