Trauma is defined as physical injury caused by violence or other forces; in serious trauma the patient will be at risk of death or loss of function . Trauma is a leading cause of morbidity and mortality among all age groups .
Trauma and its adverse effects are leading cause of hospitalization in Saudi Arabia representing about 20% of all admissions. Many of these patients require long-term rehabilitation care because of residual disabilities. It is estimated that about 74% of all plegic patients in Saudi Arabia are due to road traffics accidents (RTAs) .
According to World Health Report 2002 trauma is a long-overlooked health problem as it estimated about 12.2% of total burden of disease .
Sports injuries are the leading causes of trauma in children and the upper limbs are the most part injured .
Our study was conducted to describe the different patterns of injury of upper limbs in patients attending the pediatric emergency department of Security Forces Hospital-Al-Riyadh, Saudi Arabia.
1.1.1. General Objective
To study the pattern and outcome of upper limb trauma in children attending pediatric emergency department.
1.1.2. Specific Objective
- To identify the demographic distribution.
- To identify the mechanism of trauma.
- To study the site of trauma.
- To know the disposition.
This was a retrospective cross-sectional study conducted in Department of Pediatrics at Security Forces Hospital-Al-Riyadh.
The ethical approval was taken from the Institutional Ethical Review Board.
All pediatrics patients aged less than 14 years with history of injury to the upper limb during the study period from 1st August to 30th October 2021 were included in the study.
All pediatrics patients more than 14 years old, or seen and treated in other hospital after trauma were excluded from the study.
The details of the patients were taken from computerized medical records and patient files of the hospital.
All the data like demographic profiles, patterns of injury, mode of injury, diagnosis and disposition were documented in a questionnaire.
The disposition was recorded as admission in orthopedics ward, discharge from the emergency, left against medical advice (LAMA), referred to plastic surgery, admission in Intensive Care unit (ICU) and trauma clinic referral.
Trauma was defined as per American College of Surgeons Definition: “Potentially severe physical injury caused by an external source (fall, auto crash, farm or industrial accident, knife or gunshot wound, etc.) that requires emergency medical intervention to attempt to prevent loss of life or limb or substantial, permanent physical impairment. It does not include moderate or minor injuries; heart attacks, strokes, or other internal conditions; chronic, contagious, or infectious diseases; or mental illness not caused by a severe physical injury”.
Data were analyzed by SPSS software version 24.
The total number of patients seen during the study period was 343 patients, their age range between 6 months and 13 years old with a mean age of 5.473 (±3.8572); also, results showed boys were 187 (54.5%) patients and girls were 156 (45.5%) patients.
Table 1: Patients less than five years old were 178 (51.9%) patients, 5 - 10 years old were 108 (31.5%) patients, and more than ten years old were 57 (16.6%) patients.
Table 2: Trauma occurred indoors in 260 (75.8%) patients and outdoors in 83 (24.2%) patients.
Table 3: Showed the mechanism of trauma. Fall occurs in 166 (48.4%) patients, direct hit by object in 73 (21.3%) patients, other mechanisms in 92 (26.8%) patients, and road traffic accidents (RTA) in 8 (2.3%) patients.
Table 4: The clinical presentation of patients who came to the emergency department showed pain in 138 (40.2%) patients, pain and swelling in 104 (30.3%) patients, pain with deformity and limitation of function in 32 (9.3%) patients, swelling in 23 (6.7%) patients, laceration in 21 (6.1%) patients, limitation in function in 14 (4.1%) patients, deformity in 5 (1.5%) patients and pain with deformity in 6 (1.7%) of patients.
Table 5: Site of trauma in the upper limbs showed lacerations in 114 (33.2%) patients, Hand and/or Wrist fracture in 67 (19.5%) patients, Nursemaid Elbow in 43 (12.5%) patients, both Radius and Ulnar bones fracture in 33 (9.6%) patients, Radius bone fracture in 29 (8.5%) patients, supracondylar fracture in 22 (6.4%) patients, Clavicle bone fracture in 20 (5.8%) patients, Humorous bone fracture in 7 (2%) patients, Condylar bone fracture 6 (1.7%) patients, and 1 (0.3%) patients with Scapulae and Ulna fracture.
