Hrev_master Abstract The COVID-19 pandemic affected pediatric emergency department (ED) visits for traumatic injuries. This retrospective study analyzed data from Merano Hospital, Italy, spanning January 2018 to October 2022, focusing on standardized ED visits per 1000 orthopedic attendances. Findings indicated a significant decline in ED visits at the pandemic’s onset (March 2020), followed by a gradual increase until April 2022, when emergency measures ended. Fracture and orthopedic procedure rates remained stable, while dislocations saw a temporary increase, then declined signif- icantly. Overall, the pandemic’s influence on pediatric trauma was minimal, with ED visits and injury patterns returning to pre-pan- demic levels. These findings suggest that pandemic-related restric- tions, including reduced outdoor activities and fewer traffic acci- dents, may have temporarily modified injury risk factors. Introduction Trauma remains the leading cause of morbidity and mortality in children, frequently stemming from accidents at home, play, sports, or traffic incidents.1,2 The COVID-19 pandemic notably impacted healthcare systems and societal behaviors, affecting pediatric trauma incidences, as well as having an impact on the Emergency Department (ED) system in general.3,5 While some studies indicated a decline in pediatric injuries, such as in New Zealand,6 others, like a UK study, reported an increase in brain trauma linked to abuse during the pandemic.7 In the U.S., overall pediatric injuries decreased, but with rises in specific cases such as burns and penetrating injuries.6 The full extent of the pandemic’s impact on pediatric ED visits remains unclear, necessitating accu- rate analysis for timely diagnosis and treatment.1,6,8 Pandemic- related factors like lockdowns and reduced ED visits may have influenced trauma risk and attendance rates.9-11 This study aims to evaluate changes in ED attendances for pediatric trauma during pre- and post-pandemic periods to inform health policy and child safety strategies. Materials and Methods Study design and setting This retrospective study included children aged 1-14 years vis- iting the ED at Merano General Hospital, Italy, between January 2018 and October 2022. This hospital, located in a high-tourism Emergency Care Journal 2025; volume 21:12965 [Emergency Care Journal 2025; 21:12965] [page 53] The impact of COVID-19 pandemic on traumatic injuries in children: a longitudinal observational study Arian Zaboli,1 Mara Molaro,2,3 Gianni Turcato,4 Serena Sibilio,5 Gloria Brigiari,6 Gaia Weissmann,2 Paola Cogo,7 Olaf Schmidt,3,8 Francesco Brigo1 1Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy; 2Pediatrics Department, Hospital of Merano-Meran (ASDAA-SABES), Merano, Italy; 3Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Salzburg, Austria; 4Department of Internal Medicine, Intermediate Care Unit, Hospital Alto Vicentino (AULSS-7), Santorso, Italy; 5Institute of Nursing Science, University of Basel, Basel, Switzerland; 6Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy; 7Department of Medicine, University Hospital of Udine, Udine, Italy; 8Department of Orthopedic and Traumathology, Hospital of Merano-Meran (SABES-ASDAA), Merano-Meran, Italy Correspondence: Arian Zaboli, Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy. E-mail: zaboliarian@gmail.com Key words: COVID-19; pediatric patients; injury; trauma; pediatric; longitudinal; emergency department. Funding statement: Not applicable. Conflict of interest: the authors declare that they have no conflict of interest. Contributions: AZ, conceptualization, methodology, formal analysis, data curation, writing-original draft preparation, writing - review & editing; FB, data curation; writing-original draft preparation, writing - review & editing; GB, data curation; formal analysis; GT, concep- tualization; methodology; writing-original draft preparation, writing - review & editing; MM, data curation, writing-original draft prepa- ration; SS, GW, writing-original draft preparation; PC, supervision; OS, conceptualization, writing-original draft preparation. Ethics approval: the study was conducted in accordance with local ethics committees (Ethics Committee for Clinical Research, South Tyrol Health Authority, Bolzano, Italy, approval number 84-2022) and was conducted according to the Declaration of Helsinki princi- ples for ethical medical research involving human subjects. Since the study is retrospective and based on an anonymized database, informed consent for participation in the study was not required. Data availability statement: data available on request due to priva- cy/ethical restrictions. Received: 25 August 2024. Accepted: 15 November 2024. Early view: 27 January 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:12965 