CC BY-NC-ND 4.0 · Avicenna J Med 2022; 12(02): 061-066
DOI: 10.1055/s-0042-1748832
Original Article

Characteristics of School Injuries Presenting to the Emergency Department

1   Department of Emergency Medicine, University of Health Sciences Ümraniye Training and Research Hospital, Istanbul, Turkey
,
2   Department of Emergency Medicine, Karamanoğlu Mehmet Bey University, Karaman, Turkey
,
1   Department of Emergency Medicine, University of Health Sciences Ümraniye Training and Research Hospital, Istanbul, Turkey
,
3   Department of Emergency Medicine, Aksaray University, Aksaray Training and Research Hospital, Aksaray, Turkey
,
1   Department of Emergency Medicine, University of Health Sciences Ümraniye Training and Research Hospital, Istanbul, Turkey
› Author Affiliations
FundingNone.
 

Abstract

Background School injuries account for approximately one-fifth of pediatric injuries. We aimed to investigate the frequency and severity of school injuries among school-aged children and determine clinical diagnoses and surgery requirement data.

Methods In this prospective study, children who were admitted to the emergency department due to school accidents over a 5-month period were included. Demographics, activity during trauma, mechanism of trauma, nature, severity, emergency department outcomes, and surgery requirement were evaluated.

Results The study included a total of 504 school-aged children, of whom 327 (64.9%) were male and 177 (35.1%) were female. Of the children, 426 (84.5%) had no evidence of injury or minor injury, while 78 (15.5%) had moderate or severe injury. There was a statistically significant difference between these two groups in terms of gender (p = 0.031). Of the 78 children with moderate or severe injuries, 45 had extremity fractures, 18 had lacerations, 5 had maxillofacial injuries, 4 had cerebral contusion, 1 had lung contusion, and 1 had cervical soft-tissue damage. Two patients with fractures and two with eyelid lacerations were treated surgically, and four patients with brain contusion were hospitalized for a close follow-up.

Conclusion This study revealed that the most common moderate or severe injuries in school accidents referred to emergency department were distal radius fractures and lacerations.


#

Introduction

Trauma is the major cause of mortality in children in both developed and developing countries worldwide.[1] The mortality rate in children hospitalized due to trauma has been reported to vary between 0.3 and 8.5% in various studies.[1] Traffic accidents, falls, and burns are the most common causes of mortality in this period of life.[1]

School-aged children spend a large percentage of their active time in school. School injuries account for approximately one-fifth of pediatric injuries.[2] [3] There are many epidemiological studies on school accidents in the literature.[4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] Such studies are based on records obtained from school nursing units, national trauma registry, or emergency department (ED). Some researchers have evaluated injuries in subgroups, such as athletes and footballers, or specific injury sites, such as the head and lower extremity.[16] [17] [18] [19] The Injury Surveillance Guidelines prepared by the World Health Organization are frequently used in epidemiological studies in this area.[20] However, most of these studies, especially those with large samples, did not include clinical diagnoses and surgical requirement data.[4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19]

This study aimed to investigate the frequency and severity of school injuries referred to ED among school-aged children according to the Injury Surveillance Guidelines and determine clinical diagnoses and surgery requirement data.


#

Material and Method

Study Design

This study was designed as a prospective, observational, cohort study including patients with school-related injuries presenting to our ED over a 5-month period. The ED where this study was conducted receives an annual number of 438,000 emergency visits (both children and adults), located in a tertiary general hospital of a metropolis serving approximately 3 million people. Our ED is also the biggest pediatric trauma center of the region.


#

Study Population

The study population of this study consisted of patients admitted to our ED with school-related injuries between October 10, 2019, and March 12, 2020. During the study period, there were a total of 51,986 admissions to ED, of which 8,416 were traumatic, and 2,609 of these traumatic admissions belonged to school-aged children. All school-aged children referred to our ED with a traumatic injury that occurred in the school building or yard were included in the study. Patients whose legal guardian did not give consent for their participation in the study and those with incomplete or unavailable forms or hospital records were excluded from the study. [Fig. 1] shows the inclusion and exclusion process of the patients.

Zoom Image
Fig. 1 Flowchart of the study.

