Background/Objectives: The purpose of this study was to analyze the demographics and injury patterns of children with transportation-related non-fatal injuries occurring on public roads, streets and highways using a nationwide emergency department (ED) database. Methods: Data from the National Electronic Injury Surveillance System (NEISS) All Injury Program (AIP) 2005-2021 was used. Five transportation methods (motor vehicle occupant, bicyclist, pedestrian, motorcyclist, other) occurring on a public highway, street, or road were analyzed. Statistical analyses were performed with SUDAAN 11.0.01™ software to obtain national estimates. Results: There were an estimated 8,188,810 ED visits for traffic-related injuries in children; the median age is 14.3 years. Sex distribution was equal; 93.4% were discharged from the ED, and the head/neck was the most injured area (51.9%). The most common diagnoses were contusion (35.7%), strain/sprain (28.0%), internal organ injuries (13.3%), fracture (8.4%), lacerations (7.4%) and concussions (4.1%). Predictor variable of not being discharged from the ED was the presence of a fracture (OR = 119.7 [71.3, 200.7], p < 0.0001), injury to the trunk (OR = 3.2 [2.7, 3.8], p < 0.0001), a pedestrian (OR = 3.9 [2.8, 5.3], p < 0.0001), those <1.5 years old (OR = 4.3 [2.8, 6.6], p < 0.001), and males (OR 1.5 [1.4, 1.6], p < 0.0001). The greatest prevalence of head/neck fractures was in motor vehicle occupants (23.3%), upper extremity fractures in bicyclists (73.1%) and motorcyclists (49.2%), and lower extremity fractures in pedestrians (56.6%). Conclusions: This detailed study can be used to compare/contrast these injuries to other countries regarding road traffic injuries in children. This data can be used to assess the outcomes of prevention strategies introduced in the future.

Purpose:To evaluate medieval and postmedieval Dutch skeletal collections for signs of cam impingent. Methods:The medieval collections from Alkmaar Paardenmarkt and Klaaskinderkerke and the postmedieval period from Middenbeemster were studied. Standard osteological methods for sex and age estimation were used. From digital photographs of the femora, the apparent neck shaft angle, true neck shaft angle, angles of version and inclination, and the α and β angles of Nötzli were measured with ImageJ software. Results:The time spans were ~1448 to 1573 for Alkmaar Paardenmarkt, ~1286 to 1573 for Klaaskinderkerke, and 1615 to 1866 for Middenbeemster. Femora exhibiting signs of trauma, disease, or poor preservation were excluded. There were 116 individuals (186 femora) available for study: 21 individuals (35 femora) from Alkmaar Paardenmarkt, 38 individuals (52 femora) from Klaaskinderkerke, and 57 individuals (99 femora) from Middenbeemster. There were 104 male and 68 female femora (sex not known in 14). Using an α angle of ≥50°, ≥55°, and ≥60°, the prevalence of cam deformity was 25%, 16%, and 10%, respectively. The cam deformity prevalence (α ≥ 50°) was higher in the medieval group (39%) than the postmedieval group (13%) (P < .001) and in male individuals (35%) compared with females (9%) (P < .001). The prevalence of cam deformity was 46% in Klaaskinderkerke, 29% in the Alkmaar Paardenmarkt, and 13% in the Middenbeemster collection (P < .001). There were no differences by laterality, paired/unpaired femora, or individual/comingled burials. The prevalence of cam deformity correlated with the physical activities of the individuals. The highest prevalence was in the Klaaskinderkerke (46%) collection and soldiers (62%) from the Alkmaar Paardenmarkt collection. With increasing urbanization and a concomitant decrease in self-sufficiency, the prevalence dropped to 13% in the Middenbeemster collection. Conclusions:Cam deformities that correlate with physical activity levels were found in historical Dutch skeletal specimens. Clinical Relevance:Cam deformity is considered an adaptive response to modern athletic activity. Evaluation of historical specimens will provide a fuller understanding of this condition by revealing whether cam deformity was present in historical skeletal specimens.