doi:10.4081/ecj.2025.12965 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Alpine area with around 100,000 residents, prioritizes patients using the Manchester Triage System (MTS). Pediatric patients with orthopedic issues are assessed in the ED’s orthopedic section, while severe trauma cases are handled by other specialists. Data from all ED attendances are digitally recorded, capturing details like triage codes, treatments, and outcomes. During the pandemic, the ED remained fully operational. From March to April 2020, the hospital served as the COVID-19 referral center for South Tyrol, subsequently rotating COVID-19 patients with other regional hospitals between November 2020 and June 2021. Patients and data collection Data were extracted for children presenting with orthopedic complaints or traumatic injuries. The data were extracted from the anonymized emergency department database. Excluded were those under one year, with isolated head or thoracic injuries, or with life- threatening trauma, as these cases bypass the orthopedic section. We collected demographic and clinical data, including age, visit date, weekday/weekend arrival, time of day, MTS code, disposi- tion (hospitalization, discharge, or left ED), and presence of frac- tures or dislocations. ED attendances for traumatic injuries were standardized to total attendances to the ED orthopedic section using the following formula: Standardization was applied to ED attendances to account for monthly variations across pandemic phases, aligning with previous methodologies.3,12,13 Statistical analysis Categorical variables were summarized as counts and percent- ages, while continuous variables were described as mean and Standard Deviation (SD) or median with Interquartile Range (IQR), depending on distribution. Univariate comparisons used Chi-square, Student’s t-test, or Mann-Whitney test. Interrupted Time-Series Analysis (ITSA) evaluated the impact of COVID-19 on pediatric ED visits, comparing pre-pandemic (January 2018 to February 2020) with post-pandemic (March 2020 to October 2022) trends. Analyses used STATA 16.0, with significance at p<0.05. Ethical consideration The study was conducted in accordance with local ethics com- mittees (Ethics Committee for Clinical Research, South Tyrol Health Authority, Bolzano, Italy, approval number 84-2022) and was conducted according to the Declaration of Helsinki principles for ethical medical research involving human subjects. Since the study is retrospective and based on an anonymized database, informed consent for participation in the study was not required. Results Between January 2018 and October 2022, 79,114 patients attended the Emergency Department (ED) for traumatic injuries, of whom 10,285 were children aged 1 to 14 years, meeting the study’s inclusion criteria. The yearly distribution of pediatric attendances is detailed in Supplementary materials, Table 1. In 2018, these cases accounted for 13.8% (2,653/19,167) of all ED orthopedic attendances, decreasing to 11.6% (1,437/12,307) in 2020, before rising to 13.3% (1,987/14,948) by 2022. The overall trend for pedi- atric and adult ED attendances is shown in Figure 1. Of the 10,285 children, 4.1% experienced dislocations, 25.2% sustained fractures, and 1.9% required hospitalization for orthope- dic procedures, with 7.7% of fractures needing surgery (Table 1). The average age of pediatric patients was 9.4 years, with most attending on weekdays (73.4%) and during daytime hours (88.9%). Brief report Figure 1. Number of attendances to the ED orthopedic section for traumatic injuries divided by month and according to patient age (patients aged 1-14 versus all other age groups). [page 54] [Emergency Care Journal 2025; 21:12965] A majority received non-urgent green triage codes and were brought to the ED in private vehicles. The characteristics of ED attendances were categorized into pre-pandemic, pandemic, and post-pandemic periods (Table 1). There were statistically significant variations in patient age (p<0.001), weekday versus weekend attendances, and triage code distribution (p<0.001) across these periods. Notably, urgent cases decreased and non-urgent cases increased during the pandemic. ITSA results, depicted in Figure 2 and detailed in Supplementary materials, Table 2, show that standardized ED Brief report [Emergency Care Journal 2025; 21:12965] [page 55] Table 1. Characteristics of included patients and comparison of patient characteristics before and after the outbreak of COVID-19 pan- demic (March 2020). Variables Total study population Pre COVID-19 period Post COVID-19 period pa (Until February 2020) (After March 2020) Patients, n (%) 10,285 (100) 5742 (55.8) 4543 (44.2) Age, year, mean (SD) 9.4 (3.5) 9.2 (3.6) 9.6 (3.4) <0.001 Day of arrival, n (%) 0.805 Weekday (Mon-Fri) 7549 (73.4) 4220 (73.4) 3329 (73.2) Weekend (Sat-Sun) 2736 (26.6) 1522 (26.5) 1214 (26.7) Time of arrival, n (%) 0.006 Day (8 a.m. - 8 p.m.) 9139 (88.9) 5146 (89.6) 3993 (87.9) Night (8 p.m. - 8 a.m.) 1146 (11.1) 596 (10.3) 550 (12.1) Mode of arrival to the ED, n (%) 0.452 Private vehicle 9537 (92.7) 5313 (92.5) 4224 (92.9) Ambulance 679 (6.6) 393 (6.8) 286 (6.3) Emergency physician/helicopter 69 (0.7) 36 (0.7) 33 (0.8) MTS code, n (%) <0.001 Blue 190 (1.8) 35 (0.6) 155 (3.4) Green 7600 (73.9) 4026 (70.1) 3574 (78.7) Yellow 2434 (23.6) 1635 (28.4) 799 (17.6) Orange 60 (0.7) 45 (0.8) 15 (0.3) Red 1 (0.0) 1 (0.0) 0 (0.0) Dislocations, n (%) 420 (4.1) 239 (4.1) 181 (3.9) 0.688 Fractures, n (%) 2593 (25.2) 1424 (24.8) 1169 (25.7) 0.283 Fractures requiring orthopedic operation, n (%) 200 (1.9) 108 (1.8) 92 (2.0) 0.615 Outcome, n (%) <0.001 Patient leaves ED without medical evaluation 197 (1.9) 143 (2.5) 54 (1.2) Patient discharged 9807 (95.3) 5443 (94.8) 4364 (96.0) Patient hospitalized 281 (2.8) 156 (2.7) 125 (2.8) ED, Emergency Department; MTS, Manchester Triage System; SD, Standard Deviation; aCategorical variables were compared with a chi-square test. When more categories are present, the chi-squared test can detect differences across multiple levels. In this case, the p-value tells if there is an overall association between the variables, but it does not specify which categories are different from each other. Figure 2. Interrupted time series analysis assessing the rate of pediatric patients with traumatic or orthopaedic problems per 1,000 atten- dances to the ED orthopedic section per month. attendances for pediatric traumatic injuries significantly decreased at the pandemic’s onset in March 2020 (-23.49/1000; 95% CI: - 40.29 to -6.66; p=0.007), followed by a gradual recovery up to April 2022 (1.51/1000; 95% CI: 0.22 to 2.79; p=0.022). Fracture and orthopedic procedure rates remained stable post-pandemic (Supplementary materials, Table 3). A non-significant increase in dislocations occurred in March 2020, followed by a significant monthly decrease (-0.19/1000; p=0.006), as shown in Supplementary Materials, Figure 1. After April 2022, ED attendances, fractures, dislocations, and surgical interventions returned to pre-pandemic levels. Although overall trends normalized, the pandemic prompted significant shifts in pediatric trauma visits, highlighting its impact on health- care-seeking behaviors. Ongoing monitoring of ED utilization pat- terns may inform future strategies for managing pediatric trauma care during public health crises. Discussion Our study utilized ITSA over a prolonged period to assess the impact of the COVID-19 pandemic on pediatric ED attendances for trauma, revealing initial changes followed by a return to pre- pandemic levels. Unlike the general reduction in ED visits reported elsewhere, such as the 41.5%-63.5% decrease in U.S. ED atten- dances noted by Jeffrey et al. and the 70% reduction for non- COVID-19 cases described by Santi et al., our findings indicate that fracture incidence among children remained stable despite decreased ED usage.14-16 Studies on pediatric trauma during the pandemic present mixed outcomes. For instance, Sullivan et al. reported a post-pandemic increase in pediatric trauma, while Harthi et al. found a decrease in ED visits for traumatic injuries.17-18 Our study contributes by stan- dardizing pediatric trauma incidences, adjusting for fluctuating ED attendances, which provides a more accurate reflection of the pan- demic’s impact on pediatric trauma. Fracture rates remained steady when standardized per 1000 attendances, suggesting that while overall ED attendance declined, fractures remained relatively constant. This trend may be attributed to reduced outdoor activity during lockdowns, which minimized injury risks from activities like sports and road accidents, as indi- cated by Keys et al. who reported a significant drop in pediatric road accident injuries during the pandemic.19 Consequently, pan- demic-related restrictions likely mitigated some trauma risk factors but had minimal effect on those occurring in domestic settings. Interestingly, our study identified a transient increase in limb dislocations in March 2020, with rates later reverting to pre-pan- demic levels. Existing research on dislocations during the pandem- ic is limited, with only one study comparing trauma types before and after the pandemic, reporting fewer dislocations post-pandem- ic but lacking standardization, which limits interpretability.19 Our data suggest an initial rise in dislocations due to domestic incidents during lockdowns, as potential exposures to trauma shifted indoors. However, without granular detail on injury