#

Data Collection

Data were collected using two sources: a study form and the computer-based system of the hospital. The study form was completed for each study patient whose parents provided consent at the time of patient admission to the emergency trauma area. This form was prepared and completed according to the Injury Surveillance Guidelines of the World Health Organization. It included information on patient ID (allocated by the computer-based system of the hospital), demographic data, activity that was performed when the injury occurred, mechanism, nature, and severity of injury, and ED outcomes. Activity was noted as education, playing, or others; mechanism of injury was noted as falling, blunt trauma, sharp object trauma, moving vehicle, and others; nature of injury was noted as soft-tissue injury to the limbs, soft-tissue injury to the face and neck, open wound, bruise, fracture, head injury, and sprain; and ED outcome was noted as discharge and hospitalization. According to their age, the children were grouped as kindergarten (3–5 years), primary school (6–10 years), middle school (11–13 years), and high school (14–18 years). The clinical diagnoses and clinical follow-up of the patients who underwent surgery were recorded from the computer-based system of the hospital.


#

Statistical Analysis

IBM SPSS Statistics for Mac, Version 27.0 (Armonk, NY, IBM Corp) was used to perform statistical analyses. The Kolmogorov–Smirnov test was conducted for the evaluation of the conformance of variables to a normal distribution. The data that complied with a normal distribution were presented with mean and standard deviation values, and the remaining data were expressed as interquartile range and median values. Categorical data were presented with the number of cases and percentages. For the comparison of quantitative and qualitative data between two groups, the chi-square and Mann–Whitney U tests were used.


#

Ethics

Ethical approval was obtained from the local ethical committee of clinic research (approval number: B.10.1. TKH.4.34.H.GP.0.01/112). Before completing the study form, the legal guardians of the patients were asked to provide consent for their children's participation in the study, and the clinical data of only the patients for whom the guardians signed the informed consent form were included in the study.


#
#

Results

A total of 504 school-aged children who presented to our clinic with a traumatic injury that occurred in the school building or school yard were included in the study during the study period ([Fig. 1]). Of the children, 327 (64.9%) were male and 177 (35.1%) were female. There was no evidence of injury or only minor injury was present in 426 (84.5%) children, while 78 (15.5%) children had moderate or severe injury. There was a statistically significant difference between these two groups in terms of gender (p = 0.031) ([Table 1]). The baseline characteristics of the enrolled patients and the comparison of characteristics between the no/minor injury and moderate/severe injury groups are summarized in [Table 1].

Table 1

Baseline characteristics of enrolled patients and comparison of characteristics between the injury severity groups

Total

No evidence of injury or minor injury

Moderate or severe injury

p-Value

504

426 (84.5%)

78 (15.5%)

Age (y)

11 (3–17)

11 (3–17)

11 (4–16)

0.947

Age (y)

 3–5

9 (1.8%)

8 (1.9%)

1 (1.3%)

0.494

 6–10

155 (30.9%)

134 (31.7%)

21 (26.9%)

 10–12

288 (57.5%)

239 (56.5%)

49 (62.8%)

 13–18

49 (9.8%)

42 (9.9%)

7 (9%)

Gender

 Male

327 (64.9%)

268 (62.9%)

59 (75.6%)

0.031

 Female

177 (35.1%)

158 (37.1%)

19 (24.4%)

Activity

 Playing

107 (21.2%)

91 (21.3%)

16 (20.5%)

0.763

 Educational activity

114 (22.6%)

94 (22.1%)

20 (25.6%)

 Other

283 (56.2%)

241 (56.6%)

42 (53.8%)

Accompanying person

 Alone/friends

16 (3.2%)

13 (3.1%)

3 (3.8%)

0.514

 Parents

458 (90.8%)

390 (91.5%)

68 (87.2%)

 Teacher

5 (1%)

2 (0.5%)

3 (3.8%)

 Other

25 (5%)

21 (4.9%)

4 (5.1%)

Type

 Unintentional

458 (90.9%)

384 (90.1%)

74 (94.9%)

0.179

 Violence

15 (3%)

14 (3.3%)

1 (1.3%)

