Examining Pediatric Orthopaedic Conditions and Risk Through the Childhood Opportunity Index: How Social Determinants of Health Can Affect Conditions and Patient Care

In two recent studies, Amanda McCoy, MD, MPH, assistant professor, orthopaedic surgery, UPMC Children’s Hospital of Pittsburgh, has used the Child Opportunity Index (COI) to examine how neighborhood conditions are associated with different pediatric orthopaedic conditions: in the first study, slipped capital femoral epiphysis (SCFE), and in the other, supracondylar humerus fractures.

A primary focus of Dr. McCoy’s research revolves around social determinants of health, and how these environmental, community, and societal factors can influence the nature, incidence, and risk for different orthopaedic conditions in children and adolescents, but also how they may directly affect patient care and outcomes.

“My research is focused on trying to understand how the environments in which children live influence the conditions and injuries that orthopaedic surgeons ultimately treat,” Dr. McCoy says. "One may think that bones and joints, how they develop and how they may be injured are not related to the built environment, but in reality, they are just as related to the large environment in which one lives as anything else is in the body.”

Using a Child-Specific Measure of Neighborhood Opportunity

The COI was developed specifically to characterize the neighborhood conditions and resources associated with healthy childhood development. COI incorporates 29 indicators spanning education, health and environmental conditions, and social and economic resources. Scores can be normalized nationally or within a metropolitan area and grouped into five levels ranging from very low to very high opportunity.

“We have started using the Child Opportunity Index for our research because it is specifically designed around factors that affect children. It captures much more than income or economic resources. It includes features of the built environment, educational resources, and other characteristics of a community that can influence long-term childhood outcomes,” Dr. McCoy says.

Higher Opportunity, Higher Supracondylar Fracture Rates

The supracondylar humerus fracture study included 2,097 patients age 18 years or younger who underwent surgical fixation at UPMC Children’s between 2010 and 2022. Using residential ZIP codes, the researchers assigned COI levels to individual patients and examined fracture rates across different levels of childhood opportunity. Because UPMC Children’s is the only pediatric hospital in the Pittsburgh metropolitan area, the researchers also conducted a separate analysis of 1,384 patients from the region to more accurately estimate fracture incidence.

Within the metropolitan cohort, supracondylar humerus fracture rates increased from 19.66 per 100,000 person-years among children living in the lowest COI quintile to 27.05 per 100,000 person-years in the highest. Each increase in COI quintile was associated with a 9% increase in fracture risk. Falls involving playground equipment are among the common mechanisms for these injuries in children.

“A recreational facility can exist within a community, but that does not necessarily mean every child has the same opportunity to use it. Neighborhood safety, parental work schedules, and the availability of supervision can all affect how much opportunity children have for outdoor play,” Dr. McCoy says. “Those differences in recreational activity may be part of what we are seeing in the fracture rates.”

Lower Childhood Opportunity and SCFE

In the study “Incidence of Slipped Capital Femoral Epiphysis Is Associated With Low Childhood Opportunity Index,” published in January 2026 in the Journal of Pediatric Orthopaedics, Dr. McCoy and colleagues applied the COI to slipped capital femoral epiphysis, an adolescent hip disorder in which the femoral head slips relative to the femoral neck through the proximal femoral growth plate.

Dr. McCoy became interested in examining social determinants associated with SCFE after researchers in the United Kingdom reported an association between SCFE and neighborhood deprivation. She and her colleagues wanted to determine whether a similar relationship could be identified in the Pittsburgh region using the COI.

The study found higher rates of SCFE among children living in lower-opportunity communities. Lower childhood opportunity also was associated with later presentation.

“With SCFE, we found that children from lower-opportunity communities had higher rates of the condition, which was consistent with findings previously reported using a socioeconomic deprivation index in the United Kingdom,” Dr. McCoy says. “The supracondylar fracture study shows a very different relationship with childhood opportunity.”

Dr. McCoy also is interested in whether differences in nutrition and bone health could contribute to the relationship, for example, whether vitamin D deficiency or supplementation may have an impact.

“I think SCFE involves more than the bone itself. Nutrition and bone health may be part of the relationship we are seeing, although that needs to be studied more directly,” Dr. McCoy says.

Different Conditions, Different Relationships With Childhood Opportunity

Viewed individually, the two studies examine distinct orthopaedic conditions with different etiologies and different patient populations. Dr. McCoy’s use of the same child-specific measure across both studies allows her to examine how community and environmental factors may relate differently to particular conditions.

“The findings go in opposite directions, but I think they both demonstrate that where a child lives and what is available within that community are related to what we see in pediatric orthopaedics,” Dr. McCoy says.

Dr. McCoy is continuing to use the COI to investigate other areas of pediatric orthopaedic care. A recently submitted study examined COI and femoral shaft fractures, the publication of which will occur in the future.

Dr. McCoy also has an interest in applying the COI to other conditions, including clubfoot, examining differences in bracing and recurrence over time. Because recurrence may occur years after initial correction, this research will require longer-term follow-up.

“Pediatric orthopaedic surgery is a very technical specialty, and much of our research has understandably focused on surgical treatments, which implant to use, which screw to use, or which technique produces a particular outcome,” Dr. McCoy says. “But our patients come to us from communities, and I want to look more broadly at how those environments relate to the conditions and injuries we treat so we can do more in terms of prevention and risk mitigation and ultimately provide more equitable and informed patient care.

Study References

Luck C, Armet G, Feder N, Wittman S, Ray K, McCoy A. Higher Child Opportunity Index is Associated With Supracondylar Humerus Fracture Rates in the Pediatric Population. J Pediatr Orthop. 2026. Online ahead of print.

McCoy AJ, Ray K, Wittman S, McClincy M. Incidence of slipped capital femoral epiphysis is associated with low childhood opportunity index. J Pediatr Orthop. 2026; 35(1): 49-56.