Table 6: Disposition of patients from ED showed 130 (37.9%) patients discharged to home, 77 (22.4%) patients given Trauma clinic follow-up, 72 (21%) patients referred to Orthopedic unit, and 64 (18.7%) patients referred to Plastic surgery unit.
Table 1. Age distribution.
Table 2. Place of trauma.
Table 3. The mechanism of trauma.
Table 4. Clinical presentation of patients to the emergency department.
Table 5. Site of trauma in Upper Extremities.
Table 6. Disposition from ED.
Trauma is a leading cause of disability and preventable death. It frequently occurs in people aged 15 - 40 years, with a global mortality rate of 10% .
The present study aimed to describe the pattern of different injuries in upper limbs of pediatrics patients attending the Emergency Department (ED) of Security Forces Hospital in Riyadh from 1st August to 30th October 2021.
A total of 343 patients were seen with a mean age of 5.473-year-old, most of them less than five years old, and most of them were boys. In Boyce SH et al. , and Pramendra Prasad Gupta et al. , studies, most of the cases attended their ED were boys. In Norway, Brudvik reported that upper extremity injury was commonest in school children .
In a study by Sharma et al. , the mean age was 6.3 years. It is the most common age group for school-going and playing outside independently.
Many studies from Bangladesh, Iran, Nigeria, and major Indian cities, and these studies have found boys to be more injured than girls .
Most of our patients with upper limbs trauma occurred indoors due to indoor activities following the COVID-19 pandemic restrictions and protocols. Our finding was similar to the Italian study during the COVID-19 pandemic, which showed an increase in home-related injuries that were observed during the pandemic. In contrast, fracture diagnosis was less frequent in the pre-pandemic group . Like our findings, most traumas in the Gupta FP et al.  study occurred at home.
Most of the trauma in our study happened on Friday because it’s the weekend, and most children were at home as per COVID-19 pandemic precautions.
Fall from height while playing is the most mechanism of injury followed by other mechanisms, e.g., accident cut, road traffic accidents are the least mechanism. In Gupta PP et al. , study fall was the most common cause of trauma. Boyce SH et al.  study showed sport is the most common cause of trauma.
In our study, fall from height is the most typical mechanism of trauma occurs in 48.4%, other mechanisms in 26.8%, direct object trauma in 21.3%, and RTA in 1.2%. In Gupta PP et al. , most of the cases were due to fall injury either during playing or from height in-home or tree, and the second most common mode was Road traffic accident (RTA) followed by physical assault. Also, in Systema, Renee et al.  study fall from height is the commonest cause of trauma in the upper extremities.
In our study, the pain was the commonest presenting complaint in 40.2%, pain and swelling in 30.3%, laceration in 6.1%, and swelling in 6.7% of patients. In a study done by Caitlin Farrel et al. , they noticed that all parents noted at least one sign or symptom following accidental extremity fracture.
In Sorensen L et al. , the main types of injuries were contusions 37.1%, fractures 22.0%, sprains 24.8%, wounds 9.5%, strains 5.0% and luxation 1.4%.
In our study, most of the patients who attended the ED had a laceration, Hand/Wrist bone fracture in 19.5%, Nurse Maid Elbow in 12.5%, both Radius/Ulnar bone fracture in 9.6%, Radius bone fracture occurred to 8.5%, Supracondylar and Condylar bone fracture in 6.4 and 1.7% respectively.
Similar findings to our study by Krauss et al. , & Kirsch et al. , found laceration to be the most common pattern of injury.
In Gupta PP et al. , Supra-condylar fractures (37%) were the most common fractures found in upper limb injuries, followed by both bone fractures (28%) and then medial epicondylar fractures (24%). Their findings were not like ours because it was in a tertiary hospital.
Disposition of patients showed that most of them were discharged home, 22.4% and 21% given trauma clinic and orthopedic follow-up, respectively, and 18.7% referred to plastic surgery based upon our ED protocols. Similar findings by Gupta PP et al. , as most of their patients were discharged Home from ED.
