Assessing Morbidity of Pediatric Firearms Injuries

Firearm injuries represent a significant cause of morbidity and mortality in the pediatric population of the United States, with 4,972 fatalities in children ages 0-21 years-old in 2016 alone.¹ Additionally, firearms were responsible for 28,844 nonfatal injuries in 2016, up from 23,880 in 2010 for the same age range.¹

These injuries result in significant financial burdens, costing almost $30,000 per child² and up to a total of $181,443,000 in 2010 for those aged 0 to 19 years admitted to the hospital.³ Beyond financial burdens, particularly in the orthopedic population, firearm injuries have implications for risk of spinal cord and nerve injury, amputation, deep infection, non-union⁴ and growth arrest.

Research Focuses on Children Under Age 10 Years

Emily Boschert, BA, University of Missouri-Kansas City School of Medicine, year 6 medical student, and Richard M. Schwend, MD, FAOA, FAAP, Interim Chairman, Department of Orthopedic Surgery and Musculoskeletal Medicine, recently presented a study virtually at the Pediatric Orthopedic Society of North America meeting addressing the risk for adverse outcomes in pediatric firearm-related musculoskeletal injuries that may lead to poor quality of life due to chronic health burden.

For this report, the authors focused on a retrospective analysis of firearm-related musculoskeletal injuries treated at Children’s Mercy from 1995 to 2017. During that 22-year timeframe, 189 children were identified and evaluated in two cohorts: age < 10 years and age ≥ 10 years.

The study’s purpose was to investigate the 22-year epidemiology of pediatric firearm injuries at Children’s Mercy and determine if children under 10 years of age had more adverse life outcomes as a result of the injury.

Statistics Demonstrate Adverse Outcomes

Of the 189 injured children:

• 46 (24.3%) were under 10 years old, with a bimodal distribution (figure 1).
• 32 were females and 157 were males.
• Over 90% of both age groups were from the Kansas City metropolitan area.
• Of the injured children, 163 (86.2%) were injured as the result of an assault, typically during the teen years.

Adverse outcomes were seen in 52 children (27.5% of total group), with 23.1% of those 10 years or older having an adverse outcome; and 41.3% of those under age 10 years old.

A total of 11 (5.8%) had a spinal cord injury and 38 (20.1%) had a serious nerve injury. Other adverse outcomes included three late deaths, seven amputations, 17 with a growth disturbance and 44 with a long-term disability.

Utilizing Data to Implement Change

Pediatric survivors of firearm injuries often have an adverse outcome (27.5%), including growth disturbance, amputation, long-term disability, often from spinal cord or nerve injury, and even death. Although children ≥ 10 years in the Children’s Mercy study were more likely to be injured by a firearm, children < 10 years when injured are the most vulnerable for adverse outcomes and future disability.

Going forward, the study proposes that continuing efforts should be used to analyze this information across various locations, providing systematic data on gun ownership and storage. A prospective registry of injuries, with special attention to those < 10 years-old that evaluates epidemiological data with clear descriptions of injury circumstances, risk factors for adverse outcome, and long-term clinical outcomes would be highly useful for properly characterizing injuries, and the overall burden firearms injuries have on these young patients’ disability-adjusted life years (DALY).

Figure 1

Firearm injuries involving the musculoskeletal system in children treated at Children’s Mercy Kansas City 1995-2017. Bimodal age distribution, with peak ages at 3 years and 15 years. Younger children are more frequently victims of unintentional shooting when someone else is handling the firearm. In the teen years, the shooting is more likely to be the result of an intentional assault. There is also a marked sex difference for older children, with boys being much more likely to be injured. Adult victims over 17 years are typically cared for at adult facilities.

Learn more about Pediatric Orthopedic Surgery at Children’s Mercy

Richard M. Schwend, MD, FAOA, FAAP, Interim Chairman, Department of Orthopedic Surgery and Musculoskeletal Medicine; Pediatric Orthopedic Surgery Director, Orthopedic Research Program; Past Chair, American Academy of Pediatrics, Section on Orthopedics; Past President, Pediatric Orthopedic Society North America; Professor of Orthopedic Surgery and Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Professor of Orthopedic Surgery, University of Kansas School of Medicine

rmschwend@cmh.edu

(816) 234-3693

For consults, admissions or transport call: 1 (800) GO MERCY / 1 (800) 466 3729.

References:

1. Centers for Disease Control and Prevention National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). 2005. Available at www.cdc.gov/injury/wisqars. Accessed July 19, 2018.

2. Dowd MD, Sege RD. Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics. Firearm-related Injuries Affecting the Pediatric Population. Pediatrics. 2012 Nov;130(5):e1416-23. doi: 10.1542/peds.2012-2481. Epub 2012 Oct 18. PubMed PMID: 23080412.

3. Carter CW, Sharkey MS, Fishman F. Firearm-related Musculoskeletal Injuries in Children and Adolescents. J Am Acad Orthop Surg. 2017 Mar;25(3):169-178. doi: 10.5435/JAAOS-D-15-00642. Review. PubMed PMID: 28134675.

4. Perkins C, Scannell B, Brighton B, Seymour R, Vanderhave K. Orthopaedic Firearm Injuries in Children and Adolescents: An Eight-year Experience at a Major Urban Trauma Center. Injury. 2016 Jan;47(1):173-7. doi: 10.1016/j.injury.2015.07.031. Epub 2015 Jul 29. PubMed PMID: 26365475.

5. Boschert E, Stubblefield C, Schwend RM, Reid KJ. Twenty-two Years of Pediatric Musculoskeletal Firearm Injuries: Adverse Outcomes for the Very Young. J Pediatr Orthop 2020 in Press.