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The association of weather, temperature, and holidays on pediatric maxillofacial trauma

Abstract Objective To evaluate the association of weather, seasons, months and holidays on the frequency and pattern of pediatric facial fractures. Methods Retrospective review of pediatric patients treated for facial fractures at two Level I trauma centers in a midsize Midwestern US city over a 5‐year period. Patients were included only if presentation was within 3 hours of inciting trauma, transfers from other facilities were excluded. Demographic characteristics, fracture patterns, operative interventions, weather data, and local public school schedules were acquired and associations were analyzed with unpaired t tests, χ2, multivariate and binomial regression model analyses. Results Two hundred and sixty patients were included. The average age (SD) was 11.8 (5.0) years, with 173 males and 87 females. The highest distribution of presentations occurred in the summer season (35.0%), on weekends and holidays (58.1%), and when the weather was described as clear (48.5%). The most common mechanisms of injury were motor vehicle collisions (25.8%), followed by sports—(21.5%) and assault—(16.5%) related injuries. Mechanisms were significantly associated with certain fracture patterns. Older age was associated with fewer orbital fractures (P < .01). Seventy‐five patients (28.8%) required operative intervention. Age was found to impact the likelihood of operative intervention (Exp(β) = 1.081, P = .03) while weather, temperature, and mechanism did not. Conclusion Pediatric facial fractures are linked to warmer weather with clear skies and warmer season. Age predicts some fracture patterns and need for operative intervention. These results can be used to inform public health interventions, policymaking, and trauma staffing. Level of Evidence: Level 2b (retrospective cohort).


| INTRODUCTION
Trauma is the leading cause of pediatric morbidity and mortality.
Pediatric maxillofacial fractures comprise up to 14.7% of all facial fractures in the United States 1 and can generate lasting and occasionally irreversible impairment in function and cosmesis. 2 Furthermore, pediatric trauma patients with facial fractures are more likely to have substantial injury, increased hospital length of stay, ICU admissions, need for mechanical ventilation, and health care cost burden. 3 Pediatric maxillofacial trauma most commonly affects boys who are involved in motor vehicle accidents, which accounts for up to 80.2% of pediatric facial fractures. 4 Various associations have been found between trauma admissions and factors such as weather, temperature, seasons, time of day, holidays, and weekends. A study of trauma admissions at three level I trauma centers in Minneapolis found weekends, summer, lack of rain, and snowfall to be predictive of daily trauma admissions. 5 These associations have not been firmly established with respect to maxillofacial trauma in either the adult or pediatric literature. Despite the burden of injury and health care burden associated with pediatric facial trauma, factors associated with the incidence of injury remain poorly studied. The goal of this retrospective analysis is to help identify and characterize associations between pediatric maxillofacial trauma at our institution and factors such as weather, seasons, time of day, holidays, and temperature. We hypothesize that pediatric maxillofacial trauma has the greatest incidence in warmer weather during daylight hours because this is when children are most likely to be active. The results may be used to guide public health and safety measures, policymaking, emphasize the importance of adherence to motor vehicle traffic laws and regulations, inform parents and caretakers, and optimize resource allocation for otolaryngologists, facial plastic and reconstructive surgeons, and oral-maxillofacial surgeons at centers that manage pediatric trauma.

| Geography and climate
Indianapolis, Indiana is a midsize Midwestern city with a population of 867 125. 6

| Data aggregation
Data extracted included basic demographics, mechanism of injury, fracture pattern, interventions, and temporal/calendar data such as the time of the encounter, day of the week, month, and season. All fracture radiology reports and images were reviewed and categorized into basic categories. Local public-school calendars were used to mark the day as a "school day" or a "school-free day." Holiday dates were gathered, and encounters were marked for analysis if they coincided

| Statistical analysis
The analytic dataset was compiled using Excel 2013 software (Microsoft Corp, Redmond, Washington). All statistical analyses were performed using IBM SPSS Statistics (version 24, IBM Corp., Armonk, New York). Unpaired t test, χ 2 , multivariate and binomial regression analysis was performed; we provide the β coefficient and Exp(β) value as an exponentiation of the β coefficient, which is an odds ratio. Pvalues <.05 were considered statistically significant.