The limitation of our study is that our hospital is not a trauma center, and it covers part of our community.
This study showed that trauma occurs mainly in those less than five years old and outdoors. Most of the patients seen in the ED were discharged home. More studies were needed to get more and practical conclusions.
 Ali, K., Arain, G.M., Masood, A.S. and Aslam, M. (2006) Pattern of Injuries in Trauma Patients Presenting in Accident and Emergency Department of Jinnah Hospital, Lahore. Annals of King Edward Medical University, 12, 26.
 Ansari, S., Akhdar, F., Mandoorah, M. and Moutaery, K. (2000) Causes and Effects of Road Traffic Accidents in Saudi Arabia. Public Health, 114, 37-39.
 Boyce, S.H. and Quigley, M.A. (2001) Rollerblading Injuries in Children Attending an Accident & Emergency Department: Should the Use of Wrist Splints Be Compulsory?. Scottish Medical Journal, 46, 102-103.
 Mizelle, H.L., Rothrock, S.G., Silvestri, S. and Pagane, J. (2002) Preventable Morbidity and Mortality from Peripheral Paralytic Assisted Intubation: Can We Expect Outcomes Comparable to Hospital-Based Practice? Prehospital and Emergency Care, 6, 472-475. https://doi.org/10.1080/10903120290938184
 Boyce, S.H. and Quigley, M.A. (2003) An Audit of Sports Injuries in Children Attending an Accident & Emergency Department. Scottish Medical Journal, 48, 88-90.
 Gupta, P.P., Malla, G.B., Bhandari, R., Kalawar, R.P. and Mandal, M. (2017) Patterns of Injury and Mortality in Pediatric Patients Attending Emergency Department in a Tertiary Care Center in Eastern Nepal. Eye, 115, 2-9.
 Sharma, M., Lahoti, B.K., Khandelwal, G., Mathur, G.K., Sharma, S.S. and Laddha, A. (2011) Epidemiological Trends of Pediatric Trauma: A Single-Center Study of 791 Patients. Journal of Indian Association of Pediatric Surgeons, 16, 88-92.
 Verdoni, F., Ricci, M., Di Grigoli, C., Rossi, N., Lombardo, M.D., Curci, D., Accetta, R., Viganò, M., Peretti, G.M. and Mangiavini, L. (2021) Effect of the COVID-19 Outbreak on Pediatric Patients’ Admissions to the Emergency Department in an Italian Orthopedic Trauma Hub. Children, 8, 645.
 Sytema, R., Dekker, R., Dijkstra, P., ten Duis, H.J. and van der Sluis, C.K. (2010) Upper Extremity Sports Injury: Risk Factors in Comparison to Lower Extremity Injury in More than 25 000 Cases. Clinical Journal of Sport Medicine, 20, 256-263.
 Farrell, C., Rubin, D.M., Downes, K., Dormans, J. and Christian, C.W. (2012) Symptoms and Time to Medical Care in Children with Accidental Extremity Fractures. Pediatrics, 129, e128-e133. https://doi.org/10.1542/peds.2010-0691
 Sørensen, L., Larsen, S.E. and Röck, N.D. (1996) The Epidemiology of Sports Injuries in School-Aged Children. Scandinavian Journal of Medicine & Science in Sports, 6, 281-286. https://doi.org/10.1111/j.1600-0838.1996.tb00471.x
 Krauss, B.S., Harakal, T. and Fleisher, G.R. (1993) General Trauma in a Pediatric Emergency Department: Spectrum and Consultation Patterns. Pediatric Emergency Care, 9, 134-138. https://doi.org/10.1097/00006565-199306000-00003
 Kirsch, T.D., Beaudreau, R.W., Holder, Y.A. and Smith, G.S. (1996) Pediatric Injuries Presenting to an Emergency Department in a Developing Country. Pediatric Emergency Care, 12, 411-415. https://doi.org/10.1097/00006565-199612000-00006