Accidental and nonaccidental femur fractures in children

Simultaneous traumatic bilateral femur fractures in the paediatric population: Case report

INTRODUCTION

Paediatric femur fractures are well described. Simultaneous bilateral femur fractures are a much more rare occurrence with limited literature on their incidence, treatment protocol and outcomes. This case report outlines the radiological and clinical outcomes of bilateral femur fractures which were managed surgically in our institution.

CASE REPORT

We report a 7 year old child that sustained bilateral femur fractures subsequent to an access gate falling on him. He was managed surgically with titanium elastic nailing on the left and a proximal femur locking plate for the right.

DISCUSSION

Bilateral femur fractures are rare and mostly due to motor vehicle accidents and falls. They can present with multiple comorbid injuries due to the high-energy accidents. The incidence and mean age of injury are unclear. The treatment of bilateral femur fractures in the paediatric population can be conservative or surgical depending on age and other factors.

CONCLUSION

Simultaneous traumatic bilateral femur fractures, although rare, have good clinical and radiological outcomes when treated conservatively or surgically, as is shown in our case.

Identifying Child Abuse in Patients With Femur Fractures Through Pathway Compliance: A Pilot Study

Background Child abuse is a significant cause of morbidity and mortality in children. A thorough history and physical exam is critical to identifying abuse. Standardized screening tools as well as clinical pathways can assist with identifying patients who may have an injury secondary to abuse. There are varied recommendations for the upper age in which to routinely evaluate pediatric patients for child abuse. Objectives The primary objective of this study was to describe the outcomes of the implementation of an evidence-based clinical pathway for suspected non-accidental trauma for all pediatric patients aged five years and under presenting with a femur fracture. This pathway includes orders for imaging, labs, and consults. In addition, the characteristics of this population and the findings were described. Methods A retrospective study of patients at a single institution who met the National Trauma Data Standard registry inclusion criteria and had a femur fracture was performed. Variables analyzed included age, demographics, mechanism and location of injury, admission status and service, injury severity, hospital characteristics, and discharge status. Patients with a metabolic bone disease were excluded. Results There were 200 patients who met the inclusion criteria. Thirty-two patients had a diagnosis of confirmed or suspected child abuse. While all 32 patients had a skeletal survey performed, only 23 (71.9%) had the complete workup per the clinical pathway, and 21 (65.6%) had a diagnosis of confirmed child abuse. Conclusion Clinical pathways are established to provide the standardization of clinical assessments and interventions; however, this process relies on a single individual to make a judgment determining whether or not to implement the pathway. Children presenting to an emergency department with confirmed or suspected child abuse are a vulnerable population. A child abuse diagnosis is a clinical judgment; however, clinical pathways aid in the diagnosis in hopes to stop any further abuse. For a pathway to be successful, each step needs to be addressed.

Investigating the Determinants of Nonaccidental Trauma Evaluation in Pediatric Femur Fractures

BACKGROUND

Femoral fractures in children have the highest probability for abuse after skull fractures and humeral shaft fractures. However, the reported proportion of pediatric femur fractures that result from nonaccidental trauma (NAT) varies in the literature from 2% to 60%. The purpose of this study was to determine the patient characteristics associated with a physician's decision to conduct a NAT workup and challenge universal clinical practice guidelines stating that all children younger than 3 years with a diaphyseal femur fracture be evaluated for NAT.

METHODS

A retrospective review was conducted on patients aged 0 to 36 months diagnosed with a femur fracture between January 1, 2004, and April 9, 2019, at our institution. NAT was defined as a diagnosis of trauma that was nonaccidental in the medical chart after a positive workup by skeletal survey, ophthalmological examination, or other appropriate referral made by the institution's child abuse and neglect team. Patients with incomplete medical records were excluded.

RESULTS

A total of 299 patients were identified, and 22 were excluded. 71% (197/277) were screened for NAT. Patients younger than 1 year were significantly more likely to undergo a NAT workup ( P = 0.009; Odds Ratio [OR], 2.3; 95% CI, 1.2 to 4.4) and receive a positive result from the NAT workup ( P < 0.0005; OR, 11.3; 95% CI, 4.6 to 27.4). Additional injuries were also a significant predictor of a positive NAT workup ( P < 0.001; OR, 5.3; 95% CI, 2.4 to 11.9). Patient race/ethnicity, sex, and fracture type were not markedly associated with the physician's decision to conduct a NAT workup.

CONCLUSIONS

Infants younger than 1 year with a femur fracture and children younger than 3 years presenting with a femur fracture and another injury are at increased risk of possible NAT. While clinical practice guidelines may minimize racial bias in NAT evaluation, this study demonstrates that universal NAT workups for walking-age children in the absence of other evidence of abuse may be unnecessary.

LEVEL OF EVIDENCE

This is a Level III retrospective cohort study.

Femoral fractures and abuse in children under 36 months old: a Swiss case series

Abuse should be suspected in infant femoral fractures without significant trauma, especially if the child is non-ambulatory. Review the epidemiological and radiological characteristics of femoral fractures in children under 36 months old to identify those potentially related to child abuse. Cases involving 102 patients presenting with 103 femoral fractures between January 1990 and December 2020 were investigated, paying close attention to mechanisms of injury, fracture patterns, and their possible relations to child abuse. The annual incidence of femoral fractures in patients under 36 months old was estimated at 24.6 per 100 000; the incidence in infants under 13 months was significantly higher than among children between 13 and 36 months old. Most infants under 13 months suffered from transverse or oblique metaphyseal/diaphyseal fractures (93.2%), whereas 67.8% of older children presented with spiral shaft fractures. Data confirmed child abuse in 4.9% of all patients (one with bilateral fractures); femoral fractures were incompatible with their reported mechanisms of injury in 31 patients (30.4%), whereas 12 fractures (11.8%) occurred in unexplained circumstances. More than 50% of femoral fractures occurred with low-energy trauma. The difference in patterns according to patients' ages suggested different mechanisms of trauma in ambulatory and non-ambulatory infants. Confirmed abuses and unclear or inconsistent mechanisms of trauma, raised potential total child abuse cases to 47.1% of our cohort. Level of evidence: Level IV.

Simultaneous bilateral femoral fracture in children

Introduction

Bilateral femoral fractures in children (BFFC) are an uncommon condition. Only a few cases were reported in the literature. The frequency and outcome in low-setting facilities are unknown. This study aims to describe our experience in managing BFFC.

Patients and Methods

A 10-year ongoing study spanning from 2010 to 2020 was held in a level-1 paediatric facility. We included all cases of BFFC on a bone-free disease with at least 10 months of follow-up time. Data were collected and analysed with statistical software.