BACKGROUND:Horse riding is a common sport, but no study specifically addresses joint dislocations. The purpose of this study is to describe joint dislocations due to equines using a national emergency department (ED) database. Such data can be helpful in injury prevention strategies. METHODS:The National Electronic Injury Surveillance System (NEISS) database for the years 2000-2023 was used. The NEISS database is a statistically representative sample of injuries seen in EDs across the US giving national estimates. Mechanism of injury was tabulated into groups: 1) did the patient fall from the horse 2) was the patient bucked, thrown, or kicked off of the horse, 3) was there equipment (tack) malfunction, 4) was the patient stepped on by the horse, 5) was the patient struck by/against an object, 6) was the patient kicked by the, 7) and others. RESULTS:There were 625 dislocations which involved the shoulder (289, 46.2%), elbow (95, 15.2%), finger (85, 13.6%), acromioclavicular joint (48, 7.7%), patellofemoral joint (39, 4.8%), hip (22, 3.5%), pubic symphysis (16, 2.6%), and ankle (7, 1.1%). The average age was 41 years; 49.7% were male and 50.3% female. Mechanisms of injury were falling from the horse (54.1%), bucked/thrown off (27.7%), equipment malfunction (7.3%), stepped on by the horse (2.1%), struck by/against an object (1.9%), kicked (0.6%), and others (4.0%). Those with elbow dislocations were the youngest (average 32 years) and pubic symphysis the oldest (average 52 years) (p < 10-4). Females had the highest percentage of patellofemoral dislocations (70.2%) and males the highest percentage of pubic symphysis dislocations (92.9%) (p = 0.0018). CONCLUSION:Although joint dislocations due to equestrian activity are uncommon, the majority occurred in the upper extremity. Male/female involvement is equal, different than the typical female predominance in equestrian activity and overall equestrian related injuries.

Increases in humeral retroversion have been suggested to result from certain shoulder activities, especially throwing. Could retroversion also increase as a result of other upper extremity activities in addition to throwing? It was the purpose of this study to investigate humeral retroversion in the Nubian Tombos population (1400656 BCE) and correlate retroversion with entheseal changes which are used as an assessment of physical activity. Humeral retroversion was measured from photographs. Two photographs were used to define angles from the bony landmarks relative to the table surface, one directly superior to inferior, and one directly inferior to superior. From these photographs the skew humeral head and transepicondylar axes lines were drawn relative to the table plane, from which the axis/table plane angle was measured using ImageJ software. From these two angles the final retroversion was calculated. All lines were drawn by one senior orthopedic surgeon. Upper extremity entheseal scores, taken from a previous Tombos study using the same remains, were grouped as very low, low, high, and very high. Sex was estimated using standard archaeological protocols. Age at death was evaluated using transition analysis, and was grouped as 1524, 2534, 3549, 5069, and = 70 years old. There were 121 complete humeri available for study (61 right and 60 left). The average retroversion was 20 ° ± 10 °, and was 17.5 ° ± 9.6 °, 22.3 ° ± 8.7 °, 26.5 ° ± 11.8 °, 22.2 ° ± 5.9 ° for the very low, low, high, and very high entheseal score groups respectively (p = = 0.041). Those = 70 years old had a large number in the low entheseal score group while those 35 to 49 years old had the greatest number in the very high entheseal score group (p = 0.000001). There were no differences by sex, laterality, age, or burial cemetery. We hypothesize that those who were able to live to old age were better resourced with lower physical demands than other members of the community and thus developed less retroversion. Our results also indirectly support the postulate that an increase in general upper extremity physical activity may result in increased retroversion, and not exclusively due to throwing activities.

