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Firearm-Related Musculoskeletal Injuries in Children and Adolescents

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Firearm-Related Musculoskeletal Injuries in Children and Adolescents Review Article Firearm-related Musculoskeletal Injuries in Children and Adolescents Abstract Cordelia W. Carter, MD Firearm injuries are a major cause of morbidity and mortality among Melinda S. Sharkey, MD children and adolescents in the United States and take financial and emotional tolls on the affected children, their families, and society as a Felicity Fishman, MD whole. Musculoskeletal injuries resulting from firearms are common and may involve bones, joints, and neurovascular structures and other soft tissues. Child-specific factors that must be considered in the setting of gunshot injuries include physeal arrest and lead toxicity. Understanding the ballistics associated with various types of weaponry is useful for guiding orthopaedic surgical treatment. Various strategies for preventing these injuries range from educational programs to the enactment of legislation focused on regulating guns and gun ownership. Several prominent medical societies whose members routinely care for children and adolescents with firearm- related injuries, including the American Academy of Pediatrics and the American Pediatric Surgical Association, have issued policy statements aimed at mitigating gun-related injuries and deaths in children. Healthcare providers for young patients with firearm-related musculoskeletal injuries must appreciate the full scope of this important public health issue. From the Department of Orthopaedics and Rehabilitation, Yale School of ecently, firearm-related injuries school campus or grounds, as Medicine, New Haven, CT. Dr. Carter in children and adolescents have documented by the press and con- or an immediate family member R serves as a board member, owner, been featured prominently in the firmed through further inquiries with officer, or committee member of the media. Mass shootings that are law enforcement;” in 2014 alone, 60 American Academy of Orthopaedic committed by and upon young peo- of these school shootings occurred.1 Surgeons and the Pediatric ple continue to occur in the United The rate of firearm-related fatalities Orthopaedic Society of North America. Neither of the following States at an alarming rate. The mass among children and adolescents in authors nor any immediate family shooting that occurred in an elemen- the United States far exceeds that of member has received anything of tary school in Newtown, Connecticut, similar Western nations. The Centers value from or has stock or stock in December 2012, in particular, for Disease Control and Prevention options held in a commercial company or institution related directly or brought the issue of pediatric firearm- (CDC) estimated this rate to be indirectly to the subject of this article: related injuries and fatalities to the approximately 3 per 100,000 chil- Dr. Sharkey and Dr. Fishman. forefront of public discourse in the dren aged 0 to 19 years in the United J Am Acad Orthop Surg 2017;25: United States. However, the problem of States (2,465 fatalities) in 2013, 169-178 firearm injuries in children and ado- more than 50 times greater than that DOI: 10.5435/JAAOS-D-15-00642 lescents remains unsolved. of the United Kingdom for a similar Independent school shootings are timeframe (0.057 per 100,000 chil- Copyright 2017 by the American 2,3 Academy of Orthopaedic Surgeons. defined as the discharge of a firearm dren). The CDC reported a total “inside a school building or on a of 15,091 nonfatal firearm injuries in March 2017, Vol 25, No 3 169 Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Firearm-related Musculoskeletal Injuries in Children and Adolescents the US population aged #19 years American adolescents aged 15 to 19 intervention 61% of the time. The during 2013, for an annual rate of years is 1 in 672. Of the children authors also noted an in-hospital approximately 18 per 100,000 per- hospitalized for firearm injuries, mortality rate of 3.5%.8 sons aged #19 years.3 61.5% required a major procedure in the operating room, and 6.1% (453 patients) died during the hospitaliza- Economic and Societal Epidemiology of Pediatric tion. Of those hospitalized for Costs of Pediatric Firearm Firearm Injuries in the attempted suicide, 35.1% died.5 Injuries United States In 2013, Newgard et al6 published the results of a retrospective cohort Firearm-related injuries in children In 2014, Srinivasan et al4 published a study from the Western Emergency and adolescents undoubtedly result retrospective analysis of data regard- Services Translational Research Net- in direct and indirect costs to society; ing emergency department (ED) and work. This study included children these costs can be calculated in many ambulatory visits obtained from the aged #19 years with gunshot injuries ways. The CDC has estimated the National