Results

A total of eight patients with ten BFFC were collected. It involved mainly boys (n = 7/8) with median age of 8 years. Mechanism of injury were a road traffic accident (n = 4), a fall from height (n = 3), and been crushed by a falling wall (n = 1). Associated injuries were frequent (n = 6/8). Patients were managed nonoperatively with spica cast (n = 5) and by elastic intramedullary nails (n = 3). After 6.11 years of mean follow-up time, all fractures healed. The outcome was excellent and good in 7 cases. One patient sustained knees stiffness.

Conclusion

Non-operative management of BFFC showed satisfactory outcomes. Early surgical care must be developed in our low-income settings to reduce in-hospital stay and encourage early weight-bearing.

Orthopedic manifestations of child abuse

Child abuse is common in the United States but is often undetected. The incidence of this form of abuse is difficult to quantify, but children with a history of abuse are at risk of chronic health conditions. Medical providers are in the unique position of triaging trauma patients and differentiating unintentional from abusive trauma, as well as having the important position of being a mandated reporter of abuse in all states. Obtaining a detailed history and screening for risk factors can help identify children at risk of abuse. Certain orthopedic injuries may be related to abuse, which may trigger clinical suspicion and lead to further workup or intervention. By increasing awareness, through medical provider education and increased screening, earlier detection of abuse may prevent more serious injuries and consequences. This review evaluates current literature regarding the orthopedic manifestations of child abuse in hopes of increasing medical provider awareness. IMPACT: Child abuse is common in the United States but often remains undetected. Medical professionals are in the unique position of evaluating trauma patients and identifying concerns for abusive injuries. Certain orthopedic injuries may raise concern for abuse triggering clinical suspicion and further workup or intervention.

Paediatric femur fractures-the value of contextual information on judgement in possible child abuse cases: are we bias?

The majority of paediatric femur fractures result from accidental trauma; however, it is important to consider non-accidental trauma, especially in pre-ambulatory children. We study whether irrelevant contextual information subconsciously influences conclusions of healthcare professionals with respect to whether observations provide evidence for non-accidental trauma. A survey with nine radiographs of femur shaft fractures was designed. Two different clinical histories (vignettes) with contextual information were designed, non-abuse versus abuse context. One of both vignettes was randomly assigned to the radiograph shown to the participant, followed by a question with a 5-point answer scale, which represents a verbal expression of the likelihood ratio of the fracture regarding a non-accidental versus accidental cause. Participants were medical residents and staff members of different specialties from several Dutch hospitals. A total of 172 participants responded. The reported evidential strength of the vignettes with a non-abuse context was 0.19 (n = 784; 95%CI 0.10-0.28) and for the abuse context 0.94 (n = 764; 95%CI 0.86-1.02; p < 0.001). Women reported a stronger evidential strength than men, but both were influenced by context. Emergency department and paediatric doctors were more likely to decide that non-accidental trauma was the cause; paediatric radiologists were the least likely. Experience in years of practice and current function did not prevent participants from being bias.Conclusion: This study shows that the interpretation of medical results by healthcare professionals can be influenced by contextual information, such as low income and marital status, which are irrelevant to the decision as to whether abuse might have occurred. Given the same information about an injury, women, emergency department and paediatric doctors were more likely to decide that non-accidental trauma was the cause, while paediatric radiologists were least likely to decide this outcome. It is important to prevent contextual influence as much as possible, by recognizing it and implementing a management contextual information procedure. What is Known: • Contextual information is of possible influence on healthcare professionals in identifying non-accidental trauma. • Increased working experience is thought to be protective against this influence. What is New: • Contextual information influenced the interpretation of medical results by healthcare professionals regardless of work experience. • The interpretation of medical results by healthcare professionals is influenced by both affirmative and negative contextual information.

Can we increase detection? A nationwide analysis of age-related fractures in child abuse

PURPOSE

The purpose of this study was to stratify fractures associated with child abuse in relation to the child's age.

METHODS

The Kids' Inpatient Database (1997-2012) was queried for all patients (<18 years old) with a diagnosis of fracture and child abuse. The primary outcome was age-related determinants of fracture distribution. Chi-squared analysis was used for statistical analysis where appropriate, with significance set at p < 0.05.

RESULTS

More than 39,000 children were admitted for child abuse, and 26% sustained fractures. Most were infants (median age 0 year [IQR 0-1]). 28% sustained multiple fractures, and 27% had skull fractures. By age, infants had the highest rate of multiple fractures (33% vs 16% 1-4 years), and the highest rate of closed skull fractures (33% vs 21% ages 1-4), while adolescents had more facial fractures (43% vs 11% ages 9-12), all p < 0.001. Multiple rib fractures were more commonly seen in infants (28% vs 8% ages 1-4), while children 5-8 years had the highest rates of clavicular fractures (7% vs 3% in infants), all p < 0.001.

CONCLUSION

Age-related fracture patterns exist and may be due to changing mechanism of abuse as a child grows. These age-related fracture patterns can help aid in healthcare detection of child abuse in hopes to thwart further abuse.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Identifying Maltreatment in Infants and Young Children Presenting With Fractures: Does Age Matter?

OBJECTIVES

Child abuse is a significant cause of morbidity and mortality in preverbal children who cannot explain their injuries. Fractures are among the most common injuries associated with abuse but of themselves fractures may not be recognized as abusive until a comprehensive child abuse evaluation is completed, often prompted by other signs or subjective features. We sought to determine which children presenting with rib or long-bone fractures should undergo a routine abuse evaluation based on age.

METHODS

A systematic review searching Ovid, PubMed/Medline, Scopus, and CINAHL from 1980 to 2020 was performed. An evidence-based framework was generated by a consensus panel and applied to the results of the systematic review to form recommendations. Fifteen articles were suitable for final analysis.

RESULTS

Studies with comparable age ranges of subjects and sufficient evidence to meet the determination of abuse standard for pediatric patients with rib, humeral, and femoral fractures were identified. Seventy-seven percent of children presenting with rib fractures aged less than 3 years were abused; when those involved in motor vehicle collisions were excluded, 96% were abused. Abuse was identified in 48% of children less than 18 months with humeral fractures. Among those with femoral fractures, abuse was diagnosed in 34% and 25% of children aged less than 12 and 18 months, respectively.

CONCLUSION

Among children who were not in an independently verified incident, the authors strongly recommend routine evaluation for child abuse, including specialty child abuse consultation, for: 1) children aged less than 3 years old presenting with rib fractures and 2) children aged less than 18 months presenting with humeral or femoral fractures (Level of Evidence: III Review).

