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Cross country variation of fractures in the childhood population. Is the origin biological or “accidental”?
  1. M Moustaki1,
  2. M Lariou1,
  3. E Petridou2
  1. 1Department of Hygiene and Epidemiology, Athens University Medical School, Greece
  2. 2Department of Hygiene and Epidemiology, Athens University Medical School, 75 Mikras Asias, Goudi, Athens 115-27, Greece Department of Epidemiology, Harvard School of Public Health, Boston, USA
  1. Correspondence to:
 Dr Petridou in Athens

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Editor,—The interesting paper by Lyons et al revealed that the annual incidence rate of fractures among children aged 0–12 years was two to three times higher in Wales1 than in other western European countries.2, 3 This discrepancy prompted us to briefly report on the epidemiological profile of fractures in the childhood population of Greece and discuss the implications of the observed differences.

Our data derive from the Emergency Department Injury Surveillance System (EDISS) database which is run by the Center for Research and Prevention of Injuries among the Young (CEREPRI).4 All types of childhood injuries treated at the emergency departments of the participating hospitals, which have well circumscribed catchment areas in rural and urban Greece, are routinely recorded in this database. The catchment area includes the Greater Athens area, where about 40% of the country's population resides, Magnesia county in Greece mainland, and Corfu county on the island of Corfu. Our methodology was similar to that followed by Lyons et al thus allowing for reasonable comparisons.

A total of 8557 fractures were recorded during the three year period 1996–98 among children 0–14 years old and the estimated annual incidence rate was 12 fractures/1000 children. No significant variation was noted among children from the different sites participating in EDISS. This rate is just one third of that recorded in the Welsh childhood population. In line with what is reported by Lyons et al,1 and other investigators,2, 3 boys were also over represented in the Greek data set (male to female ratio: 1.9) and this preponderance increased with age. Altogether 2.7% of the injured children presented with multiple fractures, a figure that is higher than that reported by Lyons et al (1.8%) and may be due to the high road traffic injury toll in Greece. In fact, one third of the multiple fracture injuries were the result of a road traffic crash, whereas traffic accidents accounted for less than 5% among injured children with one fracture.

The distribution of children by injured body part was comparable to that of the Welsh population, with fractures of radius and ulna accounting for 43% of the total, followed by fractures of fingers (13.9%), humerus (6.9%), and carpal/metacarpals (4.8%). The similarity in the pattern of fractures among children who sought emergency hospital care in the two countries can be considered as an indicator of the high quality registration system in both sites and enhances the possibility that the observed difference of the fracture incidence rate is genuine. It is worth noting, however, that despite the low overall incidence of fractures in the Greek childhood population, the proportion of skull fractures was more than twice as high as that reported in the Welsh1 and in a related Swedish study.3 Cycle helmet use may not be optimal in the UK,5, 6 but according to data derived from EDISS, use of protective devices for road traffic injuries is unacceptably low, and playgrounds do not usually comply with international standards. Therefore, the underlying causes for the discrepancy in skull fracture incidence should be carefully monitored in Greece, whether it is caused by reluctance to wear helmets or otherwise, and corrective action taken.

One third of the recorded fracture injuries in both studies occurred in residential areas, where children spend most of their time, followed by school areas and public premises. An average of 40% of fractures resulted from sports and leisure activities. Cultural differences and different sports and leisure time preferences between the two population groups, however, become obvious when the injuries are further analyzed by type of sport activity. Thus, ball related injuries were dominant in our population (70% of sports related injuries among Greek compared with 40% among Welsh children), whereas wheeled sports activities were almost twice as common in Welsh compared with Greek children (35% and 20% respectively).

In conclusion, comparison of data from these studies indicate that the incidence of fractures in the Greek childhood population is similar to that observed in Sweden but much lower than that reported by Lyons and his colleagues in Wales. The question is: could this variation simply be attributed to different exposure levels and/or different prevention strategies that are followed in the respective countries, or does it reflect the expression of a biological mechanism, possibly related to nutritional factors,7 that accounts for fewer Greek children suffering from fractures. The latter hypothesis cannot be properly addressed, however, without careful consideration of differences in data collection, coding, and processing methods. To test this hypothesis, comparative, population based crude and fracture specific injury incidence data among children from southern and northern European countries could be used to elucidate whether the observed differences simply reflect a corresponding difference in all-injury incidence or whether they are mainly related to differences in the incidence of fractures. If the latter is the case, further investigation focusing on possible differences of bone mass density or dietary intake should be considered in the interpretation of the observed variation of fractures on different population groups.