Objective:The majority of the published literature regarding the septal aperture (SA) dates to the last 200 years. The archeological literature is sparse. The collection from Tombos along the Nile River (1400-656 BCE) provides an opportunity for further study of SA in ancient populations. The purpose of this study was to determine the prevalence and shape of SA in the population as well as the size of the humerus and correlate that with and without SA in the Tombos population. Methods:Adult humerus specimens from the Tombos skeletal population with intact distal humeri were studied using both photography and caliper measurements. The caliper and photographic methods gave equal results. Results:There were 164 distal humeri; an SA was present in 40.9%. There were no differences by sex, age group, or laterality. Of the 34 individuals with bilateral intact paired humeri, 47% had SAs. The involvement was bilateral in 13, left in 2, and right in 1. The shapes of the apertures were oval/elliptical in 73%, irregular in 15%, and circular in 12%. Those humeri with an SA had smaller epicondylar breadths, vertical humeral head diameters, humeral shaft diameters, condylar articular width, and trochlear articular width. There were no differences in the coronoid or olecranon fossa width/height. The 41% prevalence of SA in the Tombos population is similar to the 45%-60% in other African archeological studies but higher than the 20%-37% in prehistoric Native Americans. Smaller humeri had a higher prevalence of SA similar to several modern-day studies. Conclusions:The etiology of SA is not definitively known, with mechanical, structural, and genetic etiologies postulated. A high prevalence of bilaterality is supportive of a genetic etiology; our 81% prevalence of bilaterality suggests a strong genetic component in the etiology of SA in this particular population.

Intimate partner violence (IPV) and firearm violence threaten women's health and safety in the United States. Despite the magnitude of female homicides and mass shootings resulting from IPV-related firearm incidents, research in this critical area remains limited. A retrospective review of prospectively collected data using the National Electronic Injury Surveillance System (NEISS) Firearm Injury Surveillance Study from 1993 through 2019 was performed. The study focused on firearm shooting injuries seen in US Emergency Departments (ED) during assaults, excluding unintentional injuries, suicide attempts, or law enforcement activity. The demographics and injury patterns of IPV and non-IPV groups were compared using statistical methods accounting for the weighted, stratified nature of the data. Over the 27-year period from 1993 through 2019, there were 60,730 ED visits for firearm injuries (limited to assaults when shot by the firearm for those 10 years or older) for an estimated 1,564,078 visits. IPV represented 0.9% (137,740 of the 1,564,078) estimated firearm-related injuries. IPV patients were more likely to be older (39.3 vs 27.7 years; p < 0.0001), female (59.0% vs 11.3%; p < 0.0001), white (62.5% vs 19.5%; p < 0.0001), occurred at home (67.1% vs 13.8%; p < 0.0001), sustained head and neck injuries (30.2% vs 15.0%; p = 0.0056) and with a higher mortality (12.3% vs 6.6%; p < 0.01) compared with non-IPV patients. Female IPV patients had more head and neck injuries (37.2% vs 20.2%; p = 0.03) than male patients. The average age of IPV patients when the perpetrator was an ex-boyfriend/girlfriend was lower (25.8 years) than when the perpetrator was a spouse (40.6 years) or ex-spouse (37.7 years) (p < 0.0001). One-third of the IPV patients were not married or did not report their marital status, supporting firearm restrictions for those already convicted of domestic violence offenses from a public health viewpoint. The study highlights the urgent need for interventions to reduce IPV-related firearm injuries, given the deliberate targeting of head and neck regions in female IPV patients and the high fatality rates observed in IPV patients presenting to ED.

Background/Objectives: Equestrian activities can result in spine injuries. Most studies are from single centers, and none use a national database. It was the purpose of this study to describe the demographics, injury mechanisms, and types of equestrian-associated spinal injuries using a US national ED database. Methods: The National Electronic Injury Surveillance System database was queried for equestrian-related spine injuries from 2000–2023. ED disposition was categorized as discharged or not discharged. Statistical analyses accounted for the weighted, stratified nature of the data to obtain national estimates. Results: There were an estimated 54,830 patients, having an average age of 42 years. Most were female (73.6%) and White (93.7%); one-half (51.1%) were not discharged from the ED. The spine level was the lumbar (49.1%), thoracic (24.4%), sacrococcygeal (15.5%), and cervical (11.0%) spine. Multiple spine fractures occurred in 4.0%. A simple fall off a horse occurred in 53.6% of the injuries, and the patient was bucked/thrown/kicked off the horse in 39.7%. Neurologic injury was rare (1.8%). Hospital admission was highest in the cervical group (74.3%) and lowest in the sacrococcygeal group (33.5%). The cervical group had the highest percentage of males (43.7%) compared to the thoracic, lumbar, and sacrococcygeal groups (22.8%, 27.3%, 16.8%, respectively). There were proportionally fewer females in those over 50 years of age, where the male percentage was 11.7%, 25.6%, and 31.6% for those <18 years, 18–50 years, and >50 years old, respectively. Conclusions: This large study can be used as baseline data to evaluate further changes in equestrian injuries, especially the impact of further prevention strategies, education protocols, and legislative/governmental regulations of public equestrian localities.