The "New Science" of Abusive Head Trauma

Claims that new science is changing accepted medical opinion about abusive head injury have been made frequently in the media, legal publications and in legal cases involving abusive head trauma (AHT). This review analyzes recently published scientific articles about AHT to determine whether this new information has led to significant changes in the understanding, evaluation and management of children with suspected AHT. Several specific topics are examined: serious or fatal injuries from short falls; specificity of subdural hematoma for severe trauma; biomechanical explanations for findings; the specificity of retinal hemorrhages; the possibility of cerebral sinus thrombosis presenting with signs similar to AHT; and whether vaccines can produce such findings. We conclude: a) that the overwhelming weight of recent data does not change the fundamental consensus b) that abusive head trauma is a significant source of morbidity and mortality in children c) that subdural hematomas and severe retinal hemorrhages are commonly the result of severe trauma d) that these injuries should prompt an evaluation for abuse when identified in young children without a history of such severe trauma and e) that short falls, cerebral sinus thrombosis and vaccinations are not plausible explanations for findings that raise concern for abusive head trauma.

Femur loading in feet-first fall experiments using an anthropomorphic test device

BACKGROUND

Femur fractures are a common orthopedic injury in young children. Falls account for a large portion of accidental femur fractures in young children, but there is also a high prevalence of femur fractures in child abuse, with falls often provided as false histories. Objective information regarding fracture potential in short distance fall scenarios may aid in assessing whether a child's injuries are the result of abuse or an accidental fall. Knowledge of femur loading is the first step towards understanding likelihood of fracture in a fall.

OBJECTIVE

Characterize femur loading during feet-first free falls using a surrogate representing a 12-month-old child.

METHODS

The femur and hip joint of a surrogate representing a 12-month-old were modified to improve biofidelity and measure femur loading; 6-axis load cells were integrated into the proximal and distal femur. Femur modification was based upon CT imaging of cadaveric femurs in children 10-14 months of age. Using the modified 12-month-old surrogate, feet-first free falls from 69 cm and 119 cm heights onto padded carpet and linoleum were conducted to assess fall dynamics and determine femur loading. Femur compression, bending moment, shear and torsional moment were measured for each fall.

RESULTS

Fall dynamics differed across fall heights, but did not substantially differ by impact surface type. Significant differences were found in all loading conditions across fall heights, while only compression and bending loads differed between carpet and linoleum surfaces. Maximum compression, bending, torsion and shear occurred in 119 cm falls and were 572 N, 23 N-m, 11 N-m and 281 N, respectively.

CONCLUSIONS

Fall dynamics play an important role in the biomechanical assessment of falls. Fall height was found to influence both fall dynamics and femur loading, while impact surface affected only compression and bending in feet-first falls; fall dynamics did not differ across carpet and linoleum. Improved pediatric thresholds are necessary to predict likelihood of fracture, but morphologically accurate representation of the lower extremity, along with accurate characterization of loading in falls are a crucial first step.

An Evaluation of Seasonal Variation of Nonaccidental Fractures in Children Less Than 1 Year of Age

The aim of this study was to identify seasonal variation in nonaccidental injury (NAI) in children <1 year of age. Fifty consecutive patients age ≤12 months with a fracture were identified between January 2010 and June 2012. Patients' records were reviewed for demographic, clinical, and radiographic data. Zip code was used to collect socioeconomic data. Out of 50 patients included in the study, fractures in 16 (32%) patients were reported for abuse. NAI was reported in 2/13 (15%) fracture cases presenting in the spring, 5/6 (83%) in summer, 6/15 (40%) in autumn, and 3/14 (21%) in winter. The ratio of NAI to accidental injury was highest in the summer. Presentation in summer was associated with NAI ( P < .001). In addition, NAI was associated with parental unemployment, single parents, and lower socioeconomic status ( P < .001). Seasonal variation occurred, and the most common season for NAI was the summer; also, NAI in children <1 year of age was associated with parental unemployment, single parent, and poverty.

Identifying non-accidental fractures in children aged <2 years

PURPOSE

Fractures are the second most common presentation of child abuse following soft-tissue bruising and burns. It is often difficult to determine potential abuse in a child presenting with a non-rib fracture(s) and without soft-tissue injuries.

METHODS

One hundred and fifteen consecutive patients aged ≤2 years who presented with a fracture between January 2010 and June 2012 to our emergency department (ED) or pediatric fracture clinic were retrospectively analyzed. Statistical analyses were carried out for non-accidental fractures based on age (<1 year vs 1-2 years), location of presentation (ED vs pediatric fracture clinic), type of long bone fracture, number of fractures, and patient demographics.

RESULTS

Fractures in 19 of 115 (17 %) patients were reported as non-accidental trauma (NAT). Eighty (70 %) of the 115 patients first reported to the ED. Thirty-two percent of fractures in children aged <1 year and 5 % of fractures in children aged 1-2 years were reported as NAT (p < 0.001). Sixteen of 19 (84 %) patients reported for abuse had multiple fractures; 15 of these patients were aged <1 year. Eight of 11 (73 %) reported femoral fractures were transverse fractures. Corner fractures (12) only occurred in children aged <1 year and never occurred in isolation; all of them were reported as NAT. Four of 60 patients (7 %) with commercial insurance and 15 of 55 patients (28 %) with Medicaid were reported as NAT.

CONCLUSIONS

Age less than 1 year, multiple fractures, corner fractures, transverse fractures, and covered by Medicaid were the most common factors associated with reporting of NAT.

Testing for Abuse in Children With Sentinel Injuries

OBJECTIVE

Child physical abuse is commonly missed, putting abused children at risk for repeated injury and death. Several so-called sentinel injuries have been suggested to be associated with high rates of abuse, and to imply the need for routine testing for other, occult traumatic injuries. Our objective was to determine rates of abuse evaluation and diagnosis among children evaluated at leading children's hospitals with these putative sentinel injuries.

METHODS

This is a retrospective secondary analysis of the Pediatric Health Information System database. We identified 30 355 children with putative sentinel injuries. We measured rates of abuse diagnosis and rates of testing commonly used to identify occult injuries.

RESULTS

Among all visits for children <24 months old to Pediatric Health Information System hospitals, the rate of abuse diagnosis was 0.17%. Rates of abuse diagnosis for children with at least 1 putative sentinel injury ranged from 3.5% for children <12 months old with burns to 56.1% for children <24 months with rib fractures. Rates of skeletal survey and other testing that can identify occult traumatic injury were highly variable between centers and for different injuries.