contexts, a definitive link between dislocation trends and domestic violence or other specific causes remains speculative. Our study also observed significant shifts in triage prioritiza- tion during the pandemic, with an increase in non-urgent (blue and green) codes. This change aligns with previous studies that noted a rise in ED visits for less urgent conditions post-pandemic.3 Factors contributing to this trend include increased health-related anxieties and reduced access to primary care services. Green et al. reported over a 25% reduction in general practitioner visits from 2019 to mid-2021, potentially diverting patients to EDs as the only acces- sible care facility.20 This trend underscores the need for strategies that bolster primary care access to prevent ED overcrowding with non-urgent cases during health crises. We employed standardization of pediatric trauma data, which aligns with methodologies from prior studies,3,12,13 to control for fluctuations in ED attendance volumes and improve data reliabili- ty. The pandemic’s irregular attendance patterns, driven by lock- downs and fears of viral transmission, necessitated such measures to ensure meaningful comparisons. By standardizing per 1000 ED attendances, we achieved consistency across time periods, enabling accurate cross-period comparisons and reducing potential bias due to confounding factors like shifts in healthcare-seeking behavior. Standardization also facilitated the analysis of proportion- based outcomes (e.g., trauma rates) rather than raw numbers, which can be misleading when overall ED visits fluctuate. This approach allowed us to generate valid insights into trauma trends, independent of the broader pandemic-related variations in health- care access. This study’s retrospective design could introduce biases; how- ever, we used consistently collected, high-quality data. While cer- tain variables, such as trauma location, were not included due to limitations in data granularity, the study’s large sample size—over 10,000 pediatric trauma cases—enhanced the precision of findings despite the modest clinical significance of observed effect sizes. Excluding patients with severe life-threatening injuries or those with isolated head and thoracic traumas may limit generalizability. Additionally, we could not isolate data for local residents versus tourists, which may influence our conclusions. The primary strength of our study is its use of ITSA and data standardization, providing robust insights into trauma trends over an extended period. This approach offers a reliable framework for understanding the long-term impacts of the COVID-19 pandemic on pediatric trauma, despite varied healthcare-seeking behaviors. Conclusions In conclusion, while COVID-19 notably reduced overall pedi- atric ED attendances for trauma, standardized data revealed a sta- ble fracture rate across pre-, intra-, and post-pandemic periods, with initial declines in attendance during early 2020. The apparent stability in fractures per 1000 attendances suggests that pandemic restrictions limited certain trauma risks, such as those related to outdoor activities, without significantly affecting injuries within the home. An initial spike in dislocations was observed at the pan- demic’s onset, potentially reflecting increased trauma incidents in domestic environments, followed by a reversion to prior levels. These findings highlight the differential impact of COVID-19 on trauma types and underline the need for preparedness in healthcare systems to address shifts in trauma risks during public health emer- gencies. 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Remote general practi- tioner consultations during COVID-19. Lancet Digit Health 2022;4:e7. Brief report [Emergency Care Journal 2025; 21:12965] [page 57] Online supplementary materials Table 1. Distribution of ED orthopedic accesses by year and patient age Table 2. Comparison of patient characteristics between before and after the outbreak of COVID-19 pandemic. Legend: ED: Emergency Department; MTS: Manchester Triage System; SD: Standard Deviation. Table 3. Comparison of patient characteristics between before and after the outbreak of COVID-19 pandemic. Legend: ED: Emergency Department; MTS: Manchester Triage System; SD: Standard Deviation. Figure 1. (A) Interrupted time series analysis assessing the rate of pediatric patients with fractures per 1,000 attendances to the ED orthopedic section per month. (B) Interrupted time series analysis assessing the rate of pediatric patients requiring a surgical intervention per 1,000 attendances to the ED orthopedic section per month. Figure 2. Interrupted time series analysis assessing the rate of pediatric patients with dislocation per 1,000 attendances to the ED orthopedic section.