Background:Sexual assault often increases during crises, yet trends in United States (US) emergency department (ED) visits for sexual assault during COVID-19 remain unclear. Objective:To examine demographic, incident and injury trends in US sexual assault presentations during early and late COVID-19 compared with pre-COVID-19. Methods:This study analysed National Electronic Injury Surveillance System All Injury Programme (2014-2021) retrospective data. ED visits for assault (n=246 499) and sexual assault (n=22 752) were compared across pre-COVID-19 (January 2014-March 2020), early COVID-19 (March 2020-January 2021) and late COVID-19 (February 2021-December 2021). Demographic and injury trends were analysed via t-tests, analysis of variance or χ² tests, with national trends assessed using Joinpoint regression and weighted data in SUDAAN. Results:From 2017 to 2021, while assault-related ED visits declined (-5.05% annually; p=0.003), sexual assault ED visits remained stable (-1.15% annually; p=0.57). During COVID-19, sexual assault cases decreased among 0-19 years (46.1% pre-COVID-19 to 37.3% late COVID-19) but increased among 20-34 years (36.0% to 40.3%) and 35-64 years (17.2% to 21.0%). From early to late COVID-19, cases increased among black (31.7% to 32.8%) and Hispanic (13.8% to 15.6%) populations but declined among white populations (49.5% to 47.7%). Assaults by parents (9.0% to 11.2%) and partners (10.9% to 13.5%) increased, as did poisoning-related (1.4% to 5.5%) and anoxia-related injuries (0.1% to 0.7%). Conclusions:Despite the pandemic, ED visits for sexual assault persisted, with demographic shifts and increased injury severity (eg, drug-facilitated violence, strangulation-related anoxia). These findings highlight the need for targeted interventions during public health crises.

BACKGROUND:There has been minimal research on drive-by shootings since the 1990s. It was the purpose of this study to investigate the demographics and injury patterns of drive-by shootings across the entire US using a national database. METHODS:The Inter-University Consortium for Political and Social Research Firearm Injury Surveillance Study 1993-2020 (ICPSR 38574) data for 1993 through 2020 was analyzed using statistical analyses accounting for the stratified and weighted nature of the data. RESULTS:There were an estimated 63,882 emergency department visits due to drive-by shootings. The drive-by group was younger compared to the no-drive-by group (average age 24.5 years vs. 28.7 years - p less than 10-4). Patients injured in drive-by shootings were more prevalent in medium and large size hospitals. There was a lower percentage of White (17.9% vs. 42.3%) and a higher percentage of Hispanic (30.1% vs. 13.1%) peoples in the drive-by group compared to the no-drive-by group (p = 0.0009). The head/neck (14.3% vs. 3.5%) and lower extremity (35.5% vs. 25.5%) were more commonly injured in the drive-by group compared to the no-drive by group (p = 0.0008). While those in the drive-by group were admitted to the hospital more often (43.9% vs. 32.7%), there was no difference in the percentage of fatalities between the two groups (4.4% drive-by, 4.9% no-drive-by). CONCLUSIONS:This study encompasses both rural and urban areas, all races, and both sexes. These national estimates give health care providers and health facility administrators important demographic information. While both drive-by and no-drive-by shootings increased from 2014 onward, the average annual increase was much greater for the drive-by group (22.7%) compared to the non-drive-by group (8.6%). This data provides helpful information that could be useful when analyzing prevention strategies and firearm legislation and their impact on drive-by shootings.

