RESEARCH AND PRACTICE

even after adjustment for concurrent increases in motorcycle registrations or miles

traveled. Exempting adult motorcycle riders
from wearing motorcycle helmets is counterproductive for motorcyclists health and unnecessarily increases insurance and medical
care expenses.

Femur Fractures in
Infants and Young
Children
| Desmond Brown, MD, and Elliott Fisher, MD,
MPH

About the Author

The author is with the Department of Health Services Administration, University of Arkansas at Little Rock, and
the Department of Health Policy and Management, College
of Public Health, University of Arkansas for Medical Sciences, Little Rock.
Requests for reprints should be sent to Andreas
Muller, PhD, UALR, Ross Hall 202, 2801 S University Ave, Little Rock, AR 72204 (e-mail: axmuller@
ualr.edu).
This brief was accepted June 18, 2003.

Human Participation Protection

No protocol approval was needed because no individuals are identified by the analysis.

Acknowledgments
I would like to thank the anonymous reviewers for their
helpful comments.

References
1. US Dept of Transportation, National Highway
Traffic Safety Administration, National Center for Statistics and Analysis. Fatality Analysis Reporting System
(FARS) Web-based encyclopedia. Reports: people: motorcyclists. Available at: http://www-fars.nhtsa.dot.gov.
Accessed February 18, 2003.
2. US Dept of Transportation, Federal Highway Administration. Highway statistics (multiple years). Available at: http://www.fhwa.dot.gov/policy/ohpi/hss/
hsspubs.htm. Accessed February 18, 2003.
3. Preusser DF, Hedlund JH, Ulmer RG. Evaluation
of Motorcycle Helmet Law Repeal in Arkansas and Texas.
Final Report, DTNH2297-D-05018. Springfield Va:
National Technical Information Service; September
2000.
4. Florida Senate. The 2002 Florida Statutes, Title
XXIII, Chap 316.211. Available at: http://www.flsenate.
gov/Statutes. Accessed March 5, 2004.
5. Hotz GA, Cohn SM, Popkin C, et al. The impact
of a repealed motorcycle helmet law in Miami-Dade
County. J Trauma. 2002;52:469474.
6. Box GEP, Jenkins GM. Time Series Analysis: Forecasting and Control. Rev ed. San Francisco, Calif:
Holden-Day; 1976.
7. Pankratz A. Forecasting With Dynamic Regression
Models. New York, NY: John Wiley & Sons; 1991.

Using an administrative database,

we determined rates of femur fracture
by year of age for children younger
than 6 years and by month of age. The
highest rate of femur fracture was in
children younger than 1 year and in 2year-olds; the greatest number of fractures occurred during the third month
of life. While femur fractures in children are often due to accidental injury, the reasons for the peak in the
first year and the subsequent decline
are not clear. (Am J Public Health.
2004;94:558560)

The incidence of femur fractures in children is believed to have 2 peaks, one at the
age of 2 to 3 years and another during adolescence.1 This view is based, however, on
older studies from Scandinavia24 and a
more recent study from Maryland5 and may
not reflect the experience of the US population. Previous studies have also categorized
children by year of age, which may be insufficiently precise for the infant or young
child in whom rapid changes in size, physical ability, and behavior may affect the risk
of fracture.
Although most femur fractures in children
are caused by falls or other unintentional injuries, abuse is considered more likely in the
child aged younger than 1 year or not yet
able to walk. In this brief, we focus on this
youngest group, reporting data on hospital
discharges for femur fractures from a national
database in which children were categorized
by age in months.

resenting nearly a third of the estimated 6.7

million pediatric discharges during that year.
Using International Classification of Diseases,
Ninth Revision, Clinical Modification (ICD-9CM) codes for fracture of the proximal femur,
femoral shaft, and distal femur (diagnosis
codes 820821.39), we identified 3308 records of children under the age of 6 discharged from a hospital with a diagnosis of
femur fracture. Fractures occurring during
childbirth were excluded.
Using population weights provided with
the database, we calculated national estimates
for the number of femur fractures in each 1year age group. We determined fracture incidence rates by dividing the number of fractures by the estimated number of children in
each age group, using population estimates
for 1997 from the US Bureau of the Census.
To examine the relationship between age and
femur fractures more closely, we identified
2753 records for which the age in months
was available. Because we lacked the population denominator to determine rates of fracture, we report the counts for this subset of
patients.