| RESULTS
A total of 260 patients were included over the 5-year period. The average age (SD) at the time of presentation for pediatric facial fractures was 11.8 (5.0) years with a 2:1 male to female ratio ( Table 2).  Table 2). Facial fractures resulting from motor vehicle collisions were more common in Caucasian or White patients than Black or African American patients (30.0% vs 12.1%) while battery injuries were more in the Black or African American cohort (29.7% vs 10.9%, χ 2 = 18.6, P < .01, Figure 2).
Facial fractures most often occurred with clear skies (N = 126, 48.5%). Overall, there was no significant difference in frequency of facial fractures related to weather descriptors over this 5-year period (χ 2 = 8.9, P = .11, Table 1). Fractures were shown to occur more frequently in temperature range of 51 to 70 F (χ 2 = 25.3, P < .01, Table 1). Facial fractures generally occurred during daylight hours (N = 146, 56.2%), and occurred more frequently during the daylight in warmer temperatures while less frequently during colder temperatures (χ 2 = 44.0, P < .01, Figure 3). All mechanisms of injury were more frequent during warmer temperatures.
Multivariate regression analysis was performed to evaluate predictors of fracture patterns. Freezing temperatures (≤32 F) significantly predicted risk of nasal fractures (P = .03). No other fracture patterns were identified to be influenced by weather nor temperature-related patterns. Less predicted risk of orbital fractures was found with increased age (F = 14.28, P < .01). The mechanism of injury also significantly predicted injury patterns including orbit,  The rate of operative intervention was 28.8% (75 patients).
Binary Logistic Regression analysis revealed increased age was predictive of intervention (Exp(β) = 1.08, P = .03) as well as mandible, orbit, and midface fractures. Mandible fractures greatly increased risk of intervention vs orbit and midface fractures which were less likely to need intervention (Table 3). Other factors including mechanism of injury, weather, temperature as well as frontal sinus and midface fracture did not increase risk of intervention.

| DISCUSSION
Pediatric facial trauma incurs significant morbidity and mortality in the United States. Our study confirms that the most common mechanism of pediatric facial fractures is motor vehicle collisions (MVCs), with sports and violence among the next most common etiologies. 2,4,[9][10][11][12][13][14] This was not the case in African American or Black patients for whom battery related facial fractures were the most common cause, followed by sports. There is a higher incidence of facial fractures in male vs female children, ranging from 1.1:1 to 8.5:1 male to female ratio, and this disparity has a positive correlation with age. 4,9,12,14 In our study, weather patterns were found to predict fracture occurrence. The distribution of weather over this 5-year period did not significantly differ from the distribution of weather during fracture presentation. Temperature patterns seemed to play a much more significant role in facial fractures. The most common presentation was T A B L E 2 Distribution of patients admissions, with lower rates of trauma on days with rainfall. [15][16][17] There was an increased distribution of fractures in the 51 to 70 F group vs other temperatures, although not significantly increased compared to the >70 F group. One postulate is that this range indicates a sudden change in temperature, either relative warming or cooling, that could be linked with an increase in outdoor activities.
We also found that during the warmest temperatures (≥71 F), facial fractures occurred much more commonly during the daylight hours; this may be related to both outdoor activity at these temperatures and the increased number of daylight hours during the summer in Indiana, which peaks at 15 hours in the Summer compared to 9 hours in the Winter. 18 We found that the majority of facial trauma occurred during the summer months, which supports findings from previous studies. 13 In our study population, these months coincide with the local public-school system's summer break and have the highest average temperatures.
Peak facial trauma hours were in the early evening, specifically 5 to 9 PM; conversely, the nadir occurred in the early morning hours around 4 AM These results agree with previous trauma study findings, 15 and correspond with the level of activity in the typical American pediatric population. These hours also correspond with peak daylight hours and daily temperatures.
Increased leisure time during holidays and school-free days appears to contribute to the incidence of pediatric trauma. In a mas-   Further studies may be valuable in assessing temporal, temperature, and weather patterns related to facial trauma.