BACKGROUND:Emergency departments are on the front lines of non-fatal self-harm injury (SHI). This study identifies patterns in patients presenting to emergency departments with SHI compared with patients presenting with assault and intimate partner violence. METHODS:Using the National Electronic Injury Surveillance System All Injury Program database, we analyzed SHI cases in the emergency department from 2005 to 2021 and examined demographic characteristics, injury mechanism and anatomic location, emergency department disposition and temporal patterns relative to cases involving assault and intimate partner violence. RESULTS:Of all injury-related emergency department visits, 1.5% (7 774 900) were due to SHI, 4.8% (24 165 696) due to assault and 0.6% (3 188 790) due to intimate partner violence. SHI peaked in ages 15-19 (18.3%), assault in ages 20-24 (17.3%) and intimate partner violence in ages 25-29 (19.2%). Patients with SHI were 41.0% males, compared with assault (66.3%) and intimate partner violence (19.3%) groups (p<0.0001). Most SHIs involved white patients (75.2%), compared with assaults (46.2%) and intimate partner violence (40.4%) (p<0.0001). Lacerations (20.6%) were the most common injury for SHI, while contusions/abrasions were the most common injuries for both assaults (27.8%) and intimate partner violence (39.1%) (p<0.0001). The upper extremity was the most common injury location in SHI (71.11%), while the head/neck was the most injured area in assaults (58.4%) and intimate partner violence (59.7%). Of adolescents sustaining SHI, 76.7% were women, compared with 59.0% of emerging adults and 53.2% of adults (p<0.0001). Among adolescents, the prevalence of SHI was lowest on weekends and during the summer. CONCLUSIONS:Our findings highlight distinct demographic, injury and temporal patterns observed in patients with SHI.

IntroductionAmputations and avulsion injuries due to horse-associated activity are rare, yet they can result in significant impairment. The purpose of this study was to further investigate such injuries using a national emergency department database.MethodsThe US National Electronic Injury Surveillance System (NEISS) was used to identify horse-associated amputation and avulsion injuries occurring between 2000-2023. Demographic data of age, sex, and injury details were collected.ResultsThere were 34,091 emergency department visits for equine-associated injuries, with 120 (0.35%) due to amputations/avulsions; 53 (44%) patients sustained amputations, and 67 patients (56%) sustained avulsions. The average age was 37 (SD = 21 years). There were 78 female and 42 male patients. The most common mechanism of injury was riding the horse, with further details not specified (31%), followed by equipment issues (19%), bucked/thrown/kicked off the horse (15%), falling off the horse (11%), and others (6%). A rope/chain was involved in 29 patients (24%). There were 55 amputations involving the finger (40), thumb (13), and others (2). Rope-related injuries were more commonly involved in those sustaining amputations versus avulsions (42% vs 10%, P < .001). Males had more rope-associated injuries (36% vs 18%, P = .043).ConclusionsThis is the largest study to date of amputations and/or avulsions due to horse-associated injuries. There were multiple mechanisms of injury, with ropes involved in one-quarter. This baseline data can be useful for evaluating the effectiveness of future prevention programs.

BACKGROUND:Early identification of non-fatal strangulation in the context of intimate partner violence (IPV) is crucial due to its severe physical and psychological consequences for the individual experiencing it. This study investigates the under-reported and underestimated burden of IPV-related non-fatal strangulation by analysing assault-related injuries leading to anoxia and neck injuries. METHODS:An IRB-exempt, retrospective review of prospectively collected data were performed using the National Electronic Injury Surveillance System All Injury Programme data from 2005 to 2019 for all assaults resulting in anoxia and neck injuries. The type and mechanism of assault injuries resulting in anoxia (excluding drowning, poisoning and aspiration), anatomical location of assault-related neck injuries and neck injury diagnosis by morphology, were analysed using statistical methods accounting for the weighted stratified nature of the data. RESULTS:Out of a total of 24 493 518 assault-related injuries, 11.6% (N=2 842 862) resulted from IPV (defined as perpetrators being spouses/partners). Among 22 764 cases of assault-related anoxia, IPV accounted for 40.4%. Inhalation and suffocation were the dominant mechanisms (60.8%) of anoxia, with IPV contributing to 41.9% of such cases. Neck injuries represented only 3.0% of all assault-related injuries, with IPV accounting for 21% of all neck injuries and 31.9% of neck contusions. CONCLUSIONS:The study reveals a significant burden of IPV-related anoxia and neck injuries, highlighting the importance of recognising IPV-related strangulation. Comprehensive screening for IPV should be conducted in patients with unexplained neck injuries, and all IPV patients should be screened for strangulation events.