RESULTS
The rate of femur fracture was highest during the first year of life and in 2-year olds
(Table 1). One-year-olds were less likely to
sustain a fractured femur than those aged
younger than 1 year. While the ratio of boys
to girls was nearly equal in those aged younger than 1 year, all older age groups had
more boys.
In children for whom the age in months
was known, the greatest number of fractures
occurred during the third month of life (Figure 1). There were slightly fewer fractures in
children aged 4 to 11 months, and fewer still
in children aged 12 to 20 months. After the
first peak during infancy, there was a second
peak in children aged 20 to 40 months. In
children older than 40 months but younger
than 72 months, the number of fractures was
lower and relatively constant.

METHODS
DISCUSSION
The 1997 Kids Inpatient Database6 contains 1.9 million records of hospital discharges for children aged 18 or younger, rep-

558 | Research and Practice | Peer Reviewed | Brown and Fisher

Previous studies of femur fractures in childhood have identified a peak in incidence at

American Journal of Public Health | April 2004, Vol 94, No. 4

 RESEARCH AND PRACTICE

180
160

Femur Fractures

140
120
100
80
60
40
20
0
1

10 13

16 19 22 25

28 31 34 37

40 43 46 49

52 55 58 61

64 67 70

Age, months

Source. Kids Inpatient Database, 1997.6

FIGURE 1Estimated number of femur fractures among children in the United States, by
month of age.

TABLE 1US Population Estimates for Femur Fractures in Children, by Year of Age
No. of Femur Fractures

Femur Fractures/100 000 (95% CI)

Age, y

Male

Female

Total

Male

Female

Total

<1
1
2
3
4
5

849
759
1126
889
680
622

763
485
449
349
307
342

1612
1244
1575
1238
987
964

44 (39, 49)
40 (35, 44)
58 (53, 63)
45 (40, 50)
34 (29, 38)
30 (26, 34)

41 (37, 46)
26 (22, 30)
24 (21, 28)
19 (15, 22)
16 (13, 19)
17 (14, 20)

43 (39, 46)
33 (30, 36)
42 (38, 45)
32 (29, 35)
25 (23, 27)
24 (22, 26)

Note. CI = confidence interval.

Source. Kids Inpatient Database, 1997.6

age 2 to 3 years. By contrast, femur fractures

in children younger than 1 year of age are
thought to be less common and, when they
occur, to be highly suggestive of abuse.7,8 We
found that femur fractures were as common
in children younger than 1 year as in those
aged 2 years and older, with the greatest
number of fractures occurring during the
third month of life. There are few plausible
explanations for a femur fracture in this age
group other than intentional injury. These
data suggest that an infant has as great a
chance of sustaining a femur fracture from
physical abuse as an older child does from all
causes.

The reason for the rise in incidence at age

2 to 3 years, and the subsequent fall, is less
clear. Although most children are walking by
age 15 months, femur fractures were infrequent at this age. The 2- to 3-year-old may
be at increased risk of injury owing to
changes in gait,9 increased mobility, greater
climbing ability, and exposure to vehicular
traffic. The decline in femur fractures after
age 3 may be due to improvements in gait
and judgment, as well as to increased bone
strength. Although child abuse is thought to
be a less common cause for femur fracture in
children who are walking,10 there are widely
varying estimates of its occurrence, reflecting