 Self-harm

11 (2.2%)

9 (2.1%)

2 (2.6%)

 Other

20 (4%)

19 (4.5%)

1 (1.3%)

Mechanism of injury

 Falling

252 (49.9%)

206 (48.4%)

46 (59%)

0.068

 Blunt objects

207 (41.1%)

180 (42.3%)

27 (34.6%)

 Sharp objects

10 (2%)

6 (1.4%)

4 (5.1%)

 Moving vehicle

4 (0.8%)

4 (0.9%)

0

 Other

31 (6.1%)

30 (7%)

1 (1.3%)

Injured area

 Head/neck

110 (22.6%)

85 (20.8%)

25 (32.1%)

0.008

 Fingers

93 (19.1%)

81 (19.8%)

12 (15.4%)

 Hand/wrist

84 (17.2%)

64 (15.6%)

20(25.6%)

 Rest of the upper limb

61 (12.5%)

53 (13%)

8 (10.3%)

 Foot/ankle and toes

91 (18.7%)

81 (19.8%)

10 (12.8%)

 Rest of the lower limb

34 (7%)

32 (7.8%)

2 (2.6%)

 Thorax/abdomen

14 (2.9%)

13 (3.2%)

1 (1.3%)

Nature

 Soft-tissue injuries (limbs)

225 (44.6%)

225 (52.8%)

0

0.006

 Soft-tissue injuries (face and neck)

32 (6.3%)

22 (5.1%)

10 (12.8%)

 Open wound

19 (3.7%)

1 (0.2%)

18 (23%)

 Bruise/sprain

102 (20.1%)

102 (23.9%)

0

 Fracture (extremity)

45 (8.9%)

0

45 (57.6%)

 Head injury

80 (15.8%)

76 (17.8%)

4 (5.1%)

 Organ system injury

1 (0.2)

0

1 (1.2%)

Note: Bolded p-Values are significant.


Of the 78 children with moderate or severe injuries, 45 had extremity fractures, 18 had lacerations, 9 had maxillofacial injuries, 4 had cerebral contusion, 1 had lung contusion, and 1 had cervical soft-tissue damage. The distribution of the extremity fractures is shown in [Table 2]. Of the 18 children with lacerations, 10 had laceration on the extremities, 4 under the chin area, 2 on the scalp, and 2 on the eyelid. There was canalicular damage in one of the eyelid lacerations. The lacerations other than the lacerations of the eyelid were sutured in the ED. The eyelid lacerations were sutured in the operating room. Four children with cerebral contusion were hospitalized for a close follow-up without the need for a neurosurgical intervention. Of the nine children with maxillofacial injuries, three had displaced nasal fractures without a septal hematoma. These patients were discharged after an outpatient clinic appointment was arranged. The demographics, mechanisms of injury, and final diagnoses of the patients who were treated surgically are presented in [Table 3]. No burn or mortality was observed in the study population.

Table 2

Distribution of the fractures in the extremities

n (45)

%

Fifth metacarpal neck

1

2.2

Fifth metacarpal shaft

1

2.2

Distal phalanx

3

6.6

Proximal phalanx

8

17.7

Distal radius (isolated)

18

40

Distal radius and ulna[a]

1

2.2

Proximal ulna

1

2.2

Humerus transcondylar[a]

1

2.2

Humerus supracondylar

1

2.2

Fifth metatarsal (neck)

1

2.2

Proximal phalanx (foot)

1

2.2

Lateral malleolus

7

15.5

Medial malleolus

1

2.2

a Surgically treated.


Table 3

Characteristics of surgically treated patients

Age, y

Gender

Mechanism of injury

Diagnosis

Patient 1

10

Female

Falling

Humerus transcondylar fracture

Patient 2

13

Male

Blunt trauma

Distal radius and ulnar fracture

Patient 3

7

Male

Blunt trauma

Eyelid laceration

Patient 4

16

Male

Blunt trauma

Lower eyelid canalicular laceration


#

Discussion

Many epidemiological studies have been performed in EDs related to accidents that occur in schools and nurseries around the world. The difference of our study from these studies is the definition of injury and ED outcomes including surgical requirement as well as epidemiological data. The most important finding of this study is that 15% of the injuries were moderate or severe, and the most common moderate or severe injury was a distal radius fracture. Two patients with fractures and two with eyelid lacerations were treated surgically, and four patients with brain contusion were hospitalized for a close follow-up.

