August 2021

Changes in Product-related Lower Extremity Injuries Treated at Emergency Departments During the COVID-19 Pandemic

By Mathias B. Forrester, BS

Background: During 2020, emergency department (ED) visits in the United States (US) not related to COVID-19 declined during the COVID-19 pandemic, particularly for certain populations and certain types of illness or injury. This study described product-related lower extremity injuries managed at EDs during 2020 and compared it to previous years.

Methods: Product-related lower extremity injuries were identified through the National Electronic Injury Surveillance System (NEISS), a database of consumer product-related injuries collected from the EDs of approximately 100 US hospitals. These data were used to calculate national injury estimates. The estimated number of injuries during 2020 was compared to the estimated numbers reported during 2018 and 2019.

Results: An estimated 2,477,446 product-related lower extremity injuries were reported during 2020, a 20.8% decrease from 2018 (n=3,129,214) and 22.5% decrease from 2019 (n=3,196,826). The estimated number of patients with lower extremity injuries treated or evaluated and released was 2,160,113 in 2020, a decrease of 24.5% from 2018 (n=2,861,830) and decrease of 25.2% from 2019 (n=2,888,782). The estimated number of patients with lower extremity injuries treated and admitted for hospitalization in 2020 was 247,412, an increase of 26.5% from 2018 (n=195,522) and increase of 10.3% from 2019 (n=224,225).

Conclusions: Product-related lower extremity injuries treated at US EDs declined by more than 20% when compared to 2018 and 2019. While the estimated number of patients treated or evaluated and released decreased in 2020, the estimated number of patients treated and admitted for hospitalization, suggesting more serious or complicated injuries, increased.


On January 20, 2020, the first laboratory-confirmed case of COVID-19, caused by infection with SARS-CoV-2, was reported in the United States (US).1 The World Health Organization (WHO) characterized the COVID-19 outbreak as a pandemic on March 11, 2020.2 The US declared COVID-19 a national emergency on March 13, 2020.3 To slow the spread of SARS-CoV-2, a number of states enacted stay-at-home orders and closed or restricted other facilities and businesses.2,4

Emergency department (ED) visits not related to COVID-19 declined in the US during the COVID-19 pandemic, particularly for certain populations and certain types of illness or injury.5-12 Thus, it might be expected that lower extremity injuries treated at EDs declined during the COVID-19 pandemic. The objective of this study was to describe lower extremity injuries treated at EDs in 2020 and compare them to previous years.

Methods

This study used data from the National Electronic Injury Surveillance System (NEISS) website (https://www.cpsc.gov/cgibin/NEISSQuery/home.aspx). Operated by the US Consumer Product Safety Commission (CPSC), the NEISS collects data on consumer product-related injuries from the EDs of approximately 100 hospitals as a probabilistic sample of the more than 5,000 hospitals with EDs in the US.13,14 Data are publicly available and de-identified; therefore, the study is exempt from institutional review board approval.

Cases were lower extremity injuries reported during 2018-2020. The NEISS database has two numeric fields (Body_Part and Body_Part_2) for coding as many as two body parts that were injured. Only those records with body part codes for the lower extremity [Knee; Leg, lower (not including knee or ankle); Ankle; Leg, upper; Foot; Toe] were included in the study. According to the NEISS Coding Manual, the Body_Part_2 field was added in 2018,14 although it appears the field was not used until 2019. Thus, 2018 records had only one lower extremity body part coded while 2019 and 2020 records can have as many as two lower extremity body parts coded. This needs to be taken into consideration when making comparisons between 2018 and 2020.

The variables examined were treatment year and month, patient age and sex, location of the incident, product involved, patient disposition, lower extremity body part, and diagnosis. The NEISS database uses four-digit product codes to code the product(s) involved in an injury. The list of product codes is available in the NEISS Coding Manual.14 Product codes are entered into the Product_1, Product_2, and Product_3 numeric fields in the NEISS database. The NEISS Coding Manual reports that the Product_3 field was added in 2018,14 but it appears the field was not used until 2019. Thus, 2018 records may have as many as two product codes while 2019 and 2020 records may have as many as three product codes. However, only 971 of the 2019 records and 1011 of the 2020 records included in the study had product codes in the Product_3 field, a small fraction of the records for those years included in the study. The 24 product codes most frequently reported during 2018-2020 combined were analyzed. The diagnosis is coded in the Diagnosis and Diagnosis_2 numeric fields. As with the Body_Part_2 field, the Diagnosis_2 field was added in 2018 but not used until 2019.14

The distribution of national injury estimates was determined for the variables for each year and the percent change in the estimates between 2018 and 2020 and between 2019 and 2020 were calculated. National injury estimates were calculated by summing the values in the Weight numeric field in the NEISS database.

Results

The total estimated number of injuries affecting any body part in the NEISS database in 2020 declined 21.2% from 2018 and 18.3% from 2019. The estimated number of lower extremity injuries in 2020 declined 20.8% from 2018 and 22.5% from 2019 (Table 1). The estimated number of lower extremity injuries during January and February 2020 was slightly higher than the estimated number of injuries in the corresponding months during the preceding two years then began to decline in March, reaching the lowest estimated number in April, and remained lower for May-December (Figure 1).

Table 1 shows the estimated number of lower extremity injuries by patient demographics. The estimated number of lower extremity injuries declined in 2020 for all age groups, with the exception being the 60 years or older age group increasing when compared to 2018. The percent decrease was greatest for patients age 13-19 years followed by those age 6-12 years. The estimated number of lower extremity injuries declined by a similar percent for both sexes.