April 2004, Vol 94, No. 4 | American Journal of Public Health

the difficulty of establishing the diagnosis of

abuse with certainty.11
Our study, based on an administrative
database, lacks the clinical detail of a case series. The sample size is large, however, and
the coding of femur fractures and age are
likely to be accurate.12 The rate of femur fracture in children younger than 2 years of age
was 38.0 per 100 000; this is greater than
the rate of 25.5 per 100 000 reported by
Hinton and colleagues for femoral shaft fractures in this age group in Maryland.5 We included fractures of the proximal and distal
femur, which may contribute to the higher
rate we report.
We cannot determine how often fractures
were due to abuse or neglect, but child abuse
is thought to be common in children younger
than 1 year old with femur fractures.7,8 Other
possible causes include heritable disorders of
connective tissue such as osteogenesis imperfecta13 and motor vehicle accidents. Short
falls, as occur when a child rolls off a bed or
table, are unlikely to cause a femur fracture
in an infant.14,15 The equal number of boys
and girls younger than age 1, and the predominance of boys among those older than 1
year, may signify a shift from intentional to
accidental injury.
Although not as specific for abuse as the
metaphyseal corner fracture or rib fracture, a
single long-bone fracture may be the most
common type of fracture due to abuse.16
Abuse should be suspected if caretakers provide inconsistent or implausible accounts of
how a femur fracture occurred, or if there are
additional unexplained injuries. A skeletal
survey may provide evidence of occult injuries and may support a diagnosis of abuse.
Efforts to prevent femur fractures in children
should focus on preventing physical abuse
in infants and accidental injury in the 2- and
3-year-old children at greatest risk.

About the Authors

At the time of this study, Desmond Brown was with the
Center for the Evaluative Clinical Sciences, Dartmouth
Medical School, Hanover, NH. Elliott Fisher is with the
Department of Community and Family Medicine, Dartmouth Medical School, Hanover.
Requests for reprints should be sent to Desmond Brown,
MD, Boston University School of Medicine, Department of
Orthopaedic Surgery, 850 Harrison Ave, Boston, MA
02118 (e-mail: tdesmond.brown@bmc.org).
This brief was accepted June 30, 2003.

Brown and Fisher | Peer Reviewed | Research and Practice | 559

 RESEARCH AND PRACTICE

Contributors
D. Brown conceived the study, performed the analyses,
and wrote the brief. E. Fisher assisted in the design of the
study and statistical analyses and contributed to the design of the tables and the writing of the brief.

Human Participant Protection

Institutional review board approval was not required
for this study.

References
1. Wilkins KE. The incidence of fractures in children. In: Rockwood CA, Wilkins KE, Beaty JH, eds.
Fractures in Children. 4th ed. Philadelphia, Pa: LippincottRaven; 1996:317.
2. Hedlund R, Lindgren U. The incidence of femoral
shaft fractures in children and adolescents. J Pediatr Orthop. 1986;6:4750.
3. Nafei A, Teichert G, Mikkelsen SS, Hvid I.
Femoral shaft fractures in children: an epidemiological
study in a Danish urban population, 197786. J Pediatr Orthop. 1992;12:499502.
4. Landin LA. Fracture patterns in children. Analysis
of 8,682 fractures with special reference to incidence,
etiology and secular changes in a Swedish urban population 19501979. Acta Orthop Scand Suppl. 1983;
202:1109.
5. Hinton RY, Lincoln A, Crockett MM, Sponseller P,
Smith G. Fractures of the femoral shaft in children. Incidence, mechanisms, and sociodemographic risk factors. J Bone Joint Surg. 1999;81:500509.
6. Agency for Healthcare Research and Quality.
1997 Kids Inpatient Database. Available at: http://
www.ahrq.gov/data/hcup/hcupkid.htm. Accessed
March 2, 2004.

Asthma, Wheezing, and

Allergies in Russian
Schoolchildren in Relation
to New Surface Materials
in the Home
| Jouni

J. K. Jaakkola, MD, DSc, PhD,

Helen Parise, PhD, Victor Kislitsin, MSc,
Natalia I. Lebedeva, MD, DSc, and John D.
Spengler, PhD

In a cross-sectional study of 5951

Russian 812-year-old schoolchildren,
risks of current asthma, wheezing, and
allergy were related to recent renovation and the installation of materials
with potential chemical emissions. New
linoleum flooring, synthetic carpeting,
particleboard, wall coverings, and furniture and recent painting were determinants of 1 or several of these 3
health outcomes. These findings warrant further attention to the type of materials used in interior design. (Am J
Public Health. 2004;94:560562)