Hospital Ambulatory Med- who were served by emergency medical costs, the cost of the loss of ical Care Survey from 2001 to 2010. services from one of 47 emergency productive work, and the combined During the study period, 198,969 medical services agencies trans- costs of these two factors for all firearm-related ED and clinic visits for porting to 93 hospitals in five regions firearm-related injuries occurring in children aged #19 years were iden- of the western United States during the year 2010 in children aged 0 to 19 tified (annual average, 19,897 visits). the 3-year period from 2006 to 2008. years. For patients with nonfatal The calculated annual rate of firearm The rate of firearm-related injuries in injuries treated in the ED and released, injuries was 23.9 per 100,000 chil- this population was 7.5 per 100,000 the average medical cost reported by dren versus the CDC estimate of 18 children. However, most of these the CDC was $2,882 per visit, for per 100,000 children. The fatality rate injuries were severe, accounting for a total annual medical cost of in the ED for non–firearm-related only 1% of injured children but 21% $23,669,000.3 The estimated com- visits was 0.03% in this population; of deaths, which reflects a dispro- bined medical plus work-loss cost for however, the fatality rate for firearm- portionate burden of adverse out- these nonfatal injuries was $5,931 related visits was 2%, more than comes for this population.6 per patient, or a total of $48,705,000 60-fold greater. Patients with firearm- The results of other recent studies per year.3 Table 1 outlines the costs related injuries were more likely to be echo these findings. In 2012, Allareddy for patients with nonfatal injuries male, African American, older (age, et al7 examined the Nationwide requiring hospital admission and for 12 to 19 years), and uninsured. In this Emergency Department Sample for those with fatal firearm injuries.3 study, 64% of firearm injuries the year 2008. Culling from all ED Several groups of researchers have occurred unintentionally.4 visits involving children aged ,18 attempted independently to estimate In a retrospective review of data from years, the authors reported a total of the societal costs of pediatric firearm the Kids’ Inpatient Database, a 14,831 ED visits for firearm-related injuries in the US. Leventhal et al5 nationally representative sample of injuries; 89.2% of these patients were found that the average length of discharge data from 4,121 acute care males with an average age of 15.9 hospital stay for patients with hospitals that care for pediatric years.7 Similar to previous studies, the firearm-related injuries was 6.14 patients in 44 states, a total of 7,391 authors noted that the fatality rate of days, and the average cost of hospi- hospitalizations in 2009 were for children in the ED versus those talization was $19,755, totaling an firearm-related injuries, an overall admitted to the hospital was 3.4% overall estimated annual direct hos- annual rate of 8.87 firearm-related and 6%, respectively.7 In 2015, pital cost of $146,710,029 for the hospitalizations per 100,000 persons Veenstra et al8 reported on their year 2009. These figures are incom- aged ,20 years.5 On average, 20 experience with pediatric firearm plete, however, because they omit children aged ,20 years were hospi- injuries at an urban institution from ancillary costs for services such as talized daily for a firearm injury. As in 2003 to 2012. Confirming previous emergency medical services, physi- the study by Srinivasan et al,4 adis- researchers’ data, the authors reported cian care, rehabilitation, home proportionate number of these patients that 74% of their study population health care, mental health care, were male (89.2%) and African were male, and 80% were African social services, and hospital read- American (47.2%). In fact, the authors American. The mean length of stay in missions. Newgard et al6 estimated calculate that the risk of hospitaliza- the hospital was 5 days. Patients with that the acute care cost per pediatric tion from a firearm injury for African firearm injuries required surgical patient with a firearm-related injury 170 Journal of the American Academy of Orthopaedic Surgeons Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Cordelia W. Carter, MD, et al Table 1 Estimated Cost of Firearm-related Injuries in Children Aged 0 to 19 Years in 20103 Type of Cost Treated in ED and Released Admitted to Hospital Fatality Medical treatment Average = $2,882 Average = $25,881 Average = $9,924 Total = $23,669,000 Total = $181,443,000 Total = $26,904,000 Loss of work Average = $3,049 Average = $75,7785 Average = $1,770,532 Total = $25,037,000 Total = $531,297,000 Total = $4,799,911,000 Combined medical treatment Average = $5,931 Average = $101,667 Average = $1,780,456 and loss of work Total = $48,706,000 Total = $712,740,000 Total = $4,826,815,000 ED = emergency department was $28,510.
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