Table 2 presents the estimated number of lower extremity injuries by location of incident and most commonly reported products involved. The estimated number of lower extremity injuries declined in 2020 for all of the most frequently reported locations, the only exception being street or highway injuries increasing when compared to 2018. The greatest percent of decline involved injuries occurring at school followed by a place of recreation or sports. The estimated number of lower extremity injuries declined in 2020 when compared to 2019 for 23 of the 24 most frequently reported products, the exception being an increase in skateboard injuries. Of the 23 products reporting declines in estimated injuries, the percent decline was greatest for soccer, football, dancing, and basketball.

Table 3 shows the distribution of lower extremity injuries by patient disposition, lower extremity body part, and diagnosis. The estimated number of injuries among patients treated or examined and released in 2020 declined by approximately one-quarter when compared to 2018 and 2019. In contrast, the estimated number of injuries among patients treated and admitted for hospitalization in 2020 increased when compared to the previous two years. Among the most frequently reported diagnoses, the percent decline in 2020 was greatest for strain or sprain, contusion or abrasion, and puncture, and lowest for fracture. The estimated number of laceration injuries in 2020 was similar to that in the previous two years.

Discussion

The estimated number of lower extremity injuries treated at EDs declined in 2020 by 20.8% when compared to 2018 and by 22.5% when compared to 2019, percents comparable to that observed for all product-related injuries. A number of studies have reported that ED visits not related to COVID-19 decreased in the US during the COVID-19 pandemic.5-12

The decrease in the estimated number of lower extremity injuries treated at EDs started in March 2020 and reached the lowest estimated number of injuries in April 2020. While the estimated number of injuries increased in May 2020, it still remained lower for the rest of 2020 than for the corresponding months in 2018 and 2019. The COVID-19 pandemic and US national emergency were both declared in March 2020, and states began to enact stay-at-home orders and close or restrict schools, businesses, and other facilities that month.2-4 In subsequent months, stay-at-home orders and closures and restrictions were lifted or modified, although this varied from state to state.2,4 The Centers for Disease Control and Prevention (CDC) has reported that US ED visits initially declined during March-April 2020, then increased through July 2020, but at lower levels than 2019, then declined again during December 2020-January 2021.5

There are various possible reasons for the decrease in lower extremity injuries treated at EDs during 2020. Fewer people may have been engaging in activities that might lead to injuries that would result in ED visits. Potentially serious injuries that may require treatment at EDs may have occurred, but the persons failed to seek care at an ED. Persons with less serious, nonemergency injuries may have decided to avoid EDs. Persons with injuries may have used alternatives to the ED such as visiting their primary care physician or using telemedicine.

While the estimated number of lower extremity injuries generally declined in 2020 among all age groups, the percent decline was greatest for patients age 13-19 years followed by those age 6-12 years. These age groups include children of school age. Because of the closure or other restrictions of schools, many children of these ages may have been unable to engage in activities at school that might have led to lower extremity injuries.

When the location of the incident was examined, the greatest percent of decline involved injuries occurring at school followed by a place of recreation or sports. Stay-at-home orders and the closure or restriction of schools, businesses, and other facilities, including parks and fitness centers, is a likely explanation for this reduction. Because of the stay-at-home orders, an increase in injuries that occurred at home might be expected. However, the estimated number of lower extremity injuries that occurred at home declined by approximately 16% in 2020.

The estimated number of almost all of the most commonly reported products in lower extremity injuries decreased in 2020 when compared to 2019, the only exception being an increase in skateboard injuries. The percent decrease in injuries was greatest for soccer, football, dancing, and basketball. The differences in the amount of injury decrease in 2020 by product, and the increase in skateboard injuries, may partly be due to differences in where the activity typically is performed and the number of participants typically involved. Many sports and other athletic activities, such as dancing, require specific locations, such as sports fields or courts or studios, and often involve multiple people in close proximity to one another. The closure or restriction of such facilities and the recommendation or requirement for social distancing made the participation in many sports more difficult during the COVID-19 pandemic. Skateboard injuries possibly increased because skateboarding does not require dedicated facilities and can be performed alone and outdoors. Many of the other most frequently reported products that involved more moderate declines in lower extremity injuries may be found or used at home.

The estimated number of injuries among patients treated or examined and released in 2020 declined by approximately 25% when compared to 2018 and 2019. In contrast, the estimated number of injuries among patients treated and admitted for hospitalization in 2020 increased when compared to 2018 and 2019. Injuries requiring hospitalization might be more serious or complicated than those where the patient is released from the ED. Patients requiring hospitalization may be less able to manage their injuries outside of EDs.

While the percent decline in 2020 was greatest for strain or sprain, contusion or abrasion, and puncture, it was lowest for fracture; moreover, the estimated number of laceration injuries in 2020 was similar to that in 2018 and 2019. Strains or sprains, contusions or abrasions, and punctures may be considered less serious injuries and may be more likely to be successfully treated at home or otherwise outside of a hospital. In contrast, fractures and lacerations may be considered more serious and require management at an ED.

This study has limitations. Inclusion of a case was based on coding of a lower extremity body part in the Body_Part and Body_Part_2 fields. As stated previously, the Body_Part_2 field was not used in 2018, limiting the ability to make comparisons between 2018 and 2020. Similar changes in coding fields affect the analyses of product and diagnosis.

In conclusion, the estimated number of product-related lower extremity injuries treated at US EDs declined approximately 20% in 2020, during the COVID-19 pandemic, when compared to 2018 and 2019. The change in the estimated number of injuries in 2020 varied by such factors as patient age, location of incident, product involved, patient disposition, and diagnosis.

Mathias B. Forrester, BS, is an independent researcher in Austin, Texas. Now retired, he previously performed public health research for various university and government programs for 33 years.

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