7. Kocher MS, Kasser JR. Orthopaedic aspects of

child abuse. J Am Acad Orthop Surg. 2000;8:1020.
8. Nimkin K, Kleinman PK. Imaging of child abuse.
Radiol Clin North Am. 2001;39:843864.
9. Sutherland DH, Olshen R, Cooper L, Woo SL.
The development of mature gait. J Bone Joint Surg Am.
1980;62:336353.
10. Schwend RM, Werth C, Johnston A. Femur shaft
fractures in toddlers and young children: rarely from
child abuse. J Pediatr Orthop. 2000;20:475481.
11. Blakemore LC, Loder RT, Hensinger RN. Role of
intentional abuse in children 1 to 5 years old with isolated femoral shaft fractures. J Pediatr Orthop. 1996;16:
585588.
12. Fisher ES, Baron JA, Malenka DJ, Barrett J,
Bubolz TA. Overcoming potential pitfalls in the use of
Medicare data for epidemiologic research. Am J Public
Health. 1990;80:14871490.
13. Ablin DS, Sane SM. Non-accidental injury: confusion with temporary brittle bone disease and mild osteogenesis imperfecta. Pediatr Radiol. 1997;27:
111113.
14. Tarantino CA, Dowd MD, Murdock TC. Short vertical falls in infants. Pediatr Emerg Care. 1999;15:58.
15. Nimityongskul P, Anderson LD. The likelihood of
injuries when children fall out of bed. J Pediatr Orthop.
1987;7:184186.
16. King J, Diefendorf D, Apthorp J, Negrete VF, Carlson M. Analysis of 429 fractures in 189 battered children. J Pediatr Orthop. 1988;8:585589.

The Soviet era has been followed by increased activity in construction and renovation of housing in the Russian Federation, as
well as an introduction of new building technology and new materials used in interior design, furniture, and textiles. Two recent studies indicated that exposure to plastic flooring
and wall materials may increase the risk of
respiratory conditions in children.1,2 As part
of a cross-sectional study of air pollution and
respiratory health in Russia in 1996 to
1997,3,4 we tested a hypothesis that the risks
of childrens asthma and allergic diseases are
related to recent renovation, especially newly
installed synthetic surface materials, furniture,
and painting.

METHODS
The study population included 5951 children in second to fifth grade (812 years old)
in 8 Russian cities in the Sverdlovsk Oblast re-

560 | Research and Practice | Peer Reviewed | Jaakkola et al.

gion and the city of Cherepovets in the Upper

Volga Oblast.3 The participation rate in schools
varied from 96% to 98%. The questionnaire,
modified from previous European and North
American questionnaires for the Russian conditions,5,6 inquired about the childs personal
characteristics, health information, and socioeconomic factors. Local elementary schoolteachers were trained to conduct the interviews, and parents and guardians were invited
to meetings after the school day was finished.
After signing an informed consent form, a parent completed the questionnaire.
The current study focused on asthma,
wheezing, and allergy. Current asthma was defined as a history of doctor-diagnosed asthma
and symptoms, signs, or medication of asthma
during the past 12 months. Current wheezing
was defined as wheezing during the past 12
months. Any allergy was defined as any history of doctor-diagnosed allergy or parentalreported hay fever or pollinosis.
Exposure assessment was based on the following question: Have you conducted any of
the following renovations in your home within
the past 12 months or earlier? The choices
were installation of linoleum floor, painting,
particleboard, new furniture, synthetic carpet,
wall covering, and suspended ceiling.
We used the odds ratio (OR) as a measure
of effect and logistic regression analysis to adjust for age, gender, preterm birth, low birthweight, parental atopy, maternal smoking during pregnancy, exposure to environmental
tobacco smoke at home (at ages 01 years,
ages 26 years, and currently), and mothers
and fathers education.

RESULTS
Of the children, 1.5% had current asthma,
13.4% had current wheezing, and 33.2% had
an allergy. Table 1 shows the occurrence of
the potential sources of emissions.
The risks of current wheezing (adjusted
OR = 1.36; 95% confidence interval [CI] =
1.00, 1.86) and allergy (adjusted OR = 1.31;
95% CI = 1.05, 1.65) were significantly related
to the installation of linoleum flooring during
the past 12 months (Table 2). The corresponding risk estimates were slightly lower when
focusing on exposure earlier than 12 months
ago. There was a general pattern of positive as-

American Journal of Public Health | April 2004, Vol 94, No. 4