Purpose: To identify intimate partner violence (IPV)-related injury patterns of U.S. patients of three age groups: <18 years (adolescents), 18-25 years (emerging adults), and >25 years (adults). Methods: We performed a nationally representative retrospective review of all patients presenting to U.S. Emergency Department for IPV-related injuries from 2005 through 2020. Demographics and injury patterns were calculated using statistical methods accounting for the weighted stratified data. Main outcomes were injury morphology, mechanism, severity, location, and temporal associations of IPV-related injuries among the three age groups. Results: There was a higher proportion of female victims, sexual assault cases, and lower trunk injuries among adolescents compared to emerging adults and adults. There was increasing injury severity, fractures, and hospital admissions with increasing age. Adolescents experienced a greater prevalence of fractures of the head, neck, hands, fingers, and distal lower extremity, while trunk fractures increased with age. The peak prevalence of violence -related Emergency Department visits among adolescents was in June and September, with the peak day as Tuesday. Discussion: Injurious forms of IPV are prevalent across all age groups, with sexual assault cases demonstrably higher among adolescents and increasing severity of injuries as victims age. Identi fication of age -speci fic injury patterns will aid health-care professionals and policymakers in developing targeted interventions for adolescents who experience IPV. (c) 2024 Society for Adolescent Health and Medicine. All rights reserved.

BACKGROUND:Falls and interpersonal violence pose significant threats to older adults, leading to injuries, hospitalizations, and emergency department (ED) visits. This study investigates the demographics and injury patterns in older adults (aged 60 and above) who sought ED care due to assaults, comparing them with those who experienced falls to gain a deeper understanding of older adult abuse patterns. METHOD:This study utilizes data from the National Electronic Injury Surveillance System (NEISS) All Injury Program (2005-2019) to examine injuries among older adults aged 60 years and above. Participants were categorized into two groups: older adult abuse and injuries due to falls. The differences between the groups by demographics, injury locations, patterns, and temporal trends were analyzed using statistical methods accounting for the weighted stratified nature of the data. Cosinor analysis and Joinpoint regression were used for temporal analysis. RESULTS:Over 15 years, there were an estimated 307,237 ED visits for older adult abuse and 39,477,217 for falls. Older adults experiencing abuse were younger and had lower hospital admission rates compared to fall patients. Injuries associated with abuse included contusions/abrasions, penetrating injuries, and fractures to the head/neck, fingers, toes, ribs, and lower extremities. In contrast, fall patients had higher admission rates, with more fractures, including cervical spine and hip fractures. Temporal patterns showed a higher rate of assaults during the summer, whereas abuse demonstrated bimodal peaks in the summer and fall. CONCLUSIONS:Injuries associated with abuse such as facial, upper trunk, and upper extremity fractures should raise suspicion even in the absence of severe symptoms. These findings emphasize the importance of early identification to connect older adults with support resources, as patients experiencing abuse often get discharged from the ED.