CONCLUSIONS

Several putative sentinel injuries are associated with high rates of physical abuse. Among eligible children with rib fracture(s), abdominal trauma, or intracranial hemorrhage, rates of abuse were more than 20%. Future work is warranted to test whether routine testing for abuse in these children can improve early recognition of abuse.

Prevalence of abuse among young children with femur fractures: a systematic review

BACKGROUND

Clinical factors that affect the likelihood of abuse in children with femur fractures have not been well elucidated. Consequently, specifying which children with femur fractures warrant an abuse evaluation is difficult. Therefore the purpose of this study is to estimate the proportion of femur fractures in young children attributable to abuse and to identify demographic, injury and presentation characteristics that affect the probability that femur fractures are secondary to abuse.

METHODS

We conducted a systematic review of published articles written in English between January 1990 and July 2013 on femur fracture etiology in children less than or equal to 5 years old based on searches in PubMed/MEDLINE and CINAHL databases. Data extraction was based on pre-defined data elements and included study quality indicators. A meta-analysis was not performed due to study population heterogeneity.

RESULTS

Across the 24 studies reviewed, there were a total of 10,717 children less than or equal to 60 months old with femur fractures. Among children less than 12 months old with all types of femur fractures, investigators found abuse rates ranging from 16.7% to 35.2%. Among children 12 months old or greater with femur fractures, abuse rates were lower: from 1.5% - 6.0%. In multiple studies, age less than 12 months, non-ambulatory status, a suspicious history, and the presence of additional injuries were associated with findings of abuse. Diaphyseal fractures were associated with a lower abuse incidence in multiple studies. Fracture side and spiral fracture type, however, were not associated with abuse.

CONCLUSIONS

Studies commonly find a high proportion of abuse among children less than 12 months old with femur fractures. The reported trauma history, physical examination findings and radiologic results must be examined for characteristics that increase or decrease the likelihood of abuse determination.

Pediatric bed fall computer simulation model: parametric sensitivity analysis

Falls from beds and other household furniture are common scenarios that may result in injury and may also be stated to conceal child abuse. Knowledge of the biomechanics associated with short-distance falls may aid clinicians in distinguishing between abusive and accidental injuries. In this study, a validated bed fall computer simulation model of an anthropomorphic test device representing a 12-month-old child was used to investigate the effect of altering fall environment parameters (fall height, impact surface stiffness, initial force used to initiate the fall) and child surrogate parameters (overall mass, head stiffness, neck stiffness, stiffness for other body segments) on fall dynamics and outcomes related to injury potential. The sensitivity of head and neck injury outcome measures to model parameters was determined. Parameters associated with the greatest sensitivity values (fall height, initiating force, and surrogate mass) altered fall dynamics and impact orientation. This suggests that fall dynamics and impact orientation play a key role in head and neck injury potential. With the exception of surrogate mass, injury outcome measures tended to be more sensitive to changes in environmental parameters (bed height, impact surface stiffness, initiating force) than surrogate parameters (head stiffness, neck stiffness, body segment stiffness).

Treatment of pediatric femur fractures with the Pavlik harness: multiyear clinical and radiographic outcomes

BACKGROUND

Femur fractures account for 1.4% to 1.7% of all pediatric fractures. The use of the Pavlik harness has been described for infants; however, previous reports have included only short-term follow-up. This study describes the multiyear clinical and radiographic results from patients younger than 6 months of age treated with a Pavlik harness.

METHODS

The clinical and radiographic records were reviewed for all children under the age of 6 months who were treated with a Pavlik harness for an isolated femoral shaft fracture at a level 1 pediatric trauma center. Radiographs were obtained at final follow-up, as well as a standing full-length anteroposterior scanogram. Clinical examination was completed and inquiry regarding patient activity limitations, complications of treatment, and overall parent/provider satisfaction was made.

RESULTS

Ten patients with 10 fractures met inclusion criteria. The average age of the patients at the time of injury was 2.2 months. The average duration of Pavlik harness treatment was 43 days (range, 31 to 54 d). The average age at final follow-up was 5.2 years (range, 2.6 to 7.3 y). At final follow-up, average angulation was 3 degrees valgus (range, 0 to 8 degrees) and 5 degrees procurvatum (range, 0 to 24 degrees). Only 1 patient had a measurable leg-length discrepancy of 7 mm at final follow-up. There were no complications noted.

CONCLUSIONS

It is felt that pediatric patients have a significant potential for bone remodeling and that any angulation at the time of fracture union will remodel. Our study supports this notion as the final angulation at follow-up averaged 3 degrees valgus and 5 degrees procurvatum. In the patient group presenting with >20 degrees of angulation at the time of injury, final angulation averaged 5 degrees valgus and 11 degrees procurvatum. Treatment with the Pavlik harness provides for excellent clinical outcomes with a minimal complication rate. However, some patients, especially those presenting with a high degree of angulation, may have some degree of persistent radiographic angulation.

Assessment of injury potential in pediatric bed fall experiments using an anthropomorphic test device

Falls from beds and other furniture are common scenarios provided to conceal child abuse but are also common occurrences in young children. A better understanding of injury potential in short-distance falls could aid clinicians in distinguishing abusive from accidental injuries. Therefore, this study investigated biomechanical outcomes related to injury potential in falls from beds and other horizontal surfaces using an anthropomorphic test device representing a 12-month-old child. The potential for head, neck, and extremity injuries and differences due to varying impact surfaces were examined. Linoleum over concrete was associated with the greatest potential for head and neck injury compared to other evaluated surfaces (linoleum over wood, carpet, wood, playground foam). The potential for severe head and extremity injuries was low for most evaluated surfaces. However, results suggest that concussion and humerus fracture may be possible in these falls. More serious head injuries may be possible particularly for falls onto linoleum over concrete. Neck injury potential in pediatric falls should be studied further as limitations in ATD biofidelity and neck injury thresholds based solely on sagittal plane motion reduce accuracy in pediatric neck injury assessment. In future studies, limitations in ATD biofidelity and pediatric injury thresholds should be addressed to improve accuracy in injury potential assessments for pediatric short-distance falls. Additionally, varying initial conditions or pre-fall positioning should be examined for their influence on injury potential.

Characteristics of femur fractures in ambulatory young children

OBJECTIVES

To determine and identify the characteristics and circumstances of femur fractures in ambulatory young children.

DESIGN AND SETTING

Retrospective review of 203 ambulatory children, between 1 and 5 years old, presenting with femur fractures to an urban paediatric hospital over a 10-year period. χ(2) And Student's t test were employed for statistical analysis.