This study revealed that the frequency of extremity fractures was higher than moderate or severe head injuries in school-aged children. This may be because in school accidents, the injury mechanism is often due to falling, blunt impact, or use of hands to protect oneself.[21] Other plausible explanations for the higher number of extremity injuries include clumsiness and gait disturbances that can be caused by the elongation of the extremities and delays in motor development during adolescence.[22] We were unable to assess this hypothesis using our dataset, but we consider that it should be investigated in further studies.

Previous studies have been conducted to identify groups at risk for school injuries. Studies have shown that different age groups are at higher risk.[6] [9] [11] Linakis et al showed that children aged 10 to 14 years are at higher risk for school injuries.[6] In another study, Al-Hajj et al reported that 3 to 5 years of age constituted the risk group.[9] However, Ramirez et al showed that the 5 to 9 years group was at higher risk for school injuries.[11] In our study, there was no difference between those with no/minor injury and those with moderate/severe injury by age. All studies evaluating injury risk by gender have shown that male gender constitutes greater risk for school accidents. Our study showed similar results. There are several explanations for this finding, such as the more aggressive nature or stronger physical activity level of boys, or different expectations of parents and society from males, all of which may lead to more serious injuries.[10]

Ninety-five percent of the children were referred to our ED by their parents or relatives who were their legally acceptable guardians. One percent of the children were brought to ED by their teachers. The reason for this is that when a child is injured at school, the school administration informs the parents, and if the parents are available, they are expected to take their child to ED. If the parents are not available, the teacher assumes this responsibility. Only 3.2% of the children presented to ED themselves or were taken there by their friends who were not their legal guardians. Although this demonstrates the independence and self-sufficiency of a child, it can cause legal problems for the medical team in cases requiring medical interventions.

Our study has several limitations. First, we had to terminate the study before the initially planned deadline due to the COVID-19 pandemic. In our country, due to the pandemic, face-to-face education was suspended in March 2020. Therefore, we were not able to include any more patients after this date in our sample. Second, we only included patients who presented to ED and did not evaluate those presenting to outpatient clinics with school injuries. We were also not able to evaluate minor injuries that were treated by school nurses and did not require referral to ED. Another limitation of our study is that the results have limited generalizability due to its single-center design. Multicenter studies should be performed with larger populations to identify groups at risk for different subgroups of injury.

In conclusion, our study revealed that the most common moderate or severe injuries in school accidents referred to ED were distal radius fractures and lacerations.


#
#

Conflict of Interest

None declared.

Availability of Data and Materials

The dataset generated and analyzed during this study is available from the corresponding author.


Informed Consent

Written informed consent was obtained from legal guardian of patient.


Ethical Approval

Ethical approval for this study was obtained from Ümraniye Training and Research Hospital Ethics Committee (approval number: B.10.1. TKH.4.34.H.GP.0.01/112). The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki.


Authors' Contributions

All authors are responsible for conception, design of the study, data collection, data analysis, and assembly. The manuscript was written and approved by all authors