This report is a case of a healed proximal intertrochanteric femur fracture nonunion in an ancient Nubian adult female, approximately 58 years old at the time of death, from the Tombos archaeological site in present day northern Sudan. Tombos was founded as an Egyptian colonial town during the New Kingdom Period (14001070 BC). The individual was radiocarbon dated to 1114-910 BC and also exhibited healed fractures of the left proximal humerus and ribs. There was shortening and mild atrophy of the right femur compared to the left; radiographs demonstrated a varus deformity of the proximal femur with associated retroversion. Bone density analysis revealed that the tissue mineral density z-score for this individual was −0.798, with the z-score for Tombos females 15–24 years old being 0.396, or a total difference of 1.194. This indicates that the individual was osteopenic but not osteoporotic prior to demise. This is an important case as it occurred approximately 3000 years ago and is the oldest known reported case of a healed intertrochanteric hip fracture in the archaeological literature. Archaeological cases of intertrochanteric hip fractures are rare, with none previously reported from the BC era. The timing of these multiple fractures is unknown, but all healed before the demise of the individual. Thus, there must have been considerable care afforded to such an individual to minimize the morbidities associated with nonoperative care of such a fracture. If all these fractures occurred at the same time due to a traumatic, accidental injury, the Modified Injury Severity Score (MISS) would be 25. Modern day trauma resuscitation and orthopaedic care gives an estimated mortality for such a MISS score of 28% for those <50 years old. It is likely that this individual’s high socioeconomic status allowed for intensive nursing care which likely decreased the morality risk.

1Professor Emeritus of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA R. T. Loder, Orthopaedics, 705 Riley Hospital Drive, Phase 1, Suite 1100, Indianapolis, IN 46202, USA, Email: [email protected] (RE: O’Connor MI. Equity360: Gender, Race, and Ethnicity: Sex and Fairness in Sports. Clin Orthop Relat Res. 2023;481:1080-1083. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR®, The Association of Bone and Joint Surgeons®, or the Indiana University School of Medicine and Riley Hospital for Children.

Massive bone destruction in a human right proximal femur is described and differentially discussed in this case study. The individual was an older adult female buried at the ancient Nubian site of Tombos (modern-day Sudan) dating to the early Napatan/Third Intermediate Period (c. 1069-750 BCE). The right femur displayed a pathologic fracture with extensive lytic destruction and resorption of the entire femoral neck, most of the femoral head, and trochanters. Macroscopic and radiographic analyses revealed cortical thinning of the proximal diaphysis with new bone formation enclosing the medullary cavity. The lesion is eccentrically located involving the anterior aspect of the neck. Numerous vascular channels are apparent in the underlying bone. Sclerotic bone marks the limit of the lesion, and osseous lucency is visible in the radiograph. The individual displayed no other lytic lesions; vertebral osteophytic growth, compression fractures, and Schmorl's nodes were observed along with dental disease typical for older individuals. A traumatic etiology is eliminated due to the extensive osteolysis. Vascular, congenital, and developmental conditions are also not consistent with the observed changes. Expansive osteolytic lesions may have been caused by a cyst. Neoplastic tumors resulting in lytic lesions with a high risk of pathologic fracture are also consistent. There have been few reports of such extensive lytic lesions of the proximal femur in the paleopathological and clinical literature; this case adds an example of this underreported condition.

Background: Fractures often occur due to equestrian activities with injury patterns varying by age. The purpose of this study was to investigate in detail fracture patterns and associated demographics in children due to equine activities. Materials: The US National Electronic Injury Surveillance System was queried for all injuries with the consumer product code 1239 (horseback riding) from 2000 to 2023. Those <16 years old with fractures were extracted. Statistical analyses were performed with SUDAAN 11.0.01™ software to obtain national estimates. Results: There were an estimated 101,677 patients with a fracture. Girls comprised 72.5% and the patient was discharged from the hospital in 81.5% of cases. Fractures involved the upper extremity in 80,973 (80.0%), the pelvis/lower extremity in 11,794 (11.7%), the spine in 3060 (3.0%), the skull/face in 4321 (4.4%), and the rib/sternum in 940 (0.9%). The humerus, elbow, radius/ulna, and wrist accounted for 62.4% of all the fractures. The youngest age group (0- to 5-year-olds) had more boys and was more likely to be admitted to the hospital. The child was injured due to a fall from the horse in 75.7%, bucked/thrown off/kicked off in 17.0%, with the remaining 7.3% from other mechanisms. Conclusions: This extensive description of fractures in children due to equestrian injuries can be used to determine the effectiveness of future prevention strategies, such as protective equipment and educational programs. It also gives pediatric trauma and orthopedic surgeons an overall view of the types of fractures which occur in children due to equestrian activities.