RESULTS

The mean age was 36.6 months, with 155 (76.2%) being male. The most frequent mechanism of injury was fall from a height (n=62, 30.5%). The highest number of injuries occurred in 2-3-year-olds. The most common history in 1-2-year-olds was stumbling on/over something causing a fall. For 4-5 year olds it was road traffic accidents. Other additional physical findings were infrequent (14.3%) and not suspicious of inflicted injury. Child protective services concluded three of the cases to be likely non-accidental, and four cases were inconclusive but requiring close follow-up. Of these seven children, six occurred in 1-2-year-olds. No distinguishing feature was noted in fracture type or location.

CONCLUSIONS

Femur fractures can occur with low velocity injury whether from a short fall or twisting/stumbling injury in young healthy ambulatory children.

The incidence of fractures in children under the age of 24 months--in relation to non-accidental injury

INTRODUCTION

Fractures in children are the second most common presentation of child abuse. In younger children, especially in those less than 18 months, fractures should be considered suspicious of a non-accidental injury (NAI). Risk factors associated for abuse are: age younger than 12 months, non-ambulatory status, delayed presentation, unknown or inconsistent history of mechanism of injury, and presence of any other injuries. Our objective was to identify the incidence of fractures in children below the age of 24 months who presented to our institution's Emergency Department (ED), and identify which cases should arouse suspicion around possible NAI.

METHODS

A 2 year retrospective analysis was carried out of our ED and hospital notes from 2007 to 2008, of all children under the age of 24 months who presented with a fracture of any description to the ED. The study looked at the patients age (months) and gender, the site and type of fracture, whether the patient was hospitalised or discharged from the ED, if any concern was reported or a child protection referral was made, and also the area of the city the child was from.

RESULTS

In 2007-2008 there was an incidence of 53 fractures per 10,000 children less than 2 years. The proportion increased with age with femur and skull fractures found in the youngest age category being associated with a referral to the child protection services. An unclear history regarding mechanism of injury was also noted in a high proportion of referrals. In 34% of patients the time interval was not recorded, a crucial risk factor in NAI.

CONCLUSION

Age is a strong determinant when accessing NAI and a non-ambulant child presenting with a femur or skull fracture should be regarded highly suspicious of NAI. The time interval between the injury and presentation to the ED must be recorded in all notes when assessing a child for NAI.

Paediatric bed fall computer simulation model development and validation

Falls from beds and other household furniture are common scenarios stated to conceal child abuse. Knowledge of the biomechanics associated with short-distance falls may aid clinicians in distinguishing between abusive and accidental injuries. Computer simulation is a useful tool to investigate injury-producing events and to study the effect of altering event parameters on injury risk. In this study, a paediatric bed fall computer simulation model was developed and validated. The simulation was created using Mathematical Dynamic Modeling(®) software with a child restraint air bag interaction (CRABI) 12-month-old anthropomorphic test device (ATD) representing the fall victim. The model was validated using data from physical fall experiments of the same scenario with an instrumented CRABI ATD. Validation was conducted using both observational and statistical comparisons. Future parametric sensitivity studies using this model will lead to an improved understanding of relationships between child (fall victim) parameters, fall environment parameters and injury potential.

Suspected nonaccidental trauma and femoral shaft fractures in children

The question of suspected nonaccidental trauma as a possible cause of injury for femoral shaft fractures in children is a troubling but common issue facing orthopedic surgeons. The purpose of this study is to analyze femoral shaft fractures at a major pediatric level I trauma center in a large metropolitan area over a 5-year period to determine the incidence of suspected nonaccidental trauma and the risk factors associated with that diagnosis. This study is a retrospective review of all children younger than 5 years at a large trauma center in a southwestern metropolitan area who presented with a femoral shaft fracture. Patient charts were reviewed to determine demographics, mechanism of injury, and fracture type. Referrals to social work and Child Protective Services were also reviewed to determine an overall incidence of suspected nonaccidental trauma.Over the 5-year study period, 137 patients presented to our institution with a femoral shaft fracture. Mean patient age at the time of injury was 2.2 years (range, 1 month to 4 years). Overall, 43 patients with a mean age of 1.8 years were determined to have injuries suspicious of nonaccidental trauma and were referred to Child Protective Services, giving an overall incidence of 31%. Age younger than 1 year was a highly significant risk factor for suspected nonaccidental trauma. Of the 20 children younger than 1 year, 18 (90%) were referred to Child Protective Services, comprising 42% of those children suspicious of nonaccidental trauma. The presence of either Medicaid or no insurance was a highly statistically significant risk factor for suspected nonaccidental trauma.

Femur fractures in the pediatric population: abuse or accidental trauma?

BACKGROUND

Child abuse represents a serious threat to the health and well-being of the pediatric population. Orthopaedic specialists will often become involved when child abuse is suspected as a result of the presence of bony injury. Distinguishing abuse from accidental trauma can be difficult and is often based on clinical suspicion.

QUESTIONS/PURPOSES

We sought to determine whether accidental femur fractures in pediatric patients younger than age 4 could be distinguished from child abuse using a combination of presumed risk factors from the history, physical examination findings, radiographic findings, and age.

METHODS

We searched our institution's SCAN (Suspected Child Abuse and Neglect) and trauma databases. We identified 70 patients in whom the etiology of their femur fracture was abuse and compared that group with 139 patients who had a femur fracture in whom accidental trauma was the etiology.

RESULTS

A history suspicious for abuse, physical or radiographic evidence of prior injury, and age younger than 18 months were risk factors for abuse. Patients with no risk factors had a 4% chance, patients with one risk factor had a 29% chance, patients with two risk factors had an 87% chance, and patients with all three risk factors had a 92% chance of their femur fracture being a result of abuse.

CONCLUSIONS

Clinicians can use this predictive model to guide judgment and referral to social services when seeing femur fractures in very young children in the emergency room.

LEVEL OF EVIDENCE

Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

The epidemiology of nonaccidental trauma in children

BACKGROUND

Abuse of children is abhorrent in Western society and, yet, is not uncommon. Nonaccidental trauma (NAT) is the result of a complex sociopathology. Not all of the causative factors of NAT are known, many are incompletely described, not all function in each case, and many are secondary to preexisting pathology in other areas.

QUESTIONS/PURPOSES

We therefore addressed the following questions in this review: (1) what is the general incidence of NAT; (2) what factors are intrinsic to the abused child, family, and society; and (3) what orthopaedic injuries are common in NAT?