  • References

  • 1 Aoki M, Abe T, Saitoh D, Oshima K. Epidemiology, patterns of treatment, and mortality of pediatric trauma patients in Japan. Sci Rep 2019; 9 (01) 917
  • 2 Sleet DA, Ballesteros MF, Borse NN. A review of unintentional injuries in adolescents. Annu Rev Public Health 2010; 31: 195-212
  • 3 Scheidt PC, Harel Y, Trumble AC, Jones DH, Overpeck MD, Bijur PE. The epidemiology of nonfatal injuries among US children and youth. Am J Public Health 1995; 85 (07) 932-938
  • 4 Khan UR, Bhatti JA, Zia N, Farooq U. School-based injury outcomes in children from a low-income setting: results from the pilot injury surveillance in Rawalpindi city, Pakistan. BMC Res Notes 2013; 6: 86
  • 5 Park HA, Ahn KO, Park JO, Kim J, Jeong S, Kim M. Epidemiologic characteristics of injured school-age patients transported via emergency medical services in Korea. J Korean Med Sci 2018; 33 (10) e73
  • 6 Linakis JG, Amanullah S, Mello MJ. Emergency department visits for injury in school-aged children in the United States: a comparison of nonfatal injuries occurring within and outside of the school environment. Acad Emerg Med 2006; 13 (05) 567-570
  • 7 Zagel AL, Cutler GJ, Linabery AM, Spaulding AB, Kharbanda AB. Unintentional injuries in primary and secondary schools in the United States, 2001-2013. J Sch Health 2019; 89 (01) 38-47
  • 8 Al Zeedi MAS, Al Waaili LH, Al Hakmani FM, Al Busaidi AM. Incidence of school-related injuries among students in A'Dakhiliyah governorate schools, Oman. Oman Med J 2020; 35 (03) 127
  • 9 Al-Hajj S, Nehme R, Hatoum F, Zheng A, Pike I. Child school injury in Lebanon: a study to assess injury incidence, severity and risk factors. PLoS One 2020; 15 (06) e0233465
  • 10 Şengel A, Gür K, Kılınç E. The epidemiology of students injuries in a private primary school in Turkey from 2012 to 2018. Clin Exp Health Sci 2020; 10 (04) 362-368
  • 11 Ramirez M, Peek-Asa C, Kraus JF. Disability and risk of school related injury. Inj Prev 2004; 10 (01) 21-26
  • 12 Fothergill NJ, Hashemi K. Two hundred school injuries presenting to an accident and emergency department. Child Care Health Dev 1991; 17 (05) 313-317
  • 13 Vosoughi M, Dargahi A, Teymouri P. Environmental health and safety assessment of schools in Khalkhal City using crisis management approach. HDQ 2020; 5 (02) 91-98
  • 14 Senterre C, Dramaix M, Levêque A. Epidemiology of school-related injuries in Belgium. A better knowledge for a better prevention. Open J Prev Med 2014; 4: 408-420
  • 15 Maitra A. School accidents to children: time to act. J Accid Emerg Med 1997; 14 (04) 240-242
  • 16 Knowles SB, Marshall SW, Bowling JM. et al. A prospective study of injury incidence among North Carolina high school athletes. Am J Epidemiol 2006; 164 (12) 1209-1221
  • 17 Fernandez WG, Yard EE, Comstock RD. Epidemiology of lower extremity injuries among U.S. high school athletes. Acad Emerg Med 2007; 14 (07) 641-645
  • 18 Alhabdan S, Zamakhshary M, AlNaimi M. et al. Epidemiology of traumatic head injury in children and adolescents in a major trauma center in Saudi Arabia: implications for injury prevention. Ann Saudi Med 2013; 33 (01) 52-56
  • 19 Darrow CJ, Collins CL, Yard EE, Comstock RD. Epidemiology of severe injuries among United States high school athletes: 2005-2007. Am J Sports Med 2009; 37 (09) 1798-1805
  • 20 Holder Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye O. Injury Surveillance Guidelines. Geneva: World Health Organization; 2001
  • 21 Kokulu K, Algın A, Özdemir S, Akça HŞ. Characteristics of injuries among infants who fall from bed. Injury 2021; 52 (02) 281-285
  • 22 Cantell MH, Smyth MM, Ahonen TP. Clumsiness in adolescence: educational, motor and social outcomes of motor delay detected at 5 years. Adapt Phys Activ Q 1994; 11: 115-129

Address for correspondence

Serdar Özdemir, MD
Department of Emergency Medicine, University of Health Sciences Ümraniye Training and Research Hospital
Istanbul
Turkey   

Publication History

Article published online:
20 June 2022

© 2022. Syrian American Medical Society. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