The purpose of this study was to analyze the demographics of pediatric fracture patients before, during, and after the COVID pandemic using US national emergency department (ED) data. The National Electronic Injury Surveillance System (NEISS) data for the years 2018 through 2021 was extracted for those <16 years of age, and organized into 24 consecutive bimonthly groups. There was a decrease in the number of ED visits for fractures in 2020 and returned to pre-COVID levels by March/April of 2021, except for small hospitals which demonstrated an earlier rebound beginning in late 2020. During the pandemic the incident locale was more frequently the home and less at schools/sporting venues, which returned to pre-COVID levels by March/April 2021. The proportion of those not discharged from the ED increases from March/April 2020 to March/April 2021. The median age was 8.8, 9.0, 8.2, and 8.7 years respectively for the years 2018, 2019, 2020, and 2021. Early in the pandemic there were more radius/ulna and fewer finger fractures and more tibia/fibula and fewer toe fractures; these changes did not return to pre-COVID percentages until the end of 2021. Fractures associated with bicycles and trampolines remained stable throughout the pandemic, those due to skateboards increased, and those due to playground and sporting activities decreased, with varying times of return to pre-COVID levels. In conclusion pediatric fracture patterns during the COVID-19 pandemic demonstrated many changes; most returned to baseline patterns by early/mid 2021 except for small hospital EDs which saw a much quicker rebound by late 2020. This national data gives health care providers/administrators information about what can happen during a modern day pandemic. If another pandemic occurs in the future mandating lockdowns, this data may be useful to guide resource and manpower allocations.

BACKGROUND:Slipped capital femoral epiphysis (SCFE) is a hip disorder of late childhood and adolescence. Litigation involving SCFE may occur, as it is frequently diagnosed late, and/or may be temporally related to an injury. The purpose of this study was to review litigation cases involving SCFE in the US, focusing on the type of litigation (professional, premise, or product liability), the outcome of the litigation and indemnity payouts. METHODS:Cases of litigation involving SCFE were identified using 5 legal databases and Google Scholar searching for the term "slipped capital femoral epiphysis". These databases originated as early as 1973. The data collected was the alleged complaint, type of defendant, outcome, state where filed, and amount of indemnity payout. Payout amounts were converted to 2020 US$. Statistical analyses were performed with SYSTAT® 10 software. RESULTS:There were 135 unique cases identified which involved professional liability (103), premise liability (30), both premise and professional liability (1), and product liability (1). Complaints for professional liability cases were alleged failure in diagnosis (71), inappropriate treatment (14), both diagnosis and treatment (12), and others (7). The delay in those with an alleged late diagnosis (37 cases) was 5.8 months. The three most common specialties named as defendant(s) were primary care (31%), orthopaedic surgeons (29%), and radiologists (16%). The primary allegations against non-orthopaedic surgeons were failure in diagnosis (89%) as opposed to orthopaedic surgeons where the complaints of alleged failures in diagnosis and inappropriate treatment were equal (50%). The geographic region of the filed cases was the Northeast (44%), South (24%), Midwest (16%), and West (16%). There were no differences between premise and professional liability cases by geographic region. The overall outcome was favorable for the defendant(s) in 53% and the plaintiff in 47%; the defense prevailed in 60% of the professional liability but only 33% of the premise liability cases. The indemnity payout amount (for the 52 cases where known) averaged $1.28 million. Payout was higher in the complaints for professional compared to premise liability ($1.5 vs. $0.9 million). The average payout for those with and without avascular necrosis was $2.97 million vs. $1.02 million. For the professional liability claims, indemnity payout was most frequent in the Western US. It must be remembered that this study only represents law suits filed in the US court system. It does not include cases that might have been resolved prior to any legal action as those cases are not publicly available. CONCLUSIONS:Reported litigation involving SCFE patients involved claims of professional liability in 77% and premise liability in 22% of located cases. Due to significant exposure, this study should serve as a reminder to all health care providers to include SCFE in the differential diagnosis of knee/thigh pain in adolescents.