METHODS

We searched Medline, Medline In Process & Other Non-Indexed Citations, and Embase using OVID. Only one article fit our inclusion criteria; therefore, this is a descriptive generalized review of the epidemiology of NAT.

RESULTS

The general incidence of NAT ranges from 0.47 per 100,000 to 2000 per 100,000. Younger children are at greater risk of NAT than older children. Parents are often the perpetrators of the abuse. Rib fractures are highly indicative of NAT in young children.

CONCLUSIONS

It is important to consider child, family, and societal factors when confronted with suspicions of child abuse. Our review demonstrates the currently limited information on the true incidence of NAT. To determine a much more accurate incidence of NAT, there needs to be a population-based surveillance program conducted through primary care providers.

Child abuse and the legal system: the orthopaedic surgeon's role in diagnosis

BACKGROUND

Orthopaedic surgeons have unique training and experience in diagnosis of fractures, both accidental and nonaccidental. That experience is valuable in identifying physical child abuse and in avoiding false accusations or convictions. Both aspects are important to the welfare of children and their families. The events that follow a report of child abuse are outside the training and experience of most orthopaedic surgeons.

QUESTIONS/PURPOSES

What process follows a report of suspected child abuse? What unexpected outcomes or results occur in this process? Are medical conclusions used in this process consistent with the state of our knowledge?

METHODS

The child abuse legal process is described as experienced by one orthopaedic surgeon. Examples of unexpected problems that occurred in cases that went to trial are described.

CONCLUSIONS

Inappropriate outcomes can result from incomplete or incorrectly applied information. The input of the orthopaedic surgeon is often needed to provide the best information available to ensure that the best interests of the child and the family are protected. Working within a hospital team is the preferred method, but direct courtroom testimony is sometimes necessary.

Unexplained fractures: child abuse or bone disease? A systematic review

BACKGROUND

Child abuse and neglect (CAN) is a serious problem that has major implications for the welfare of the child involved. Unexplained fractures are of particular concern to the orthopaedic surgeon, who must often consider alternative diagnoses to CAN.

QUESTIONS/PURPOSES

We therefore (1) determined which bone diseases most commonly mimic CAN; (2) what types of osteogenesis imperfecta (OI) are most commonly confused with CAN and why; and (3) what specific findings in OI and bone disease render a mistaken diagnosis of CAN more likely.

METHODS

A systematic review of the literature was performed. We identified studies that compared cases of CAN with cases in which patients had bone disease that resulted in an unexplained fracture. We also included studies in which patients with fractures resulting from underlying bony pathology were misclassified as CAN and were subsequently reclassified as bone disease as a result of further investigation. Our search netted only five studies that directly compared and contrasted CAN with metabolic or genetic bone disease in the same study.

RESULTS

The published literature suggests OI is most frequently confused with CAN, although metaphyseal dysplasia, disorders of phosphate metabolism, and temporary brittle bone disease are also documented in the literature identified by our search. Difficulty in differentiating these bony diseases from CAN stems from ambiguity in the history and physical examination at the time of presentation.

CONCLUSIONS

Bone disease is a diagnosis of exclusion in the differential diagnosis of CAN.

The radiographic approach to child abuse

BACKGROUND

Osseous injuries are a major facet of child abuse and in most patients radiographic imaging plays a major role in diagnosis. While some injuries are typically produced as a result of excessive and inappropriate force other injuries are nonspecific in terms of their causation, but become suspicious when the history provided by the caretakers is inconsistent with the type of injury produced.

QUESTIONS/PURPOSES

I detail the radiographic imaging of the more characteristic of the highly specific injuries, discuss the major issues that relate to some moderate- or low-specificity injuries, and describe several diseases that mimic abuse.

METHODS

A review of the current and recent literature focused on the radiographic imaging of child abuse was performed by searching the National Library of Medicine database at pubmed.gov. Keywords used included: radiology, fracture, child abuse, and/or nonaccidental trauma.

RESULTS

Injuries that are highly specific for the diagnosis of abuse include metaphyseal corner fractures, posteromedial rib fractures, and sternal, scapular, and spinous process fractures. Lesions of moderate specificity include, among other injuries, multiple fractures of various ages and epiphyseal separations. Long-bone fractures and clavicular fractures, while common, are of low specificity. In addition to the appropriate accurate diagnosis of these injuries, several diseases and syndromes may mimic abuse due to the similarity in the radiographic picture.

CONCLUSIONS

Stratification of fractures sustained in child abuse according to specificity and an understanding of the several diseases that mimic abuse are helpful in the accurate diagnosis of child abuse.

LEVEL OF EVIDENCE

Level V, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Pediatric short-distance household falls: biomechanics and associated injury severity

OBJECTIVES

Short-distance household falls are a common occurrence in young children, but are also a common false history given by caretakers to conceal abusive trauma. The purpose of this study was to determine the severity of injuries that result from accidental short-distance household falls in children, and to investigate the association of fall environment and biomechanical measures with injury outcomes.

METHODS

Children aged 0-4 years who presented to the Emergency Department with a history of a short furniture fall were included in the study. Detailed case-based biomechanical assessments were performed using data collected through medical records, interviews, and fall scene investigations. Injuries were rated using the Abbreviated Injury Scale (AIS). Each case was reviewed by a child abuse expert; cases with a vague or inconsistent history and cases being actively investigated for child abuse were excluded.

RESULTS

79 subjects were enrolled in the study; 15 had no injuries, 45 had minor (AIS 1) injuries, 17 had moderate (AIS 2) injuries, and 2 had serious (AIS 3) injuries. No subjects had injuries classified as AIS 4 or higher, and there were no fatalities. Children with moderate or serious injuries resulting from a short-distance household fall tended to have fallen from greater heights, have greater impact velocities, and have a lower body mass index than those with minor or no injuries.

CONCLUSION

Children aged 0-4 years involved in a short-distance household fall did not sustain severe or life-threatening injuries, and no children in this study had moderate or serious injuries to multiple body regions. Biomechanical measures were found to be associated with injury severity outcomes in short-distance household falls. Knowledge of relationships between biomechanical measures and injury outcomes can aid clinicians when assessing whether a child's injuries were the result of a short-distance fall or some other cause.

Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center

BACKGROUND

Child abuse is a serious threat to the physical and psychosocial well-being of the pediatric population. Musculoskeletal injuries are common manifestations of child abuse. There have been multiple studies that have attempted to identify the factors associated with, and the specific injury patterns seen with musculoskeletal trauma from child abuse, yet there have been no large studies that have used prospectively collected data and controlled comparisons. The purpose of our study was to describe the patterns of orthopaedic injury for child abuse cases detected in the large urban area that our institution serves, and to compare the injury profiles of these victims of child abuse to that of general (accidental) trauma patients seen in the emergency room and/or hospitalized during the same time period.