  • References

  • 1 Aoki M, Abe T, Saitoh D, Oshima K. Epidemiology, patterns of treatment, and mortality of pediatric trauma patients in Japan. Sci Rep 2019; 9 (01) 917
  • 2 Sleet DA, Ballesteros MF, Borse NN. A review of unintentional injuries in adolescents. Annu Rev Public Health 2010; 31: 195-212
  • 3 Scheidt PC, Harel Y, Trumble AC, Jones DH, Overpeck MD, Bijur PE. The epidemiology of nonfatal injuries among US children and youth. Am J Public Health 1995; 85 (07) 932-938
  • 4 Khan UR, Bhatti JA, Zia N, Farooq U. School-based injury outcomes in children from a low-income setting: results from the pilot injury surveillance in Rawalpindi city, Pakistan. BMC Res Notes 2013; 6: 86
  • 5 Park HA, Ahn KO, Park JO, Kim J, Jeong S, Kim M. Epidemiologic characteristics of injured school-age patients transported via emergency medical services in Korea. J Korean Med Sci 2018; 33 (10) e73
  • 6 Linakis JG, Amanullah S, Mello MJ. Emergency department visits for injury in school-aged children in the United States: a comparison of nonfatal injuries occurring within and outside of the school environment. Acad Emerg Med 2006; 13 (05) 567-570
  • 7 Zagel AL, Cutler GJ, Linabery AM, Spaulding AB, Kharbanda AB. Unintentional injuries in primary and secondary schools in the United States, 2001-2013. J Sch Health 2019; 89 (01) 38-47
  • 8 Al Zeedi MAS, Al Waaili LH, Al Hakmani FM, Al Busaidi AM. Incidence of school-related injuries among students in A'Dakhiliyah governorate schools, Oman. Oman Med J 2020; 35 (03) 127
  • 9 Al-Hajj S, Nehme R, Hatoum F, Zheng A, Pike I. Child school injury in Lebanon: a study to assess injury incidence, severity and risk factors. PLoS One 2020; 15 (06) e0233465
  • 10 Şengel A, Gür K, Kılınç E. The epidemiology of students injuries in a private primary school in Turkey from 2012 to 2018. Clin Exp Health Sci 2020; 10 (04) 362-368
  • 11 Ramirez M, Peek-Asa C, Kraus JF. Disability and risk of school related injury. Inj Prev 2004; 10 (01) 21-26
  • 12 Fothergill NJ, Hashemi K. Two hundred school injuries presenting to an accident and emergency department. Child Care Health Dev 1991; 17 (05) 313-317
  • 13 Vosoughi M, Dargahi A, Teymouri P. Environmental health and safety assessment of schools in Khalkhal City using crisis management approach. HDQ 2020; 5 (02) 91-98
  • 14 Senterre C, Dramaix M, Levêque A. Epidemiology of school-related injuries in Belgium. A better knowledge for a better prevention. Open J Prev Med 2014; 4: 408-420
  • 15 Maitra A. School accidents to children: time to act. J Accid Emerg Med 1997; 14 (04) 240-242
  • 16 Knowles SB, Marshall SW, Bowling JM. et al. A prospective study of injury incidence among North Carolina high school athletes. Am J Epidemiol 2006; 164 (12) 1209-1221
  • 17 Fernandez WG, Yard EE, Comstock RD. Epidemiology of lower extremity injuries among U.S. high school athletes. Acad Emerg Med 2007; 14 (07) 641-645
  • 18 Alhabdan S, Zamakhshary M, AlNaimi M. et al. Epidemiology of traumatic head injury in children and adolescents in a major trauma center in Saudi Arabia: implications for injury prevention. Ann Saudi Med 2013; 33 (01) 52-56
  • 19 Darrow CJ, Collins CL, Yard EE, Comstock RD. Epidemiology of severe injuries among United States high school athletes: 2005-2007. Am J Sports Med 2009; 37 (09) 1798-1805
  • 20 Holder Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye O. Injury Surveillance Guidelines. Geneva: World Health Organization; 2001
  • 21 Kokulu K, Algın A, Özdemir S, Akça HŞ. Characteristics of injuries among infants who fall from bed. Injury 2021; 52 (02) 281-285
  • 22 Cantell MH, Smyth MM, Ahonen TP. Clumsiness in adolescence: educational, motor and social outcomes of motor delay detected at 5 years. Adapt Phys Activ Q 1994; 11: 115-129

Zoom Image
Fig. 1 Flowchart of the study.