METHODS

This study is a retrospective review of prospectively collected information from an urban level I pediatric trauma center. Five hundred cases of child abuse (age birth to 48 mo) were identified by membership in our institution's Suspected Child Abuse and Neglect database collected between 1998 and 2007. These cases were compared against 985 general trauma (accidental) control patients of the same age group from 2000 to 2003. Age, sex, and injury type were compared.

RESULTS

Victims of child abuse were on average younger than accidental trauma patients in the cohort of patients under 48 months of age. There was no difference in sex distribution between child abuse and accidental trauma patients. When the entire cohort of patients under 48 months were examined after adjusting for age and sex, the odds of rib (14.4 times), tibia/fibula (6.3 times), radius/ulna (5.8 times), and clavicle fractures (4.4 times) were significantly higher in child abuse versus accidental trauma patients. When regrouping the data based on age, in patients younger than 18 months of age, the odds of rib (23.7 times), tibia/fibula (12.8 times), humerus (2.3 times), and femur fractures (1.8 times) were found to be significantly higher in the child abuse group. Yet, in the more than 18 months age group, the risk of humerus (3.4 times) and femur fractures (3.3 times) was actually higher in the accidental trauma group than in the child abuse group.

CONCLUSIONS

Patients who present to an urban level I pediatric trauma center and are victims of abuse are generally younger, and have an equal propensity to be male or female. It is important for the clinician to recognize that the age of the patient (younger or older than 18 mo and/or walking age) is an important determinant in identifying injury patterns suspicious for abuse. Patients below the age of 18 months who present with rib, tibia/fibula, humerus, or femur fractures are more likely to be victims of abuse than accidental trauma patients. Yet, when patients advance in age beyond 18 months, their presentation with long bone fractures (ie, femur and humerus) is more likely to be related to accidental trauma than child abuse.

LEVEL OF EVIDENCE

level III, prognostic study.

Femoral fractures in children younger than three years: the role of nonaccidental injury

BACKGROUND

Nonaccidental injury (NAI) in children is a major cause of morbidity and mortality, with fractures being the second most common presentation. The presence of a femur fracture has been reported to be suggestive of nonaccidental trauma in 30% to 60% of young children. The purpose of this study was to determine the percentage of NAI in children younger than 3 years presenting with a femur fracture to a single institution within a western Canadian population.

METHODS

A retrospective cohort study was performed for children younger than 3 years who presented to the Alberta Children's Hospital during the years 1994 to 2005. The primary outcome variable was the percentage of NAI associated with femur fracture. Secondary outcome variables included patient demographics, injury characteristics, radiological and other workup, and suspicion of NAI.

RESULTS

The overall percentage of NAI was 11% (14/127 patients) and 17% (10/60 patients) in children younger than 12 months. Age younger than 12 months (P = 0.04), nonambulatory status (P = 0.004), delayed presentation (P = 0.002), mechanism of injury unwitnessed or inconsistent (P = 0.008), and other associated injuries (P = 0.006) were significant risk factors for NAI.

CONCLUSIONS

Children younger than 3 years who present with femoral fracture are at risk for associated NAI, although perhaps this risk is not as high as previously thought. Regardless, a high index of suspicion is mandatory when these children are encountered, and careful screening with a thorough history, physical examination, and other investigations, where indicated, is warranted to rule out associated NAI.

LEVEL OF EVIDENCE

Retrospective cohort study, level IV.

Are abusive fractures in young children becoming less common? Changes over 24 years

OBJECTIVE

To determine whether the proportion of fractures rated as abusive in children <36 months of age evaluated at a regional pediatric hospital increased over a 24-year period from 1979 to 2002. Fractures were chosen as an example of serious injuries in young children.

METHODS

Medical records were abstracted for all children <36 months of age who were seen at a single pediatric hospital with a fracture during three time periods: 1979-1983, 1991-1994, and 1999-2002. After reviewing the abstracted and radiographic information, two clinicians (one an expert on child abuse) and two pediatric radiologists each rated the likelihood of abuse using explicit criteria and a seven-point scale from definite abuse to definite unintentional injury. Ratings were done independently; when disagreements occurred, the case was discussed, and a joint rating was agreed upon, if possible. The proportions of cases rated as abuse were compared over the three time periods, and logistic regression was used to calculate adjusted odds ratios (OR).

RESULTS

In the early, middle, and late samples, there were 200, 240, and 232 children, respectively, with fractures. The proportion of cases rated as abuse decreased from 22.5% in the early period to 10.0% in the middle period and was 10.8% in the late period (p<.001). When comparing the odds of abuse in the middle and late groups to the odds of abuse in the early group (controlling for age, gender, ethnicity, type of medical insurance, and site of pediatric care), the adjusted ORs were .31 (95% CI=.15, .62) for the middle group and .45 (95% CI=.23, .86) for the late group. Thus, the odds of a given case being rated as abuse decreased by over 50% from the early period to the middle and late time periods. No statistically significant difference was found when comparing the odds of abuse for the middle group to those of the late group, OR: 1.46 (95% CI=.69, 3.08).

CONCLUSIONS

The proportion of abusive fractures in young children decreased substantially from 1979-1983 to 1991-1994 and 1999-2002 at a major pediatric hospital. We speculate that this decrease may reflect early recognition of less serious forms of maltreatment and the availability of services to high-risk families.

Suspected child abuse among victims of home accidents being admitted to the emergency department: a prospective survey from Turkey

OBJECTIVES

Association between home injuries and child abuse has received interest in Western countries. Inasmuch as it is now known that cultural differences may have an impact on child-rearing practices and the definition of maltreatment, we aimed to assess the suspected physical abuse in children presenting to the emergency department with home injuries and determine the risk factors associated with suspected child maltreatment in our region.

METHOD

The study is prospective in design. The sample was composed of 87 children younger than 72 months with presenting histories of home accidents. Data were collected by interview with the parents and by application of various questionnaires and inventories to both children and their parents.

RESULTS

Suspected physical abuse was identified in 16.1% of cases presenting with home injuries. The significant factors associated with suspected abuse were child's age younger than 12 months, having developmental delays in the social and self-care domains, younger paternal age, paternal alcohol abuse, marital discordancy, repeated history of home injuries, and requirement for radiological examination.

CONCLUSION

A missed diagnosis of child abuse can result in repeated injury, cause severe morbidity, and even result in death. This research indicates the features of "victims of accidents" who require special attention to recognize suspected abuse at the emergency department. Cultural factors might also provide additional indications that might aid in determining the cases of child maltreatment.

Broken Bones

Lower extremity injuries and fractures occur frequently in young children and adolescents. Nurses are often one of the first healthcare providers to assess a child with an injury or fracture. Although basic fracture care and principles can be applied, nurses caring for these young patients must have a good understanding of normal bone growth and development as well as common mechanisms of injury and fracture patterns seen in children. Similar to many of the injuries in the upper extremity, fractures in the lower extremity in children often can be treated nonoperatively with closed reduction and casting. However, this article will also review several lower extremity fractures that frequently require surgical intervention to obtain a precise anatomical reduction. Common mechanisms of injury, fracture patterns, and current management techniques will be discussed. Teaching strategies and guidelines that will enable nurses and nurse practitioners to confidently educate parents, families, and other providers caring for these young patients will be reviewed.

Patient and injury characteristics in abusive abdominal injuries

OBJECTIVE

To identify patient and injury characteristics associated with suspected child abuse in the setting of blunt abdominal trauma.

PATIENTS

We extracted from the National Pediatric Trauma Registry phases 2 and 3 (October 1995 to April 2001; N = 106,135) all cases of blunt abdominal injury, excluding motor vehicle injuries, in patients aged 0 to 4 years.

MAIN OUTCOME MEASURES

Independent variables included age, mortality, nutritional status, and injury type. The dependent variable was suspected child abuse.

RESULTS

Six hundred sixty-four cases were analyzed. The median age of patients was 2.6 years; 11.4% were undernourished. The 3 most common mechanisms of injury were suspected child abuse (40.5%), fall (36.6%), and struck-not child abuse (9.7%). Hepatic injury (46.1%) was the most common intra-abdominal injury, followed by splenic (26%), hollow viscous (17.9%), and pancreatic (8.6%) injuries. Eighty-four percent of deaths were related to suspected child abuse. There was a greater proportion of children with suspected child abuse in every patient and injury characteristics studied than all other mechanisms combined. In a regression model including age, undernourishment, pancreatic injury, hollow viscous injury, traumatic brain injury, and mortality, all variables were significantly associated with suspected abuse. Hollow viscous injury had the highest odds ratio (OR, 9.5; confidence limits, 5.7, 15.8), whereas traumatic brain injury had the lowest (OR, 3.6; confidence limits, 2.4, 5.6).

CONCLUSIONS

Young children with severe pancreatic or hollow viscous injuries or severe abdominal injuries in the context of either brain injury or undernourishment should be evaluated for the possibility that these injuries resulted from abuse. Increasing the awareness of the possibility of child abuse associated with a set of injury characteristics may allow for more consistent and complete medical evaluation.

Femur fractures resulting from stair falls among children: an injury plausibility model

BACKGROUND

Stair falls are common among young children and are also common false histories in cases of child abuse. When a child presents with a femur fracture and a stair-fall history, a judgment of plausibility must be made. A lack of objective injury and biomechanical data makes plausibility determination more difficult. Our objective was to characterize key features associated with femur fractures from reported stair falls, to develop a model for assessing injury plausibility (IP).

METHODS

Children 2 to 36 months of age who presented with a femur fracture from a reported stair fall were studied prospectively. Detailed history recording, examinations, fracture characterization, and injury scene analyses were conducted, and biomechanical measures associated with injury prediction were calculated. With our proposed IP model, all cases were then scored for the detail of history, biomechanical compatibility of fracture morphologic features, time to seeking care, and presence of other injuries.

RESULTS

Twenty-nine children were diagnosed with a femur fracture resulting from a reported stair fall. The IP model made a clear distinction between 2 groups, designated plausible and suspicious. Significant differences were observed for the detail of history, biomechanical compatibility of fracture, time to seeking care, presence of other injuries, and total IP scores. In the plausible group, the minimal linear momentum associated with a transverse fracture was almost 10-fold greater than that for spiral or buckle fracture types.

CONCLUSIONS

This study adds new information to the current body of knowledge regarding injury biomechanics and fractures among children. The IP model provides an objective means of assessing plausibility of reported stair-fall-related femur fractures and identifies key characteristics to facilitate decision-making.

Assessment and follow-up of suspected child abuse in preschool children with fractures seen in a general hospital emergency department

OBJECTIVE

To evaluate the emergency department assessment and follow-up of possible child abuse in children with fractures.

METHODS

A retrospective audit was conducted of children up to 3 years of age who presented with a fracture to a general hospital emergency department over a 2-year period.

RESULTS

In the 98 cases included, there was no documentation of complete physical examination in 57% of cases, whether the injury was witnessed in 54%, or time of injury in 18%. In 27% of cases the history documented was too brief to assess consistency of the injury with the history. Seventy-five per cent of children with known prior injuries did not have their past history documented. In 80% of all cases there was no indication that the emergency department doctor had considered the possibility of child abuse. Emergency doctors did not recognize four out of 16 cases (25%) with inconsistent histories. There was poor follow-up of patients in whom abuse was suspected: 46% of children less than 2 years had neither a skeletal survey nor bone scan. Patients referred to a paediatrician by the emergency department were significantly more likely to have a skeletal survey performed and to have the diagnosis of child abuse confirmed.

CONCLUSIONS

Emergency department staff in a general hospital do not document or assess for all of the indicators of child abuse in a high-risk population and they do not document consideration of the diagnosis in the majority of cases. Emergency department staff need more training and more resources to allow for full assessment of child abuse. Suspected child abuse cases should be referred to a paediatrician to improve investigation and follow-up.

Management of pediatric femoral shaft fractures

Femoral shaft fractures are the most common major pediatric injuries managed by the orthopaedic surgeon. Management is influenced by associated injuries or multiple trauma, fracture personality, age, family issues, and cost. In addition, child abuse should be considered in a young child with a femoral fracture. Nonsurgical management, usually with early spica cast application, is preferred in younger children. Surgery is common for the school-age child and for patients with high-energy trauma. In the older child, traction followed by casting, external fixation, flexible intramedullary nails, and plate fixation have specific indications. The skeletally mature teenager is treated with rigid intramedullary fixation. Potential complications of treatment include shortening, angular and rotational deformity, delayed union, nonunion, compartment syndrome, overgrowth, infection, skin problems, and scarring. Risks of surgical management include refracture after external fixator or plate removal, osteonecrosis after rigid antegrade intramedullary nail fixation, and soft-tissue irritation caused by the ends of flexible nails.